Venous Access Research Articles

Exploring Axillary Vein Central Cannulation in Critically Ill Trauma Patients: A Focus on Infraclavicular Techniques

Managing major trauma in hospital settings, especially in emergency departments, presents significant challenges. Hypovolemic shock, often resulting from hemorrhage, is commonly due to bleeding in non-compressible areas like the abdomen and thoracic cavities, complicating intravenous access. Central vein cannulation is typically performed for effective volume resuscitation and blood transfusions prior to surgery, with common sites including the internal jugular, subclavian, and femoral vessels. However, in acutely bleeding trauma patients, early pre-hospital interventions such as cervical collars and pelvic binders can impede the cannulation of these veins and limit access to traditional central venous sites. This article explores the cannulation of central axillary veins, an underutilized yet advantageous route. Central axillary veins are readily accessible and provide a viable alternative for resuscitation in major trauma patients in emergency settings, offering a practical solution when other central venous access points are compromised.

Incidence and risk factors for central venous access device failure in hospitalised adults: A multivariable analysis of 1892 catheters

Incidence and risk factors for central venous access device failure in hospitalised adults: A multivariable analysis of 1892 catheters

A Single-Centre Experience of an Anesthesia-Led Pediatric Peripherally Inserted Central Catheter Service at a Specialized Cancer Institute

Introduction: To report our experience of establishing a pediatric peripherally inserted central catheter (PICC) line procedure led by the anesthesia department of a tertiary care cancer center. Materials / Patients and Methods: A retrospective review was conducted over a period of 28 months. Variables such as demographic data, indications, the number of days the line remained in situ, and the frequency of adverse events were considered. Results A total of 112 patients between the ages of one and fourteen years who had PICC lines inserted were included. All procedures were done under general anesthesia by two separate anesthesia teams with established protocols. Insertion was guided by ultrasonography through the basilic (n = 84, 75%), median cubital (n = 12, 10.7%), femoral (n=1, 0.9%), or cephalic (n=15, 13.39%) veins in the non-dominant arm. The insertion success rate was 97.3% while the unsuccessful in 2.7%. The 4Fr (French number) PICC line was used in 95 (84.82%) patients and 5F in 17 (15.17%) patients. The PICC line was used for an average of 85.47 days (ranging from 0 to 350 days). Chemotherapy (n = 89, 78.47%), difficult Intravenous (IV) access (n=15, 13.39%), and palliative care (n=8 7.14%) patients require long-term venous access. 38 (33.92%) patients had completed treatment with PICC line while 4 (3.57%) patients lost follow-up. Conclusion: PICC - lines are an essential element of cancer treatment in children. Anesthesia-led PICC line service is a reliable option. They maintain operating room, PICC line sterility during insertion, and complications comparable to follow the recommended precautions.

Bioética e Eras: um microcosmo relevante

Abstract The objective of this article is to present a reflection on the concepts and applications of bioethics, its relationship with the development of the moral competence of health professionals, as well as to suggest strategies to mitigate ethical dissonances and clash of paradigms, which can become facilitators of other protocols or institutions. This is an experience report on developing a local protocol to accelerate pediatric cardiac surgical recovery. During this process, the health personnel presented critical points of discussion and dissonance related to venous access, anesthetic induction, parental presence, and pain control. Several reasons were presented and interpreted according to the four main scientific philosophical currents. Considering and reviewing bioethical principles was necessary, especially the autonomy applied to minors and the interrelationship between the principles and their hierarchy of importance. This reinforces the importance of continuing education and the role of medical ethics committees.

Pericardial Effusion and Superficial Abdominal Abscess as Complications of Malposed PICC Line in a Preterm Neonate: A Case Report

In neonatal critical care units, peripherally inserted central catheter lines are frequently used to provide venous access for continuous parenteral nutrition and medications in newborns. In this case report, a male neonate weighing 1270 grams was on Continuous Positive Airway Pressure (CPAP) for hyaline membrane disease and initially received Total Parenteral Nutrition (TPN) through a Peripherally Inserted Central Catheter (PICC) in the left long saphenous vein on the second day. The baby developed tachycardia, respiratory distress requiring mechanical ventilation, and erythematous swelling over the paraumbilical region. A diagnosis of pericardial effusion and superficial abdominal abscess secondary to a malposed PICC line in a preterm, very low birth weight neonate was made. Suspecting a misplaced line, it was immediately removed, and the patient showed improvement over the next 24 hours. Within the next 48 hours, the patient was extubated to CPAP. Therefore, daily inspection by an expert, as well as confirmation of the central line tip, will aid in preventing delays in detecting complications.

