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Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.

Background: The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care. Methods: We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis. Results: A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters. Conclusions: Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region, aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO—Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

Background: Chest-to-arm (CTA) tunneling has been described recently as a technique that allows an optimal exit site at mid-arm even in chronically ill patients with complex clinical issues and challenging problems of vascular access. Method: We adopted CTA tunneling in oncologic and in non-oncologic patients, in totally implanted and in external devices, for both medium and long-term intravenous treatments. We report our experience with 60 cases of CTA tunneling: 19 patients requiring a totally implantable device, who had bilateral contraindication to venous access at the arm and bilateral contraindication to placement of the pocket in the infra-clavicular area; 41 patients requiring an external central venous catheter, who had bilateral contraindication to insertion of peripherally inserted central catheters or femoral catheters, as well as contraindication to an exit site in the infraclavicular area. All venous access devices were inserted with ultrasound guidance and tip location by intracavitary electrocardiography, under local anesthesia. Results: There were no immediate or early complications. Patients with CTA-ports had no late complications. In patients with CTA-tunneled external catheters, there were two dislodgments, four episodes of central line associated blood stream infections, and one local infection. There were no episodes of venous thrombosis or catheter malfunction. Conclusion: Our experience suggests that CTA tunneling is a safe maneuver, with very low risk of complications, and should be considered as an option in patients with complex venous access.

Background: Taurolidine lock is known to be effective in preventing catheter-related infections in a variety of venous access devices, including long term venous access devices for chemotherapy. Though, literature about the use of taurolidine for treating catheter colonization or catheter-related blood stream infection is scarce. Method: We have retrospectively reviewed the safety and efficacy of 2% taurolidine lock for treatment of catheter-colonization and of catheter-related bloodstream infection in cancer patients with totally implanted venous access devices. Diagnosis of colonization or catheter-related infection was based on paired peripheral and central blood cultures, according to the method of Delayed Time to Positivity. Results: We recorded 24 cases of catheter-related infection and two cases of colonization. Taurolidine lock—associated with systemic antibiotic therapy—was successful in treating all cases of catheter-related infection, with disappearance of clinical symptoms, normalization of laboratory values, and eventually negative blood cultures. Taurolidine lock was also safe and effective in treating device colonization. No adverse effect was reported. Conclusion: In our retrospective analysis, 2% taurolidine lock was completely safe and highly effective in the treatment of both catheter-colonization and catheter-related bloodstream infection in cancer patients with totally implanted venous access devices.

Background: An adequate stabilization of a vascular device is an important part of insertion bundles and is an effective strategy in reducing complications. Dislodgment has a relevant clinical impact and an increase in healthcare costs. Method: We have retrospectively investigated the safety and efficacy of Subcutaneously Anchored Securement (SAS) for Peripherally Inserted Central Catheters (PICC) in cancer patients. Results: We analyzed 639 patients who had a PICC inserted and secured with SAS, over the past 3 years (2018–2020). No immediate complications during SAS placement were reported. In the first 24–48 h, a slight local ecchymosis was reported in 24 cases with rapid spontaneous resolution. No cases of bleeding or hematoma of the exit site were reported. The total number of catheter days was 93078. Dislodgment occurred only in seven cases (1.1%). In 16 patients, the PICC was removed because of catheter-related bloodstream infection (CRBSI): the overall incidence of CRBSI was 0.17 per 1000 catheter days. Symptomatic venous thrombosis was documented in 12 patients (1.9%) and treated with low molecular weight heparin without PICC removal. We had no cases of irreversible lumen occlusion. In 17 patients, local discomfort—including device-related pressure ulcers and painful inflammation—was reported: these cases were treated without SAS removal or PICC removal. Conclusion: In this retrospective analysis, subcutaneously anchored securement of PICCs was a safe and effective strategy for reducing the risk of dislodgment.

