The pediatric DAV-expert algorithm: A GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access device in children.

In pediatric patients, the choice of the venous access device currently relies upon the operator's experience and preference and on the local availability of specific resources and technologies. Though, considering the limited options for venous access in children if compared to adults, such clinical choice has a great critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems fully satisfactory and useful in clinical practice. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in children. After a systematic review of the available evidence, the panel of the consensus (which included Italian experts with documented competence in this area) has provided structured recommendations answering 10 key questions regarding the choice of venous access both in emergency and in elective situations, both in the hospitalized and in the non-hospitalized child. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.

Totally implanted central venous access devices inserted by the femoral route: A narrative review and the proposal of a novel approach, the FICC-port.

BACKGROUND: Femoral ports are used in patients with indication to a totally implanted venous access device but with contraindication to chest-ports and brachial ports because of obstruction of the superior vena cava. In the last three decades, femoral ports have been implanted almost exclusively by cannulation of the common femoral vein at the groin, while the position of the tip has been assessed by X-ray. METHODS: We report our experience with a new approach to femoral ports, which includes recent methods and techniques developed in the last few years. These novel femoral ports, which we call "FICC-ports," are characterized by (a) long femoral 5 Fr polyurethane catheter inserted by ultrasound-guided puncture of the superficial femoral vein at mid-thigh; (b) intraprocedural location of the tip in the sub-diaphragmatic inferior vena cava, using ultrasound visualization by the transhepatic and/or the subcostal view; (c) low-profile or very low-profile reservoir implanted above the quadriceps muscle, at mid-thigh. RESULTS: In the last 3 years, we have implanted 47 FICC-ports in young adults with mediastinal lymphoma compressing the superior vena cava. We had no immediate/early complication, and only three late complications (one kinking of the catheter in the subcutaneous tissue; one tip migration with secondary venous thrombosis; one persistent withdrawal occlusion due to fibroblastic sleeve). CONCLUSION: If there is indication to a femoral port, the implantation of a "FICC-port"-as described above-is to be strongly considered in terms of safety, effectiveness, and cost-effectiveness: no immediate-early complications, minimal late complications, no X-ray exposure, low invasiveness, low cost.

Applicability and feasibility of intraprocedural tip location of femorally inserted central catheters by transhepatic ultrasound visualization of the inferior vena cava in adult patients.

BACKGROUND: The ideal intraprocedural method for tip location during insertion of femorally inserted central catheters (FICCs) is still a matter of debate. When the catheter tip is meant to be in the right atrium or in the supradiaphragmatic inferior vena cava (IVC), tip location by either intracavitary electrocardiography or transthoracic echocardiography may be accurate and easy to perform. When the catheter tip is planned to be placed in the subdiaphragmatic IVC, fluoroscopy-though inaccurate and unsafe-has been regarded as the only option for intraprocedural tip location. METHODS: We have investigated prospectively the applicability and feasibility of transhepatic ultrasound as intraprocedural method for assessing the location of the catheter tip in the subdiaphragmatic tract of IVC, during FICC insertion. RESULTS: We enrolled 169 consecutive patients undergoing FICC insertion by ultrasound guided puncture of the superficial femoral vein. In 165 out of 169 patients, the subdiaphragmatic IVC was visualized by the transhepatic ultrasound view. In all cases of IVC visualization, the catheter tip could be identified by ultrasound, either directly (direct evidence of the tip inside the vein) or indirectly (enhanced visualization of the tip after "bubble test"). There was no immediate or early complication, and very few late complications. CONCLUSION: The intraprocedural method of tip location of FICCs by transhepatic ultrasound was applicable in 97.6% of cases and feasible in 100%. When the position of the catheter tip is planned to be in the subdiaphragmatic IVC, this method of tip location is accurate, safe, and inexpensive, and should be considered as an alternative to fluoroscopy.

Point-of-care ultrasound for vascular access in neonates and children.

Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications. CONCLUSION: Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications. WHAT IS KNOWN: • Ultrasound is obviously useful for vascular access procedures in neonates and children. WHAT IS NEW: • Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.

Femoral venous access: State of the art and future perspectives.

In the past 5 years, non-dialysis femoral venous access has changed in terms of indications, techniques of insertion, and expected incidence of complications. To the traditional non-emergency indication for femoral catheters-obstruction of the superior vena cava-many other indications have been added, both in intensive and non-intensive care. The insertion technique has evolved, thanks to ultrasound guided venipuncture, tunneling, and ultrasound based intraprocedural tip location. Insertion of femorally inserted central catheters may be today regarded as a procedure with an extremely low intraprocedural and post-procedural risk. The risk of infection is reduced by the possibility of the exit site at mid-thigh, by the use of cyanoacrylate glue for sealing the exit site, and by appropriate intraprocedural strategies of infection prevention. The risk of catheter-related thrombosis is low, due to several concomitant strategies: a proper match between vein diameter and catheter caliber; an accurate intraprocedural assessment of tip location by ultrasound and/or intracavitary ECG; the consistent use of ultrasound guided venipuncture and micro-introducer kits; an adequate stabilization of the catheter at the exit site. The risk of mechanical complications and the risk of lumen occlusion are minimized when using polyurethane, power injectable catheters. All these novelties have brought a revolution in the field of femoral venous access, so that this route may be considered as safe and effective as other approaches to central venous catheterization.

A GAVeCeLT bundle for PICC-port insertion: The SIP-Port protocol.

In the last decade, a new type of brachial port has been introduced in clinical practice, the so-called "PICC-port." This is a brachial port, but inserted according to the methodologies and technologies currently adopted for the insertion of peripherally inserted central catheters (PICCs). Several studies have shown that PICC-port insertion is safe, not associated with any relevant immediate or early complication, and that the expected incidence of late complications is significantly lower if compared to "traditional" brachial ports (i.e. inserted without ultrasound guidance). Furthermore, PICC-ports yield excellent esthetic results and are associated with optimal patient compliance. This paper describes an insertion bundle-developed by GAVeCeLT, the Italian Group of Long Term Venous Access Devices, and nicknamed "SIP-Port" (Safe Insertion of PICC-Ports)-which consists of few evidence-based strategies aiming to further minimize all immediate, early, or late complications potentially associated with PICC-port insertion. Also, this insertion bundle has been developed for the purpose of defining more closely the differences between a traditional brachial port and a PICC-port. The SIP-Port bundle is currently adopted by all training courses on PICC-port insertion held by GAVeCeLT. It includes eight steps: (1) preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; (2) appropriate skin antiseptic technique and maximal barrier precautions; (3) choice of appropriate vein, in terms of caliber and site; (4) clear identification of the median nerve and of the brachial artery during the venipuncture; (5) ultrasound-guided puncture and cannulation of the vein; (6) ultrasound-guided tip navigation; (7) intra-procedural assessment of tip location by intracavitary ECG or by trans-thoracic echocardiography; (8) appropriate creation and closure of the subcutaneous pocket.

The Good, the Bad, and the Serum Creatinine: Exploring the Effect of Muscle Mass and Nutrition.

Muscle wasting (sarcopenia) is one of the hallmarks of critical illness. Patients admitted to intensive care unit develop sarcopenia through increased protein catabolism, a decrease in protein syntheses, or both. Among the factors known to promote wasting are chronic inflammation and cytokine imbalance, insulin resistance, hypermetabolism, and malnutrition. Moreover, muscle wasting, known to develop in chronic kidney disease patients, is a harmful consequence of numerous complications associated with deteriorated renal function. Plenty of published data suggest that serum creatinine (SCr) reflects increased kidney damage and is also related to body weight. Based on the concept that urea and creatinine are nitrogenous end products of metabolism, the urea:creatinine ratio (UCR) could be applied but with limited clinical usability in case of kidney damage, hypovolemia, excessive, or protein intake, where UCR can be high and independent of catabolism. Recent data suggest that the sarcopenia index should be considered an alternative to serum creatinine. It is more reliable in estimating muscle mass than SCr. However, the optimal biomarker of catabolism is still an unresolved issue. The SCr is not a promising biomarker for renal function and muscle mass based on the influence of several factors. The present review highlights recent findings on the limits of SCr as a surrogate marker of renal function and the assessment modalities of nutritional status and muscle mass measurements.

