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1.
J Vasc Access ; : 11297298241262932, 2024 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-39097780

RESUMO

Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions).

2.
J Vasc Access ; 23(1): 18-23, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33198573

RESUMO

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.


Assuntos
COVID-19 , Humanos , Itália/epidemiologia , Pandemias , SARS-CoV-2
4.
J Vasc Access ; 22(5): 716-725, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32613887

RESUMO

BACKGROUND: Subcutaneously anchored securement devices (or subcutaneous engineered securement devices) have been introduced recently into the clinical practice, but the number of published studies is still scarce. The Italian Group of Long-Term Central Venous Access Devices (GAVeCeLT)-in collaboration with WoCoVA (World Congress on Vascular Access)-has developed a Consensus about the effectiveness, safety, and cost-effectiveness of such devices. METHODS: After the definition of a panel of experts, a systematic collection and review of the literature on subcutaneously anchored securement devices was performed. The panel has been divided in two working groups, one focusing on adult patients and the other on children and neonates. RESULTS: Although the quality of evidence is generally poor, since it is based mainly on non-controlled prospective studies, the panel has concluded that subcutaneously anchored securement devices are overall effective in reducing the risk of dislodgment and they appear to be safe in all categories of patients, being associated only with rare and negligible local adverse effects; cost-effectiveness is demonstrated-or highly likely-in specific populations of patients with long-term venous access and/or at high risk of dislodgment. CONCLUSION: Subcutaneously anchored securement is a very promising strategy for avoiding dislodgment. Further studies are warranted, in particular for the purpose of defining (a) the best management of the anchoring device so to avoid local problems, (b) the patient populations in which it may be considered highly cost-effective and even mandatory, (c) the possible benefit in terms of reduction of other catheter-related complications such as venous thrombosis and/or infection, and-last but not least-(d) their impact on the workload and stress level of nurses taking care of the devices.


Assuntos
Cateterismo Venoso Central , Cateterismo Periférico , Cateteres Venosos Centrais , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Criança , Consenso , Humanos , Recém-Nascido , Estudos Prospectivos
5.
J Cardiothorac Vasc Anesth ; 35(8): 2297-2302, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33039288

RESUMO

OBJECTIVES: Video-assisted thoracoscopy surgery-lobectomy is less invasive than conventional thoracotomy and is associated with fewer complications. However, the pain related is classified as moderate and requires adequate treatment. Ultrasound-guided serratus anterior plane block (SAPB) provides analgesia by blocking the lateral branches of the intercostal nerves, avoiding the complications of epidural analgesia and paravertebral block. The aim of the present study was to evaluate the efficacy and safety of the SAPB compared with the intercostal nerve block (ICNB). DESIGN: This was a non-randomized prospective study, in which surgery-lobectomy pain after video-assisted thoracoscopy was treated with the following multimodal approach: SAPB or ICNB, morphine-patient controlled analgesia, and paracetamol. SETTING: The study was undertaken in a single community hospital. PARTICIPANTS: The study comprised 40 patients. INTERVENTIONS: Execution of ultrasound-guided SAPB. MEASUREMENTS AND MAIN RESULTS: Nineteen (47.5%) men and 21 (52.5%) women were enrolled, and the mean age was 67.22 ± 11 years. Both groups showed any visual analog scale values >4, which was significantly lower in the SAPB group at the 6th hour and at the 12th and 24th hours only during coughing (p < 0.05). The sedation score was significantly lower in the ICNB group at 0 and at the 2nd and 4th hours; it was lower in the SAPB group at the 6th hour. All patients had a sedation score <1, and they all were awake and oriented. After 24 hours, the total morphine requirement was 19.3 ± 14.4 mg and 11.3 ± 8.5 mg (p = 0.038); after 48 hours, it was 12.2 ± 7.9 mg and 8.2 ± 5.8 mg in the ICNB and SAPB groups, respectively. CONCLUSIONS: The multimodal approach of SAPB, morphine-patient controlled analgesia, and paracetamol is effective, safe, and time efficient.


Assuntos
Nervos Intercostais , Parede Torácica , Idoso , Feminino , Humanos , Nervos Intercostais/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , Toracoscopia
6.
J Vasc Access ; 21(6): 861-867, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32126882