Persistent withdrawal occlusion is a specific catheter malfunction characterized by inability to withdraw blood through the device while infusion is maintained. The main causes are fibroblastic sleeve and tip malposition (associated or not to venous thrombosis around the tip). All current guidelines recommend infusing vesicant/antiblastic drugs through a central venous port only after assessment of blood return. In PWO, blood return is impossible. We have recently started to assess the intravascular position of the tip and the delivery of the infusion in the proximity of the cavo-atrial junction utilizing transthoracic/subxiphoid ultrasound with the ‘bubble test’. We found that this is an easy, real-time, accurate and safe method for verifying the possibility of using a port for chemotherapy even in the absence of blood return, as it occurs with persistent withdrawal occlusion.

Background Accidental dislodgement of central venous catheters is a frequent complication in NICU and it often requires catheter replacement. Subcutaneously anchored sutureless devices (SAS) have been recently introduced in clinical practice for securement of different types of central catheters, but they have never been used in neonates. We evaluated safety and efficacy of SAS in neonates. Methods All neonates who required central venous catheters inserted via ultrasound-guided cannulation during 12 months of clinical practice in our NICU. We adopted SAS for securement of all central venous catheters inserted in neonates via ultrasound guided cannulation either of the brachio-cephalic vein (centrally inserted central catheters: CICC) or the femoral vein (femorally inserted central catheters: FICC). Results: seventy-two central catheters were inserted in 70 preterm and term neonates (3-4 Fr power injectable polyurethane catheters; 62 CICC + 10 FICC) and they were all secured with SAS. Mean postmenstrual age at the time of insertion was 31 weeks and mean weight was 1400 g. SAS was easy to place in all cases. The median duration of the line was 6 weeks. No accidental dislodgement of CICC or FICC was recorded. All SAS but one were left in place until elective removal of the catheter. In all patients, SAS removal was easy and uneventful, and it did not require any sedation or local anesthesia. Conclusions: SAS was effective in preventing accidental catheter dislodgement in 100% of cases. Complications during insertion, maintenance and removal were negligible.

Central venous access devices are often needed in neonates admitted to Neonatal Intensive Care Unit. The location of the tip of the central catheter is usually assessed by post-procedural X-ray. However, this strategy is inaccurate and time consuming. Recent guidelines strongly recommend intra-procedural methods of tip location, to increase the cost-effectiveness of the maneuver and to shorten the time between device placement and utilization. In this regard, real-time ultrasound represents the most promising tool for tip navigation and location in neonates. The aim of this paper is (a) to review all the evidence available about ultrasound-based tip navigation and tip location of central catheters in the neonatal population (b) to propose a novel protocol for tip navigation and location (Neo-ECHOTIP) based on such evidence.

Background: In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also—as suggested by few recent studies—by puncture of the superficial femoral vein at mid-thigh. Methods: We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications. Results: From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis. Conclusions: The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

Introduction: Although several guidelines recommend that prolonged administration of vancomycin should be preferably carried out by a central venous access, vancomycin is often given peripherally. Whether such risk may be affected by different modalities of administration in terms of dilution and time of infusion, it is a matter of controversy. Methods: This single-center prospective study enrolled all consecutive patients requiring prolonged intravenous infusion of vancomycin (1 g/day) using long peripheral cannula “mini-midline.” Patients were randomized in study group (4 mg/ml) and control group (20 mg/ml). All patients were systematically evaluated every 24 h by the Visual Exit-Site Score and a daily ultrasound scan of the veins of the arm. Results: The daily ultrasound evaluation showed venous thrombosis at the distal tip of the cannula in all patients, in both groups. After this finding in the first 14 patients, the study was interrupted. All thromboses were completely asymptomatic and occurred in absence of any sign of catheter malfunction. The onset of thrombosis was significantly earlier in the control group (ranging from 24 to 48 h) than in the study group (ranging from 48 to 96 h), with an average of 30 ± 11 versus 68 ± 16 h ( p < 0.001). Conclusion: Continuous intravenous infusion of vancomycin should be preferably delivered by a central venous access, as largely recommended by current guidelines, since peripheral infusion is inevitably associated with venous thrombosis, independently from the type of peripheral venous access device adopted (short peripheral cannula vs long peripheral cannula) and from the extent of dilution.

