Venous Access Procedures Research Articles

A systematic review of the complications of skin puncturing procedures in the upper limbs of patients that have undergone procedures on the axilla or breast.

The increasing incidence and prevalence of breast malignancies have led to increasing numbers of surgical interventions performed on the axilla and breast, including axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), and mastectomy. The risk of postoperative complications, like breast cancer-related lymphoedema (BCRL), can have significant deleterious cosmetic and quality of life effects. National guidelines and cancer councils publish recommendations to avoid skin puncturing procedures, such as venepuncture and intravenous (IV) cannulation, on arms ipsilateral to the surgical site to prevent BCRL occurrence. The initial trials that established a link between BCRL and skin puncture were conducted in the 1950s and 1960s; the evolution of surgical management of breast cancer has likely led to large decreases in complication rates. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, four databases were systematically searched for relevant articles. Eleven relevant articles were identified for inclusion in the final analysis. Updated Australian and New Zealand College of Anaesthetists & Faculty of Pain Medicine (ANZCA) guidelines were included in the analysis following their publication after the initial search had been completed. The overall quality and quantity of evidence in this field is sufficient to conclude that skin puncturing procedures on ipsilateral arms should not be avoided in patients with previous breast or axillary surgery. The highest-quality and most recent available evidence does not support an association between BCRL and skin puncturing procedures. Policies and practices that advocate avoiding skin puncture procedures to prevent BCRL may lead to delays in clinical care. The 2023 ANZCA guidelines recommend against avoiding affected arms for peripheral access and suggest the removal of institutional policies preventing this practice. In patients that have undergone breast surgery or axillary procedures, venous access procedures can be safely performed on the ipsilateral arm. The evidence does not support overarching restrictions on using the ipsilateral arm without pre-existing lymphoedema.

Safety of multi-access site venous closure following catheter ablation of atrial fibrillation and flutter

BackgroundFollowing catheter ablation, vascular access management involves potential complications and prolonged recovery. Recently, suture-mediated closure (SMC) devices were approved for venous access procedures. The objective of this study is to evaluate the safety of a commercially available SMC for multiple access site venous closure by duplex ultrasound (DUS) in asymptomatic subjects with non-visible complications.MethodsThirty-six subjects (63 ± 10.7 years old, 12 female) were enrolled. Following catheter ablation for atrial fibrillation, all subjects had SMC of every venous access site. Subjects underwent DUS of femoral veins and arteries. DUS was performed at discharge, and again at 30 days. Subjects were evaluated for clinically apparent vascular complications.ResultsMean procedure duration was 138.6 min, and the time to hemostasis was 3.1 min/access site and 9.5 min/subject. Median time to ambulation was 193.5 min, and median time to discharge was 5.95 h, with discharge as early as 2.4 h. A median of 2 sheaths/vein and a median of 2 SMC devices/vein were used. There were no major complications and a 16.7% (6/36) minor complication rate at discharge. All complications resolved at 30 days. The complication rate was not higher in patients with 2 SMC per access site as compared to the patients who just received 1 SMC per access site.ConclusionsThis study demonstrates the safety of multi-access closure using SMC, following catheter ablation procedures, for closure of sites that use sheath sizes from ≤ 8F to ≥ 15F and for those that use 2 or more SMCs per access site.Graphical abstract

Decreasing Pain in Hospitalized Patients by Increasing Topical Anesthetic Use for Peripheral IVs.

