PICC insertion and veins of the arm size variation during dialysis treatment: A prospective observational study.

BACKGROUND: Peripherally Inserted Central Catheters play an increasingly important role in Central Venous Access Devices. However, the use of these devices should be carefully considered in specific situations such as central catheterisation in patients with chronic kidney disease. When evaluating the feasibility of placement for a patient undergoing dialysis, the relationship between changes in circulating volume before and after dialysis treatment, and potential variations in the size of deep veins in the upper limbs, should be considered. MATERIALS: Upper limb veins, specifically the basilic or brachial veins, were identified and measured before and after dialysis treatment. Patient data and weight loss data during dialysis treatment were also collected. Linear regression analysis was performed to assess the correlation between the variables. RESULTS: The average variation in vein size for the entire sample was +0.17 ± 0.43 mm. The mean volume removed was 2.2 ± 0.8 l. In subgroup 1 (fluid volume loss <2000 ml), the population experienced a decrease in the measured vein size after dialysis. In subgroup 2 (fluid volume loss ⩾2000 ml), the population experienced an increase in the measured vein size after dialysis. CONCLUSIONS: Upper arm vascular access placement in dialysed patients with fluid removal of less than 2000 ml should be performed after the dialysis session. Conversely, in dialysed patients with fluid removal of more than 2000 ml, where a significant increase in vein size was observed, vascular access placement should be performed before the dialysis session when the veins are smaller. Additionally, it should be noted that in patients with chronic kidney disease, the venous system of the upper limbs should be preserved as much as possible to prevent thrombosis and stenosis in potential arteriovenous fistula creation.

Midline catheters for blood gas and acid/base monitoring in critical patients: A prospective observational study.

BACKGROUND: Arterial lines and central venous catheter (CVC) allow to monitor patients' acid-base status and gas exchange. Their placement and maintenance may however be burdened by severe complications. Midline Catheters (MC) are peripheral venous accesses that are less invasive and easier to insert compared to CVC and arterial lines. METHODS: A prospective observational study was performed including stabilized critical patients with clinical indication to midline positioning before intensive care unit (ICU) discharge. The primary aim was to assess if venous sampling from MCs can be a reliable alternative to CVC for pH and CO2 monitoring. The secondary aim was to evaluate the correlation between samplings from MC, CVC and arterial line with regards to pH, carbon dioxide tension (pCO2), lactates and electrolytes. Three samples from CVC, arterial line and MC were collected simultaneously. Agreement and correlation of the studied parameters between different sampling sites were explored. RESULTS: 40 patients were included in the analysis. A good agreement for pH and pCO2 was recorded between MC and CVC: mean differences were 0.001 (95% CI -0.006 to 0.007) and 0.7 (-0.1 to 1.5), percentage error 0.4% and 11.2%, respectively. Correlation between MC and both central venous and arterial samples for pH, pCO2, lactates and electrolytes was found to be moderate-to-strong (Pearson's R coefficient range 0.59-0.99, p < 0.001 for all these parameters). CONCLUSIONS: In stabilized critical patients, midline catheters represent a reliable alternative to CVC and arterial lines to monitor acid-base disturbances, CO2 levels and electrolytes. The present findings add to the known advantages of MC, which might be considered a first-line vascular access for non-critical or stabilized patients who do not require infusion of vesicant or irritant drugs.

Management of vascular access for extracorporeal life support: A cohort study.

Extracorporeal membrane oxygenation (ECMO) is required for patients with refractory cardiac or respiratory failure. Inadequate securement of ECMO cannulae may lead to adverse events, ranging from line kinking to catastrophic accidents, such as air entrainment into the circuit or massive bleeding. Furthermore, the micro-motion of the cannulae at the entry site might increase the risk of local infections. Since 2015, we implemented a written protocol for management of ECMO cannulae and tubing, which specifically includes the securement of each cannula with three sutureless devices. The aim of the present study was to retrospectively assess cannulae micro-motion and the rate of bleeding events at the insertion site. Secondarily we aimed to evaluate the impact of prone positioning maneuvers during ECMO on these events. We performed a single-centre retrospective analysis of prospectively collected data on nursing care of ECMO cannulae. We included adult patients treated with veno-venous (V-V) or veno-arterial (V-A) ECMO between 2015 and 2018 in our general intensive care unit. The distance between the insertion site and the end of the wire-wound part of the cannula was recorded daily. Variations of this distance (defined as "cannula micro-motion") were recorded. Forty-five ECMO consecutive adult patients (40 V-V and 5 V-A) were included. No accidental cannula dislodgement was recorded. Median daily "cannula micro-motion" was 0.0 (-0.5 to 0.2) cm, without any significant difference between ECMO configuration, cannula type, and insertion site. Twelve patients (26%) presented at least one bleeding episode at cannula insertion site, none of which required surgical intervention. In the subgroup of patients who underwent prone positioning, no difference in cannulae micro-motion was recorded. An ECMO nursing protocol for cannulae management providing sutureless devices for cannula and tubing securement allows safe line stabilization, with the potential to reduce complications related to ECMO vascular access.