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

Clinical trial registration number: NCT02950168, NCT02951039.

Clinical application of ultrasound-guided totally implantable venous access ports implantation via the posterior approach of the internal jugular vein.

To determine the feasibility and safety of ultrasound-guided totally implantable venous access port (TIVAP) implantation via the posterior approach of the internal jugular vein (IJV). From September 2021 to August 2022, 88 oncology patients underwent ultrasound-guided implantation of TIVAPs via the posterior approach of the IJV for the administration of chemotherapy. The catheter tip was adjusted to be positioned at the cavoatrial junction under fluoroscopic guidance. Clinical data including surgical success, success rate for the first attempt, intraoperative, and postoperative complications were all collected and analyzed. All patients underwent successful surgery (100%), whereby 58 were via the right IJV and 30 via the left IJV, and the success rate for the first attempt was 96.59% (85/88). The operation time was 20 to 43 minutes, with an average of 26.59 ± 6.18 minutes with no intraoperative complications. The follow-up duration ranged from 1 to 12 months (mean = 5.28 ± 3.07) and the follow-up rate was 100%. The rate of postoperative complications was 4.55% (4/88), including port-site infection in two cases, fibrin sheath formation in one case, and port flip in one case. No other complications were observed during follow-up. Ultrasound-guided TIVAP implantation via the posterior approach of the IJV is feasible, safe, and effective, with a low rate of intraoperative and postoperative complications. Not only was the curvature of the catheter device smooth, but patients were satisfied with the comfort and cosmetic appearance. Additionally, we could reduce the possible complications of pinching and kinking of the catheter by using this approach. Therefore, further large-sample, prospective, and randomized controlled trials are warranted.

A retrospective cohort study of implantable venous access port-related and peripherally inserted central catheter-related complications in patients with hematological malignancies in China.

We explored the differences in deep venous catheterization-associated complications between patients with hematological malignancies after peripherally inserted central catheter placement and such patients after implantable venous access port catheterization. peripherally inserted central catheters and implantable venous access ports are the most popular devices used for chemotherapy. However, no study has revealed differences between peripherally inserted central catheters and implantable venous access ports in Chinese patients with hematological malignancies. The clinical data of 322 patients with hematological malignancies who were treated from January 1, 2020 to December 30, 2021 were included in a retrospective cohort study. Postoperative color Doppler ultrasonography and follow-up results were used to compare the incidence rates of deep venous catheterization -associated complications after peripherally inserted central catheters and implantable venous access ports catheterization. The relative risk of catheter-related complications considering the type of device was 8.3 (95% CI = 3.0-22.8). In addition, chi-square segmentation analysis revealed a significant difference in the complication rate between the internal jugular vein and the basilic vein (χ2 = 22.002, p < 0.0001) and between the subclavian vein and the basilic vein (χ2 = 28.940, p < 0.0001). Implantable venous access ports are safer than peripherally inserted central catheters for Chinese patients with hematological malignancies. The implantation of implantable venous access ports could be firstly considered for systematic anti-cancer treatment.

Feasibility and Safety of a Technique Intended to Place the Catheter Tip in the Right Atrium without Abutment Against the Cardiac Wall during Implantation of the Totally Implantable Venous Access Port.