Background: Placement of peripheral intra-venous cannulas and epicutaneo-caval catheters is routinely performed in in Neonatal Intensive Care Unit (NICU), and both devices require visible superficial veins easy to cannulate. NICU patients are intrinsically characterized by poor and fragile vein asset, so that puncture and cannulation of superficial veins is often a challenge even for trained clinicians and cannulation frequently results in a stressful, painful, difficult procedure. Methods and results: Rapid Superficial Vein Assessment is meant to offer a systematic pre-procedural evaluation of all superficial veins of the newborn, so to allow a rational choice of the best insertion site, tailored on the single patient, and optimized for the specific type of venous access device. The superficial veins are examined systematically, both with and without NIR technology, exploring seven skin areas in the following order: (1) medial malleolus, (2) lateral malleolus, (3) retro-popliteal fossa, (4) back of the hand and wrist, (5) antecubital fossa, (6) anterior scalp surface, and (7) posterior scalp surface. Conclusions: The aim of the protocol is to increase the first attempt success rate and reduce the duration of the procedure, the number of attempts for single patient and possibly to limit complications, stress, and pain in neonates.

In this paper we describe a new protocol—named RaFeVA (Rapid Femoral Vein Assessment)—for the systematic US assessment of the veins in the inguinal area and at mid-thigh, designed to evaluate patency and caliber of the common and superficial femoral veins and choose the best venipuncture site before insertion of a FICC.

Uncooperative elderly patients with cognitive disorder are often confused and/or agitated. Risk of involuntary venous access device dislodgment is high in these patients. This is equally likely with peripherally inserted central catheters and centrally inserted central catheters but less common with femorally inserted central catheters. Solutions to this problem include strict continuous patient observation, using sutures or subcutaneous anchored securement, wrapping the arm to “hide” the line, or using soft mittens to occupy the hands. However, some patients are able to disrupt the dressing, dislodge the catheter, and often pull the catheter out completely. In some cases, the patient may also overcome the resistance offered by the stitches or by the subcutaneous anchored securement device. In a recent paper on the impact of subcutaneously anchored securement in preventing dislodgment, the only demonstrated failures occurred in non-compliant elderly patients. Creation of an alternative exit site is an emerging trend in patients with cognitive impairment at high risk for catheter dislodgement. Subcutaneous tunneling from traditional insertion sites such as the jugular, axillary, or femoral veins allows placement of the exit site in a region inaccessible to the patient. The following two case reports demonstrate the technique for tunneling a femorally inserted central catheter downward to the patellar region and for tunneling a centrally inserted central catheter to the scapular region. Internal review board approval was not deemed necessary as subcutaneous tunneling is not a new technique. In our experience, such maneuvers can be successfully performed at the bedside.

BACKGROUND Whether peripherally inserted central catheters (PICCs) are appropriate as safe and durable venous access devices (VADs) is still controversial. The aim of this 7-year, prospective cohort study was to compare the incidence rate differences of catheter-related complications (CRCs) among 4 types of central VADs in cancer patients receiving home parenteral nutrition (HPN). METHODS We enrolled all adult cancer outpatients who were candidates for HPN and who had a central VAD inserted during the study period, focusing on the incidence rate of CRCs. RESULTS We evaluated 854 central VADs (401 PICCs, 137 nontunneled centrally inserted central catheters [CICCs], 118 tunneled-cuffed CICCs, and 198 ports) in 761 patients, for a total of 169,116 catheter-days. Overall, the rate of total CRCs was 1.08/1000 catheter-days. The incidence of catheter-related bloodstream infections was low (0.29/1000), particularly for PICCs (0.08/1000; P < .001 vs tunneled-cuffed CICCs) and for ports (0.21/1000; P < .019 vs tunneled-cuffed CICCs). The rates of mechanical complications (0.58/1000) and of catheter-related symptomatic thrombosis (0.09/1000) were low and similar for PICCs, tunneled-cuffed CICCs, and ports. In terms of duration and removal rate due to complications, PICCs were like tunneled-cuffed CICCs and ports. Altogether, PICCs had fewer total complications than tunneled-cuffed CICCs (P < .001), there was no difference in total complications between PICCs and ports. CONCLUSION PICCs had significantly better outcomes than tunneled-cuffed CICCs and were safe and durable as ports. Our extensive, long-term study suggests that PICCs can be successfully used as safe and long-lasting VADs for HPN in cancer patients.