RESUMO

INTRODUCTION: Transthoracic echocardiography with bubble test is an accurate, reproducible, and safe technique to verify the location of the tip of the central venous catheter. The aim of this study is to confirm the effectiveness of this method for tip location in patients with atrial arrhythmia. METHODS: Transthoracic echocardiography with bubble test was adopted as a method of tip location in patients with atrial arrhythmia requiring central venous catheter. If bubbles were evident in the right atrium in less than 2 s after simple saline injection, tip placement was assumed as correct. In cases of uncertain visualization of the bubble effect, the test was repeated injecting a saline-air mixture. Tip location was also assessed by post-procedural chest X-ray. RESULTS: In 42 patients with no evident P-wave at the electrocardiography, we placed 34 centrally inserted central catheters and 8 peripherally inserted central catheters. Transthoracic echocardiography with bubble test detected two centrally inserted central catheter malpositions. In four patients with peripherally inserted central catheter, transthoracic echocardiography with bubble test was positive only when repeated with the saline-air mixture. When the transthoracic echocardiography was positive, the mean (±standard deviation) time for onset of the bubble effect was 0.89 ± 0.33 s in patients with centrally inserted central catheter and 1.1 ± 0.20 s in those with peripherally inserted central catheter; such time difference was not statistically significant (p > 0.05). CONCLUSION: Tip location of central venous catheter by transthoracic echocardiography with bubble test is feasible, safe, and accurate in patients with atrial arrhythmia. This method can also be applied in peripherally inserted central catheters; however, further studies may be needed to confirm its use in this type of catheters.


Assuntos
Arritmias Cardíacas/complicações , Cateterismo Venoso Central/instrumentação , Cateteres de Demora , Cateteres Venosos Centrais , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos
8.
J Vasc Access ; 16(5): 394-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26109544

RESUMO

PURPOSE: The purpose of this study is to verify as early as possible the correct positioning of the peripherally inserted central catheter (PICC) tip in order to reduce complications due to possible malpositioning. The ECG-guided technique proved to be reliable, easy to carry out, straightforward, low-cost and allows us to recognize an incorrect or a suboptimal positioning throughout the procedure. The purpose of this study is to compare two methods used during the PICC insertion so as to prevent catheter malpositioning; the first study estimates the catheter length by the landmark method (based on cutaneous anatomical landmarks, CALs) with the addition of the postprocedural verification of tip location by chest X-Ray (CxR), whereas the second method of intraprocedural tip location is based on the observation of the morphological variations of the P wave (ECG-guided technique) with the addition of the postprocedural verification by CxR. METHODS: From 2010 to 2012, 90 PICCs were positioned, 48 using the anatomical landmarks and 42 using the ECG technique. RESULTS: Twenty-five percent of the catheters positioned with the anatomical landmark technique did not reach the correct position of the tip in SVC; of these, 6.25% were placed in an aberrant position and others in a sub-optimal position.Of the 42 PICCs positioned with the ECG technique, only in three cases (equal to 7.14%), a suboptimal position of the tip was observed, whereas there was no case of aberrant positioning. CONCLUSIONS: The ECG technique represents an accurate, low-cost and safe technique to verify the correct positioning of the tip. The use of the ECG allowed a more correct positioning in terms of catheter tip-carina distance and catheter tip-tracheobronchial angle, and in no patient was it necessary to place a catheter again.


Assuntos
Pontos de Referência Anatômicos , Função Atrial , Cateterismo Venoso Central/instrumentação , Cateterismo Periférico/instrumentação , Cateteres Venosos Centrais , Eletrocardiografia , Potenciais de Ação , Adulto , Idoso , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Punções
9.
J Vasc Access ; 16(2): 137-43, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25198817

RESUMO

PURPOSE: The Italian Group for Venous Access Devices (GAVeCeLT) has carried out a multicenter study investigating the safety and accuracy of intracavitary electrocardiography (IC-ECG) in pediatric patients. METHODS: We enrolled 309 patients (age 1 month-18 years) candidate to different central venous access devices (VAD) - 56 peripherally inserted central catheters (PICC), 178 short term centrally inserted central catheters (CICC), 65 long term VADs, 10 VADs for dialysis - in five Italian Hospitals. Three age groups were considered: A (<4 years, n = 157), B (4-11 years, n = 119), and C (12-18 years, n = 31). IC-ECG was applicable in 307 cases. The increase of the P wave on IC-ECG was detected in all cases but two. The tip of the catheter was positioned at the cavo-atrial junction (CAJ) (i.e., at the maximal height of the P wave on IC-ECG) and the position was checked during the procedure by fluoroscopy or chest x-ray, considering the CAJ at 1-2 cm (group A), 1.5-3 cm (group B), or 2-4 cm (group C) below the carina. RESULTS: There were no complications related to IC-ECG. The overall match between IC-ECG and x-ray was 95.8% (96.2% in group A, 95% in group B, and 96.8% in group C). In 95 cases, the IC-ECG was performed with a dedicated ECG monitor, specifically designed for IC-ECG (Nautilus, Romedex): in this group, the match between IC-ECG and x-ray was 98.8%. CONCLUSIONS: We conclude that the IC-ECG method is safe and accurate in the pediatric patients. The applicability of the method is 99.4% and its feasibility is 99.4%. The accuracy is 95.8% and even higher (98.8%) when using a dedicated ECG monitor.