One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study.

OBJECTIVES: Patients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic. DESIGN & SETTING: Single-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021. RESULTS: One hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9-16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6-9, range: 2 - 17). Median duration of ECMO support was 14 days (IQR: 9-24), whereas the ICU stay was 24 days (IQR:18-44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549). CONCLUSION: In this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.

Femorally inserted central catheters with exit site at mid-thigh: A low risk alternative for central venous catheterization.

BACKGROUND: Femorally inserted central catheters are increasingly used, especially after the COVID-19 pandemic, also thanks to widespread of tunneling techniques that allow the exit site to be moved away from the groin. METHODS: In this retrospective observational study, femorally inserted catheters, with exit site at mid-thigh and the tip in Inferior vena cava or in Inferior vena cava at the junction with right atrium, have been observed and complications have been analyzed. All catheters were inserted by trained Nurses of a tertiary hospital Vascular Access Team. RESULTS: In 142 catheters (126 inserted via common femoral vein and 16 inserted via superficial femoral vein) and 3060 catheter days, we observed an infection rate of 1.3 events/1000 catheter days (all of them in oncologic patients and up to 30 days of catheterization), 2 cases of thrombotic events (1.41%) and 17 cases of accidental removal (11.97%). Other rare complications, as primary malposition, tip migration, arterial pseudoaneurysm, have been recorded. The average length of catheters inserted, from the exit site to the tip, was 47.6 ± 2.4 cm. CONCLUSION: The attention to the correct position of the tip, the exit site at mid-thigh and the new techniques during insertion make these femoral catheters as safe as other central vascular access devices. For this kind of central access device, a catheter at least 50 cm long is needed.

Reliability of cutaneous landmarks for the catheter length assessment during peripherally inserted central catheter insertion: A retrospective observational study.

INTRODUCTION: Peripherally inserted central catheters are very common devices for short, medium and long-term therapies. Their performance is strictly dependent on the correct tip location, at the junction between the upper caval vein and the right atrium. It is very important to obtain an estimated measure of the catheter, in order to reach the cavo-atrial junction and optimize the catheter length. Estimated measures are often obtained using cutaneous landmarks. OBJECTIVE: Evaluate the reliability of cutaneous landmark-based length estimation during catheter insertion. Identify any patient's related factors that may affect cutaneous landmarks reliability. METHODS: We used two distinct techniques and collected data about cutaneous landmark-based length estimation, electrocardiographic guided intravascular length, age, weight and height. We studied the reliability of possible correcting factors, balancing the error average by regression models, and we found and tested two different models of prediction. RESULTS: A total number of 519 patients were studied. The average bias, between the two studied length assessment by cutaneous landmarks and electrocardiographic guided catheter length, were 3.77 ± 2.44 cm and 3.28 ± 2.57 cm, respectively. The analysed prediction models (deviance explained 43.5%, Akaike information criterion = 1313.67% and 43.4%, Akaike information criterion = 1313.92), fitted on the validation set, showed a root mean square error of 3.07 and 3.06. CONCLUSION: Landmark-based length estimation for preventive catheter length assessment seems to be unreliable, when associated with post-procedural tip location. They are useful for distal trimming catheters to optimize the 'out of skin' portion when associated with electrocardiographic tip location. Models identified for balancing bias are probably not useful.

Ultrasound-guided tip location of midline catheters.