BACKGROUND The venous access for the insertion of permanent leads of cardiac implantable electronic devices is often achieved by venous cutdown of the cephalic vein, or by "blind" puncture of the subclavian vein using anatomical landmarks, or by fluoroscopy-assisted methods. METHODS We have retrospectively analyzed our clinical experience to verify the feasibility, the safety, and efficacy of the adoption of ultrasound-guided puncture/cannulation of the axillary vein for this purpose. RESULTS Nine hundred eighty-seven leads were placed during 548 consecutive procedures, accessing the axillary vein in the infraclavicular area using real-time ultrasound guidance. Venipuncture was successful in 99.8% of cases. The access time was 11 seconds (range 4-580). We recorded three cases of pneumothorax (0.5%), but no hemothorax and no hemo-mediastinum. The incidence of local hematoma was 2.1% (12 cases). No injury to the brachial plexus or to the phrenic nerve was recorded. In a follow-up of 33 months (range 16-39), we observed no cases of "subclavian crush syndrome" (damage of the leads at the level of the thoracic inlet), and the rate of pocket infection/infective endocarditis was 0.7%. CONCLUSION In our experience, ultrasound-guided puncture/cannulation of the axillary vein for implantation of permanent leads is feasible, effective, and safe. It might be considered as a first option for this procedure.

Ultrasound for diagnostic and procedural purposes is becoming a standard in daily clinical practice including anaesthesiology and peri-operative medicine. The project of European Society of Anaesthesiology (ESA) Task Force for the development of clinical guidelines on the PERioperative uSE of Ultra-Sound (PERSEUS) project has focused on the use of ultrasound in two areas that account for the majority of procedures performed routinely in the operating room: vascular access and regional anaesthesia. Given the extensive literature available in these two areas, this paper will focus on the use of ultrasound-guidance for vascular access. A second part will be dedicated to peripheral nerve/neuraxial blocks. The Taskforce identified three main domains of application in ultrasound-guided vascular cannulation: adults, children and training. The literature search were performed by a professional librarian from the Cochrane Anaesthesia and Critical and Emergency Care Group in collaboration with the ESA Taskforce. The Grading of Recommendation Assessment (GRADE) system for assessing levels of evidence and grade of recommendations were used. For the use of ultrasound-guided cannulation of the internal jugular vein, femoral vein and arterial access, the level evidence was classified 1B. For other accesses, the evidence remains limited. For training in ultrasound guidance, there were no studies. The importance of proper training for achieving competency and full proficiency before performing any ultrasound-guided vascular procedure must be emphasised.

Background: The correct position of the tip of a central venous access device is important in all patients, and especially in neonates. The traditional method of tip location (approximated intra-procedural length estimation + post procedural chest X-ray) is currently considered inaccurate and not cost-effective by most recent guidelines, which recommend the adoption of tip location by intracavitary electrocardiography (IC-ECG) whenever possible. Methods: This study prospectively investigated the applicability, the feasibility, the accuracy, and the safety IC-ECG for tip location in neonates requiring insertion of ultrasound-guided centrally inserted central venous catheters (CICCs) with caliber 3Fr or more. All catheter tip locations were verified using simultaneously both IC-ECG and ultrasound-based tip location, using the Neo-ECHOTIP protocol. Results: A total of 105 neonates were enrolled. The applicability of IC-ECG was 100% since a P wave was evident on the surface ECG of all neonates recruited for the study. The feasibility was also 100% since an increase of the P-wave was detected in all cases. The accuracy was also 100%, since a perfect match between IC-ECG based tip location and ultrasound-based tip location was found. There were no adverse events directly or indirectly related to the IC-ECG technique; no arrhythmias occurred. Conclusions: When applied to ultrasound guided CICCs, tip location by IC-ECG is applicable and feasible in neonates, and it is safe and accurate.

