Reliable Vascular Access Research Articles

Emergency intraosseous access in a helicopter emergency medical service: a retrospective study

BackgroundIntraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation of critically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseous techniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articles document IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS.MethodsWe reviewed all medical records from the period May 2003 to April 2010, and compared three different techniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical Device Technologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients.ResultsDuring this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were 50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success on first attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p < 0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%) and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used in connection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Other diagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratory failure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger than two years. No cases of osteomyelitis or other serious complications were documented on the follow-up.ConclusionsNewer intraosseous techniques may enable faster and more reliable vascular access, and this can lower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believe that all emergency services that handle critically ill or injured paediatric and adult patients should be familiar with intraosseous techniques.

Ultralyddoppler ved arteriovenøs fistel for hemodialyse

Permanent and reliable vascular access is of utmost importance for patients (with chronic renal failure) in need of haemodialysis. Autogenous arteriovenous fistula (AVF) on the forearm are robust and have the benefits of providing long-term access with relatively few complications. The main problem is insufficient blood flow due to stenoses requiring early intervention. The AVF therefore needs surveillance with regular clinical examination supplemented with imaging. In recent years Doppler sonography has gained an increasingly important role in the assessment of AVFs. This paper discusses AVFs and frequent complications and stresses the benefit of Doppler sonography in the planning and surveillance of AVFs. The survey is based on literature retrieved from a PubMed search, and our experience from sonographic examinations of AVFs in the Central Hospital of Lillehammer, Norway. Doppler sonography is a non-invasive imaging modality without discomfort for the patient, and well suited for examination of AVFs. The method has a high sensitivity for detection of stenoses and other AVF-related problems, and can provide a detailed image of the course and diameter of blood vessels, with quantitative measurement of blood flow. Indications for Doppler sonography are preoperative mapping, assessment of fistula problems and maturity; it is also a useful method for continuous surveillance of fistulas. Doppler sonography can be used for immediate treatment of patients with sudden AVF problems; and if necessary endovascular intervention or surgery can follow. Recent European guidelines recommend the method as a standard procedure before and after creation of an AVF. Doppler sonography should have a central position in a multidisciplinary teamwork on surveillance of patients with AVFs in need of haemodialysis.

Umbilical Catheters, Placement, and Complication Management

Umbilical arterial and venous catheter placement have become the standard of care in the neonatal intensive care unit. These catheters allow for rapid and reliable vascular access for the administration of fluids and medications, as well as a means for accurate laboratory determinations and invasive monitoring. Catheter placement and maintenance require training and education of all healthcare workers to prevent or minimize the associated risks.

Pediatric: Nurse-Placed Peripherally Inserted Central Catheters in an Interventional Radiology Setting Improves Outcomes

Pioneering quality performance management for the vascular access needs in children is of critical importance. Specifically, appropriate assessment and timely intervention of central line access are priorities. Santolucito (2001) indicates that improved triage of appropriate vascular access intervention, for example Peripherally Inserted Central Catheters (PICC) placement, could reduce the trauma and costs of multiple conventional short peripheral IV catheter insertions, as well as potentially reducing length of hospital stay. “Failure to establish a reliable vascular access prior to discharge often results in postponed discharge dates, prolonged hospitalization and increased cost.” A proactive approach to known barriers related to catheter selection and care will be pivotal to the success of the Pediatric-placed PICC. We embarked on a unique approach to improve outcomes in children. As a result Vascular Access Nurses currently place PICCs in the Interventional Radiology setting. The team consists of a Radiology Nurse, a Vascular Access Nurse, a Radiology Technologist, and an Interventional Radiology Attending Physician. In this model patients are evaluated for appropriateness of a nurse-placed PICC, sedation, urgency, and scheduled accordingly. In the Interventional Radiology setting the patient receives IV sedation, PICC lines are placed using maximum sterile barrier technique, ultrasound and fluoroscopy capability. This is made possible only with the expertise of all team members. Significant results of this patient care model include efficiency, patient safety, and cost effectiveness.

