Central Venous Access Placement Research Articles

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9.

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7–10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7–10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

Ultrasound-Guided Central Line Placement as Compared with Standard Landmark Technique: Some Unpleasant Arithmetic for the Economics of Medical Innovation

Objective We perform a simple cost estimation of ultrasound guidance for the placement of central venous access, considering the US federal reimbursement for ultrasound guidance of central line placement to the federal reimbursement for treating the complication of pneumothorax. Methods We utilize national statistics on the number of central lines placed annually to determine the cost savings incurred if all central lines placed in the United States were placed with ultrasound guidance. Results The initial “cost” of placing central lines was found to be 390,780,000 to 651,300,000 dollars per year by the landmark technique, as compared with 494,820,000 to 824,700,000 dollars per year by ultrasound guidance. Conclusions The cost of ultrasound guidance was not mitigated by its reduction in the cost of treating pneumothoraces.

Selective use of preoperative venous duplex ultrasound and intraoperative venography for central venous access device placement in cancer patients.

Central venous access in cancer patients is often challenging. A history of access is common. Appropriate indications for venous imaging studies are not clearly defined. This study was a retrospective analysis of selective use of preoperative venous duplex ultrasound and intraoperative venography in 248 consecutive cancer patients undergoing central venous access placement. Ninety patients had a history of central venous access placement. Eleven had a history of deep venous thrombosis of an upper extremity or central vein. One hundred three underwent preoperative ultrasound. Previous central venous access placement was not associated with an abnormal preoperative ultrasound; however, previous central venous access with deep venous thrombosis was (P =.014). Thirty patients underwent intraoperative venography, of which 18 also had preoperative ultrasound. Fifty percent of patients with an abnormal intraoperative venogram had no abnormal findings on preoperative ultrasound. Routine preoperative ultrasound is unnecessary. We advocate the selective use of preoperative ultrasound in those with a history of central venous access associated with deep venous thrombosis. We advocate the use of intraoperative venography when there is difficulty advancing the guidewire or catheter or when preoperative ultrasound is negative despite a history of central venous access with deep venous thrombosis.

Recommended standards for reports dealing with arteriovenous hemodialysis accesses

The incidence rate of treated end-stage renal disease in the united states is 180 per million and continues to rise at a rate of 7.8% per year. Arteriovenous hemodialysis access (AV access) creation and maintenance are two of the most difficult issues associated with the management of patients on hemodialysis. The 1-year complication rate of a primary prosthetic AV access for hemodialysis ranges from 33% to 99%. Various investigators report on patency and complications of AV access. However, it is rather difficult to compare outcomes because of the wide variety of access materials, configurations, locations, risk factors, and quality of inflow and outflow vessels. Although there have been reporting standards for dialysis access endovascular interventions and for central venous access placement, standards regarding surgical access placement and its revision are lacking. The "Dialysis Outcome Quality Initiative," published by the National Kidney Foundation, provides recommendations for optimal clinical practices aimed at improving dialysis outcome and patient survival. This reporting standards document is not meant to be a "practice guidelines" or "best practices" document. Rather, the purpose of this document is to provide standardized definitions related to AV access procedures and to recommend reporting standards for patency and complications, to be used by surgeons, nephrologists, and interventional radiologists, that will permit meaningful comparisons among AV access procedures. The terms, definitions, and categories featured in this article have been approved by the Committee on Reporting Standards of the Society for Vascular Surgery and the American Association for Vascular Surgery and should be observed in preparing manuscripts on AV accesses for submission to the Journal Of Vascular Surgery.

“Blind” Placement of Long-Term Central Venous Access Devices: Report of 589 Consecutive Procedures

Placement of long-term central venous access devices, such as Hickman catheters and implanted subcutaneous ports, has traditionally been performed in the operating room with fluoroscopy. This study reports our experience with percutaneous placement of these devices in the outpatient clinic setting without the use of real-time imaging. Results were generated from a prospective database of all adult patients undergoing placement of central venous access in the outpatient clinic of the Wake Forest University Baptist Medical Center. This database revealed that during the years 1996 and 1997, long-term central venous catheter placement was attempted in 589 adult patients in the outpatient clinic. Technical success was achieved in 558 patients (92%). This included 278 tunneled catheters and 280 totally implanted devices. Repositioning of the catheter tip was required in 16 patients (2.9%). The incidence of pneumothorax was 1.9 per cent. Late complications, including infection and thrombosis, occurred in 9 per cent. The average procedure-related charge for placement of a single-lumen central venous port in the outpatient clinic was $1691 versus $4559 in the operating room and $3890 in the radiology department. We conclude that routine placement of long-term central venous access devices in the outpatient clinic, without the use of real-time imaging, yields acceptable success rates and may have economic advantages over procedures performed in the operating room or radiology department.

A Successful Continuous Spinal Anesthetic in a Patient with Preoperative Baseline Hypercapnia Exceeding 100 mm Hg

A Successful Continuous Spinal Anesthetic in a Patient with Preoperative Baseline Hypercapnia Exceeding 100 mm Hg

Placement of Central Venous Access via Subclavian Vein under Fluoroscopic Guidance with Intravenous Contrast Injection

Placement of Central Venous Access via Subclavian Vein under Fluoroscopic Guidance with Intravenous Contrast Injection