Background: The ideal intraprocedural method for tip location during insertion of femorally inserted central catheters (FICCs) is still a matter of debate. When the catheter tip is meant to be in the right atrium or in the supradiaphragmatic inferior vena cava (IVC), tip location by either intracavitary electrocardiography or transthoracic echocardiography may be accurate and easy to perform. When the catheter tip is planned to be placed in the subdiaphragmatic IVC, fluoroscopy—though inaccurate and unsafe—has been regarded as the only option for intraprocedural tip location. Methods: We have investigated prospectively the applicability and feasibility of transhepatic ultrasound as intraprocedural method for assessing the location of the catheter tip in the subdiaphragmatic tract of IVC, during FICC insertion. Results: We enrolled 169 consecutive patients undergoing FICC insertion by ultrasound guided puncture of the superficial femoral vein. In 165 out of 169 patients, the subdiaphragmatic IVC was visualized by the transhepatic ultrasound view. In all cases of IVC visualization, the catheter tip could be identified by ultrasound, either directly (direct evidence of the tip inside the vein) or indirectly (enhanced visualization of the tip after “bubble test”). There was no immediate or early complication, and very few late complications. Conclusion: The intraprocedural method of tip location of FICCs by transhepatic ultrasound was applicable in 97.6% of cases and feasible in 100%. When the position of the catheter tip is planned to be in the subdiaphragmatic IVC, this method of tip location is accurate, safe, and inexpensive, and should be considered as an alternative to fluoroscopy.

Purpose: Ultrasound-guided peripherally inserted central catheters (PICCs) are increasingly used in children, though their insertion may be limited by the small caliber of the deep veins of the arm. Previous studies have suggested to use age or weight as a guide to the feasibility of PICC insertion. We have planned an observational study with the purpose of identifying the actual feasibility of PICC insertion based on the ultrasound evaluation of the deep veins of the arm in groups of children of different weight range. Methods: We have studied 252 children weighing between 2.5 and 20 kg, divided in five different groups (group 1: 2.5–4 kg; group 2: 4.1–7 kg; group 3: 7.1–10 kg; group 4: 10.1–15 kg; group 5: 15.1–20 kg): the caliber of brachial vein, basilic vein, and cephalic vein at mid-upper arm + the caliber of the axillary vein at the axilla were measured by ultrasound scan. Results: Veins of caliber >3 mm (appropriate for insertion of a 3 Fr non-tunneled PICC) were found at mid-upper arm in no child of group 1 or 2, in 13% of group 3, in 28% of group 4, and in 54% of group 5. An axillary vein >3 mm (appropriate for insertion of a 3 Fr tunneled PICC) were found in 5.8% of group 1, 30.6% of group 2, 67% of group 3, 82% of group 4, and 94% of group 5. Conclusions: The age and the weight of the child have a small role in predicting the caliber of the veins of the arm. Veins should be measured case by case through a proper and systematic ultrasound evaluation; however, the clinician can expect that insertion of a 3 Fr PICC may be feasible in one third of children weighing between 4 and 7 kg, and in most children weighing more than 7 kg, especially if adopting the tunneling technique.

Introduction: Current guidelines recommend intraprocedural methods—such as Intra-Cavitary ECG (IC-ECG) and echocardiography—for verifying the location of the tip of central venous catheters. Nonetheless, there are clinical conditions which may require to verify tip location by less accurate methods such as Chest X-Ray (CXR). We have compared the feasibility and accuracy of two radiological methods for tip location—the Sweet Spot Criterion (SSC) and the Carina Criterion (CC)—using IC-ECG as reference. Methods: In this retrospective multicenter study, we reviewed the radiology databases of three hospitals, examining all CXRs performed on patients after insertion of Peripherally Inserted Central Catheters (PICCs), as long as the tip location had been successfully performed during the procedure by IC-ECG. Tip location was verified using SSC and CC, comparing the two methods in terms of feasibility and accuracy. Results: We reviewed the CXR of 1116 PICCs successfully inserted by IC-ECG. CC was not feasible in 0.5% (impossible visualization of the carina) and difficult in 1.5%; in 97.7% of cases, the position of the tip was adequate (1–5 cm below the carina), in 0.6% too high (Conclusion: CC and SSC were similar in terms of feasibility (99.5% vs 99.1%) and accuracy (98.1% vs 100%), though CC was subjectively perceived to be easier and more rapid to perform.