Venous access is a common source of pain for hospitalized patients. Topical anesthetics are effective at decreasing needle pain, can improve success rate, and decrease procedure time; however, use before peripheral intravenous line (PIV) placement is inconsistent. The aim was to reduce pain experienced by hospitalized pediatric patients by increasing topical anesthetic use for PIV placement from a mean of 11% to 40% within 6 months. The Model for Improvement was utilized. An institutional clinical pathway and PIV order panel were developed. Pre-checked orders for topical anesthetics were added to order sets. Visual aids were placed on IV carts, including reminders for anesthetics, pathway use and scripting examples. Nurses received individual feedback. Statistical process control charts were posted weekly on daily management system boards on medical-surgical floors, and data were shared at daily nursing huddles to increase awareness of performance and discuss opportunities for improvement. Topical anesthetic use for PIV placement increased from a mean of 11% to 46%. Documentation of comfort measures during PIV placement increased from a mean of 6% to 13%. The percentage of PIV placements with an order for a topical anesthetic in the electronic health record increased from a mean of 14% to 54%. PIV procedures with documentation of placement attempts increased from a mean of 47% to 70%. Through systems and culture change, awareness of the importance of pain prevention for venous access procedures increased, and patient-centered care improved with greater collaboration between nurses, providers, and families for venous access planning.

Periprocedural Edoxaban Management and Clinical Outcomes in Patients Undergoing Transcatheter Cardiovascular Procedures in the EMIT-AF/VTE Program.

Clinical trial registration number: NCT02950168, NCT02951039.

A case of persistent left superior vena cava: an anatomical rarity with clinical implications

Persistent left superior vena cava (PLSVC) is a rare congenital anomaly characterised by the presence of a persistent left-sided SVC in addition to the normal right-sided SVC. This case report presents a unique instance of PLSVC in a 13-year-old male patient who was incidentally diagnosed during routine cardiac imaging for an unrelated condition. The diagnostic journey, including imaging modalities such as echocardiography and computed tomography, revealed the presence of this anatomical variation. Despite being asymptomatic, the case highlights the importance of recognising PLSVC, as it can have clinical implications in various medical and surgical scenarios, particularly in cardiac catheterization, pacemaker implantation, and central venous access procedures. This report discusses the clinical significance, diagnostic challenges, and management considerations associated with PLSVC, emphasising the need for increased awareness among healthcare professionals to ensure safe and effective patient care.

To transfuse or not to transfuse? A pilot study evaluating preoperative transfusion practices for pediatric sickle cell patients undergoing central venous access procedures

IntroductionPerioperative transfusion guidelines for pediatric sickle cell disease (SCD) patients are underdeveloped. The American Society of Hematology (ASH) provides transfusion recommendations for procedures requiring general anesthesia and lasting >1 hour. However, many pediatric SCD patients require long term central venous access and these short procedures do not fall within these guidelines. The objective of this study is to investigate our institutional preoperative transfusion practices in central venous access procedures. MethodsA retrospective chart review was performed from 2018 to 2022 of SCD patients who underwent a line placement or removal at a stand-alone quaternary care children's hospital. Clinical information including demographics, Hgb levels, number of transfusions, and postoperative complications were collected. Statistical analysis was performed using Fisher exact and Wilcoxon rank sum tests. ResultsA total of 30 patients underwent 34 venous access procedures (76 % line placement, 36 % line removal). Half of the patients (15) had an initial Hgb <9 g/dL. There were no significant differences in the demographics, complications, or readmission rates between patients with an initial Hgb <9 or >9 g/dL. Significantly more patients received a preoperative blood transfusion in patients with a Hgb <9 g/dL compared to those with a Hgb >9 g/dL (73% vs 20 %, p = 0.01) Length of stay, postoperative complications, intraoperative transfusion, and readmission rates were not significantly different in patients who received a preoperative transfusion. ConclusionWe encountered variability in the preoperative transfusion threshold; however, outcomes remained similar with no significant differences based on preoperative Hgb. Future studies focused on quality, safety, and resource allocation are needed for development of practice recommendations.