A Case of Catheter-related Thrombosis Treated with Local Low-dose Urokinase

Although indwelling central venous catheters guarantee a reliable vascular access, and are essential for the management of children undergoing anticancer chemotherapy or stem cell transplantation, these catheters may cause serious mechanical, infectious and thrombotic complications. Central venous catheter-related thrombosis is one of the most important complications that may interfere with the course of treatment. A number of regimens utilizing urokinase have been used but the optimum management of this common problem remains undetermined. We report an 8 year-old boy, who had catheter-related atrial thrombus treated successfully with urokinase. A short course treatment with the use of low-dose urokinase was feasible for the thrombolysis of catheter-related right atrial thrombus in this boy diagnosed with neuroblastoma and undergoing high-dose chemotherapy with autologous peripheral blood stem cell rescue. This treatment was not associated with bleeding. (Korean J Hematol 2006;41:220-224.)

Vascular Access in the Adult Home Infusion Patient

The dependence of IV hyperalimentation programs on the achievement and maintenance of reliable vascular access in the home infusion patient population has necessitated a review of the current methods used to establish and maintain adequate long-term vascular access. Vascular access device-related complications are significant contributors to the medical course and costs associated with the care of home parenteral nutrition (HPN) patients. The purpose of this manuscript is to review current thoughts on the establishment of long-term vascular access for HPN with regard to techniques used, device selection, and associated complications.

Surgiclose technique allows fast, easy and reliable remote vascular access for EVAR and cannulation for aorto-coronary bypass surgery

Background: To evaluate a minimally invasive, fast, easy and reliable no-clamping technique for vascular access and closure. Material and Methods: Prospective analysis of a new technique for vascular access needing minimal preparation and without the need for arterio- or venotomy. Over a one year period 89 arteries in 84 patients were accessed for endovascular stentgrafting (21 thoracic, 68 abdominal) and 24 vessels were accessed for cannulation (12 arteries, 12 veins) by the surgiclose technique. Results: Technical success rate was 100%. There was no technically related complication such as stenosis, dissection, thrombosis, bleeding or pseudoaneurysm. Conclusions: The surgiclose technique proved to be minimally invasive, fast and complication free in over 80 cardiovascular patients. This technique has become the technique of choice for vascular access in EVAR patients and cardiac patients requiring cannulation in our institution.

Partial Excision of Infected Fistula Results in Increased Patency at the Cost of Increased Risk of Recurrent Infection

Reliable vascular access is often an issue of ongoing frustration for those requiring dialysis. Synthetic arteriovenous fistulae (SAVF) have been widely used to provide vascular access; however, the risk of infection at the SAVF site is significant, especially because the SAVF is potentially exposed to pathogens on a regular basis due to the cannulation required for dialysis. Between 11 and 35% of all SAVF become infected and require surgical removal. The purpose of this investigation was to: (1) compare the risk of recurrent infection with complete versus partial excision of the infected SAVF (ISAVF) and (2) explore the risks and benefits of attempting to preserve patency of noninfected portions of ISAVF. In a retrospective review to determine the risk of recurrent infection after removal of ISAVF, charts of 77 patients undergoing surgery for the removal of an ISAVF from the arm were identified with 84 instances of excision of an ISAVF. Of the 84 ISAVF, 26 (31 %) were treated with complete excision (CE), 30 (35.7%) grafts were partially excised with blood flow restoration through a new interposed PTFE segment (PERF), and 28 (33.3%) grafts were partially excised with no flow restoration (PENF), leaving portions that were not grossly infected. Fourteen of 30 (46.7%) PERF grafts, 4/28 (14.3%) PENF, and 0/26 CE grafts developed further infection at the excision site. These differences were significant when comparing PERF to CE (p < 0.001) and PERF to PENF (p < 0.025), but no significance was found when comparing CE to PENF. Patency was significantly greater for the PERF group at 1 and 2 years than for both CE (p < 0.001) and PENF (p < 0.001). In conclusion, the data suggest that restoring blood flow to the remainder of a partially excised ISAVF significantly increases patency without necessitating catherer placement and a new hemoaccess site, but at the cost of significantly increased risk of recurrent infection.

Vascular Access via Peripherally Inserted Central Venous Catheters (PICCs): Experience in 40 Patients with Acute Myeloid Leukemia at a Single Institute

