Search

Abstract Background IV access is a commonly performed procedure that is often taught based on tradition rather than evidence. The effect of arm retroflexion on vein width, either alone or in combination with a tourniquet or general anesthesia (GA), remains unclear. In this case, the sonographically measured vein width is a surrogate parameter for the success of the puncture. Methods Prospective, cross-sectional study involving 57 patients scheduled for surgery in general anesthesia. We analyzed the impact of arm retroflexion, tourniquet, general anesthesia, and their combinations on the antebrachial veins in supine patients by ultrasound. Measurements were taken awake and during general anesthesia, each with and without the application of a tourniquet, and in three different arm positions (0°, 30°, and max° retroflexion) each. Data are presented as median and interquartile range [IQR]. Results Tourniquet application (AT) had the greatest single effect on Cubital vein outer diameter compared to the baseline value of all measures (3.9 mm [3.4–5.1]; 4.8 mm [4.1–5.7], P = 0.001, r = 0.515). This effect was surpassed by the combination of AT and GA (5.1 mm [4.6–6.6], P = 0.001, r = 0.889). In contrast, retroflexion alone did not result in an increase at either 30° (4.2 mm [3.7–5.1], p = 1.0, r = 0.12) or max° (4.2 mm [3.6–4.9], p = 0.72, r = 0.23). With GA and AT, no further enlargement was measurable by 30° (5.4 mm [4.6–6.6], p = 1.0, r = 0.15) or max° (5.4 mm [4.6–6.6], p = 1.0, r = 0.07) retroflexion compared to GA-AT-0° (5.1 mm [4.6–6.6], p = 1.0, r = 0.15). Conclusions This study provides evidence that retroflexion of the arm in supine patients, whether alone or in addition to a tourniquet or general anesthesia, does not have any additional effect on vein width as a surrogate parameter for successful IV success. It shows for the first time that general anesthesia effectively increases vein diameter. Trial registration DRKS00029603 (date of registration 07.07.2022).

Abstract Introduction Physicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD). Methods This is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the “PICC” team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs. Results The UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the “PICC” team. Conclusion Contamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

Nicholas Mielke,1 Yuying Xing,2 Steven Matthew Gibson,3 Emily DiLoreto,4 Amit Bahl4 1Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA; 2Corewell Health Research Institute, Royal Oak, MI, USA; 3Vascular Access Consulting, Henderson, KY, USA; 4Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USACorrespondence: Amit Bahl, Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, 3601 13 Mile Road, Royal Oak, MI, 48073, USA, Email amit.bahl@corewellhealth.orgObjective: Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC).Methods: This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices.Results: A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001).Conclusion: This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.Keywords: peripheral intravenous catheter, venous access, vascular access score, traditional insertion, operation stick, palpation method

Introduction: Perioperative 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. Methods: A 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. Results: A 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. Significantly more patients received a preoperative blood transfusion in patients 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. Conclusion: We 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.

Abstract Background Venous access devices commonly used in clinical practice for long-term chemotherapy of breast cancer include central venous catheters (CVCs), peripherally inserted central venous catheters (PICCs), and implantable venous access ports (IVAPs). CVCs and PICCs are less costly to place but have a higher complication rate than IVAPs. However, there is a lack of cost-utility comparisons among the three devices. The aim of this study was to assess the cost-effectiveness of three catheters for long-term chemotherapy in breast cancer patients. Methods This study used propensity score matching (PSM) to establish a retrospective cohort. Decision tree models were used to compare the cost-effectiveness of three different intravenous lines in breast cancer chemotherapy patients. Cost parameters were derived from data extracted from the outpatient and inpatient charging systems, and total costs included costs of placement, maintenance, extraction, and handling of complications; utility parameters were derived from previous cross-sectional survey results of the research group; and complication rates were derived from breast cancer catheterization patient information as well as follow-up information. Quality-adjusted life years (QALYs) were measured for efficacy outcomes. Incremental cost-effectiveness ratios (ICERs) were used to compare the three strategies. To assess uncertainty in model parameters, sensitivity analyses (univariate sensitivity analysis and probabilistic sensitivity analysis) were performed. Results A total of 10,718 patients (3780 after propensity score matching) were included. IVAPs had the smallest cost-utility ratio, and PICCs had the largest cost-utility ratio when left in place for more than 12 months. The incremental cost-utility ratio of PICC to CVC was $2375.08/QALY, IVAP to PICC was $522.01/QALY, and IVAP to CVC was $612.98/QALY. Incremental cost-effectiveness ratios showed that IVAPs were more effective than CVCs and PICCs. Model regression analysis showed that the IVAP was recommended as the best regimen regardless of the catheter indwelling time (6 months, 12 months or more than 12 months). The reliability and stability of the model were verified by single-factor sensitivity analysis and Monte Carlo simulation (probabilistic sensitivity analysis). Conclusion This study provides economic evidence for the selection of vascular access in breast cancer chemotherapy patients. In the case of limited resources in China, establishing a decision tree model comparing the cost-effectiveness of three vascular access devices for breast cancer chemotherapy patients determined that the IVAP was the most cost-effective regimen.