Central venous access in children: Placement trends over the last decade

PurposeTo evaluate central venous access placement trends for radiology and non-radiology services over the last decade. Materials and methodsChildren who had central venous access procedures included in a large administrative database of 49 pediatric institutions in the United States between 2010 and 2020 were included. Patient demographics and patient specific factors were compared between groups. The percentage of procedures performed by interventional radiology (IR) and non-radiology services were compared over time and by region. ResultsA total of 483,181 vascular access encounters were recorded (45.3% female; median age 2 years (IQR 0–11 years)). Approximately one quarter of vascular access encounters were IR-led, with a slight increase of 3.8% between 2010 and 2020. Children who underwent IR-placed vascular access were older (median age of 4 years compared to 1 year in non-radiology encounters). Interventional radiology-placed access was greatest in the Midwest (33.5%) with a decrease of 5.9% over the study period; in the other three regions, IR-performed encounters increased. Patient comorbidities more prevalent in the IR encounters were technology dependence (42.4% of all radiology encounters), gastrointestinal (34.9%), respiratory (20.8%), and transplant (8.1%), while those which were more prevalent in the non-radiology encounters were nephrology/urology (21.4% of all non-radiology encounters), prematurity/neonatal (17.3%), and malignancy (17.3%). ConclusionsInterventional radiology-provided vascular access services have slightly increased over the last decade without significant service-line transfer to other specialties. Underlying comorbidities in IR-led vascular access encounters vary across institutions based on referral patterns, possibly reflecting the adoption of ultrasound guidance by other pediatric subspecialties.

Closure of Transsplenic Access Tracts Using Tract Embolics: Success, Clinical Outcomes, and Complications in a Tertiary Center

Abstract Purpose The aim of the study was to evaluate the safety and effectiveness of transsplenic venous access closure. Materials and Methods Twenty patients (mean age: 51.8 years; range: 28–72), underwent 21 transsplenic venous access procedures over 4 years in this retrospective study. Comorbidities, active hemorrhage, anticoagulation, coagulation parameters, platelets, indications for transsplenic access, needle gauge, sheath size, variceal embolization method, tract embolization method, bleeding complications, and transfusion requirements and additional procedures to manage bleeding complications were recorded. Results Preprocedure comorbidities included portal hypertension (n = 18/20, 90%), portal vein thrombosis (n = 14/20, 70%), hemorrhage (n = 6/20, 30%), splenic vein thrombosis (n = 7/20, 35%), anticoagulation (n = 2/20, 10%), and sinistral portal hypertension (n = 2/20,10%). Mean baseline international normalized ratio was 1.3 (range: 1–1.9), platelets 122 (range: 18–492). Most common transsplenic access indications were gastric varices with nonpatent portosystemic shunt (n = 11/21, 52%) and portal vein targeting for transjugular intrahepatic portosystemic shunt (n = 8, 38%). Most common access sheath sizes were 4-French (n = 5, 24%) and 6-French (n = 6, 29%). Fifteen procedures (71%) involved variceal embolization. Transsplenic tracts were embolized with microfibrillar collagen alone (n = 7), coils and microfibrillar collagen (n = 8), or others (n = 6). Based on the Society of Interventional Radiology adverse event classification system, embolization complications included one major (splenic artery pseudoaneurysm and a splenic vein pseudoaneurysm) and three moderate (19%) adverse bleeding events, which required blood transfusion. Conclusion Transsplenic venous access tract embolization is a safe and moderately effective method to achieve tract hemostasis, with an overall clinical failure rate of 20%.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures.

Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows. We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above. Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients. Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

Management of Inadvertent Supra-Aortic Arterial Lesions During Central Venous Access Procedures: Report of Six Cases and Proposed Algorithm

A retrospective single-center review was performed from 2015 to 2020. Six patients were treated for accidental supra-aortic arterial cannulation during central venous catheter insertion. Three punctures were due to 12F central vein catheters. Four patients had undergone diagnostic duplex ultrasound (DUS) and two had undergone computed tomography angiography (CTA). Surgical intervention with direct repair was performed in four patients for common carotid artery injuries, and endovascular treatment with stent graft deployment was performed in two patients for subclavian artery injuries. Early diagnosis using DUS or CTA and prompt repair are crucial to achieve good outcomes and determine whether an endovascular technique (stent-graft) or open vascular surgery is optimal.

The use of virtual reality in children undergoing vascular access procedures: a systematic review and meta-analysis.