Reliable long-term vascular access is essential for the treatment of patients with acute myeloid leukemia (AML). Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy. We retrospectively reviewed all AML patients who had a PICC inserted between July 95 and May 98. Fifty two PICCs were inserted in 40 patients with AML. Thirty three PICCs were inserted during severe thrombocytopenia (platelets < 50 × 109/L), and 31 during severe neutropenia (neutrophils < 0.5 × 109/L). Mean catheter duration was 82 (median 63, range 3–441) days fora total of 4274 catheter days. A mean of 1.8 chemotherapy courses were administered via each PICC. There were 5 early complications of PICC placement. Other mechanical complications occurred in 14 catheters and phlebitis in 12. Twenty blood stream infections (BSI) occurred in 17 patients. All BSIs occurred during neutropenia. Seventeen PICCs were removed due to the following complications - phlebitis (11), possible catheter related BSI (4), mechanical reasons in 3 (2 with concomitant phlebitis) and persistent fever (1). PICC duration was significantly shorter in these 17 catheters (52.9 v 96.4 days in the other 35, p=0.0289). We conclude that PICCs provide long-term vascular access with an acceptable complication rate in patients with AML. However, a randomised trial is required before PICCs can be considered an alternative to tunneled central venous catheters in these patients.

Successful Use of Central Venous Catheter as Permanent Hemodialysis Access: 84-Month Follow-Up in Lucania

Cuffed tunneled venous access catheters are commonly used for temporary and permanent access in hemodialysis (HD) patients. These catheters serve an essential role in providing permanent access in subjects in whom all other access options have been exhausted. The predominant complications are catheter thrombosis, catheter fibrin sheating and infection. The aim of this study was to evaluate long-term survival and complications of permanent venous catheters (PVC) placed for the purpose of HD during the period from January 1992 to December 1998, at the Dialysis Units of Lucania (a southern Italian region). A total of 98 PVC were placed in 88 patients during this period. The catheters used were of three types: (a) 72 VasCath Soft Cell catheters (Bard Instrument Company, Toronto, Ont., Canada); (b) 22 PermCath catheters (Quinton Instrument Company, Seattle, Wash., USA), and (c) 4 Tesio catheters (Bellco SpA, Mirandola, Italy). Survival curves of catheters were calculated using the Kaplan-Meier product-limit estimator. The patient survival was 60% at the 78th month. Actually, 52 patients (27 males, 25 females) are still alive: 15 (26.9%) of these patients have diabetes mellitus and 1 has been transplanted. The actuarial survival rate of PVC was 89% in the whole population studied and 82% in subjects alive after 84 months. Twenty-five patients (28.4%) had PVC as the first reliable vascular access. Long-term complications occurred 27 times (1 episode every 44.81 month/patient) as: breakage (3.1%); thrombosis (10.2%); displacement (2.0%); subcutaneous tunnel bleeding (3.1%); inadequate blood flow (7.1%), and infection (10.2%). In conclusion, our data confirm that PVC might represent an effective long-term blood access route for HD. Again, PVC are getting the access of choice for selected patients (i.e., older subjects with cardiovascular diseases and cancer patients) and are enjoying a dramatic increase in use for subjects who are terrified of repetitive venopuncture.

High-Tech Homecare Infusion Therapies

Dramatic changes in health care delivery have created an increased reliance on ambulatory care. Adults and children increasingly are receiving infusions of intravascular medication or fluid in the home for a wide array of conditions. Several therapies have been adapted to the home, including chemotherapy, BRMs, TPN, blood components, anti-infectives, analgesics, inotropic agents, and investigational drugs. High-technology therapy in the home mandates safe and reliable vascular access to maximize positive outcomes, independence, and self-care; minimize costs and disruption of daily activities and work schedules; and enhance client and family adjustments and satisfaction. Currently, the four main VADs for vascular access are central venous catheters (CVCs), peripherally inserted central catheters (PICCs, implantable infusion ports, and external or implantable ambulatory infusion pumps.

Transhepatic PermCath for Hemodialysis

The establishment and maintenance of a reliable vascular access continues to be a problem in hemodialysis. We report a patient with end-stage lupus nephritis who had no alternative for vascular access and failed peritoneal dialysis. A vascular access device (PermCath, Quinton Instrument Co, Bothell, WA) was inserted using a transhepatic approach. There were no bleeding or thrombotic complications. The catheter was replaced once through the same track due to poor blood flow and reinserted once after 5 days due to infection. The patient has been doing well and receiving adequate dialytic therapy for over 1 year with this form of vascular access.

Arteriovenous Fistula: Vascular Access for Long-Term Hemodialysis

Long-term hemodialysis remains the most important support for patients with ESRD, and reliable vascular access is an essential component of this management plan. Recent refinements in AV fistula surgical techniques have produced this dependable, well-tolerated, long-term access route for hemodialysis.

