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Purpose Few prospective follow-up studies evaluating the use of peripherally inserted central catheters (PICCs) to deliver chemotherapy and/or home parenteral nutrition (HPN) have focused exclusively on oncology outpatients. The aim of this prospective study was to assess the reliability and the safety of PICCs over a 5-year use in non-hospitalized cancer patients requiring long-term intravenous therapies. Methods Since June 2008, all adult oncology outpatient candidates for PICC insertion were consecutively enrolled and the incidence of catheter-related complications was investigated. The follow-up continued until the PICC removal. Results Two hundred sixty-nine PICCs in 250 patients (98 % with solid malignancies) were studied, for a total of 55,293 catheter days (median dwell time 184 days, range 15–1,384). All patients received HPN and 71 % received chemotherapy during the study period. The incidence of catheter-related bloodstream infections (CRBSIs) was low (0.05 per 1,000 catheter days), PICC-related symptomatic thrombosis was rare (1.1 %; 0.05 per 1,000 catheter days), and mechanical complications were uncommon (13.1 %; 0.63 per 1,000 catheter days). The overall complication rate was 17.5 % (0.85 per 1,000 catheter days) and PICCs were removed because of complications only in 7 % of cases. The main findings of this study were that, if accurately managed, PICCs can be safely used in cancer patients receiving chemotherapy and/or HPN, recording a low incidence of CRBSI, thrombosis, and mechanical complications; a long catheter life span; and a low probability of catheter removal because of complications. Conclusions Our study suggests that PICCs can be successfully utilized as safe and long-lasting venous access devices in non-hospitalized cancer patients.

Background Acutely ill patients admitted to the emergency department (ED) constantly require at least one fast and reliable peripheral intravenous (PIV) access. In many conditions (morbid obesity, underweight state, chronic diseases, intravenous drug abuse, adverse local conditions, etc.), PIV placement may be challenging. Ultrasound guidance is a useful tool for obtaining a peripheral intravenous access in the emergency department, particularly when superficial veins are difficult to identify by palpation and direct visualization, though standard peripheral intravenous cannulas are not ideal for this technique of insertion and may have limited duration. Long polyurethane catheters inserted with ultrasound guidance and direct Seldinger technique appear to have several advantages over short cannulas in terms of success of insertion and of duration. Methods A retrospective analysis was conducted on all the ultrasound-guided peripheral venous accesses obtained by insertion of long polyurethane catheters in patients admitted to the emergency department of our university hospital during 1 year. The main indication to the procedure was the urgent need of a peripheral venous access in patients with superficial veins difficult to palpate and/or visualize. All relevant data concerning the insertion and the maintenance of these peripheral lines were collected from the chart. Results Seventy-six patients were included in this review. The success rate of insertion was 100 %, with an average of 1.57 punctures per each successful cannulation. The mean time needed for the complete procedure was 9.5 min. In 73 % of patients, the catheter was used for more than 1 week; a minority of catheters were removed prematurely for end of use. No major infective or thrombotic complication was reported. Conclusions In our experience, 8- to 10-cm-long polyurethane catheters may offer a fast and reliable peripheral venous access in the emergency department, if placed by ultrasound guidance and with the Seldinger technique. Further studies with prospective, randomized, and controlled design are warranted to confirm our results.

In emergency situations, patients may need a fast and reliable peripheral venous access, which sometimes may be difficult to obtain, because of poor visualization of the superficial veins due to edema, obesity, hypovolemia or local abnormalities. In such cases, insertion of a central line is potentially time consuming and possibly associated with complications. Furthermore, central lines inserted in emergency are known to be at high risk of infection, so guidelines recommend that they should removed within 24 to 48 hours. In this setting, ultrasound-guided placement of a peripheral venous access might be more rapid, safer and more cost-effective than a central line.

In ICUs, peripherally inserted central catheters (PICCs) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters.

Dear Editor, We thank Dr. Kayashima for his interest in our publication. His comments about the identification of the artery behind the right internal jugular are very relevant. We agree that this vessel is most likely to be the thyrocervical trunk or one of its branches, rather than the normally deeper sited vertebral artery, but without imaging the vessel upwards and downwards the artery cannot be reliably identified in this one plane image. The important point clinically is that there are major arteries and their branches in close proximity behind the internal jugular vein on both sides of the lower neck. These include the subclavian artery and its branches, in particular the vertebral artery and thyrocervical trunk. The latter then branches into a number of vessels, some of which lie behind the vein. In fact, the careful sonologist assumes that there are sensitive tissues in proximity in all cases and adheres to proper and safe technique. Nomenclature of the thyrocervical trunk and its branches probably varies nationally and internationally. There is much variability in the anatomical patterns of such vessels, which are also probably different in the infant, adult and elderly patient with ectatic vessels. It is of paramount importance to maintain clinical relevance amidst theoretical anatomic discussions. The critically important goal during ultrasound guided vascular puncture is that sonologists learn how to properly identify target vessels for cannulation, prove they are the desired vessel type (vein versus artery), and then accurately guide the needle to the vessel. Finally, the needle and its tip must always be under the precise control of the sonologist to avoid potential complications. All of these points are stressed repeatedly in our manuscript [1], and readers should not be drawn away from these important points by hunting variable anatomy, particularly in infants where vascular structures are very close. As Dr. Kayashima has stated [2], such arteries are vulnerable low in the neck, if the vein is transfixed, which is often necessary in low-pressure veins or when the head has to be tilted up for intracranial hypertension. We too are aware of clinically significant damage to the vertebral, subclavian and thyrocervical arteries during attempted internal jugular cannulation. The use of high-resolution ultrasound devices allows the identification and avoidance of such

Introduction: In the ICU, peripherally inserted central catheters (PICCs) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome with the use of power-injectable catheters. Methods: We retrospectively reviewed all of the power-injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results: We collected 89 power-injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related bloodstream infection. Non-infective complications during management were not clinically significant. There was one episode of symptomatic thrombosis during the stay in the ICU and one episode after transfer of a patient to a non-intensive ward. Conclusion: Power-injectable PICCs have many advantages in the ICU: they can be used as multipurpose central lines for any type of infusion including high-flow infusion, for hemodynamic monitoring, and for high-pressure injection of contrast media during radiological procedures. Their insertion is successful in 100% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infective and non-infective complications.

In the critically ill, a reliable peripheral or central venous access is of paramount importance. Nonetheless, access may be difficult or may carry a significant risk of complications (pneumothorax, central line infection, etc.). Peripherally inserted venous catheters – either central (PICC) or peripheral (midline catheters (MC)) – are associated with a low risk of catheter-related bacteremia; also, using the ultrasound guidance and the microintroducer technique (UG + MIT), they can be inserted in any patient, regardless of the availability of superficial veins. We have reviewed our experience of 56 peripherally inserted catheters in 53 patients in different ICUs (surgical ICU, trauma unit, coronary unit, neurosurgical ICU, stroke unit, pediatric ICU, etc.); all catheters were positioned at the mid-arm, in the basilic vein or in the brachial veins, using UG + MIT. We assessed the feasibility of this technique in the acutely ill and the rate of complications.

Ultrasound (US) significantly facilitates central venous catheterization, reducing the percentage of failure, the percentage of accidental arterial puncture, and the percentage of complications (haematoma, haemothorax, pneumothorax). Nonetheless, it is not clear whether US guidance (USG) (so-called 'dynamic' or 'real-time' US techniques: that is, venipuncture under direct US control) may be better than US assistance (USA) (so-called 'static' or 'indirect' US techniques: that is, US imaging of the vein, with or without skin marking, and then blind venipuncture).