Venous access procedures are painful and feared by children and their parents. Virtual reality has become increasingly prominent and has been shown to be effective in various procedures. The aim of this meta-analysis was to examine virtual reality's effect on pain and fear in children from 4 to 12 in the context of vascular access. From the 20th to the 26th December 2020, we searched Sciencedirect, Springerlink, CENTRAL, Pubmed and PMC. Studies using virtual reality versus a control in vascular access for children were included in a meta-analysis to evaluate the effect of virtual reality regarding pain as a primary and fear/anxiety as a secondary endpoint during the procedures. The Jadad scale and Delphi List were used to assess study quality. 20,894 citations were identified, 9 met our inclusion criteria. One publication was conducted in two different situations and was thus considered as 2 studies. Compared to standard of care, virtual reality significantly reduced pain (10 studies, 930 participants: standardized mean difference [SMD] 2.54, 95%CI 0.14-4.93, p = 0.038), and fear/anxiety (6 studies, 648 participants: SMD 0.89, 95%Cl 0.16-1.63, p = 0.017). For both parameters, we found significant heterogeneity between studies. This is the first meta-analysis to look at the use virtual reality in young children undergoing vascular access procedures, providing weak to moderate evidence for its use. Although large effect sizes provide evidence for a positive effect of virtual reality in reducing pain and fear, there is significant heterogeneity between studies. More research with larger groups and age stratification is required.

Periprocedural anticoagulation management in edxoaban patients undergoing catheter-based cardiovascular procedures: analyses of the noninterventional global EMIT study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background The optimal periprocedural management of direct oral anticoagulants (DOAC), including edoxaban, in patients undergoing catheter-based cardiovascular procedures is unknown, and mainly based on physician opinion and experience. Purpose To assess real-world management of edoxaban in patients undergoing cardiovascular procedures, and to report their clinical events. Methods Global EMIT-AF/VTE is a prospective study of periprocedural management in edoxaban-treated patients undergoing diagnostic and therapeutic procedures. We report the data from patients undergoing cardiovascular procedures. Timing and duration of edoxaban interruption were at the treating physician’s discretion. Outcomes were collected from 5 days before until 30 days post procedure. Primary outcome was the incidence of major bleeding (MB); secondary outcomes included incidence of clinically relevant non-major bleeding (CRNMB) and acute thromboembolic events (ATE). Results Data was collected from 301 and 311 procedures with arterial or venous access, respectively. Baseline characteristics are shown in Table 1. Edoxaban was not interrupted in 36.9% of arterial and 52.7% of venous procedures. Edoxaban was interrupted pre-procedure in 41% of arterial and 32.8% of venous procedures. The median periprocedural interruption was 2 days. The overall incidence of bleeding was very low. Any bleeding was reported in 8 patients undergoing arterial and 10 patients undergoing venous procedures (2.7% and 3.2%). MB or CRNMB occurred in 2 arterial and 3 venous procedures (0.7% and 1.0%) and ATE occurred in 5 arterial and 1 venous procedure (1.7% and 0.3%, Table 1). Conclusions In this study, the periprocedural risks of bleeding and thrombotic events were low. About a third of arterial access procedures and half of venous access procedures were performed without edoxaban interruption. Arterial(n = 301) Venous(n = 311) Baseline characteristics Age, year, mean (SD)Male, n (%)Weight (kg), mean (SD) 71.9 (8.5)211 (70.1%)80.8 (16.7) 64.6 (11.1)215 (69.1%)84.1 (17.4) CrCL (mL/min), mean (SD) CHA2DS2-VASc score, mean (SD)HAS-BLED score, mean (SD) 73.5 (29.8) 3.3 (1.5)2.0 (1.0) 88.9 (35.5) 2.2 (1.5)1.3 (1.0) Edoxaban 60 mg / 30 mg, % 73% / 26% 88% / 26% Coronary heart disease, n (%) Congestive heart failure, n (%) 101 (33.6%) 58 (19.3%) 51 (16.4%) 33 (10.6%) Interruption of edoxaban, n (%) No interruption Pre-procedure only Post-procedure only Pre- and post-procedure 111 (36.9%)125 (41.5%)12 (4.0%)53 (17.6%) 164 (52.7%)102 (32.8%)8 (2.6%)37 (11.9%) Clinical events, n (%) MB or CRNMBACSStroke/Transient ischemic attackCV mortalityAll-cause mortality 2 (0.7%)2 (0.7%)3 (1.0%)1 (0.3%)2 (0.7%) 3 (1.0%) 01 (0.3%)00

Biomechanical analysis of expert anesthesiologists and novice residents performing a simulated central venous access procedure.