Introduction: According to current guidelines, tip location of peripherally inserted central catheters (PICCs) should be verified during insertion, preferably using non-invasive methods such as intracavitary ECG (IC-ECG) or echocardiography. An interesting new option is represented by a new pressure-based device, the CatFinder System (CFS), which might be theoretically useful also for tip navigation. Methods: We planned a single-center, prospective, non-randomized trial on adult patients requiring PICC insertion, using simultaneously CFS and IC-ECG, with the purpose of verifying the applicability, feasibility, safety, and accuracy of CFS for intra-procedural tip location. Patients with known ECG abnormalities or cardiac diseases of any type were excluded. The ability of CFS to assess wrong directions of the catheter during insertion (tip navigation) was evaluated by comparison with ultrasound scan. Results: Out of 136 enrolled adult patients, CFS was found to be applicable in 131 cases (five cases were excluded because of ECG abnormalities) and feasible in 111 cases (in 20 cases, tip location by CFS could not be carried out because of technical issues). There were no complications directly or indirectly related to the CFS maneuvers. Using IC-ECG as a comparison, 87 tips placed by CFS were within 2 cm from the target, 17 were >2 cm from target. In seven cases, CFS was able to detect a wrong direction (to the ipsilateral internal jugular vein), as confirmed by ultrasound. Conclusion: Applicability of CFS in patients with sinus rhythm was 96.3%, feasibility was 84.7%, and safety was 100%. If compared to IC-ECG, accuracy was 83.6% (accepting an error 3 cm) were 3.8% (the tip was too high inside the SVC). This study confirms a possible future role of CFS for intra-procedural tip location and tip navigation, though its use cannot be currently recommended.

The insertion of central venous catheters through the femoral veins is not uncommon and is potentially associated with the risk of immediate puncture-related complications and severe late complications as infection and thrombosis. As for other central venous access devices, the use of a standardized protocol of insertion and the correct application of evidence-based strategies are beneficial in reducing the risk of complications. We proposed a standardized protocol (S.I.F.: Safe Insertion of Femorally Inserted Central Catheters) consisting of seven strategies that should be part of vascular cannulation and should be adopted during the insertion of femoral venous catheters, aiming to minimize immediate, early and late insertion-related complications. These strategies include: preprocedural evaluation of the patient history and of the veins, appropriate aseptic technique, ultrasound guided puncture and cannulation of the vein, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and appropriate coverage of the exit site.

Physical exercise is often encouraged in cancer patients, mainly for the purpose of rehabilitation and for its psychological benefit. Some authors also suggest that exercise—specially in patient with peripherally inserted central venous access devices—may contribute to reduce the risk of catheter-related thrombosis. Still, the impact of physical exercise on the risk of device-related complications is not yet defined. We report a case of secondary migration of the tip of an arm port, caused by high-intensity exercise in a woman undergoing chemotherapy because of ovarian cancer. Tip migration was suspected because of malfunction (persistent withdrawal occlusion) and diagnosis established after ultrasound examination and chest x-ray. Even if exercise may yield benefit in the cancer patient on chemotherapy, the risk of mechanical complication of the venous access device—such as tip migration—should be considered in the case of high-intensity exercise.

Short peripheral intravenous cannulas have different features, as they may be winged or non-winged, ported or non-ported, equipped or not with needle stick prevention and “blood stop” mechanisms, and integrated or not with preassembled extensions or preassembled needle free connector. In the current range of commercially available short peripheral cannulas, there is one device that is apparently associated with several clinical advantages. In fact, short peripheral cannulas with safety mechanisms, closed system, winged, non-ported, and equipped with preassembled extension and preassembled needle-free connector appear to be associated with prolonged dwell time, reduction of the incidence of several complications (infiltration/extravasation, dislodgement, phlebitis, infection, blood leakage), cost reduction, and increased satisfaction of patients and clinicians. To clarify the current terminology and to identify this device for future clinical studies, the authors advocate the use of the term “integrated short peripheral cannula.” A rapid review of the current evidence suggests that this new device may have different clinical performance and different indications if compared to standard short peripheral cannulas. Though, the optimal clinical outcome can be achieved only when the device is inserted and maintained with proper protocols.