Assuntos
Cateterismo Venoso Central/métodos , Cateteres Venosos Centrais/efeitos adversos , Eletrocardiografia/métodos , Adolescente , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Criança , Pré-Escolar , Desenho de Equipamento , Estudos de Viabilidade , Humanos , Lactente , Itália , Posicionamento do Paciente , Estudos Prospectivos , Diálise Renal/instrumentação
10.
J Vasc Access ; 13(3): 393-6, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22388970

RESUMO

BACKGROUND: Intra-cavitary electrocardiography (ECG) is a well-known method for correct positioning of the tip of central venous catheters (CVC). A significant increase in the P wave, as registered by the intra-cavitary electrode, signals the entrance of the catheter into the right atrium. METHODS: In this prospective observational study, 155 consecutive oncologic patients were enrolled for cannulation of the right or left internal jugular vein for insertion of a tunneled Groshong catheter. In 150 patients the tip was positioned by means of intracavitary ECG. Five patients with atrial fibrillation (N=4) or pacemaker in place (N=1) were excluded from the study. As the P-wave amplitude began to increase, the catheter was secured in that position and the insertion depth was registered. RESULTS: Intra-cavitary ECG was always apt to detect the increase in the P wave. On the post-operative chest x-ray all Groshong catheters except two were in the correct position. CONCLUSIONS: The need for chest x-ray or fluoroscopy may be virtually eliminated by using the ECG technique.


Assuntos
Antineoplásicos/administração & dosagem , Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Cateteres de Demora , Cateteres Venosos Centrais , Eletrocardiografia , Veias Jugulares , Idoso , Desenho de Equipamento , Feminino , Humanos , Veias Jugulares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Radiografia
12.
J Vasc Access ; 13(3): 357-65, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22328361

RESUMO

PURPOSE: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. METHODS: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. RESULTS: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position. CONCLUSIONS: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.


Assuntos
Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Cateteres de Demora , Cateteres Venosos Centrais , Eletrocardiografia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/efeitos adversos , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Flebografia , Valor Preditivo dos Testes , Resultado do Tratamento , Adulto Jovem
14.
Reg Anesth Pain Med ; 31(6): 563-8, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-17138200

RESUMO

BACKGROUND AND OBJECTIVES: A variety of brachial plexus block techniques via the interscalene approach have been proposed. We describe here a new middle interscalene perivascular approach to the brachial plexus. To verify its effectiveness, we studied 719 patients scheduled for shoulder arthroscopy. Furthermore, to verify the accuracy of the proposed bony landmarks to use in the case of inability to palpate the subclavian artery pulse, we simulated the block on 10 cadavers. METHODS: The aim of our technique is to cannulate the neurovascular bundle by inserting a 35-mm needle lateral to the subclavian arterial pulse near the midpoint of the upper edge of the clavicle in a horizontal or slightly cephalad direction while pointing toward the seventh cervical vertebra. If the pulse of the subclavian artery is not palpable, we localize the direction of the needle with reference to 3 bony landmarks (the middle point of the clavicle, the spinous process of C7, and the sternoclavicular joint). By connecting these 3 landmarks, we obtain an angle whose apex lies at the midpoint of the clavicle and its bisecting line points to the plexus. The needle is introduced in the transverse plane of C7. RESULTS: The block was performed successfully in 692 of 719 cases (96.2%). Horner's syndrome occurred in 93.5% of the cases, arterial puncture with hematoma occurred in <1%, phrenic nerve block without respiratory impairment in 60%, with transient respiratory failure in <1%, and laryngeal nerve block in <1%. The incidence of severe complications or permanent injuries was zero (upper limit 95% confidence interval = 0.4% or 1:250 patients). The technique performed on cadavers showed that the previously mentioned bony landmarks were reliable reference points in reaching the brachial plexus. CONCLUSIONS: Our technique via a middle interscalene approach is easy to perform and provides a high success rate. Even in the absence of a subclavian artery pulse, the easily recognizable bony landmarks reliably guide us in the insertion of the needle. Furthermore, this technique appears to avoid complications that are theoretically possible in other supraclavicular perivascular approaches (pneumothorax) and paravertebral approaches (injection into the vertebral artery and subarachnoidal injection). However, further comparative studies will be required to assess the clinical relevance of the block.


Assuntos
Anestésicos Locais/administração & dosagem , Plexo Braquial/anatomia & histologia , Bloqueio Nervoso/métodos , Articulação Esternoclavicular/anatomia & histologia , Artéria Subclávia/anatomia & histologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Amidas/administração & dosagem , Artroscopia , Bupivacaína/administração & dosagem , Bupivacaína/análogos & derivados , Cadáver , Feminino , Humanos , Injeções Espinhais , Levobupivacaína , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Estudos Prospectivos , Ropivacaina , Articulação do Ombro/cirurgia , Fatores de Tempo
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