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Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions)., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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 <2 cm) and 96.1% (for an error <3 cm). Unacceptable tip positions (>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., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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 (<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 10.5%; though, according to SSC the tip location was always acceptable (in 94.2% the tip was in the middle of the spot, in 2.5% close to the superior border, and in 2.3% close to the inferior border); no tip was visualized outside of the spot., 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., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare no conflict of interest. Currently A. Bilancia is employee of Becton Dickinson and G. Ortiz Miluy discloses employment with Izasa Medical, but they had no relationship with their companies at the time of planning and developing the study.

Introduction: Over the past decades, significant efforts have been made to reduce early and late catheter-related complications in critically ill patients, using approaches based on bundles of evidence-based interventions., Methods: In this prospective clinical study, the authors evaluated the incidence of catheter-related complications in their neuro-intensive care unit during a 4-year period, adopting systematically the GAVeCeLT bundles for the insertion and management of all central venous access devices: centrally inserted central catheters (CICCs), peripherally inserted central catheters (PICCs) and femorally inserted central catheters (FICCs). All early/immediate and late complications were recorded., Results: On 486 central lines (328 CICCs, 149 PICCs and 9 FICCs), the only clinically relevant early/immediate complication was primary tip malposition (1%). In regards late infective complications, the authors did not record any case of catheter-related bloodstream infection; though, they observed one case of central line associated blood stream infection (one CICC; 0.14/1000 catheter days), and 15 cases of catheter colonization (12 CICCs and 3 PICCs; 2.09 episodes/1000 catheter days). Late non-infective complications were few: 14 accidental dislodgments (2.9%), 18 irreversible lumen occlusions (3.7%), and no episodes of symptomatic catheter-related thrombosis or tip migration., Conclusion: The systematic adoption of the GAVeCeLT bundles for CVAD insertion and maintenance was associated with a minimization of catheter-related complications. The strict adherence to the recommendations included in these bundles was the major determinant for clinical success., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Peripheral venous access for extracorporeal photopheresis (ECP) may be difficult in graft versus host disease (GVHD) patients, because of previous intravenous therapies and multiple peripheral cannulations; in this population of patients, ultrasound guided midline catheters may be an alternative option to central venous access., Methods: In this single-center, prospective preliminary study, we enrolled all consecutive patients with a diagnosis of GVHD and candidate to ECP, over a period of 10 months. We used inserted power injectable, non-valved, polyurethane, 20-25 cm single lumen midline catheters (MC)., Results: Sixty-nine ECP procedures were carried out in six patients, using single-lumen MCs for outflow (5Fr in 74% and 4Fr in 26% of cases). For inflow, we used 5Fr or 4Fr MCs, or central venous access devices previously placed for other clinical reasons. There were no catheter-related complications during the entire period of ECP treatment. Mean outflow was significantly higher for 5Fr than for 4Fr MCs (35.8 ± 7.3 vs 29.2 ± 7.8 ml/min; p  = 0.0008) and the procedure time was significantly shorter (92.9 ± 9.2 vs 108 ± 13.2 min; p  < 0.0001)., Conclusion: In GVHD patients, ECP can be performed efficiently and safely using single lumen polyurethane power injectable MCs. The best results are obtained with 5Fr rather than with 4Fr catheters. This strategy of venous access should be implemented in DIVA patients requiring ECP treatments, and probably also in other types of apheresis., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p  = 0.21), pocket hematoma (0.8% vs 1.7%, p  = 0.32), infection (0.28% vs 1.05%, p  = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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.

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.