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Long-term tunneled Groshong catheters have been widely used in our institution since 1987, both in adult and pediatric patients, for different purposes (chemotherapy, parenteral nutrition, etc.). In the period 1987–2003, most of these catheters were inserted adopting the ‘blind’ percutaneous venipuncture of the internal jugular vein, by the so called ‘low lateral’ approach (Jernigan's technique). Also, with the exception of selected pediatric cases, they have been inserted at the bedside, without intra-operative fluoroscopy. A retrospective analysis of 1848 tunneled Groshong catheters inserted at our institution over a 15 year period (1987–2003) showed that this protocol was particularly safe (low incidence of complications) and cost-effective (low costs: limited use of fluoroscopy and the operating room).

Two preliminary studies were conducted to determine feasibility of using the electrocardiography (EKG) method to determine terminal tip location when inserting a peripherally inserted central catheter (PICC). This method uses the guidewire inside the catheter (or a column of saline contained in the catheter) as an intracavitary electrode. The EKG monitor is then connected to the intracavitary electrode. The reading on the EKG monitor reflects the closeness of the intracavitary electrode (the catheter tip) to the superior vena cava (SVC). The studies revealed that the EKG method was extremely precise; all tips placed using the EKG method and confirmed using x-ray were located in the superior vena cava. In conclusion, the EKG method has clear advantages in terms of accuracy, cost-effectiveness, and feasibility in conditions where x-ray control may be difficult or expensive to obtain. The method is quite simple, easy to learn and to teach, non-invasive, easy to reproduce, safe, and apt to minimize malpositions due to failure of entering the SVC.

1Cohort studies of surgical patients have shown that the incidence of VTE is markedly higher in patients with cancer than in patients without cancer. 2 Postmortem studies have also demonstrated a higher incidence of VTE in patients with cancer. 3 The association between cancer and VTE arises both as a direct consequence of tumor growth and host inflammatory responses and indirectly as a consequence of cancer treatment, venous stasis, and direct vessel trauma. 4 It is well known that the risk for developing VTE in cancer patients is significantly increased during chemotherapy and as a result of long-term central venous catheter (CVC) placement. Many cancer patients require long-term central venous access for the safe deliverance of chemotherapeutic agents, nutrients and fluids, and transfusion of blood and blood products, as well as for the withdrawal of blood samples from the central circulation. Long-term CVCs may remain in position for months or years, and their role in facilitating patient care is clear. Nevertheless, they are associated with a

Purpose: The position of the tip of PICCs is often verified at the end of the procedure by chest x-ray (CXR). Though, the radiological criteria for defining tip location are sometimes poorly defined, subjective and/or non-repeatable. We considered two recent methods for tip location at CXR the Sweet Spot criteria (SSC) (developed by Ken Symington) and the Carina criteria (CC) (developed by German radiologists) e comparing them in terms of feasibility and accuracy. Methods: Using the radiology database of three hospitals, we examined all CXR performed on patients after PICC insertion, choosing catheters whose tip location had been verified by the intracavitary ECG technique (IC-ECG). Tip location was identified by SSC and CC on all CXR. Results: We reviewed 1116 PICC insertion successfully placed by IC-ECG (maximal height of P wave 1⁄4 tip at the cavo-atrial junction). CC was not feasible in 0.45% (impossible visualization of the carina) and difficult in 1.5% (difficult visualization of the carina); in 97.7%, tip position was appropriate (1-5 cm below the carina), in 0.6% too high (< 1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 8.6%; in 99.1%, the tip was within the spot (94.2% in the middle, 2.5% close to the superior border, 2.3% close to the inferior border); no tip was visualized outside of the spot. Limitations: The interpretation of CXR was performed directly by the authors, though being a retrospective study the basic image quality of the film introduced an uncontrolled variable. Conclusions: CC and SSC were similar in terms of feasibility (99.5% vs. 99.1%) and accuracy (97-7% vs. 99.1%). Though, CC was easier to perform (98.05%) if compared to SSC (89.5%).

