Vascular Access Service

Our story so far Dott.ssa Alessandra Palo

Direttore AAT Pavia - SAV

Dipartimento Medicina Intensiva

Fondazione IRCCS San Matteo Pavia

More and more

patients with

chronic illness

Vascular

access

devices

Vascular access everywhere

More than 5 millions of CVCs inserted every year

Our origins

Our hospital specialized in OncoEmatology and

organ transplantation

This led to a strong demand of advanced vascular

access devices

Our origins

This challenge was taken up by Dr.Bellinzona

(anesthesiology and critical care), Dr.Albertario

(surgery and critical care) and Dr.Serafini

(pediatric anesthesiology) in the ‘80s

The first implants (Groshong and Broviac) were

done in OR and radiological suite

0

100

200

300

400

500

600

700

800

900

2013 2014 2015 2016 2017

Procedures

Procedures

Our areas of expertise

360° vascular access

Totally US-guided

X-ray free

Outpatient-centered

H24 mobile phone (calls, SMSs and WhatsApp)

360° vascular access =

SAV

Selection

Insertion

Management

Complications

Counselling

Training

360° vascular access =

SAV

Adult and pediatric

CICC

PICC

MIDLINE

PORT

Tunnelled

and dialysis-tunnelled

devices

Totally Implantable

Vascular Access Devices

360° vascular access =

SAV

Adult and pediatric

Experts

Residents

Trainees

Consultants

Visiting physician

Nurses

DEVICE CHOISE

• CVC short term (CICC)

• CVC long term (> 30 days)

INFORMED CONSENT

LONG TERM CVC

• Dialysis and apheresis

• High-flow catheters

• Tunneled short & long-term

• Drug-linked patency

• Jugular or femoral access

LONG TERM CVC

• Tunnelled catheters

• Exit-site far from puncture site – mostly sub-cutaneous

• Lower infection complications

• Difficult and complex insertion and removal

• Totally implanted catheter (Port)

• Surgical insertion and removal

• Catheter life

• Very low infection complications

LONG-TERM CVC

• PICC

• Less complications than CICC

• More infectious complication than tunneled devices

• Thrombosis ? - Mispositioning – Slow flow

• Less in-site span than tunneled and totally implanted devices

• New role in intensive and surgical settings

SHORT/LONG-TERM CVC

Antiseptic or antimicrobial coated CVC • Antiseptic agents (chlorhexidine-sulfadiazine)

• Antimicrobial agents (minocycline-rifampicin)

• SETTINGS

• Operating Units or patients with CRBSI frequency above institutional objective despite of basal prevention procedures

• Patients with poor venous asset and history of recurrent CRBSI, patients with higher risk of serious consequences in case of CRBSI

VEIN CHOICE

• PICC (basilic-brachial-cephalic vein)

• CICC

• Dialysis

• Femoral vein for urgency vascular access

• Subclavian vein blind-access 1° choice subclavian vein echoguided

• Right jugular vein elective for dialysis/apheresis

CVC

CICC

Centrally Inserted

Central Catheter

PICC

Peripherally Inserted

Central Catheter

Same insertion

CVC NOT a CVC

Midline vs. PICC

PVC

MiniMidline

Midline

PICC

Not C

VC

C

VC

PICC

Peripherally

Inserted

Central

Catheter

0

100

200

300

400

500

600

2014 2015 2016 2017

PICC

PICC

PICC-Related Thrombosis

Big catheters in small veins

It is considered the most important

issue related to PICCs

Not well known

PICC-RT

The first real-world study to describe early onset PICC-RT

Weekly US screening

Recruiting, stop 31st Dec 2017, n=300

Insertion • Effectiveness

• Safety

Total US-guide

Always RACEVA/RAPEVA

Choose the right vein/the right side)

Simulate during LA

Always check the guidewire before dilation

SAV insertion bundle

Tip-navigation and -confirmation: best performance/complications

Bubble-test: check iv position

From blindess to ultrasounds

Always use US

Always perform RACEVA

RApid Central Vein Assessment

It’s similar to the old concept of “static” ultrasound

guidance (i.e. to take a look before puncture)

http://www.officialpsds.com/

Neck-High

Neck-Low

Neck-Lateral

Ax SX

Ax LX

Always perform RAPEVA

RApid PEripheral Vein Assessment

It’s similar to the old concept of “static” ultrasound

guidance (i.e. to take a look before puncture)

1. Cephalic v. at elbow

2. Brachial a . and vv. at

elbow

3. Basilic v. upward

4. Vascular nerve bundle

(brachial a.+vv.

+median nerve)

5. Cephalic v.

6. Axillary v.

7. Supraclavicular

subclavian v.+ internal

jugular v. + innominate

v.

What to look at during RACEVA/RAPEVA

Is there the vein?

Anatomical relations?

Thrombosis?

Diameter!!!

Depth

Vein: CVC ratio 2:1 minimum

3:1 best

Guidewire verification

It’s a very important step

You must always check the intravenous position of

your guidewire before dilation

Failure to check can result in serious mechanical

complications

SAV Pavia 2016 (N~1000)

RIJV Others

0.0% failure 0.0% complications

TIP POSITION

WHY IS TIP POSITION SIGNIFICANT?

FAR FROM THE HEART

• Low flow

• Stenosis

• Perforation

IN THE HEART

• Malfunction

• Perforation

• Arrhythmias

CLOSE TO

THE HEART

• High flow

• No trauma

“Confirm the final

position of the

catheter tip as soon

as clinically

appropriate.”