INTRODUCTION: Midline catheters are widely used in clinical practice. Proper placement of midline catheter tip is usually assessed only by aspirating blood and flushing with normal saline without resistance. PURPOSE: To describe the ultrasound-guided tip location for midline catheters and its feasibility and to compare incidence of catheter-related venous thrombosis associated with or without ultrasound tip localization. METHODS: The ultrasound-guided tip location is described step by step. Feasibility of the technique and incidence of catheter-related venous thrombosis were measured (study group) and compared with two historical groups: study group, 20-cm midline catheters inserted with ultrasound-guided tip location; group 1, 25-cm midline catheters inserted without ultrasound-guided tip location and group 2, 20-cm midline catheters inserted without ultrasound-guided tip location. RESULTS: In the study group, ultrasound-guided tip location was easily feasible in 98.9% of patients. Incidence of catheter-related venous thrombosis was 2.42% in control group 1, 9% in control group 2 and 2.62% in the study group. DISCUSSION: In the study group and control group 1, the tip was placed in the axillary vein, about 3 cm distal to the clavicle and in the subclavian vein. In control group 2, the tip was probably located at the transition between the axillary and the subclavian vein. It is possible that such position may have been associated with an increased incidence of catheter-related venous thrombosis. CONCLUSION: The ideal position of the tip of a midline catheter might be inside the axillary vein, about 3 cm distal to the axillary-subclavian transition or inside the subclavian vein. Ultrasound-guided tip location is safe, inexpensive, easy and potentially useful during midline catheters insertion.

How different helmet fixing options could affect patients' pain experience during helmet-continuous positive airway pressure.

BACKGROUND: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. AIMS AND OBJECTIVES: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: 'armpits strap' versus 'counterweights system'. DESIGN: This was a non-randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. RESULTS: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0-10 scale was: 0·5 ± 1·4 at T0 (baseline), 1·5 ± 2·0 at T1 (after 1 h) and 2·6 ± 2·5 at T2 (end of cycle) (p = 0·023). The same analysis was performed for the counterweights fixing option. The mean score was 0·3 ± 0·6 at T0 , 0·3 ± 0·2 at T1 and 0·5 ± 0·7 at T2 (p = 0·069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3·0 ± 1·0 and 3·9 ± 2·3 h, respectively (p < 0·001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0·23 ± 0·20 cm2 . After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0·27 ± 0·21(p = 0·099) and 0·30 ± 0·25, respectively (p = 0·080). CONCLUSIONS: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. RELEVANCE TO PRACTICE: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience.

[Enteral nutrition during prone positioning in mechanically ventilated patients]. / Nutrizione enterale continua durante la postura prona in pazienti in ventilazione invasiva.

. Enteral nutrition during prone positioning in mechanically ventilated patients. INTRODUCTION: The Enteral Nutrition (EN) tends to be stopped during prone positioning to prevent the risk of acid reflux and vomiting. AIMS: To compare the gastric residual volume during continuous enteral nutrition in patients in prone and supine position. METHODS: Observational restrospective study on Acute Respiratory Distress Syndrome patients, mechanically ventilated, with continuous enteral nutrition implemented according to the same protocol, in prone and supine position. RESULTS: The 25 patients included had a mean age of 51.13±15.93 (range: 16-80) years. Gastic residual volume was checked on 656 occasions (408 in supine and 248 in prone position). Mean infusion rate was 63.3±18.5 ml/h: 62.1±18.9 ml/h in supine and 66.2±16.5 ml/h in prone position. The mean overall gastric residual volume was 24.4±54.2 ml: 20.6±18.9 ml in supime and 23.6±50.0 ml in prone posizion. In 4 occasions (2 in prone and 2 in supine position9, the gastric residual volume was > 300ml; EN was interrupted on 1 occasion with a gastric residual volume >500ml. CONCLUSIONS: No clinically relevant differences of gastric residual volume were observed in prone and supine position. A protocol for the management of gastric residual volume allows a safe and effective administration of EN also in patients positioned for several hours in prone position.

"Extended subcutaneous route" technique: a quick subcutaneous tunnelling technique for PICC insertion.

PURPOSE: To describe a quick tunnelling technique for peripherally inserted central catheter (PICC) insertion called the "extended subcutaneous route" technique. METHODS: The "extended subcutaneous route" technique is described step by step. RESULTS: In 18 consecutive PICCs, inserted with extended route technique in ASST Monza, no complications during insertion were registered. In 969 catheter days observed, we identified only one accidental dislodgement. No other mid-term complications were observed. CONCLUSIONS: Extended subcutaneous route technique allows the creation of a subcutaneous tunnel <5 cm, without skin incision and additional manipulation. Extended subcutaneous route technique may be feasible and useful, particularly for patients with high risk of bleeding or infection.

