Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU.

The goal of the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was to define indications and appropriate practices for peripherally inserted central catheters (PICC) use; however, MAGIC recommendations virtually reduced the use of PICC in hospital settings, including critical care. The aim of this review is to present an assessment of the MAGIC guidelines, considering contemporary evidence to date. The validity of the MAGIC recommendations and their applicability to current practice are called into question given important concerns with the methodology for their development (e.g. high volume of clinical scenarios for evaluation) and the supporting evidence used. There is a considerable amount of contemporary evidence not considered in MAGIC that reports on evolving practices, techniques, and technologies targeted to reduce complications associated with central venous access devices (CVADs). Recent evidence dictates that CVADs are necessary in the intensive care unit (ICU), and that PICCs are a safe, reliable, and appropriate type of central lines, which cannot be replaced in several ICU situations. In light of evolving evidence and practice, as well as the methodological concerns identified, the MAGIC guidelines should be revisited. It is also recommended to create a clinical assessment tool that identifies potential uses of specific CVADs, based on patient needs. The choice of the CVAD should be based on unique clinical considerations and current scientific evidence, not on fears informed by antiquated data.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients.

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

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 Superficial Vein Assessment (RaSuVA): A pre-procedural systematic evaluation of superficial veins to optimize venous catheterization in neonates.

BACKGROUND: Placement of peripheral intra-venous cannulas and epicutaneo-caval catheters is routinely performed in in Neonatal Intensive Care Unit (NICU), and both devices require visible superficial veins easy to cannulate. NICU patients are intrinsically characterized by poor and fragile vein asset, so that puncture and cannulation of superficial veins is often a challenge even for trained clinicians and cannulation frequently results in a stressful, painful, difficult procedure. METHODS AND RESULTS: Rapid Superficial Vein Assessment is meant to offer a systematic pre-procedural evaluation of all superficial veins of the newborn, so to allow a rational choice of the best insertion site, tailored on the single patient, and optimized for the specific type of venous access device. The superficial veins are examined systematically, both with and without NIR technology, exploring seven skin areas in the following order: (1) medial malleolus, (2) lateral malleolus, (3) retro-popliteal fossa, (4) back of the hand and wrist, (5) antecubital fossa, (6) anterior scalp surface, and (7) posterior scalp surface. CONCLUSIONS: The aim of the protocol is to increase the first attempt success rate and reduce the duration of the procedure, the number of attempts for single patient and possibly to limit complications, stress, and pain in neonates.

Rapid Femoral Vein Assessment (RaFeVA): A systematic protocol for ultrasound evaluation of the veins of the lower limb, so to optimize the insertion of femorally inserted central catheters.

In this paper we describe a new protocol-named RaFeVA (Rapid Femoral Vein Assessment)-for the systematic US assessment of the veins in the inguinal area and at mid-thigh, designed to evaluate patency and caliber of the common and superficial femoral veins and choose the best venipuncture site before insertion of a FICC.

Comparison between sedation room and operating room in central venous catheter positioning in children.

BACKGROUND: Placement of central venous access devices is a clinical procedure associated with some risk of adverse events and with a relevant cost. Careful choice of the device, appropriate insertion technique, and proper management of the device are well-known strategies commonly adopted to achieve an optimal clinical result. However, the environment where the procedure takes place may have an impact on the overall outcome in terms of safety and cost-effectiveness. METHODS: We carried out a retrospective analysis on pediatric patients scheduled for a major neurosurgical operation, who required a central venous access device in the perioperative period. We divided the patients in two groups: in group A the central venous access device was inserted in the operating room, while in group B the central venous access device was inserted in the sedation room of our Pediatric Intensive Care Unit. We compared the two groups in terms of safety and cost-effectiveness. RESULTS: We analyzed 47 central venous access devices in 42 children. There were no insertion-related complications. Only one catheter-related bloodstream infection was recorded, in group A. However, the costs related to central venous access device insertion were quite different: €330-€540 in group A versus €105-€135 in group B. CONCLUSION: In the pediatric patient candidate to a major neurosurgical operation, preoperative insertion of the central venous access device in the sedation room rather than in the operating room is less expensive and equally safe.

Preprocedural ultrasound vascular assessment is essential to decision-making.

Reliable venous access should be part of the clinical-therapeutic path of all cancer patients. A correct preliminary ultrasound evaluation of the patient's veins and the choice of the suitable vein are the fundamental requirements to guarantee a stable and long-lasting venous access.

Are single-lumen 5Fr and triple-lumen 6Fr PICCs suitable for hemodynamic assessment by trans-pulmonary thermodilution? A pilot study.

BACKGROUND: Single-lumen 4Fr or double-lumen 5Fr power injectable peripherally inserted central catheters (PICCs) are not accurate for trans-pulmonary thermodilution (TPTD), since they overestimate cardiac index and other TPTD-derived parameters when compared with centrally inserted central catheters (CICCs) because of the smaller size of their lumen. We hypothesize that PICCs with larger lumen size may be reliable for the cardiac index assessment using the TPTD. METHODS: This is a single-centre, prospective method-comparison study that included adult patients admitted in ICU who required a calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000™) for circulatory shock and had both PICC and CICC in place. We compared TPTD measurements via single-lumen 5Fr or triple-lumen 6Fr polyurethane power injectable PICCs with triple-lumen 7Fr CICC (reference standard). To rule out biases related to manual injection, measurements were repeated using an automated rapid injection system. We performed Bland-Altman analysis accounting for multiple observations per patient. RESULTS: A total of 320 measurements were performed in 15 patients. During the manual phase, the cardiac index measured with either single-lumen 5Fr or triple-lumen 6Fr PICCs were comparable with cardiac index measured with triple-lumen 7Fr CICC (3.2 ± 1.04 vs. 3.2 ± 1.06 L/min/m2, bias 2.2% and 3.3 ± 0.8 vs. 3.0 ± 0.7 L/min/m2, bias 8.5%, respectively). During the automated phase, triple-lumen 6Fr PICC slightly overestimated the cardiac index when compared to triple-lumen 7Fr CICC (CI 3.4 ± 0.7 vs. 3.0 ± 0.7 L/min/m2, bias 12.5%; p = 0.012). For both single-lumen 5Fr and triple-lumen 6Fr PICCs, percentage error vs. triple-lumen 7Fr CICC was below 20% (14.7% and 19% during the manual phase and 14.4% and 13.8% during the automated phase, respectively). Similar results were observed for TPTD-derived parameters. CONCLUSIONS: During hemodynamic monitoring with TPTD, both single-lumen 5Fr PICCs and triple-lumen 6Fr PICCs can be used for cold fluid bolus injection as an alternative to CICC (ClinicalTrials.gov NCT04241926).