To assess the safety and feasibility of intentionally positioning the catheter tip in the right atrium (RA) without an abutment during implantation of a totally implantable venous access port (TIVAP). We enrolled 330 patients who had undergone TIVAP implantation between January and December 2016 and postoperative chest CT. The TIVAP was placed using the single-incision technique to access the axillary vein directly from the incision line. To position the catheter tip in the RA without abutment, blood return was checked before cutting. Catheter length and complications were evaluated by retrospectively reviewing medical images and records. All patients achieved successful catheter tip positioning without abutment or dysfunction. The median tip position was 15.3 mm distal to the cavoatrial junction (CAJ) on fluoroscopy and 6 mm distal to the CAJ on CT. Catheter tips migrated a median of 10.4 mm cephalically on CT compared to fluoroscopy. Thromboses were detected in the RA and superior vena cava in one patient each. Intentional catheter tip positioning in the RA without abutment is a safe and feasible technique with a low incidence of thrombosis and no observed dysfunction.

Use of the transfemoral access approach for cardiac stimulation device implantation when the superior venous approach is not feasible: A single-centre twenty-year series

Background: When permanent cardiac stimulation device implantation via superior venous access (i.e., cephalic, axillary or subclavian veins) is not possible or advisable, safe and feasible surgical alternatives must be used. The transfemoral approach is relatively unknown; therefore, it is seldom used and studied. This single-centre study analysed the 20-year outcomes of patients who underwent implantation using a transfemoral implantation approach. Methods: Data on the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analysed for all patients who underwent permanent cardiac stimulation device implantation using the transfemoral approach between June 2001 and December 2021. Results: A permanent cardiac stimulation device was implanted using the transfemoral approach in 66 patients (mean age, 76 years [range: 45-96], 40 [60%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 36 patients and atrial fibrillation in 11 patients. The mean implantation time was 61 min (range: 20-210), and the mean fluoroscopy time was 7.9 min (range: 0.2-87). The minimum follow-up period was one year (December 2022), with a mean of 60 months [range: 2-180]). Overall, 26 patients (42%) were treated with oral anticoagulants postimplantation. No deaths, septic episodes, or severe complications were associated with the procedure in the short or long term. Follow-up data were available for 64 patients, of whom 52 (81%) died during follow-up (mean age, 84 years [range: 55-101]). No deaths were associated with the use of the transfemoral technique. Conclusions: Permanent cardiac stimulation device implantation using the transfemoral access approach is feasible and straightforward for an experienced implant surgeon. The outcomes of systems implanted by the transfemoral access approach were comparable to those of systems implanted by the superior venous approach, and no severe complications were observed at the 20-year follow-up.

Living, Caring, Learning - Thinking outside the box to solve care challenges in a rare blood disorder

Abstract A specialist nurse for over 20 years, Sandra reflects on her experience of finding ways to deliver effective care for a young girl with a very rare clotting disorder. Symptoms of the girl’s disorder were evident from birth and through an emergency use request Sandra and the care team enabled her family to access a treatment that at the time was in clinical trial. Poor venous access meant there was a need to adapt how treatment was administered and she worked with the girl’s parents to ensure that she was treated effectively. Alongside educating the parents, Sandra highlights the importance of her role in educating co-workers and other hospital staff likely to come into contact with the girl, to ensure that she always had access to timely and appropriate care. She also reflects on other instances where thinking creatively enabled patients in her care access to treatments that may not otherwise have been accessible. Now retired, Sandra continues to be involved in advocacy for people with bleeding disorders.

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.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis.

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood. This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care. Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched. Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included. Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used. Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor). Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications. This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis.

Indwelling invasive devices inserted into the body for extended are associated with infections. This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare. Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched. Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) postinsertion infection complications, and (4) published in English, were included. Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used. Device local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported. A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58). Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

The Impact of Cold Spray and Ice Application During Intravenous Access on Pain and Fear in Children Aged 7-15 Years in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionMany strategies have been developed to prevent procedural pain in pediatric emergency units, where nurses play a vital role in ensuring patient comfort. Easy-to-use and inexpensive nonpharmacologic analgesic methods are important in emergency units. This study was conducted to determine the effect of cold spray and ice applied during venipuncture on the level of fear and pain in children aged 7 to 15 years. MethodsThis was a randomized controlled experimental study of 96 children between the ages of 7 and 15 years (cold spray group, ice group, and control group) who were scheduled to have venous access in the pediatric emergency clinic and met the sampling criteria. ResultsEvaluations of the children, parents, and observers in the groups found a statistically significant difference between the pain and fear scores after the intervention compared with the preintervention (P < .001). The pain and fear scores of the children in the control group were higher than the scores of those in the spray and ice groups (P < .001); the pain and fear scores of the children in the spray group were lower than the scores of the children in the ice group and statistically significant (P < .001). DiscussionIn conclusion, cold spray applied during intravenous access in children aged 7 to 15 effectively reduces pain and fear and should be used in the emergency unit.