Abstract Objectives Persons who inject drugs (PWID) commonly experience venous degradation as a complication of prolonged injection, which makes routine phlebotomy difficult. Clients may decline care due to the perceived lack of skilled phlebotomy services, and this contributes to significant delays in infectious disease screening and treatment. In this study, we investigated ultrasound-guided phlebotomy in clients with difficult venous access receiving care at two low-threshold buprenorphine clinics. Our objectives were to increase the accuracy of vascular access, expedite infectious disease treatment for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), and increase client satisfaction with phlebotomy services. Methods PWID who declined routine phlebotomy at two clinic sites were offered ultrasound-guided vascular access by a trained clinician. Participants completed a survey to collect data regarding acceptability of the intervention. Results Throughout a 14-month period, 17 participants were enrolled. Of the total 30 procedures, 41.2% of clients returned for more than one phlebotomy visit, and 88.2% of clients achieved vascular access within 1 attempt. Of participating clients, 52.9% described themselves as having difficult venous access and at conclusion of the study, 58.8% expressed more willingness to have phlebotomy performed with an ultrasound device. Conclusions Offering ultrasound-guided phlebotomy for PWID with difficult venous access resulted in decreased access attempts, increased patient satisfaction, and expedited screening and treatment for HIV and HCV point-of-care ultrasound technology is an effective approach to improving care for persons who inject drugs.

Introduction: Surgeons employ central venous catheterization as a therapeutic or preventive measure in the pediatric population. These catheters are introduced into the internal jugular, subclavian, or femoral veins using the central approach, involving the insertion of the needle into the apex of Sedillot's triangle, a well-defined anatomical reference point. Using a neonatal sample, this study ascertained the precise positioning of the internal jugular vein to evaluate its suitability as a central venous catheter insertion site. We also determined the location of the vein in relation to Sedillot's triangle. Materials and methods: Nineteen formalin-fixed neonatal cadavers, encompassing both the left and right sides of the neck region (totaling 38 sides), were dissected to expose the underlying soft tissues and neurovascular structures. Thereafter, the three boundaries of Sedillot's triangle were identified, demarcated, and measured. The internal jugular vein's position within Sedillot's triangle was meticulously recorded, and the diameter of the vein was measured. Results: Among the 38 sides examined, only three exhibited fully formed triangles, with most of the samples featuring a groove instead. When the needle was placed at the apex of Sedillot's triangle (or within the groove), the needle consistently accessed the internal jugular vein only 65.8% of the time. In 23.7% of cases, the apex was observed lateral to the internal jugular vein, and in 10.5% of cases, the apex was positioned medially. Conclusion: The apex of Sedillot's triangle is an unreliable anatomical landmark for the insertion of central venous catheters in neonates. Caution should be exercised when employing this landmark in the absence of ultrasound guidance.

Abstract The distal great saphenous vein is a popular site for venous access by means of percutaneous cannulation or venous cutdown in a hemodynamically unstable patient. The aim of this study was to precisely define the surface anatomy and dimensions of the distal part of the great saphenous vein to facilitate the aforementioned procedures. Cross-sectional anatomy of the distal saphenous vein was studied in 24 cadaveric ankles sectioned at a horizontal plane across the most prominent points of the medial and lateral malleoli. The curvilinear distance from the most prominent point of the medial malleolus to the center of the saphenous vein, its widest collapsed diameter and skin depth were obtained. The great saphenous vein was located at a mean distance of 24.4 ± 7.9 mm anterior to the medial malleolus. The mean widest collapsed diameter was 3.8 ± 1.5 mm. The mean distance from the skin surface to the vein was 4.1 ± 1.2 mm. These measurements could be used to locate the saphenous vein accurately, particularly in hemodynamically unstable patients with visually indiscernible veins.

