The SIP protocol update: Eight strategies, incorporating Rapid Peripheral Vein Assessment (RaPeVA), to minimize complications associated with peripherally inserted central catheter insertion.

Insertion of Peripherally Inserted Central Catheters (PICCs) is potentially associated with the risk of immediate/early adverse events, some of them minimal (repeated punctures) and some relevant (accidental arterial puncture or nerve-related injury). Several strategies adopted during the insertion process may minimize the risk of such events, including late complication risks such as infection, venous thrombosis, or catheter dislodgment and/or malposition. This paper describes an update version of the SIP protocol (Safe Insertion of PICCs), an insertion bundle which includes eight effective strategies that aims to minimize immediate, early, or late insertion-associated complications. These strategies include: preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; appropriate skin antiseptic technique; choice of appropriate vein, adoption of the Zone Insertion Method™; clear identification of the median nerve and brachial artery; ultrasound-guided puncture; ultrasound-guided tip navigation; intra-procedural assessment of tip location; correct securement of the catheter, and appropriate protection of the exit site. This updated version of the SIP protocol includes several novelties based on the most recent evidence-based scientific literature on PICC insertion, such as the clinical relevance of the tunneling technique, the use of ultrasound for intra-procedural tip navigation and tip location, and the new technologies for the protection of the exit site (cyanoacrylate glue) and for the securement of the catheter (subcutaneous anchorage).

Rapid Central Vein Assessment (RaCeVA): A systematic, standardized approach for ultrasound assessment before central venous catheterization.

Ultrasound technology has revolutionized the practice of safer vascular access, for both venous and arterial cannulation. The ability to visualize underlying structures of the chest, neck, and upper/lower extremities provides for greater success, speed, and safety with all vascular access procedures. Ultrasound not only yields superior procedural advantages but also provides a platform to perform a thorough assessment of the vascular structures to evaluate vessel health, viability, size, and patency, including the location of other important and best avoided anatomical structures-prior to performing any procedures. Such assessment is best performed using a systematic and standardized approach, as the Rapid Central Vein Assessment, described in this study.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Preventing contamination at the time of central venous catheter insertion: a literature review and recommendations for clinical practice.

AIMS AND OBJECTIVES: To evaluate the evidence base and rationale underpinning the various infections control strategies during central venous catheter insertion and to promote discussion about the key, recurring concepts and recommendations in the literature. Logistical and organisational factors relating to central venous catheter insertion are also examined. BACKGROUND: Catheter-related bloodstream infections following the insertion of central venous catheters are associated with significant patient mortality and morbidity, prolonged hospital stays and increased economic costs. Limited published literature specifically examines microbial contamination during the peri-insertion process. METHODS: An integrative literature review supervised by a health informatics librarian was undertaken. On the basis of these data, considerations for clinical practice are provided. Retrieved articles were categorised under the following themes: risk of contamination at insertion; clinical and organisational impact of contamination; strategies for reducing contamination; controversies and challenges with decontamination strategies; recommendations for practice and implications for further research and organisational practice. RESULTS: Specific recommendations for reducing catheter-related bloodstream infections based on recurring themes include the following: reducing microbial burden on skin prior to the central venous catheter insertion; decreasing contact of gloves and insertion equipment with the patient's skin; using specifically trained staff to prepare and maintain a sterile field; and ensuring a sterile technique is adhered to throughout the central venous catheter insertion process. The need for organisational, procedural and clinical practices to support better healthcare outcomes is demonstrated. Highlighting the importance of executive support and regular review of policy and guidelines are necessary to improve patient outcomes. CONCLUSIONS: Preventing infections related to central venous catheters requires the integration of clinical, organisational and workforce factors.