Ultrasound based tip location of femorally inserted central catheters into the inferior vena cava: A comparison between the transhepatic and the subcostal view.

BACKGROUND: Intraprocedural catheter tip location is currently recommended. Intracavitary EGC and ultrasound are the preferred methods of tip location for catheters with their tip in the superior vena cava or in the right atrium. Though, the best method of intraprocedural tip location for catheters with their tip in the inferior vena cava is still uncertain. One possibility is to visualize the subdiaphragmatic inferior vena cava by ultrasound, using either the transhepatic or the subxiphoid view. METHODS: In this prospective study, we compared two different ultrasound windows for the visualization of the inferior vena cava (transhepatic vs subxiphoid) for the purpose of localizing the catheter tip during the insertion of femorally inserted central catheters. RESULTS: We studied 249 consecutive insertions of central catheters via the superficial femoral vein. Intraprocedural location of the catheter tip was performed by ultrasound, using both transhepatic and subxiphoid view. Visualization of the inferior vena cava was possible only in 81 cases (32.5%) with the subxiphoid view, but it was always possible in all 249 cases with the transhepatic view. The catheter tip was localized in 15 patients out of 81 with the subxiphoid view (18.5%); the transhepatic view allowed the visualization of the tip in all 249 patients. CONCLUSIONS: The applicability of the subxiphoid window has several limitations, both in terms of visualization of the inferior vena cava and localization of the catheter tip. The transhepatic view should be the preferred method for intraprocedural ultrasound localization of the catheter tip in the inferior vena cava.

Caliber of the deep veins of the arm in infants and neonates: The VEEIN study (Vascular Echography Evaluation in Infants and Neonates).

PURPOSE: Ultrasound-guided peripherally inserted central catheters (PICCs) are increasingly used in children, though their insertion may be limited by the small caliber of the deep veins of the arm. Previous studies have suggested to use age or weight as a guide to the feasibility of PICC insertion. We have planned an observational study with the purpose of identifying the actual feasibility of PICC insertion based on the ultrasound evaluation of the deep veins of the arm in groups of children of different weight range. METHODS: We have studied 252 children weighing between 2.5 and 20 kg, divided in five different groups (group 1: 2.5-4 kg; group 2: 4.1-7 kg; group 3: 7.1-10 kg; group 4: 10.1-15 kg; group 5: 15.1-20 kg): the caliber of brachial vein, basilic vein, and cephalic vein at mid-upper arm + the caliber of the axillary vein at the axilla were measured by ultrasound scan. RESULTS: Veins of caliber >3 mm (appropriate for insertion of a 3 Fr non-tunneled PICC) were found at mid-upper arm in no child of group 1 or 2, in 13% of group 3, in 28% of group 4, and in 54% of group 5. An axillary vein >3 mm (appropriate for insertion of a 3 Fr tunneled PICC) were found in 5.8% of group 1, 30.6% of group 2, 67% of group 3, 82% of group 4, and 94% of group 5. CONCLUSIONS: The age and the weight of the child have a small role in predicting the caliber of the veins of the arm. Veins should be measured case by case through a proper and systematic ultrasound evaluation; however, the clinician can expect that insertion of a 3 Fr PICC may be feasible in one third of children weighing between 4 and 7 kg, and in most children weighing more than 7 kg, especially if adopting the tunneling technique.

Ultrasound-guided access to the axillary vein for implantation of cardiac implantable electronic devices: A systematic review and meta-analysis.