Surgical Management of Long-Term Central Venous Access in Uraemic Patients

Over a 5-year period, 1980-1985, 39 patients from a dialysis population of over 400 treated at this centre experienced major difficulties in achieving adequate access for dialysis by conventional techniques (i.e. arteriovenous fistula or CAPD). This study has evaluated the long-term results of a new approach to circulatory access, central venous catheterisation (CVC) for so called "high risk" patients. CVC consists of inserting a single-lumen CAPD-type silastic catheter into the right atrium via an external or internal jugular vein. Forty-seven catheters have been inserted into 39 uraemic patients. All patients had failed on, or were unsuitable for, conventional access to haemodialysis or CAPD. Ten patients (26%) had previous failed renal transplants. The median duration of catheter use was 7 months (range 1-60 months) and a total of 6500 high-performance dialyses have been performed using this technique. No patient has died of catheter-related problems. The catheters were easily managed by nurses and well tolerated by the patients. The incidence of complications among patients was low: displacement (1), catheter thrombosis (2), skin exit-site infections (5), septicaemia (2). Central venous catheterisation is a method of providing safe and reliable long-term vascular access which is immediately usable by high-risk patients who have either failed on or are unsuitable for conventional circulatory access.

Initial experience with a new prosthetic angioaccess device.

Long-term vascular access has increased longevity for many patients with end-stage renal disease. Much of the hospitalization in this group of patients continues to be for maintenance of reliable vascular access. Thrombosis, infection, aneurysm, and stenosis lead to serious morbidity. The Hemasite angioaccess system has been introduced in an attempt to circumvent some of these problems. We reviewed our initial experience with 90 of these devices placed in 77 patients during the past 24 months. Thirty-five devices (39%) were placed under emergency conditions when the primary access site had failed, 34 (38%) were used as the initial access procedure, and simple patient convenience was the indication 21 times (23%). Twelve patients have died, with no deaths related to the device. Twenty-eight infections and 18 thromboses accounted for the failures. Fourteen thromboses were seen with the graftless device where collateral flow existed around it. One-year patency was 46% for all devices, 38% for 34 graftless devices placed in the upper arm, and 50% for the grafted model in the upper arm position. Overall patency is not comparable to other access methods yet patient acceptance is high. Placement in the upper arm offers the highest rate of success.

Surgical implications for infusion chemotherapy.

Technical advances that have provided reliable long-term vascular access are described in the setting of pulse and continuous venous chemotherapy infusion and for regional arterial drug delivery. Despite dramatic improvement in the morbidity of such access procedures, it is important to remember that their value still depends upon the effectiveness of the chemotherapy delivered.

The femoral venous approach to endomyocardial biopsy: Comparison with internal jugular and transarterial approaches

Endomyocardial biopsy is often used in the clinical evaluation of cardiac disease. Among 134 consecutive procedures (280 myocardial samples), 3 approaches were compared: right internal jugular (n = 69), femoral arterial (n = 30) and femoral venous (n = 35). The femoral venous approach is a new method with which a preformed guiding sheath is used to allow sampling of the apical right ventricular portion of the ventricular septum. Vascular access and myocardial sampling were successful in all femoral venous and left ventricular (LV) procedures; however, the internal jugular vein could not be located to allow biopsy in 12% of neck approaches (p <0.025). One case of pneumothorax occurred after an internal jugular approach. Chest pain occurred after 10% (3 patients) of the LV, 4% (3 patients) of internal jugular and 3% (1 patient) of femoral venous procedures. Hypotension associated with biopsy was noted after 3 internal jugular and 2 LV procedures. Pericardial effusion was observed in 3 patients after an LV procedure (p <0.01). In 1 of these patients tamponade developed. The femoral venous approach had the highest overall efficiency (successful biopsy, lack of adverse events, p <0.05). This approach may become the procedure of choice for routine endomyocardial biopsy because it allows reliable vascular access and myocardial sampling with a low incidence of adverse reactions.

The basilic vein fistula for vascular access.

The basilic vein fistula provides reliable vascular access for chronic hemodialysis therapy. Early morbidity includes edema and mild pain. Ischemic complications have not developed in this series. Patency has been excellent in the initial period and no patient has yet developed infection, aneurysm or venous fibrosis, although longer follow-up is necessary. The use of the autogenous basilic vein fistula in patients unsuited for forearm arteriovenous fistulae is supported by these results. Long-term results which would support continued use of this modality would include an expected lower incidence of infection due to the absence of a foreign body and the inherent healing property of viable tissue, and improved long-term patency attributable to the absence of a venous anastomosis.