Choice and management of vascular access in the context of COVID-19 outbreak in Italy: Recommendations from clinical practice.

On April 2020, during the outburst of the COVID-19 pandemic in Italy, the SIAARTI ("Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva") Research Group on Vascular Access has formulated some essential recommendations for the optimization of the selection, insertion, and maintenance of the vascular access devices, with the aim of guarantee the operator safety, ensure the effectiveness of the maneuvers, and reduce the risk of complications. Here we describe the key elements of clinical management of vascular access in patients affected by COVID-19.

Retrospective survey from vascular access team Lombardy net in COVID-19 era.

BACKGROUND: Venous Access Devices (VADs) are the most used devices in COVID-19 patients. OBJECTIVE: Identify VADs implanted, catheter related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and accidental remove of VADs in both COVID-19 positive and COVID-19 free patients. Successive analysis was conducted comparing COVID-19 positive patients with COVID-19 free with inverse probability propensity score weights using simple regression to account for these two confounders (peripheral tip as central/peripheral and hospitalization as no/yes). METHODS: This multicenter, retrospective cohort study collected data from seven hospitals in Lombardy during the pandemic period from February 21st to May 31st 2020. RESULTS: A total of 2206 VADs were evaluated, 1107 (50.2%) of which were inserted in COVID-19 patients. In COVID-19 cohort the first choice was Long Peripheral Cannula in 388 patients (35.1%) followed by Midline Catheter in 385 (34.8%). The number of "central tip" VADs inserted in COVID-free inpatients and COVID-19 positive were similar (307 vs 334). We recorded 42 (1.9%) CRT; 32 (79.2%) were observed in COVID-19 patients. A total of 19 CRBSI were diagnosed; 15 (78.95%) were observed in COVID-19. Accidental removals were the more represented complication with 123 cases, 85 (69.1%) of them were in COVID-19. COVID-19 significantly predicted occurrence of CRT (OR = 2.00(1.85-5.03); p < 0.001), CRSB (OR = 3.82(1.82-8.97); p < 0.001), and Accidental Removal (OR = 2.39(1.80-3.20); p < 0.001) in our propensity score weighted models. CONCLUSIONS: CRT, CRBSI, and accidental removal are significantly more frequent in COVID-19 patients. Accidental removals are the principal complication, for this reason, the use of subcutaneously anchored securement is recommended for a shorter period than usual.

Axillary vein thrombosis in COVID positive patient with midline and continuous positive airway pressure Helmet.

We describe the case of a coronavirus disease patient with midline who, during ventilation with continuous positive airway pressure helmet with underarm fastening straps, presented thrombosis of the axillary vein in the armpit. The tip of the midline ended in the armpit. The thrombosis has been resolved with anticoagulant therapy with low molecular weight heparin of 100 IU/kg bid without giving pulmonary embolism. In an emergency context like this, the need to resort to ventilation strategies even in departments generally not accustomed to the use of these devices and to the management of this type of patients, the need to use and adapt the available material (e.g. being unable to renounce to use underarm fastening straps) obliges us to consider the use of alternative strategies also in the field of vascular access. After this case, we began to consider techniques that allow us to prevent the catheter from ending in the armpit, with benefit. It is essential to continue to observe this patient.

European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia.

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access).

: Ultrasound for diagnostic and procedural purposes is becoming a standard in daily clinical practice including anaesthesiology and peri-operative medicine. The project of European Society of Anaesthesiology (ESA) Task Force for the development of clinical guidelines on the PERioperative uSE of Ultra-Sound (PERSEUS) project has focused on the use of ultrasound in two areas that account for the majority of procedures performed routinely in the operating room: vascular access and regional anaesthesia. Given the extensive literature available in these two areas, this paper will focus on the use of ultrasound-guidance for vascular access. A second part will be dedicated to peripheral nerve/neuraxial blocks. The Taskforce identified three main domains of application in ultrasound-guided vascular cannulation: adults, children and training. The literature search were performed by a professional librarian from the Cochrane Anaesthesia and Critical and Emergency Care Group in collaboration with the ESA Taskforce. The Grading of Recommendation Assessment (GRADE) system for assessing levels of evidence and grade of recommendations were used. For the use of ultrasound-guided cannulation of the internal jugular vein, femoral vein and arterial access, the level evidence was classified 1B. For other accesses, the evidence remains limited. For training in ultrasound guidance, there were no studies. The importance of proper training for achieving competency and full proficiency before performing any ultrasound-guided vascular procedure must be emphasised.

Dynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note.

The relevance of the cerebral venous system is often underestimated during neurosurgical procedures. Damage to this draining system can have catastrophic implications for the patient. Surgical decision-making and planning must consider each component of the venous compartment, from the medullary draining vein to the dural sinuses and extracranial veins. Intraoperative ultrasound (ioUS) permits the real-time study of venous compartments using different modalities, thus allowing complete characterization of their anatomical and functional features. The B-mode (brightness mode) offers a high-resolution anatomical representation of veins and their relationships with lesions. Doppler modalities (color, power, spectral) allow the study of blood flow and identification of vessels to distinguish their functional characteristics. Contrast-enhanced US allows one to perform real-time angiosonography showing both the functional and the anatomical aspects of vessels. In this technical report, the authors demonstrate the different applications of multimodal ioUS in neurosurgery for identifying the anatomical and functional characteristics of the venous compartment. They discuss the general principles and technical nuances of ioUS and analyze their potential implications for the study of various venous districts during neurosurgical procedures.

Intraoperative neurophysiological monitoring of the cortico-spinal tract in image-guided mini-invasive neurosurgery.

OBJECTIVE: To evaluate the role of intraoperative neurophysiological monitoring in image-guided mini-invasive neurosurgery. METHODS: Twenty-one patients were operated under general anaesthesia with the aid of multimodal intraoperative neurophysiological monitoring to remove supratentorials tumors closely related to the cortico-spinal tract. Pre-operative assessment included fMRI scans and tractography that were uploaded into the intraoperative neuro-navigation system. Monitoring consisted in simultaneously recording EEG, electrocorticography, transcranial and direct motor evoked potentials (tMEP and dMEP), somatosensory evoked potentials and subcortical stimulation during the whole procedures. RESULTS: The recording of all the electrophysiological signals was possible in all procedures. SSEP guided the positioning of the strip electrode over the motor cortex (N20 phase inversion) that was used to evoke dMEP and monitor the lower limb motor responses; subcortical stimulation to unveil the spatial relationship between the tumors and motor fibers. Four patients had transient worsening of the symptoms, but only two had a long-term worsening, although not severe, of the pre-op clinical status. CONCLUSIONS: Intraoperative neurophysiology has a great value in mini-invasive neurosurgery, especially because the motor cortex is not exposed, consequently it cannot be directly mapped. This report describes a valuable scheme making use of as many electrophysiological signals as possible to constantly monitor the motor functions. SIGNIFICANCE: A useful method to monitor motor functions in mini-invasive neurosurgery was described.

Risk of seizures during intraoperative electrocortical stimulation of brain motor areas: a retrospective study on 50 patients.

Tumours close to cerebral cortices involved in motor and language functions represent a major challenge for neurosurgeons. Intraoperative neurophysiologic monitoring is useful to gain insight into the anatomy of and the relationship between pathological and normal tissues. In this study we report on the experience of electrocortical stimulation in the surgery of tumours adjacent to the motor cortex in 50 patients under general anaesthesia (26 under propofol, 24 under sevoflurane), and on EMG responses from contralateral muscles. In 18 patients stimulation evoked seizures, which were controlled only with antiepileptic drugs (36%). No difference was found in the incidence of intra-operative seizures between the patients with (10 out of 27) or without (8 out of 23) pre-operative epilepsy (p = 0.8685). The majority of the patients (13 out of 18) with intraoperative seizures were under sevoflurane (p = 0.01) and there was a statistically significant difference in the mean electrical intensity used between the two groups, sevoflurane and propofol, respectively 5.3 ± 1.3 mA and 3.6 ± 2 mA (p = 0.03). Regarding pre-operative anti-epileptic drugs, the use of levitiracetam was associated with a high incidence of intraoperative seizure (5 out of 6 patients). 4 patients developed new, unwanted, permanent neurological deficits, of which 2 had intraoperative seizures controlled only with antiepileptic drugs. Electrocortical stimulation is a powerful tool to understand the functional organization of patients' eloquent areas. Intraoperative epileptic seizures may represent an unwanted complication preventing further stimulation and possibly worsening neurological results. The choice of anaesthetics according to the patients' characteristics, pre-op symptoms and medical therapy is pivotal.

