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.

The SIECC protocol: A novel insertion bundle to minimize the complications related to epicutaneo-cava catheters in neonates.

Epicutaneo-cava catheters are the most widely used central venous catheters in the neonate, but their insertion and management are potentially associated with several complications, both during placement (failure to proceed with the catheter, primary malposition, etc.) and during maintenance (infection, venous thrombosis, catheter dislocation, secondary malposition, etc.). Recent studies have identified methods and techniques that may be effective in minimizing the risk of most of these complications. This paper proposes a structured, sequential insertion bundle-nicknamed "the SIECC protocol" (SIECC = Safe Insertion of Epicutaneo-Cava Catheters)-which includes seven evidence-based strategies which have been proven to increase the safety, effectiveness, and cost-effectiveness of the procedure.

A novel neonatal protocol for Safe Insertion of Umbilical Venous Catheters (SIUVeC): Minimizing complications in placement and management.

Insertion of umbilical venous catheters is a common procedure in neonatal intensive care. Though sometimes lifesaving, this maneuver is potentially associated with early and late complications, some of which may be severe and even life threatening (catheter malposition, hepatic lesions, venous thrombosis, pericardial effusion, etc.). The recent literature suggests several operative strategies that, if adopted systematically, may significantly reduce the incidence of both early and late catheter related complications. This paper describes a standardized protocol (Safe Insertion Umbilical Venous Catheter = SIUVeC) which incorporates such novel strategies, with the goal of minimizing the complications related to this procedure.

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.

Optical detection of infiltration during peripheral intravenous infusion in neonates.

BACKGROUND: Infiltration and extravasation are common complications during peripheral intravenous infusion in the neonatal intensive care unit, and diagnosis is usually clinical, by inspection and palpation. Delay in diagnosis due to poor surveillance or misinterpretation of clinical signs may carry serious damage to the tissues of the neonate. Recently, a novel technology based on optical detection of infiltration has become available. METHODS: We have studied two groups of term and preterm infants receiving non-vesicant intravenous infusions by the peripheral route (24G short peripheral cannulas), and we evaluated the incidence of infiltration. In the first group, we have compared the clinical detection of infiltration versus the detection obtained by a novel optical device, blinding the alarms of the device. In the second group, the comparison was carried out without blinding the alarms. RESULTS: Of the neonates included in this study, 60% were female, 86% had a gestational age <37 weeks (34 ± 2.5 weeks) and a mean birth weight of 2.08 ± 0.4 g. Total recorded monitoring time was 1318 h and average monitoring time for each short peripheral cannula was 26.4 h. The incidence of infiltration was 80%, most of them having a Millam score <2. The novel device showed an overall sensitivity of 88.9% in detecting infiltration. Specificity was 84.4%, as evaluated assuming as standard the clinical diagnosis. Interestingly, in cases of documented infiltration, the event was diagnosed by the optical device approximately 6 h before the clinical diagnosis. CONCLUSIONS: Continuous monitoring of the insertion site, as automatically ensured by this novel optical device, may play a complementary role in early detection of infiltration, even if the percentage of false positives and false negatives suggests that periodic clinical assessment by expert nurses cannot be omitted.

Safe Insertion of Arterial Catheters (SIA): An ultrasound-guided protocol to minimize complications for arterial cannulation.

Direct puncture and cannulation of peripheral arteries is frequently performed in critical care and in emergency settings, mainly for hemodynamic monitoring and blood sampling. While there is abundant literature on peripheral arterial cannulation in children and adults, there is still scope for clinical improvements which may impact on patient safety. Although the radial artery is the most frequently utilized access site today, due to its superficial proximity, ease of access, and low risk of adverse events, other sites are sometimes chosen. The authors propose the Safe Insertion of Arterial Catheters (SIA) protocol, an ultrasound-guided insertion bundle applying a systematic approach to arterial cannulation, with a focus on improving insertion practices, reducing procedural complications, increasing the patient safety profile, and improving device performance.