BackgroundCentral venous access (CVA) is a frequent procedure taught in medical residencies. However, since CVA is a high-risk procedure requiring a detailed teaching and learning process to ensure trainee proficiency, it is necessary to determine objective differences between the expert’s and the novice’s performance to guide novice practitioners during their training process. This study compares experts’ and novices’ biomechanical variables during a simulated CVA performance.MethodsSeven experts and seven novices were part of this study. The participants’ motion data during a CVA simulation procedure was collected using the Vicon Motion System. The procedure was divided into four stages for analysis, and each hand’s speed, acceleration, and jerk were obtained. Also, the procedural time was analyzed. Descriptive analysis and multilevel linear models with random intercept and interaction were used to analyze group, hand, and stage differences.ResultsThere were statistically significant differences between experts and novices regarding time, speed, acceleration, and jerk during a simulated CVA performance. These differences vary significantly by the procedure stage for right-hand acceleration and left-hand jerk.ConclusionsExperts take less time to perform the CVA procedure, which is reflected in higher speed, acceleration, and jerk values. This difference varies according to the procedure’s stage, depending on the hand and variable studied, demonstrating that these variables could play an essential role in differentiating between experts and novices, and could be used when designing training strategies.

Learning effectiveness of using augmented reality technology in central venous access procedure: an experiment using phantom and head-mounted display.

Augmented reality (AR) technology improves the learning process in interventional radiology. This study hypothesized that using AR to train for central venous access is superior to using ultrasound alone. This study used an AR central venous catheterization phantom with an internal jugular vein (IJV) and subclavian vein (SCV) made of resin body and soft tubing. Ten radiologists attempted to punctuate, using needle placement simulation, under three conditions (ultrasound-, augmented reality-, and ultrasound and AR-guided methods; US-only, AR-only, and US+AR, respectively) using a smart-glass device (HoloLens, Microsoft, Redmond, WA, USA). Subjective (anatomical understanding and self-confidence for procedure) and objective evaluations (optimized needle position and time) were recorded for each condition. The subjective IJV evaluation showed no difference among the guiding methods (p=0.26 and p=0.07 for anatomical understanding and self-confidence for procedure, respectively). Conversely, there were significant improvements in subjective and objective evaluations for SCV using the AR-only and US+AR methods (p<0.05) and US+AR method (p<0.05), respectively. The AR-only method reduced the time required to fix the needle position to puncture the SCV (p<0.05), but its objective evaluation did not improve compared with the US-only method (p=0.20). Adding the AR-guided method to the US-guided method improved subjective and objective evaluations in the SVC procedure. The AR technology-assisted training may be more beneficial for use in difficult procedures. Though the AR-only method saved time, no time saving is expected with AR+US method.

Management of Inadvertent Supra-aortic Arterial Lesions During Central Venous Access Procedures: Report of Six Cases and Proposed Algorithm