Abstract Background Catheter-related right atrial thrombosis (CRAT) is an under-studied complication of a long-term implantable venous access devices (IVAD), particularly in children with incidence rates extrapolated from the adult literature ranging between 2 and 29%. This is a single-center retrospective review of electronic medical records of children who underwent insertion of IVADs and had at least one echocardiogram performed prior to catheter removal between 2008 and 2018. Data collection included demographic information, development of CRAT, systemic infection, and administration of thrombogenic chemotherapeutic agents. We identified six patients who developed CRAT and compared them to 120 control patients. We also performed a detailed chart review for the patients who developed CRAT. Data was entered and analyzed using SPSS. Results A total of 764 patients underwent IVAD placement between 2008 and 2018. Six (0.79%) patients developed CRAT, and 120 patients were identified as controls that match the CRAT patients based on definitive criteria that include age, gender, chemotherapy type, steroid therapy, reason of line insertion, site of catheter insertion, tip-location at insertion, and history of systemic infections. In the CRAT group, 3 (50%) patients had their catheter tips placed in the superior vena cava-right atrial junction and 3 (50%) in the right atrium, whereas in the control group, all patients had their catheter tips placed in the superior vena cava-right atrial junction (p=0.000). Five (83.3%) patients in the CRAT group received L-asparaginase as compared to 75 (62.5%) patients in the control group (p=0.301). In the CRAT group, all patients had a history of systemic infection compared to 47 (39.2%) in the control group (p=0.180). Conclusion We identified 6 (0.79%) children with CRAT. Catheter-tip location within the right atrium is a potential risk factor for CRAT development in children.

Background: Because of the high rates of Broviac catheter complications, we started an urgent quality process to reduce this morbidity. The aim is to assess the efficiency of the main actions we have taken in enhancing our practice and improving Broviac outcomes. Methods: We included all neonates and young infants requiring surgical central venous access using a Broviac tunneled catheter. We compared the catheters’ outcomes before and after the implementation of a quality program based on a nurse teaching program, patient selection, and catheter management multidisciplinary protocol. The significance threshold was set at p

Introduction: Venous access is a crucial element in chemotherapy delivery. It remains unclear whether cancer patients prefer a port to a peripherally inserted central catheter (PICC). Our study aimed to assess cancer patients’ satisfaction with their venous access device and to compare the quality of life (QoL) of subjects with a PICC to those with a port. Methods: In this prospective cohort study, EORTC QLQ-C30, and a locally developed quality of life survey (QLAVD), designed to assess satisfaction with venous access devices, were administered to breast or colorectal cancer patients over a one-year period following the device insertion. Mixed effects models were used to assess changes on mean scores at different time points. Results: A total of 101 patients were recruited over a three-year period, (PICC group, n = 50; port group, n = 51). Survey response rates for months one and three were 72% and 48%, respectively. Overall, no significant differences were noted between the two groups in relation to EORTC QOL. At three months, the mean pain scores were 3.5 ± 2.3 for the port and 1.3 ± 0.75 for PICC (p = 0.005). Complications related to PICCs occurred in 38% patients versus 41% with a port (p > 0.24). Conclusions: Although subjects with a port experienced more pain during the device insertion or access for chemotherapy, it had a smaller negative impact on psychosocial scores than the PICC. No significant differences in complications rates were observed between the two devices.