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.

The neonatal DAV-expert algorithm: a GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access in newborns.

In most NICUs, the choice of the venous access device currently relies upon the operator's experience and preferences. However, considering the high failure rate of vascular devices in the neonatal population, such clinical choice has a 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 in line with the current scientific evidence. 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 the neonatal population. After a systematic review of the available evidence, the panel of the consensus (which included Italian neonatologists specifically experts in this area) has provided structured recommendations answering four sets of questions regarding (1) umbilical venous catheters, (2) peripheral cannulas, (3) epicutaneo-cava catheters, and (4) ultrasound-guided centrally and femorally inserted central catheters. 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.  Conclusion: The goal of the present consensus is to offer a systematic set of recommendations on the choice of the most appropriate vascular access device in Neonatal Intensive Care Unit.

Complications associated with the use of peripherally inserted central catheters and midline catheters in COVID-19 patients: An observational prospective study.

BACKGROUND: Among the many interesting aspects of clinical care during the SARS-CoV-2 pandemic, vascular access still deserves some attention. Peripherally inserted central catheters (PICCs) and midline catheters (MCs) are venous access devices inserted by ultrasound-guided puncture of veins of the arm, which have been associated with the possibility of minimizing infectious complications in different populations of patients. We have investigated their performance in SARS-CoV-2 patients. METHODS: As the incidence of catheter-related bloodstream infections (CRBSI) in patients hospitalized for COVID-19 is still unclear, we have designed a single-center, prospective observational study enrolling all patients with established diagnosis of SARS-CoV-2 infection who were admitted to our hospital in the period between October 2020 and April 2021 and who required either a PICC or a MC. RESULTS: We recruited 227 patients. The cumulative incidence of CRBSI was 4.35% (10 cases), that is, 3.5 episodes/1,000 catheter days. Four CRBSI occurred in patients with PICCs (4.5/1,000 catheter days) and 6 in those with MCs (3.2/1,000 catheter days). CONCLUSIONS: Our data suggest that COVID-19 patients may have a more pronounced tendency for the development of catheter-related infections compared to other populations of patients.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs). STUDY DESIGN: This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis. RESULTS: In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%). CONCLUSIONS: In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments. TRIAL REGISTRATION: UMIN-CTR Clinical Trial; Registration number: R000045844.

Successful stem cell collection for atypical teratoid rhabdoid tumor in an extremely low-body weight child: A case report.

The use of peripheral blood hematopoietic stem cells for bone marrow reconstitution after myeloablative therapy is well established in children with malignant disorders. However, the peripheral blood hematopoietic stem cells collection in very low-body weight (≤10 kg) children remains a significant challenge because of technical and clinical issues. A male newborn affected by atypical teratoid rhabdoid tumor, diagnosed prenatally, received two cycles of chemotherapy following surgical resection. After an interdisciplinary discussion, it was decided to intensify the treatment with high-dose chemotherapy followed by autologous stem cell transplantation. After 7 days of G-CSF administration the patient underwent hematopoietic progenitor cells-apheresis collection. The procedure was performed in the pediatric intensive care unit, using two central venous catheters and Spectra Optia device. The cell collection procedure was completed in 200 min, during which time 3.9 total blood volumes were processed. During apheresis we did not observe electrolyte alterations. No adverse events were recorded during or immediately following the cell collection procedure. Our report describes the feasibility of performing large volume leukapheresis without complications in an extremely low-body weight patient weighing 4.5 kg using the Spectra Optia apheresis device. No catheter-related problems occurred, and apheresis was completed without any adverse event. In conclusion, we believe that very low-body weight pediatric patients need a multidisciplinary approach to manage central venous access, hemodynamic monitoring, cell collection, prevention of metabolic complications to improve safety, feasibility, and efficiency of stem cell collection procedures.

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.

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.

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.

ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients.

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.