[Isolation precautions in multi drug resistent infections and nursing workload in a general intensive care unit]. / Misure di isolamento per infezioni da microorganismi multiresistenti e carico di lavoro infermieristico in una terapia intensiva polivalente.

BACKGROUND: Critically ill patients in ICU are exposed to high risk of hospital acquired infections. In recent years, the multi drug resistant microorganisms (MDR) represent the most worrying epidemiological problem. AIM: The aim of this study is to evaluate the relationship between isolation precautions and nursing workload. METHODS: We studied patients who had an infection by MDR, subject to isolation precautions, and measured their NAS score during stay in ICU. MDR infections of studied patients were: Acinetobacter Baumannii, Klebsiella KPC, MRSA, Pseudomonas, Escherichia coli, Serratia marcescens e Clostridium difficile. Isolation precutions wer identified by color code (green, yellow, red). RESULTS: We studied 44 patients during the year 2012. NAS average was 81.54 ± 10.25. NAS average for "green code" patients was 81.25 ± 22.12, for "yellow code" patients was 82.57 ± 11.25 and for "red code" patients was 79.06 ± 29.12. DISCUSSION: the presence of isolation precautions seems to have no influence on nursing workload measured by NAS score, except for Acinetobacter Baumannii infection. Further research will be needed for better evaluation of this topic.

In vitro evaluation of fluid reflux after flushing different types of needleless connectors.

PURPOSE: To evaluate fluid reflux, when disconnecting syringe, for different needleless connectors. MATERIALS: Nine connectors were tested; 540 measurements were carried out. RESULTS: The connectors tested showed very different performances, about reflux, on disconnection of the syringe used for flushing.The calculated reflux volumes are: Max Zero® - BD: 6.90 (±2.47) mm3; MicroClave Clear® - ICU Medical: 6.14 (±1.46) mm3; Bionecteur® - Vygon: 1.24(±0.73) mm3; Neutron® - ICU Medical: 0.12 (±0.15) mm3; SmartSite® Carefusion: 33.51 (±11.50) mm3; Safe Plus® - Cremascoli: 23.54 (±3.56) mm3; NeutraClear® - Cair: 9.36 (±1.87) mm3; NeutroX® - Cair: 0.33 (±0.31) mm3; Dasa® BTC: 2.38 (±1.67) mm3.Differences between investigated devices were statistically significant (p<0.001). DISCUSSION: It is difficult to establish the best quality-price ratio for needleless connectors. It is important to consider several variable factors: continuous or discontinuous infusion, catheter type, usage environment and caliber of catheter used. It would therefore be useful to have an indication of the intraluminal space potentially affected by blood reflux in relation to a specific device. CONCLUSIONS: Needleless connector is one of the main factors involved in keeping catheter patency. It is important to perform the best choice among the connectors available.An empirical reflux measurement, relative to the needleless connector and the catheter in use, can be obtained using an 18G cannula.

[Evaluation of tip location reliability of intraprocedural ECG vs. chest Xrays in PICC placement]. / Posizionamento della punta del catetere durante l'impianto di PICC: analisi retrospettiva dell'affidabilità del metodo ECG vs. controllo radiologico.

. Evaluation of tip location reliability of intraprocedural ECG vs. chest Xrays in PICC placement. INTRODUCTION: Among the methods to assess the correct positioning of the tip of central venous catheters, the ECG method is safe and reliable. AIM: To compare the reliability of tip location by intraprocedural ECG and post-procedural radiological examination as implemented in routine care in a tertiary hospital PICC Team. METHODS: 119 PICCs positioned by the Monza hospital PICC Team were examined positioned by either ECG technique or post procedural x-rays technique. The tip location was assessed in retrospect, through occasional chest ray reports. We assessed the reliability of the ECG and X rays techniques. RESULTS: In the ECG group (75 catheters), 71 (95.7%) were correctly located vs 33/44 (75%) in the x-rays group. CONCLUSIONS: Tip location by ECG technique implemented by the PICC team is feasible and safe. The cost/benefit ratio suggests its adoption as main tip location technique.

[The impact of closed system and 7 days intravascular administration set replacement on catheter related infections in a general intensive care unit: a before-after study]. / Efficacia della linea chiusa e sostituzione delle linee infusionali ogni 7 giorni sulle infezioni da catetere vascolare in una terapia intensiva polivalente: studio pre-post.