The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p = 0.21), pocket hematoma (0.8% vs 1.7%, p = 0.32), infection (0.28% vs 1.05%, p = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve.

An ultrasound-based technique in the management of totally implantable venous access devices with persistent withdrawal occlusion.

Persistent withdrawal occlusion is a specific catheter malfunction characterized by inability to withdraw blood through the device while infusion is maintained. The main causes are fibroblastic sleeve and tip malposition (associated or not to venous thrombosis around the tip). All current guidelines recommend infusing vesicant/antiblastic drugs through a central venous port only after assessment of blood return. In PWO, blood return is impossible. We have recently started to assess the intravascular position of the tip and the delivery of the infusion in the proximity of the cavo-atrial junction utilizing transthoracic/subxiphoid ultrasound with the 'bubble test'. We found that this is an easy, real-time, accurate and safe method for verifying the possibility of using a port for chemotherapy even in the absence of blood return, as it occurs with persistent withdrawal occlusion.

Secondary malposition of a PICC-port due to heavy physical exercise: A case report.

Physical exercise is often encouraged in cancer patients, mainly for the purpose of rehabilitation and for its psychological benefit. Some authors also suggest that exercise-specially in patient with peripherally inserted central venous access devices-may contribute to reduce the risk of catheter-related thrombosis. Still, the impact of physical exercise on the risk of device-related complications is not yet defined.We report a case of secondary migration of the tip of an arm port, caused by high-intensity exercise in a woman undergoing chemotherapy because of ovarian cancer. Tip migration was suspected because of malfunction (persistent withdrawal occlusion) and diagnosis established after ultrasound examination and chest x-ray.Even if exercise may yield benefit in the cancer patient on chemotherapy, the risk of mechanical complication of the venous access device-such as tip migration-should be considered in the case of high-intensity exercise.

Midline catheters for extracorporeal photopheresis in hematological patients.

INTRODUCTION: Peripheral venous access for extracorporeal photopheresis (ECP) may be difficult in graft versus host disease (GVHD) patients, because of previous intravenous therapies and multiple peripheral cannulations; in this population of patients, ultrasound guided midline catheters may be an alternative option to central venous access. METHODS: In this single-center, prospective preliminary study, we enrolled all consecutive patients with a diagnosis of GVHD and candidate to ECP, over a period of 10 months. We used inserted power injectable, non-valved, polyurethane, 20-25 cm single lumen midline catheters (MC). RESULTS: Sixty-nine ECP procedures were carried out in six patients, using single-lumen MCs for outflow (5Fr in 74% and 4Fr in 26% of cases). For inflow, we used 5Fr or 4Fr MCs, or central venous access devices previously placed for other clinical reasons. There were no catheter-related complications during the entire period of ECP treatment. Mean outflow was significantly higher for 5Fr than for 4Fr MCs (35.8 ± 7.3 vs 29.2 ± 7.8 ml/min; p = 0.0008) and the procedure time was significantly shorter (92.9 ± 9.2 vs 108 ± 13.2 min; p < 0.0001). CONCLUSION: In GVHD patients, ECP can be performed efficiently and safely using single lumen polyurethane power injectable MCs. The best results are obtained with 5Fr rather than with 4Fr catheters. This strategy of venous access should be implemented in DIVA patients requiring ECP treatments, and probably also in other types of apheresis.

A GAVeCeLT bundle for central venous catheterization in neonates and children: A prospective clinical study on 729 cases.