An ultrasound study of cerebral venous drainage after internal jugular vein catheterization.

Objectives. It has been advocated that internal jugular vein (IJV) cannulation in patients at risk for intracranial hypertension could impair cerebral venous return. Aim of this study was to demonstrate that ultrasound-guided IJV cannulation in elective neurosurgical patients is safe and does not impair cerebral venous return. Methods. IJV cross-sectional diameter and flow were measured using two-dimensional ultrasound and Doppler function bilaterally before and after IJV cannulation with the head supine and elevated at 30°. Results. Fifty patients with intracranial lesions at risk for intracranial hypertension were enrolled in this observational prospective study. IJV diameters before and after ultrasound-guided cannulation were not statistically different during supine or head-up position and the absolute variation of the venous flow revealed an average reduction of the venous flow after cannulation without a significant reduction of the venous flow rate after cannulation. Conclusions. Ultrasound-guided IJV cannulation in neurosurgical patients at risk for intracranial hypertension does not impair significantly jugular venous flow and indirectly cerebral venous return.

Is a neutral head position safer than 45-degree neck rotation during ultrasound-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial.

BACKGROUND: The optimal degree of neck rotation during internal jugular vein (IJV) cannulation remains undetermined because previous studies suggested using sonography, but without puncturing the vein. We assessed whether a neutral position (NP) of the head (0 degrees) during ultrasound-guided cannulation of the IJV was safer than rotating the neck to 45 degrees head turned. The effect of these 2 positions during ultrasound-guided cannulation on major complications was the primary outcome. Overall complications, venous access time, and perception of difficulty during the procedure were also evaluated. METHODS: A prospective, randomized, controlled, nonblinded study was conducted in a tertiary neurosurgical hospital. Patients undergoing major elective neurosurgical procedures requiring a central venous line were randomly allocated to 2 groups; ultrasound-guided cannulation of the IJV was then performed using an out-of-plane orientation. RESULTS: One thousand four hundred twenty-four patients were evaluated, but 92 were excluded; 670 were allocated to the head turned group and 662 to the NP group. Cannulation was 100% successful. Demographic data were similar in the 2 groups except for IJV positions. There were only 10 major complications: 6 in the 0-degree NP group and 4 in the 45-degree head turned group. The frequency of these complications was not different between the 2 groups. The overall complication rate was 13%, and was higher in women, in patients with ASA physical status ≥II, and in patients with a smaller diameter vein, or when the vein was located deeper and lateral or in the anterolateral position. An increased venous access time was associated with an increased rate of overall complications. The perception of difficulty performing the procedure with the head placed in the 2 positions was not statistically different in either group. CONCLUSION: A head NP was as safe as a 45-degree neck rotation during ultrasound-guided IJV cannulation with regard to both major and minor complications, and venous access time was similar. Ultrasound guidance helps determine optimal head rotation for IJV cannulation.

Ventajas de la utilización de la ecografía como guía para la colocación de accesos vasculares en pediatría / Advantages of applying ultrasound as guidance for central vascular access in pediatric care

Está demostrado que la guía por ecografía para los accesos vasculares incrementa la seguridad y la eficacia durante el cateterismo venoso central en los adultos. Se han informado resultados similares en la población pediátrica para la canalización de la vena yugular interna, pero se dispone de escasos datos sobre el uso de esta tecnología para la canalización de las venas subclavia y femoral. Los metanálisis actuales no han favorecido la utilización de puntos de referencia de superficie en relación con la canalización guiada por ecografía. La guía por ultrasonografía incrementa la tasa de resultados positivos en el primer intento, reduce las complicaciones y es rentable. El acceso venoso central más difundido en pacientes pediátricos es la vena yugular interna, pero pueden utilizarse las venas subclavia, braquiocefálica y femoral. Se necesita un abordaje metodológico de esta técnica y un extenso entrenamiento en ecografía para la realización de este procedimiento en pacientes pediátricos.