Precise Terminology and Specified Catheter Insertion Length in Ultrasound-Guided Infraclavicular Central Vein Catheterization.

Background and Objectives: As the latest research encourages the ultrasound-guided infraclavicular central venous approach, due to the lateral puncture site displacement, in comparison to the anatomical landmark technique based on subclavian vein catheterization, the need to re-calculate the optimal catheter insertion length and possibly to rename the punctuated vessel emerges. Although naming a particular anatomical structure is a nomenclature issue, a suboptimal catheter position can be associated with multiple life-threatening complications and must be avoided. The main study objective is to determine the optimal catheter insertion length by the most proximal ultrasound-guided, in-plane infraclavicular central vein approach, to compare results with the anatomical landmark technique based on subclavian vein catheterization and to clarify the punctuated anatomical structure. Materials and Methods: 109 patients were enrolled in this study. All procedures were performed according to the same catheterization protocol. In order to determine optimal insertion length, chest X-ray scans with an existing catheter were performed. The definition of punctuated vessel was based on computer tomography and evaluated by radiologists. Independent predictors for optimal insertion length were identified, prediction equations were generated. Results: The optimal catheter insertion length is approximately 1.5 cm longer than estimated by Pere's formula and can be accurately calculated based on anthropometric data. Computed tomography revealed: five cases with subclavian vein puncture and three cases with axillary vein puncture. Conclusions: Even the most proximal ultrasound-guided infraclavicular central vein access does not guarantee subclavian vein catheterization. A more accurate term could be infraclavicular central venous access, with the implication that the entry point could be through either subclavian or axillary veins. The optimal insertion length is approximately 1.5 cm deeper than the length determined for the anatomical landmark technique based on subclavian vein catheterization.

Removal of stuck tunnelled dialysis line requiring cardiopulmonary bypass and venous repair.

Tunnelled central venous dialysis catheters can usually be removed easily. However, their removal can become rarely complicated requiring more invasive techniques. We report a case in which cardiopulmonary bypass and repair of great veins was required for safe removal. A 38-year-old female with end-stage renal failure and a 3-year-old Hickman line inserted into her right internal jugular vein was referred to our cardiac surgical unit following failed attempts of line removal by local vascular surgical team using open vascular surgical techniques. As a result, an MDT decision was made that it was safer to proceed to a cardiothoracic surgical approach rather than other techniques. Investigations showed significant calcification surrounding the line which was adherent to the venous wall. Removal of the retained catheter required median sternotomy and the use of cardiopulmonary bypass as the great veins had to be opened to free the line and allow complete removal. The line was successfully removed with its encircling calcified sheath, and the veins were closed primarily without needing a patch repair. The integrity of the great veins was maintained to meet the on-going need this young patient has for central venous access. The patient made an uneventful recovery. When other measures fail, sternotomy and cardiopulmonary bypass provide a safe option for complete removal of stuck central venous catheters with low risk to the patient.

Use of Peripheral Intravenous Access in Patients Undergoing Chemotherapy for Testicular Cancer.