BACKGROUND: In the pediatric patient, central venous catheterization may be associated with relevant complications. Though, most of them may be prevented by a wise choice of materials, methods, and techniques. Evidence-based insertion bundles for central venous catheterization have been developed in the adult patient, but not in neonates and children. METHODS: The Italian Group for Long Term Venous Access Devices (GAVeCeLT) has developed an insertion bundle for central venous catheterization in neonates, infants, and children, which includes seven evidence-based strategies: (1) preprocedural ultrasound evaluation, (2) appropriate aseptic technique, (3) ultrasound guided venipuncture, (4) intraprocedural tip location by non-radiological methods, (5) proper choice of the exit site by tunneling, (6) sutureless securement, and (7) protection of the exit site using glue and transparent membranes. The effectiveness and safety of this bundle has been tested in a prospective study. RESULTS: All neonates, infants and children requiring a non-emergency central line (except for umbilical venous catheters and epicutaneo-cava catheters) were included in the study. Out of 729 central line insertions, there were no immediate complications (no pneumothorax, no arterial puncture, no malposition); the incidence of early and late complications (local ecchymosis, dislodgment, local pain, exit site infection) was 3.7%; in the first 2 weeks after insertion, no catheter-related bacterial infection or catheter-related thrombosis was recorded. CONCLUSION: The results of this prospective study strongly validate the hypothesis that an insertion bundle is highly effective in optimizing the safety of the maneuver, reducing immediate, early, and late complications.

Chest-to-arm tunneling: A novel technique for medium/long term venous access devices.

BACKGROUND: Chest-to-arm (CTA) tunneling has been described recently as a technique that allows an optimal exit site at mid-arm even in chronically ill patients with complex clinical issues and challenging problems of vascular access. METHOD: We adopted CTA tunneling in oncologic and in non-oncologic patients, in totally implanted and in external devices, for both medium and long-term intravenous treatments. We report our experience with 60 cases of CTA tunneling: 19 patients requiring a totally implantable device, who had bilateral contraindication to venous access at the arm and bilateral contraindication to placement of the pocket in the infra-clavicular area; 41 patients requiring an external central venous catheter, who had bilateral contraindication to insertion of peripherally inserted central catheters or femoral catheters, as well as contraindication to an exit site in the infraclavicular area. All venous access devices were inserted with ultrasound guidance and tip location by intracavitary electrocardiography, under local anesthesia. RESULTS: There were no immediate or early complications. Patients with CTA-ports had no late complications. In patients with CTA-tunneled external catheters, there were two dislodgments, four episodes of central line associated blood stream infections, and one local infection. There were no episodes of venous thrombosis or catheter malfunction. CONCLUSION: Our experience suggests that CTA tunneling is a safe maneuver, with very low risk of complications, and should be considered as an option in patients with complex venous access.

Ultrasound versus intracavitary electrocardiography for intraprocedural tip location during central venous catheterization in infants and children: A prospective clinical study.

BACKGROUND: Both intracavitary electrocardiography (IC-ECG) and ultrasound (US) have been proven to be safe and accurate for intraprocedural tip location during central venous catheterization, and both are known to be easily applicable and feasible in pediatric patients. Though, no prospective clinical study has directly compared the two methods as regards their applicability, feasibility, and procedural time. METHODS: This study prospectively enrolled all children requiring a central venous access device in non-emergency situations, during a period of 1 year. All devices were inserted according to a well-defined insertion bundle including both IC-ECG and US-based tip location. The primary endpoint of the study was to compare the two methods in terms of applicability, feasibility and time required. RESULTS: This study included 100 consecutive central venous catheterizations in children of age ranging from 1 month to 18 years. The applicability of IC-ECG based tip location was 98% and its feasibility 100%; the time required for IC-ECG was 1.9 ± 2 min. The applicability of US-based tip location was 96% and its feasibility was 100%; the maneuver required 2.2 ± 3 min. CONCLUSIONS: US is an appropriate alternative method for intraprocedural tip location in children. The combined use of US and IC-ECG (both maneuvers being accurate, inexpensive, cost-effective, non-invasive, and equally fast to perform) should be recommended for tip location in pediatric patients, and it will avoid completely the use of fluoroscopy or of post-procedural x-ray.

Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices.

BACKGROUND: The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care. METHODS: We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis. RESULTS: A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters. CONCLUSIONS: Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement.

Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.

Ten years of clinical experience with cyanoacrylate glue for venous access in a 1300-bed university hospital.

In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.