Are Peripherally Inserted Central Catheters Suitable for Cardiac Output Assessment With Transpulmonary Thermodilution?

OBJECTIVES: Peripherally inserted central catheters are increasingly used in ICU as an alternative to centrally inserted central catheters for IV infusion. However, their reliability for hemodynamic measurements with transpulmonary thermodilution is currently unknown. We investigated the agreement between transpulmonary thermodilution measurements obtained with bolus injection through peripherally inserted central catheter and centrally inserted central catheter (reference standard) using a transpulmonary thermodilution-calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000). DESIGN: Prospective method-comparison study. SETTING: Twenty-bed medical-surgical ICU of a teaching hospital. PATIENTS: Twenty adult ICU patients who required hemodynamic monitoring because of hemodynamic instability and had both peripherally inserted central catheter and centrally inserted central catheter in place. INTERVENTION: The hemodynamic measurements obtained by transpulmonary thermodilution after injection of a cold saline bolus via both centrally inserted central catheter and either a single-lumen 4F or a double-lumen 5F peripherally inserted central catheter using were compared. In order to rule out bias related to manual injection, measurements were repeated using an automated rapid injection system. MEASUREMENTS AND MAIN RESULTS: A total of 320 measurements were made. Cardiac index was significantly higher when measured with double-lumen 5F peripherally inserted central catheter than with centrally inserted central catheter (mean, 4.5 vs 3.3 L/min/m; p < 0.0001; bias, 1.24 L/min/m [0.27, 2.22 L/min/m]; bias percentage, 31%). Global end-diastolic index, extravascular lung water index, and stroke volume index were also overestimated (853 ± 240 vs 688 ± 175 mL/m, 12.2 ± 4.2 vs 9.4 ± 2.9 mL/kg, and 49.6 ± 14.9 vs 39.5 ± 9.6 mL/m, respectively; p < 0.0001). Lower, albeit significant differences were found using single-lumen 4F peripherally inserted central catheter (mean cardiac index, 4.2 vs 3.7 L/min/m; p = 0.043; bias, 0.51 L/min/m [-0.53, 1.55 L/min/m]; bias percentage, 12.7%). All differences were confirmed, even after standardization of bolus speed with automated injection. CONCLUSIONS: Bolus injection through peripherally inserted central catheter for transpulmonary thermodilution using EV1000 led to a significant overestimation of cardiac index, global end-diastolic index, extravascular lung water index, and stroke volume index, especially when double-lumen 5F peripherally inserted central catheter was used (ClinicalTrial.gov NCT03834675).

Clinical experience of a subcutaneously anchored sutureless system for securing central venous catheters.

This article reports the results of three prospective clinical studies conducted in a university hospital regarding the efficacy, safety and cost effectiveness of a subcutaneously anchored sutureless system for securing central venous catheters. The results were favourable to the adoption of such a device, and the analysis of the data allowed the authors to define those categories of patients where the device should have the most benefit: neonates, children, non-compliant older patients with cognitive difficulties, patients with skin abnormalities that may reduce the effectiveness of a skin-adhesive sutureless securement system, patients who are candidates for having a peripherally inserted central catheter (PICC) in place for more than 8 weeks, and any other category of patients with a recognised high risk of catheter dislodgement.

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.

Ultrasound assessment of rectus femoris and anterior tibialis muscles in young trauma patients.

PURPOSE: Quantitative and qualitative changes of skeletal muscle are typical and early findings in trauma patients, being possibly associated with functional impairment. Early assessment of muscle changes-as evaluated by muscle ultrasonography-could yield important information about patient's outcome. METHODS: In this prospective observational study, we used ultrasonography to evaluate the morphological changes of rectus femoris (RF) and anterior tibialis (AT) muscles in a group of young, previously healthy trauma patients on enteral feeding. RESULTS: We studied 38 severely injured patients (median Injury Severity Score = 34; median age = 40 y.o.) over the course of the ICU stay up to 3 weeks after trauma. We found a progressive loss of muscle mass from day 0 to day 20, that was more relevant for the RF (45%) than for the AT (22%); this was accompanied by an increase in echogenicity (up to 2.5 by the Heckmatt Scale, where normal echogenicity = 1), which is an indicator of myofibers depletion. CONCLUSIONS: Ultrasound evaluation of skeletal muscles is inexpensive, noninvasive, simple and easily repeatable. By this method, we were able to quantify the morphological changes of skeletal muscle in trauma patients. Further studies may rely on this technicque to evaluate the impact of different therapeutic strategies on muscle wasting.

International evidence-based recommendations on ultrasound-guided vascular access.

PURPOSE: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. METHODS: An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. RESULTS: The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter's tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. CONCLUSIONS: These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.