Background: While in the XX century centrally inserted central catheters (CICC) were only inserted into the internal jugular or subclavian vein, in our century after the introduction of ultrasound (US) guidance we have other options, including the infra-clavicular approach to the axillary vein (AV). Purpose: In our courses on CICC insertion we are currently proposing the US guided infra-clavicular approach to the AV as the first option for all CICC placements in adult patients, with the only exception of dialysis catheters. Project description: In our theoretical-practical courses, we have introduced a focused discussion on the advantages of AV (easy US identification of the vein below the clavicle; puncture with different techniques, either in short axis or in long axis; very low risk of insertion-related complications), more specifically for short term CICCs (ideal location of the exit site), for totally implantable venous ports (no risk of pinch off syndrome; optimal cosmetic result; minimal local trauma) and for tunneled cuffed CICCs (easy tunneling). Technical tips are also discussed (placement of the arm in abduction, so to increase the vein diameter; catheter caliber appropriate to the caliber of AV; micro-introducer kits and modified Seldinger technique; US control of the supra-clavicular area during the passage of the catheter; intraprocedural US control of the pleura, so to rule out pneumothorax; intra-cavitary ECG technique for tip location; securement by sutureless device, glue and transparent adhesive dressing). Results and implications: The practice of CICC insertion will be strongly affected by this new central venous approach that minimized all early and late complications possibly related to the insertion technique. Conclusions: The impact of US in reducing complications during jugular venipuncture is well known. The effects of US in terms of changing venous approach (from jugular/subclavian to AV) deserve an increased attention in the next future.

Purpose: The position of the tip of PICCs is often verified at the end of the procedure by chest x-ray (CXR). Though, the radiological criteria for defining tip location are sometimes poorly defined, subjective and/or non-repeatable. We considered two recent methods for tip location at CXR the Sweet Spot criteria (SSC) (developed by Ken Symington) and the Carina criteria (CC) (developed by German radiologists) e comparing them in terms of feasibility and accuracy. Methods: Using the radiology database of three hospitals, we examined all CXR performed on patients after PICC insertion, choosing catheters whose tip location had been verified by the intracavitary ECG technique (IC-ECG). Tip location was identified by SSC and CC on all CXR. Results: We reviewed 1116 PICC insertion successfully placed by IC-ECG (maximal height of P wave 1⁄4 tip at the cavo-atrial junction). CC was not feasible in 0.45% (impossible visualization of the carina) and difficult in 1.5% (difficult visualization of the carina); in 97.7%, tip position was appropriate (1-5 cm below the carina), in 0.6% too high (< 1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 8.6%; in 99.1%, the tip was within the spot (94.2% in the middle, 2.5% close to the superior border, 2.3% close to the inferior border); no tip was visualized outside of the spot. Limitations: The interpretation of CXR was performed directly by the authors, though being a retrospective study the basic image quality of the film introduced an uncontrolled variable. Conclusions: CC and SSC were similar in terms of feasibility (99.5% vs. 99.1%) and accuracy (97-7% vs. 99.1%). Though, CC was easier to perform (98.05%) if compared to SSC (89.5%).

2014 EPIC guidelines); (c) adoption of new devices e so-called ’port protectors’ for chronic disinfection of the hub (as recommended by the 2014 SHEA/IDSA guidelines). Results and implications: We believe these new approach focused on both ELC and ILC prevention will have a positive impact on the overall risk of CRBSI in our hospitals. Conclusion: As current evidence suggests that today the prevalent route of bacterial contamination of VAD is intra-luminal, rather than extra-luminal, new policies and new strategies are necessary, so to minimize the risk of infection and getting closer to the ’targeting zero’.

Background: While in the XX century centrally inserted central catheters (CICC) were only inserted into the internal jugular or subclavian vein, in our century after the introduction of ultrasound (US) guidance we have other options, including the infra-clavicular approach to the axillary vein (AV). Purpose: In our courses on CICC insertion we are currently proposing the US guided infra-clavicular approach to the AV as the first option for all CICC placements in adult patients, with the only exception of dialysis catheters. Project description: In our theoretical-practical courses, we have introduced a focused discussion on the advantages of AV (easy US identification of the vein below the clavicle; puncture with different techniques, either in short axis or in long axis; very low risk of insertion-related complications), more specifically for short term CICCs (ideal location of the exit site), for totally implantable venous ports (no risk of pinch off syndrome; optimal cosmetic result; minimal local trauma) and for tunneled cuffed CICCs (easy tunneling). Technical tips are also discussed (placement of the arm in abduction, so to increase the vein diameter; catheter caliber appropriate to the caliber of AV; micro-introducer kits and modified Seldinger technique; US control of the supra-clavicular area during the passage of the catheter; intraprocedural US control of the pleura, so to rule out pneumothorax; intra-cavitary ECG technique for tip location; securement by sutureless device, glue and transparent adhesive dressing). Results and implications: The practice of CICC insertion will be strongly affected by this new central venous approach that minimized all early and late complications possibly related to the insertion technique. Conclusions: The impact of US in reducing complications during jugular venipuncture is well known. The effects of US in terms of changing venous approach (from jugular/subclavian to AV) deserve an increased attention in the next future.