Accidental supra-aortic arterial cannulation during central venous catheter (CVC) insertion is a rare and serious complication associated with risk of vascular and neurologic complications. The aim of this study is describing our 6 cases experience and propose a management algorithm. We retrospectively evaluated the diagnosis and treatment of six patients arrived at our Department for accidental supra-aortic arterial cannulation during CVC insertion. They underwent Doppler Ultrasonography (DUS) or Computed Tomography Angiography (CTA) to confirm the arterial damage and to decide the correct therapeutic pathway. Four patients underwent DUS as the shallow location of injured arteries and 2 patients CTA because of the arterial damage deeply located. Surgical procedure with direct arterial suture was performed in four patients. Endovascular treatment with stent graft deployment was carried out in two patients. All procedures were conducted successfully: technical success (immediate hemostasis and vessel patency) was obtained in 100% of the cases. Postoperative imaging (DUS or CTA) confirmed the absence of arterial bleeding and the arterial patency. No perioperative mortality or complications occurred. After a careful review of literature and our case series, we proposed an algorithm to delineate the optimal treatment strategy, explaining that early and careful diagnosis (by DUS or CTA) and prompt repair appear crucial to achieve good outcomes and clarifying that an endovascular technique (stent graft placement or vascular closure device) seems to be the best treatment in these cases. Finally, an open surgical technique could be indicated in case of common carotid artery injury and concurrent catheter passing through the target vein.

Feasibility of Mynxgrip®-Assisted Percutaneous Transhepatic Portal Venous Access Closure.

Life-threatening bleeding may occur following percutaneous portal venous access procedures. Various embolic agents have been utilised to minimise this risk, each with their own disadvantages, including inadvertent embolization of the portal vein and inadequate tract embolization. We aim to assess the feasibility of a novel approach to percutaneous portal venous access closure by utilising the MYNXGRIP® vascular closure device (Cardinal Health, USA). This retrospective study analysed 20 patients who underwent interventional radiological procedures with closure of the percutaneous transhepatic portal venous access tract using the MYNXGRIP® closure device with either N-butyl cyanoacrylate or thick gelatin paste. None of these patients demonstrated clinical evidence of post-procedural haemorrhage, which was further confirmed on abdominal imaging in 15 of these patients. MYNXGRIP®-assisted percutaneous transhepatic portal venous access closure is feasible and able to achieve haemostasis with minimal embolization risk.

Managing central venous access during a health care crisis

ObjectiveDuring the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. MethodsWe conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. ResultsParticipants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). ConclusionsImplementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Update from the 2019-20 ASA Committee on Standards and Practice Parameters

Committee News| July 2020 Update from the 2019-20 ASA Committee on Standards and Practice Parameters Karen B. Domino, MD, MPH; Karen B. Domino, MD, MPH Search for other works by this author on: This Site PubMed Google Scholar Jeffrey L. Apfelbaum, MD Jeffrey L. Apfelbaum, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2020, Vol. 84, 34. https://doi.org/10.1097/01.M99.0000688736.97778.ec Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Karen B. Domino, Jeffrey L. Apfelbaum; Update from the 2019-20 ASA Committee on Standards and Practice Parameters. ASA Monitor 2020; 84:34 doi: https://doi.org/10.1097/01.M99.0000688736.97778.ec Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: guidelines, intubation, difficult, professors, schools, medical, advisory committees, cardiovascular implantable electronic device, central venous access procedures The mission of the Committee on Standards and Practice Parameters (CSPP) is to offer guidance to the ASA membership by providing educational and scientific information related to the safe and effective practice of anesthesiology. As part of this mission, CSPP develops evidence-based guidelines and advisories, standards of basic anesthesia practice, and reviews patient care documents developed by other health care organizations. The ASA guidelines and practice advisories provide guidance to improve clinician decision-making and promote beneficial outcomes for the practice of anesthesiology. The guidelines and advisories are not intended as unique or exclusive indicators of appropriate care. The interpretation and application of these guidelines and advisories take place within the context of local institutions, organizations, and practice conditions. A departure from one or more of the recommendations may be appropriate if the facts and circumstances demonstrate that the rendered... © 2020 American Society of Anesthesiologists (ASA), All Rights Reserved.2020 You do not currently have access to this content.