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.

OBJECTIVES Peripherally inserted central catheters are increasingly used in ICU as an alternative to centrally inserted central catheters for IV infusion. However, their reliability for hemodynamic measurements with transpulmonary thermodilution is currently unknown. We investigated the agreement between transpulmonary thermodilution measurements obtained with bolus injection through peripherally inserted central catheter and centrally inserted central catheter (reference standard) using a transpulmonary thermodilution-calibrated Pulse Contour hemodynamic monitoring system (VolumeView/EV1000). DESIGN Prospective method-comparison study. SETTING Twenty-bed medical-surgical ICU of a teaching hospital. PATIENTS Twenty adult ICU patients who required hemodynamic monitoring because of hemodynamic instability and had both peripherally inserted central catheter and centrally inserted central catheter in place. INTERVENTION The hemodynamic measurements obtained by transpulmonary thermodilution after injection of a cold saline bolus via both centrally inserted central catheter and either a single-lumen 4F or a double-lumen 5F peripherally inserted central catheter using were compared. In order to rule out bias related to manual injection, measurements were repeated using an automated rapid injection system. MEASUREMENTS AND MAIN RESULTS A total of 320 measurements were made. Cardiac index was significantly higher when measured with double-lumen 5F peripherally inserted central catheter than with centrally inserted central catheter (mean, 4.5 vs 3.3 L/min/m; p < 0.0001; bias, 1.24 L/min/m [0.27, 2.22 L/min/m]; bias percentage, 31%). Global end-diastolic index, extravascular lung water index, and stroke volume index were also overestimated (853 ± 240 vs 688 ± 175 mL/m, 12.2 ± 4.2 vs 9.4 ± 2.9 mL/kg, and 49.6 ± 14.9 vs 39.5 ± 9.6 mL/m, respectively; p < 0.0001). Lower, albeit significant differences were found using single-lumen 4F peripherally inserted central catheter (mean cardiac index, 4.2 vs 3.7 L/min/m; p = 0.043; bias, 0.51 L/min/m [-0.53, 1.55 L/min/m]; bias percentage, 12.7%). All differences were confirmed, even after standardization of bolus speed with automated injection. CONCLUSIONS Bolus injection through peripherally inserted central catheter for transpulmonary thermodilution using EV1000 led to a significant overestimation of cardiac index, global end-diastolic index, extravascular lung water index, and stroke volume index, especially when double-lumen 5F peripherally inserted central catheter was used (ClinicalTrial.gov NCT03834675).

This article reports the results of three prospective clinical studies conducted in a university hospital regarding the efficacy, safety and cost effectiveness of a subcutaneously anchored sutureless system for securing central venous catheters. The results were favourable to the adoption of such a device, and the analysis of the data allowed the authors to define those categories of patients where the device should have the most benefit: neonates, children, non-compliant older patients with cognitive difficulties, patients with skin abnormalities that may reduce the effectiveness of a skin-adhesive sutureless securement system, patients who are candidates for having a peripherally inserted central catheter (PICC) in place for more than 8 weeks, and any other category of patients with a recognised high risk of catheter dislodgement.

We report a case of primary malposition of a PICC inserted by guidewire replacement in the emergency room. Intraprocedural tip location by intracavitary electrocardiography was not feasible because the patient had atrial fibrillation; intraprocedural tip location by ultrasound (using the so-called “bubble test”) showed that the tip was not in the superior vena cava or in the right atrium. A post-procedural chest X-ray confirmed the malposition but could not precise the location of the tip. A CT scan (scheduled for other purposes) finally visualized the tip in a very unusual location, the left pericardiophrenic vein.