INTRODUCTION: The incidence of catheter related Bloodstream infections (BSI) is high in intensive care units (ICU). AIM: To evaluate the BSI rate in a population of patients admitted to a General ICU before and after the implementation of the 2011 CDC guidelines. METHODS: Retrospective observational study on patients admitted from January 2009 to December 2013. The infusion and monitoring lines were changed every 96 hours for the first 30 months, and every 7 days for the next 30. In all patients a closed infusion line with needle-free connectors pressure was used (Microclave). The following catheters were considered in the study: central venous catheter (CVC), arterial cannula (ART) and Swan Ganz catheter (SG). RESULTS: During the period with change every 96 hours 15 BSI were observed over 13395 catheters/days (C/D), 1.12 per 1000 C/D, while when lines where changed every 7 days 11 BSI were observed over 13120 C/D, 0.83 per 1000 C/D. A statistically significant reduction of BSI was observed in SG catheters (4.17 vs. no BSI p = 0.02), while the CVCS (1.12 vs 1.45 - p = 0.37) and ART (0.35 vs 0.36 - p = 0.61) infection rates remained unchanged. CONCLUSIONS: The replacement of infusion lines every 7 days in our sample did not increase the BSI, helping to reduce the costs.

[Utilization of Behavioral Pain Scale and Critical Care Pain Observation Tool for pain evaluation in Intensive Care Unit]. / Utilizzo della Behavioral Pain Scale e della Critical Care Pain Observation Tool per la rilevazione del dolore in una terapia intensiva polivalente.

AIM: To compare two evaluation pain scale the Behavioral Pain Scale (BPS) e Critical Care Pain Observation Tool (CPOT) in Intensive Care Unit in the Azienda Ospedaliera di Monza, and their correlation. To evaluate if consciousness level (evaluate through a third scale the Ritchmond Agitation Sedation Scale - RASS) influence the use of the pain scales. METHODS: 1083 data were collected from May 2012 and November 2012. The sample was made up by 36 patients, of these 20 men and 16 women, average age of 62,94±13,21 and hospital stay on average of 17±12 days. RESULTS: BPS median is 3 (Q1: 3 - Q3:3 - range 3-12), CPOT median is (Q1-Quartile 25%: 0 - Q3- Quartile 75% : 1, range 0-8), RASS median is-1 (Q1: -4, Q3: 0 - range 0/- 5). Corellational coefficient is 0.784. There is a overall difficulty on use BPS and CPOT expecially with individuals with RASS -1. CONCLUSIONS: Results of this study suggest the need to carry out further research, expanding the validation of the pain scales for patients not able to speach to unexplored patients.

[Level of sedation level and modifications of vital signs during hygienic care in patients admitted to an intensive care unit]. / Livello di sedazione e alterazioni dei parametri vitali durante le cure igieniche nei pazienti ricoverati in una terapia intensiva polivalente.

INTRODUCTION: Hygienic care practices may represent a source of stress for intensive care patients. AIM: To identify the hygienic care practices more involved in changes of vital signs and the association to the level of sedation. METHODS: Prospective observational study of eleven patients admitted to a general intensive care unit, observed for three consecutive hygiene care morning practices. A protocol for standardizing hygiene practices was adopted. Vital signs were recorded on an electronic database at the beginning of each of the following phase: before the start of hygiene, of mouth cleaning, of sponge bath, positioning of bedpan, first and second side rotation, change of position of endotracheal tube and replacement of tapes, and at the end of hygiene. RESULTS: 29 events of hygiene practices were observed in the 11 patients included in the study (the measurements of three events were discarded). Significant vital signs alterations were induced mainly by the rotation and change of position of the orotracheal tube. Significant correlations were observed between changes in Heart Rate and Bispectral Index (BIS) (coefficient of 0.345; P: 0.329), between BIS and systolic arterial blood pressure (0.774, P: 0.009), BIS and Tidal Volume (-0.569, P: 0.086), and BIS and Respiratory Rate (0.707, P: 0.022). CONCLUSIONS: The hygienic care in intensive care patients may negatively impact on vital signs. Some nursing manoeuvres cause variations of the vital signs also related to changes in the state of consciousness caused by possible defects or excesses of sedation. The sedation level, during hygienic care, should be constantly monitored.