Objectives: The aim of this study was to examine long-term complications developing in venous port catheters inserted in oncological patients. Patients and methods: A total of 205 oncology patients (124 males, 81 females; mean age: 50.1±22.3 years; range, 6 months to 90 years) in whom vascular port catheters were inserted between March 2015 and April 2020 were retrospectively analyzed. The first preference for port catheter application was the right internal jugular vein. If failed, the contralateral internal jugular vein was used. The procedure was carried out in the operating room with ultrasound (US) guidance under general anesthesia. All patients were evaluated in terms of pneumothorax, catheter orientation, and kinking and malposition after the procedure. Results: A total 219 vascular ports were inserted in 205 patients. The indication for port catheter insertion was the receipt of long-term chemotherapy. Catheters were changed in four patients due to infection and in five patients due to catheter migration. The sites of catheter migration were the right atrium in two, the right ventricle in one, the main pulmonary artery in one, and the right pulmonary artery in one patient. Conclusion: Port catheter insertion under US guidance is a well-designed procedure which can be performed with low complication rates by an experienced surgeon in an aseptic environment. Even if complications develop, they can be usually successfully treated in most cases. [Turk J Vasc Surg 2021; 30(2.000): 127-32]

Abstract Background Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through an umbilical venous catheter (UVC) or an intraosseous (IO) access. Preference of one over the other is unclear. We wanted to evaluate practioners’ views. Methods An anonymous online questionnaire was circulated to healthcare professionals with different background and experience, all working in neonatal intensive care units in Germany. The web-based survey consisted of 13 questions and data collection was performed using an online tool. Results We received 502 completed questionnaires, 152 (30%) were from neonatologists, the remainder from residents, fellows and neonatal nurses. For resuscitation of term newborns in the DR 61% of neonatologists vs. 53% of non-neonatologists were in favour of UVC instead of an IO as an emergency access. UVC placement was rated (very) difficult to impossible by 60% of neonatologists and 90% of non-neonatologists (p

Securing stable vascular access is an important clinical skill for the anaesthesiologist. Sick children, complex surgeries, chronic illnesses, multiple hospitalisations, and prolonged treatments can make vascular access challenging. A search was done in the English language literature using the keywords “paediatric,” “vascular access,” “venous access,” and “techniques” or “complications” in Pubmed, Embase, and Google scholar databases. Articles were screened and appropriate content was included. Intraosseous access is a lifesaving technique that can be performed even in hypovolaemic patients rapidly. Transillumination and near-infrared light improve visualisation of superficial veins in difficult access. Ultrasonography has become the standard of care in selecting the vessel, size of catheter, guide placement, and prevent complications. Fluoroscopy is used during insertion of long-term vascular access devices. This article reviews the various routes of access, their indications, most appropriate site, securing techniques, advantages, disadvantages, and complications associated with vascular access in children.

Rahul Pathak, Sumalatha Gangina, Falina Jairam, Kimberly Hinton University of Central Florida School of Medicine and Heart of Florida Regional Medical Center, Davenport, FL, USA Background: We propose that substituting central lines with midlines can help reduce the total number of central line catheter-days as well as central line-associated bloodstream infections (CLABSIs), thereby reducing the associated costs and the resulting increased length of stay. A midline or vascular access program in a community hospital can bring about these positive changes.Objectives: Our objective is to evaluate whether the institution of a midline program for vascular access at a community hospital can reduce the number of central line catheter-days and the associated CLABSI rate, incidence, and cost.Materials and methods: We collected data on the number of central line catheter-days per year starting from 2012. We also collected data on the total number of patient-days during this period and the number of CLABSIs. We started Centers for Disease Control and Prevention (CDC)-based recommendations to help decrease CLABSIs in June 2014; this included the use of the central venous catheters (CVC) insertion bundles and CVC maintenance bundle. Chlorhexidine baths were also given to all patients with central lines. In June 2015, we started a midline program and tracked data till June 2017. We then compared the infection rates during these periods.Results: We conclude that instituting CDC recommendations to decrease CLABSIs did bring down the CLABSI rate; this decrease was not statistically significant. However, the addition of the midline program to replace central lines whenever possible, combined with universal CDC recommendations, did result in a significant decrease in both the number of central line days per patient-day and the CLABSI rate.Conclusion: We recommend hospitals to develop a midline program to help reduce the use of central line catheters when possible to reduce the total number of catheter-days and the CLABSI rate associated with them. Keywords: central line-associated bloodstream infections, midline, venous access, hospital-acquired infections, hospital length of stay, quality of care