Background: While in the XX century centrally inserted central catheters (CICC) were only inserted into the internal jugular or subclavian vein, in our century after the introduction of ultrasound (US) guidance we have other options, including the infra-clavicular approach to the axillary vein (AV). Purpose: In our courses on CICC insertion we are currently proposing the US guided infra-clavicular approach to the AV as the first option for all CICC placements in adult patients, with the only exception of dialysis catheters. Project description: In our theoretical-practical courses, we have introduced a focused discussion on the advantages of AV (easy US identification of the vein below the clavicle; puncture with different techniques, either in short axis or in long axis; very low risk of insertion-related complications), more specifically for short term CICCs (ideal location of the exit site), for totally implantable venous ports (no risk of pinch off syndrome; optimal cosmetic result; minimal local trauma) and for tunneled cuffed CICCs (easy tunneling). Technical tips are also discussed (placement of the arm in abduction, so to increase the vein diameter; catheter caliber appropriate to the caliber of AV; micro-introducer kits and modified Seldinger technique; US control of the supra-clavicular area during the passage of the catheter; intraprocedural US control of the pleura, so to rule out pneumothorax; intra-cavitary ECG technique for tip location; securement by sutureless device, glue and transparent adhesive dressing). Results and implications: The practice of CICC insertion will be strongly affected by this new central venous approach that minimized all early and late complications possibly related to the insertion technique. Conclusions: The impact of US in reducing complications during jugular venipuncture is well known. The effects of US in terms of changing venous approach (from jugular/subclavian to AV) deserve an increased attention in the next future.

2014 EPIC guidelines); (c) adoption of new devices e so-called ’port protectors’ for chronic disinfection of the hub (as recommended by the 2014 SHEA/IDSA guidelines). Results and implications: We believe these new approach focused on both ELC and ILC prevention will have a positive impact on the overall risk of CRBSI in our hospitals. Conclusion: As current evidence suggests that today the prevalent route of bacterial contamination of VAD is intra-luminal, rather than extra-luminal, new policies and new strategies are necessary, so to minimize the risk of infection and getting closer to the ’targeting zero’.

Purpose: The position of the tip of PICCs is often verified at the end of the procedure by chest x-ray (CXR). Though, the radiological criteria for defining tip location are sometimes poorly defined, subjective and/or non-repeatable. We considered two recent methods for tip location at CXR the Sweet Spot criteria (SSC) (developed by Ken Symington) and the Carina criteria (CC) (developed by German radiologists) e comparing them in terms of feasibility and accuracy. Methods: Using the radiology database of three hospitals, we examined all CXR performed on patients after PICC insertion, choosing catheters whose tip location had been verified by the intracavitary ECG technique (IC-ECG). Tip location was identified by SSC and CC on all CXR. Results: We reviewed 1116 PICC insertion successfully placed by IC-ECG (maximal height of P wave 1⁄4 tip at the cavo-atrial junction). CC was not feasible in 0.45% (impossible visualization of the carina) and difficult in 1.5% (difficult visualization of the carina); in 97.7%, tip position was appropriate (1-5 cm below the carina), in 0.6% too high (< 1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 8.6%; in 99.1%, the tip was within the spot (94.2% in the middle, 2.5% close to the superior border, 2.3% close to the inferior border); no tip was visualized outside of the spot. Limitations: The interpretation of CXR was performed directly by the authors, though being a retrospective study the basic image quality of the film introduced an uncontrolled variable. Conclusions: CC and SSC were similar in terms of feasibility (99.5% vs. 99.1%) and accuracy (97-7% vs. 99.1%). Though, CC was easier to perform (98.05%) if compared to SSC (89.5%).