140 Use of GoPro to Assess Central Venous Line Placement Competency Asynchronously

Complications due to failed central venous access (CVA) attempts are associated with increased morbidity and health care costs. The Agency for Healthcare Research and Quality (AHRQ) estimates a central line associated blood stream infection (CLABSI) costs approximately $70,000. There is a high failure rate in completing ultrasound guided central venous access (UGCVA) procedures among first year resident interns. Training and assessment is important, however physician time to assess resident competency is limited. Previous research has demonstrated that a GoPro camera can be used to capture procedures. In this research, we will evaluate the use of video recordings to asynchronously evaluate resident procedural competency in ultrasound guided central venous line (USGCVL) placement. This research had several steps. First, we evaluated the ability of GoPro cameras to capture procedural competencies during USGCVL procedures. Next, we developed and validated an evaluation rubric consisting of critical competencies identified from the literature and institutional guidelines. Faculty reviewers evaluated the GoPro videos asynchronously for visual clarity, and completeness of observation while using the rubric. Results demonstrated high agreement between reviewers (80-100%) for visualization of each competency. Residents were recruited to participate in this study during a training course designed to assess procedural competency in central line placement using a cadaver. Following consent, participants donned a head-mounted GoPro camera to record their performance. During the procedure, faculty evaluated residents' performance synchronously (via Qualtrics) using the same evaluation rubric validated in the prior study. At a later date, two teams each composed of a surgeon and emergency medicine (EM) physician (different than the synchronous reviewers) asynchronously viewed and independently evaluated videos divided into groups of four using the same rubric via Qualtrics. Inter-rater reliability was calculated between pairs of asynchronous reviewers and average percent agreement was calculated for both the asynchronous and the asynchronous versus live reviews. Video recordings of twenty-eight USGCVL procedures were collected. Twenty-four met study inclusion criteria (1080p 30fps continuous video no significant glare, no gross misalignment of the video field of view) and twenty are included in the data analysis. (Four videos have not been reviewed by their assigned reviewers yet.) Results are presented in Table 1. Overall percent agreement approached 80% for both asynchronous and asynchronous versus live comparisons. This study supports the feasibility of using a head mounted GoPro camera to record video for asynchronous evaluation of resident USGCVL placement. Continued refinement of data capture, scoring practices, and the grading rubric is needed to increase both the validity and reliability of the assessment process.Table 1Average percent agreement.Average Percent Agreement (%)95% CI (%)Asynchronous Rater Comparison 12 VideosRater 2 (surgeon) vs. Rater 3 (EM)73.4744.04100Live Graders vs. Asynchronous 8 VideosRater 1, 3 (EM) vs. live graders78.1242.54100 Open table in a new tab

Risk factors for venous thromboembolism (VTE) during chemotherapy in patients with germ cell tumors (GCT).

520 Background: The Khorana score is the primary tool utilized to predict VTE risk in patients with cancer. This score incorporates primary cancer site, pretreatment hematologic parameters, and body mass index. GCT are considered high-risk for VTE. However, risk factors for VTE not included in the Khorana Score have been reported for GCT including retroperitoneal lymph node (RPLN) size, elevated LDH, and poor risk disease. Methods: A retrospective chart review was conducted to correlate known VTE risk factors with VTE incidence in male patients with GCT undergoing first-line chemotherapy. Variables included venous access type, RPLN size, LDH, chemotherapy regimen, procedure history, cancer stage and histology, Khorana risk factors, and pertinent demographics. VTE and superficial vein thrombosis (SVT) events that occurred within 1 month prior through 6 months after start of chemotherapy were recorded. Fisher’s Exact test was used for univariate analysis and logistic regression for multivariate analysis of the relationship between predictors and thrombosis. P-values are two-sided at an alpha level of 0.05. Results: 47 patients with GCT were identified. 12 VTE occurred (overall incidence 25.5%), 11 in patients with central lines (39.3% incidence) and 1 with a peripheral line (5.3% incidence). SVT were observed in 5 patients with peripheral lines compared to 1 patient with a central line (26.3% vs. 3.6%). Central line access was the primary variable associated with VTE risk in both univariate and multivariate analysis (p=0.01 and p=0.03, respectively). Conclusions: Venous access type is a significant but modifiable factor that can be targeted to reduce VTE risk. Due to small sample size there is limited statistical power to detect potentially meaningful differences in known risk factors. If validated, these results may identify specific patients to be treated with prophylactic anticoagulation. [Table: see text]