Purpose: Retrospective review of the pattern and management techniques of arterial injuries related to central venous access with long-term outcomes. Materials and Methods: Between January 2007 and November 2017, a total of 20 patients (13 females) were included with the mean age of 63 (28–89 years) and mean body mass index of 25.75 (13.3–36.5). Venous access procedures included central venous catheter (CVC) placement, dialysis line insertion, or endovascular venous procedures. The study excluded patients who had arterial injuries related to arterial access, such as postarterial line placement, postangiography, or percutaneous coronary interventions. Results: Iatrogenic arterial injuries occurred after attempted venous access procedures involving the common femoral vein (n = 18) and subclavian vein (n = 2). Injuries were related to CVC placement (n = 5), temporary dialysis catheter (n = 14), and inferior vena cava filter insertion (n = 1). Nine patients had transarterial venous catheter insertion complicated by active bleeding from pseudoaneurysm and arteriovenous fistula. Other injuries included isolated fistula (n = 3), isolated pseudoaneurysm (n = 4), isolated branch injury (n = 2), and intra-arterial insertion (n = 2). Endovascular management included stent–graft placement (n = 14), embolization of bleeding vessel (n = 2), and thrombin injection for pseudoaneurysm (n = 2). Conservative management with manual compression achieved hemostasis in two patients. Technical success was achieved in 100%. One patient required repeat angiography and embolization of bleeding branch vessel following stent–graft placement to control bleeding fistula and pseudoaneurysm. Clinical success was achieved in all patients. Procedure-related complications included puncture site hematoma (n = 1) and partially occlusive thrombus/spasm of deep femoral artery after stent–graft placement. Six patients (33%) died within 20 days after the procedure (3–20 days) due to other comorbidities. Three additional patients (16%) died during the same hospital admission at the time of the procedure (38–114 days). There were no reported complaints related to possible stent–graft stenosis or occlusion at mean follow-up time of 5 years (50 days–8.64 years) in all seven patients who survived after stent–graft placement procedure. Conclusion: Despite technically successful endovascular management of arterial injuries related to venous access in critically ill patients, the mortality rate remains high due to other comorbidities. Allowing for the small sample size, stent–graft placement for arterial injuries in this cohort of patients appears to be an effective option with high long-term patency rate.

An 80-year-old male, who had undergone dual-chamber pacemaker implantation through left subclavian approach, developed tension pneumothorax of the left side. It caused a pseudoaneurysm-like contracting mass image on the chest X-ray. The diagnosis of pneumothorax was verified by chest computed tomography. Tube thoracostomy drainage was performed immediately without any sequel.

Introduction: The External Jugular Vein is superficial with a wide caliber and is also isolated from major neurovascular structures in neck. It can be simply cannulatedand used for fluid and inotrope administration without any major complications. Objectives: The goal of our retrospective pilot study is to demonstrate the feasibility of External Jugular Vein (EJV) access in the pediatric population in emergency settings. Methods: A total of seventy five childrenwere retrospectively evaluated after EJV cannulation. Results: EJV cannulation was successful in 63 children (84%) at the first attempt while 12 children (16%) required more than one attempt. All patients received vasoactive agents through the EJVcannula. Nineteen (25.33%) children had EJV cannulation related complications. Conclusions: As per our observations in this pilot study, vasoactive agents and intravenous fluids for resuscitation can be safely infused through the EJV in majority of children without any major complications. This route of administration could be considered especially in emergency and resource poor settings.

Many orphan diseases in children require life-long and regular intravenous enzyme replacement therapy. The article describes the first Russian practice of implanting venous port systems in 12 patients with type I and II mucopolysaccharidosis and Pompe disease (6 months to 17 years old) to create long-term venous access. Currently, implantable venous port systems are used in 9 (75%) of 12 patients. 4 cases of thrombosis are observed in 3 patients. All of them have been successfully treated. 1 patient had a rotation of the port camera with a membrane facing downwards due to violation of an implantation technique. The camera was adjusted during the second operation.