Systemic chemotherapy, depending on the regimen, can be administered through peripheral intravenous (pIV) access or through central venous access devices (CVADs). There is no current best practice regarding optimal access for chemotherapy for patients with testicular cancer (TC). We retrospectively evaluated patients undergoing systemic chemotherapy for TC and compared baseline characteristics and complications of patients using pIV versus CVADs. We included patients with TC who underwent first-line systemic chemotherapy at the University of Colorado Hospitals from 2005 to 2020. Data were collected on demographics, cancer characteristics, type, duration of chemotherapy, pIV or CVAD use, and associated complication rates. We then performed univariate and multivariate regression analyses to compare complication rates and risk factors for each group. One hundred fifty-four patients met inclusion criteria. Ninety-two (60%) patients used CVADs, and 62 patients (40%) used pIV for their initial treatment. Only six (9.7%) of 62 patients transitioned from pIV to CVADs during therapy. Similarly, 10 of 92 (10.9%) patients with initial CVAD needed to transition to a different type of CVAD or to pIV (P = .81). There were a greater number of venous access-related complications (48 of 92 patients, 52.2%) and overall thrombotic events (33 of 92 patients, 35.9%) for the CVAD group (P > .001) when compared with the pIV group. We observed an association between the following factors and venous access-related complications during chemotherapy: higher stage TC, increased total chemotherapy cycles, and delayed therapy. Peripheral IV use for first-line nonvesicant chemotherapy in patients with TC appears to be well tolerated with high rates of therapy completion and lower rates of complications when compared with CVADs. These data support our preferred treatment approach and provide evidence that pIV access is a safe and effective way to deliver chemotherapy for patients with TC.

Usefulness of the intracardiac electrocardiogram recorded using central venous catheters on P-wave magnification

BackgroundThe detection of atrial electrical activity is extremely valuable in recognizing complex cardiac arrhythmias. However, P-wave detection on a surface electrocardiogram (S-ECG) can sometimes be challenging. The intracardiac electrocardiogram (IC-ECG), recorded by a central venous catheter loaded with saline solution, has proven to be a safe and effective method for amplifying atrial electrical activity. We aim to compare the P-wave amplitude recorded in the S-ECG and the IC-ECG in different venous accesses, catheters, heart rhythms, and atrial dimensions. MethodsWe compared the P wave amplitude obtained by the IC-ECG and the S-ECG recordings from cardiac intensive care unit patients. ResultsIn 109 nonconsecutive patients, a total of 166 IC-ECG were collected. The median amplitude of the P wave was 0.1 (0.083–0.3) mV in the S-ECG and 0.4 (0.25–2.4) mV in the IC-ECG; p < 0.001. This difference remained significant regardless of the patient's heart rhythm, left atrial dimension, and catheter or vascular access used. ConclusionThe IC-ECG acquired using central venous catheters significantly increases atrial electrical activity signals. This technique might help identify complex cardiac arrhythmias.

Onkolojik Hastalarda İnternal Jügüler Ven Yoluyla Venöz Port Implantasyonu- Tek Bir Genel Cerrahın Deneyimi

Central venous access is pivotal for patients undergoing repetitive chemotherapy, hemodialysis, blood transfusions, total parenteral nutrition, and blood tests. This study aims to present the single-center experience of a general surgeon in Totally Implantable Access Port (TIAP) implantation under general anesthesia using ultrasonography and fluoroscopy guidance and assess early and late complications. A retrospective study was conducted on patients who underwent TIAP implantation between January 2020 and December 2022. Patients eligible for intravenous chemotherapy with solid tumors were included. A single general surgeon performed the procedures. General anesthesia was administered in all patients, and a percutaneous Seldinger technique was utilized. Early and late complications were monitored, and relevant data were collected. The study comprised 186 patients with a median age of 46, predominantly female (65.1%). The overall success rate was 99.5%. Early and late complications occurred in 1.6% and 5.9% of cases. The most common late complications were pocket infection (1.6%) and symptomatic thrombosis (1.6%). Port migration occurred in one patient but was promptly corrected. No pneumothorax cases were observed. Port removal was performed in 92 patients upon chemotherapy completion. Implantation of TIAPs under general anesthesia, guided by ultrasound and fluoroscopy, resulted in a high success rate and low complication rate when performed by a skilled general surgeon. These findings underscore the safety and efficacy of TIAP implantation under general anesthesia in a private hospital setting. The study contributes to the growing body of evidence supporting general surgeons in providing effective and safe TIAP implantation for oncology patients, potentially expanding its availability in diverse clinical settings.