ECG

CEUS

Fluoroscopy

RX

Wikidoc.org

1989

1998

2010

2009

TIM

E

• LCT has disappeared from

Literature

• No cases from 2000

Place the tip of CVC

outside of the atrium

So do we have to choose the right tip position

because there is a risk of cardiac perforation?

No

we must choose the position with less

complications and best performance

Best tip position In a vein as large as possible

Parallel to its long axis (no

zone B from the left)

Out of pericardial sac???

Low SVC-High RA

High SVC: not for a long time

Low RA-RV: pull back

Far from

SVC/RA

junction

=

More

thrombosis

and

malfunction

Distal RA

=

Arrhythmias

2 cm

Breathing

Arm movements

Body posture

Infusion flow

The CAJ is the safest site

2 cm up: still in the lower SVC

2 cm down: still in the upper RA

Chest-RX interpretation is

inconstant

ULTRASOUND

Tip position and anesthesia

BUT you have to check the intravenous position of the

CVC/guidewire before starting the operation

Check the intravascular

position of the needle

Check the intravenous

position of the guidewire

Check the functionality of

the catheter

Post-op tip position

confirmation

Flush test!

The flush test

It’s a very useful test to confirm intravenous position of the tip

CEUS patterns Negative test (=incorrect tip position)

No bubbles: caution non-intravenous tip!

Laminar flow>2 sec: misplacement

Immediate turbulent flow: RA

Positive test (=correct tip position)

Laminar flow<2 sec

CEUS limitations

2 skilled operators needed

Cardiologic probe

Subjective (learning curve)

Tricky to document

RX free

Written protocol

Tip navigation

Significant primary malposition rate of

PICC and CICCs (not from RJV) is 10-30%

Tracking

Location

Real time

tracking of

device direction

in comparison to

the heart

To avoid primary

malposition

Actual and

precise tip

position in

comparison to the

heart

Less complications

and optimal

function

NAVIGATION: intraprocedural method by

definition

Fluoroscopy

Ecography

Electromagnetic tracking

US are extremely useful but their role in tip location is

still controversial

Tracking systems

Cathfinder

Navigator

Sherlock Vasonova (Arrow VPS G4)

Electromagnetic

tracking

iECG

confirmation

+

Is the post-procedural chest X-ray sufficient? No

Precise or not…

…it’s not intra-procedural

Immediate use

Intravenous position

Bubble tests

Long-term use

Precise tip position

iEKG

US are extremely useful but

can’t be used to exactly

locate the tip of our devices

iEKG

BBraun

The tip of the device is used

as an intracavitary moving

lead electrode

Anatomical basic: SAN is the

most accurate marker of CAJ

S-A node

A-V node

http://www.hektoeninternational.org/

The CVC tip becomes the negative terminal of lead II

iEKG techniques

Metallic guidewire vs. fluid column

Home-made vs. ad-hoc

Adaptors vs. iEKG dedicated equipments

Cavo rosso (o verde)

Derivazione D2

Requisiti onda P

Applicability 90-95%

99.3% Patients with no visible P wave at the

standard baseline ECG were exclude

Still in use

today!

Pediatric access

A real problem Children’s veins are

smaller

Often no suitable kit is

available

The best sets are the ones in

PICCs trays

Real-time ultrasound techniques

(anatomy, puncture, navigation,

localization….) have their greatest

usefulness in pediatrics and are also

easier

Smaller probes

Sovraclavear approach to the innominate vein in the newborn

Tunneling in pediatrics

Tunneling can

address the lack of dedicated catheters

Correct tip location is vital in children

Management

Bundle CDC In

sert

ion

Mana

gem

ent

SAV management bundle 1 Strict hand hygene, before and after

2 Always alcoholic Clorexidine

3 Daily exit-site evaluation (VES)

4 Change dressing only when indicated (7 days)

5 Use the correct dressing (semi-permeable)

6 Use the right connector (not valved or MaxZero)

7 Disinfect connectors for 10 seconds with alcoholic Clorexidine

8 Change the lines only when indicated (minimum 96 hs)

9 Clean devices regularly and appropriately with pulsed saline

10 Daily assessment of the usefulness of devices

Ethanol lock

Biofilm “…a microbially derived sessile community

characterized by cells that are irreversibly

attached to a substratum or interface or to

each other, are embedded in a matrix of

extracellular polymeric substances that they

have produced, and exhibit an altered

phenotype with respect to growth rate and

gene transcription.”

Antibiotics and biofilm

Organism Antibiotic MIC or MBC

(mcg/mL)

MIC in biofilm

(mcg/mL)

S. aureus

(NCTC 8325-4) Vancomycin 2 (MBC) 20

P. aeruginosa (ATCC

27853) Imipenem 1 (MIC) >1,024

E. coli

(ATCC 25922) Ampicillin 2 (MIC) 512

P. pseudomallei Ceftazidime 8 (MBC) 800

S. sanguis Doxycycline 0.063 (MIC) 3.15

Donlan RM, Clin Microbiol Rev. 2002

Antimicrobial lock

Antibiotics

Vancomycin

Gentamycin

Cefazoline

Cefotaxime

Ciprofloxacin

…

Non antibiotics

Citrate

Taurolidine

Urokinase (B-I)

…

Ethanol

Ethanol lock

Extremely high concentration Extremely low

dose

High

efficacy No side

effects

NCT01186172

Ethanol Lock for the Salvage of Infected Long-term

Vascular Access

Unsuccessful for failed randomization (after the first cases, all the

physicians wanted only the Ethanol instead of the antibiotic!)