Introduction. In the article the clinical and economic analysis of the use of different systems of venous access in the treatment of children with cancer.Objective: to conduct clinical and economic analysis systems venous access in order to optimize the cost of treatment of children with cancer.Materials and Methods. The experience of installing and operating the subclavian catheters and implantable venous port systems installed in 2262 for children between the ages of 2 months up to 17 years. To calculate the cost price were taken «Price list of paid medical services» and Rates of the compulsory health insurance.Results. As the number of annual primary identified children with cancer is on average 3.000 people, according to the price list prices temporarily, for the installation of each of them for a period of treatment five subclavian catheters necessary to spend 227.25 mln. rubles. And the implantations of venous ports – 156.00 mln. rubles. Thus, the savings of using implantable venous port-systems – 71.25 mln. rubles.Conclusion. Mass introduction of the implantable venous ports will significantly reduce the cost of budgetary funds for the treatment of children with cancer, while lowering the percentage of complications and improve quality of life.

Introduction: Peripheral venous access in sick neonates is indicated for administration of fluids, drugs or nutrients. Aim: We conducted an audit of peripheral venous access in neonates admitted to paediatric surgical intensive care unit to study the morbidity, time spent on cannulation and cost with its use. Materials and Methods: One hundred consecutive neonates requiring hospital admission to paediatric surgical intensive care unit in a period of one year were included in the study. Peripheral venous access was secured in all patients. We conducted an audit for the number of venipuncture sites, wastage of cannulae, cost, time spent on cannulation and morbidity with its use. Neonates were divided into three groups depending on their surgical intervention. Namely, Group A (thoracic procedures), Group B (bowel surgery) and Group C (other surgery and nonoperative cases). Results: In Group A, mean venepuncture sites were 10.66, used cannulae were 5.6, wasted cannulae were 4.3, total cost of cannulation was 870 rupees and 93.78 minutes were spent in cannulation per neonate. In Group B, mean venepuncture sites were 7.58, used cannulae were 4.35, wasted cannulae were 2.59, total cost of cannulation was 603 rupees and 59.85 minutes were spent in cannulation per neonate. In Group C mean venepuncture sites were 2.78, used cannulae were 2.9, wasted cannulae were 0.57, total cost of cannulation was 232 rupees and 26.51 minutes were spent in cannulation per neonate. Thrombophlebitis severity was greater in neonates who had longer ICU stay and ventilator dependent days. Conclusion: Peripheral venous cannulation of longer duration is costly, time consuming, and associated with significant neonatal morbidity. It may be worthwhile to consider alternative vascular devices such as peripherally inserted central catheters or central venous catheters in such situations.

Transjugular intrahepatic portosystemic shunt is a minimally invasive endovascular procedure that has played an important role in the treatment of acute or repeated variceal bleeding or refractory ascites. The standard venous access route for this procedure is the right jugular vein. Sometimes it is better to use the left jugular vein because of lower probability of life threatening complication or technical failure. In this case reports the authors have described their experience with TIPS creation in two patients with persistent left and absent right superior vena cava and recommend using the left jugular vein as an access route in this rare anatomical variant.

Multiple venous accesses are required for catheter placement during electrophysiology study and ablation. Internal jugular/subclavian venous access, though restricted nowadays, can be important in difficult situations.

OBJECTIVES: Intravenous (IV) access in children treated in the emergency department (ED) is frequently required and often difficult to obtain. While it has been shown that ultrasound can be useful in adults for both central and peripheral venous access, research regarding children has been limited. We sought to determine if the use of a static ultrasound technique could, a) allow clinicians to visualize peripheral veins and b) improve success rates of peripheral venous cannulation in young children in the ED.METHODS: We performed a randomized clinical trial of children < 7 years in an academic pediatric ED who required IV access and who had failed the first IV attempt. We randomized patients to either continued standard IV attempts or ultrasound-assisted attempts. Clinicians involved in the study received one hour of training in ultrasound localization of peripheral veins. In the ultrasound group, vein localization was performed by an ED physician who marked the skin overlying the target vessel. Intravenous cannulation attempts were then immediately performed by a pediatric ED nurse who relied on the skin mark for vessel location. We allowed for technique cross-over after two failed IV attempts. We recorded success rate and location of access attempts. We compared group success rates using differences in 95% confidence intervals (CI).RESULTS: We enrolled 44 children over a one-year period. The median age of enrollees was 9.5 months. We visualized peripheral veins in all patients in the ultrasound group (n=23) and in those who crossed over to ultrasound after failed standard technique attempts (n= 8). Venipuncture was successful on the first attempt in the ultrasound group in 13/23 (57%, CI, 35% to 77%), versus 12/21 (57%, CI, 34% to 78%) in the standard group, difference between groups 0.6% (95% CI -30% to 29%). First attempt cannulation success in the ultrasound group was 8/23 (35%, CI, 16% to 57%), versus 6/21 (29%, CI, 11% to 52%) in the standard group, difference between groups 6% (95% CI -21% to 34%).CONCLUSION: Ultrasound allows physicians to visualize peripheral veins of young children in the ED. We were unable to demonstrate, however, a clinically important benefit to a static ultrasound aided vein cannulation technique performed by clinicians with limited ultrasound training over standard technique after one failed IV attempt in an academic pediatric ED.

Abstract Background Cephalic vein (CV) cutdown approach for chronic indwelling central venous access device (CICVAD) placement has previously been shown to be technically feasible in 82% of cancer patients. No data are available as to the potential utilization of external jugular vein (EJV) cutdown approach in cancer patients when CV cutdown approach is not technically feasible. Patients and methods One hundred and twenty consecutive cancer patients were taken to the operating room with the intention of placing a CICVAD. All patients were first subjected to attempted CV cutdown approach. If CV cutdown approach was unsuccessful and there were no contraindications to establishing central venous access in the ipsilateral neck region, an ipsilateral EJV cutdown approach was attempted. Results Ninety-five cancer patients (79%) underwent CICVAD placement via CV cutdown. Of those 25 patients in which CV cutdown was not technically feasible, 7 had a contraindication to establishing central venous access in the ipsilateral neck region and a CICVAD was placed via the ipsilateral subclavian vein percutaneous approach. Of those remaining 18 patients in which CV cutdown approach was not technically feasible, 17 (94%) underwent CICVAD placement via ipsilateral EJV cutdown approach. Combined success of the CV and EJV cutdown approaches, excluding those 7 patients with a contraindication to central venous access in the ipsilateral neck region, was greater than 99%. Conclusions Venous cutdown approaches for CICVAD placement are viable alternatives to subclavian vein percutaneous approach in cancer patients. EJV cutdown approach appears to be a highly successful and safe alternative route when CV cutdown approach is not technically feasible and may be considered a potentially useful primary route for CICVAD placement in cancer patients.

Neste trabalho, são analisadas retrospectivamente as complicações locais e sistêmicas associadas ao implante e uso de catéteres venosos centrais (CVC) de longa permanência. Num período de oito anos, foram implantados 500 CVC para quimioterapia de doenças malignas ou para suporte em transplantes de medula óssea. Dois tipos de CVC foram usados: 322 CVC totalmente implantáveis (com reservatório subcutâneo) e 178 CVC semi-implantáveis (com segmento externo). Os implantes foram feitos por via percutânea ou por dissecção venosa cirúrgica. As veias de acesso foram: jugular interna, subclávia, cefálica, e safena magna. OS CVC foram usados de três dias a 75 meses (média de 4,8 meses). Foram analisadas as complicações que necessitaram de tratamento, prolongaram a estadia hospitalar ou levaram à retirada do catéter. Complicações menores foram excluídas deste estudo. Os tipos e os números de complicações observadas foram: Anestésicas: broncoespasmo grave (um); enfisema do pescoço por perfuração traqueal (um). Cirúrgicas: deiscência da incisão (duas); hematoma do pescoço (três); infecção aguda no local de implante (duas); lesão temporária do nervo vago (três}; linfocele (uma); fístula do ducto torácico (uma). Venosas: trombose aguda da jugular (três) e da veia subclávia (cinco); síndrome da cava superior (três). Do próprio catéter: bacteremia tardia (39); trombose do catéter (48); erosão da pele sobre o catéter/reservatório(três); torção do reservatório (duas); fratura do catéter (duas). No total, ocorreram 119 complicações, para uma taxa cumulativa de 23,8%. Nenhuma complicação foi fatal. O implante e uso dos CVC de longa permanência estão associados a complicações freqüentes, que podem ser graves. Mas os benefícios trazidos por estes CVC nos pacientes que necessitam de acesso venoso confiável por tempo prolongado são certamente muito maiores do que os riscos das complicações.