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Vascular access in neonates: what we have vs. what we could have Vs. Dr. Diana N. Diaz Assistant Professor of Pediatric Surgery ZUMS much responsibility for Nurses assume the administration of intravenous therapy… With these consequences… General surgeons feel overconfident when dealing with children… With these consequences… Neither residents of Pediatrics nor Neonatology fellows get formal training in i-v line placement Just blood sampling…. Necrotic hand In the end, the pediatric Surgeon is called………. …..just for this …and what do we have? 1. Loneliness 2. Inadequate materials 3. Moribund patients The materials List of venous access devices (CHOP, April 2009) List of venous access devices (CHOP, April 2009) Materials Our setting CUT-DOWN Peripheral i-v line If unsuccessful Sick neonate Intraosseous line Vascular access in children requires skill, time, patience, and the appropriate equipment. Surg Clin North Am. 1992 Dec;72(6):1267-84. Vascular access techniques and devices in the pediatric patient. So... What do we need? 1.Cooperation = TEAM WORK 2. Adequate materials = PICC (?) 3. Patients in better shape = THINK AHEAD The importance of a VASCULAR ACCESS SERVICE VAS team is multidisciplinary • • • • • • i-v team Interventional Radiology nurses Technologists Physicians, NEONATOLOGISTS! Infection/prevention control specialists Information systems control personnel JPSN Vol.11, Number 4, October,2006 i-v team 1. 2. 3. 4. 5. Criteria for team membership NICU experience, Communication and organization skills, Motivation, IV insertion expertise, Schedule flexibility Neonatal Peripherally Inserted Central Catheter Team: Evolution and Outcomes of a Bedside-Nurse– Designed Program Advances in Neonatal Care Issue: Volume 7(1), February 2007, p 22–29 Training of the Team 1. 2. 3. 4. Review of PICC manufacturer guidelines, Insertion and dressing techniques, Radiographic confirmation of placement, Recognition and management of complications Clinical practicum • 5 successful insertions, initially supervised • Groups of 2 nurses trained at a time Catheter Care Committee • • • • • • • Oncologist Pediatric Surgeon Advanced Practice Nurse manager Infection prevention and control specialists Materials management personnel Quality practice specialist Patient safety specialist JPSN Vol.11, Number 4, October,2006 PICC Peripherally Inserted Central Catheters PICC Since 1971 showed to be superior to CUT-DOWNS Filston HC,Jhonson DG.Percutaneous venous canulation in neonates and infants.A method of catether insertion without cut-down.Pediatrics 1971 ;48 896-901 Although a PICC is inserted peripherally, the tip terminates in the superior vena cava Indications of PICCs “Infusion Nurses Society” 2006, RNAO guide “Registered Nurses' Association of Ontario” (RNAO 2004) and RCN Standards “Royal College of Nursing” (RCN 2005), Indications 1. Medication with pH < 5 or pH > 9. 2. Drugs with osmolarity >600 mOsm/L (INS 2006) or 500 mOsm/L (RNAO 2004). 3. Parenteral Nutrition with osmolarity superior glucose 10% or 5% aminoacids. 4. Administration of irritant drugs 5. Safe route for cardiovascular drugs Indications (cont.) 6. Parenteral Nutrition inferior to 3-4 weeks duration. 7. Keep vascular integrity 8. Minimum child manipulation due to pathology (Pulmonary hypertension,VLBW) 9. Treatments longer than 6 days Indications (cont.) 10. VLBW patients who cannot be fed for more than 7 days 11. Inadequate peripheral access 12. Patient in need of more than one peripheral vascular access Medications that are considered irritants due to chemical structure, pH or osmolarity Acyclovir pH 10.5 Penicillin pH 10 Amphotericin B irritant Bactrim pH 10 Cipropraxin pH 3.3 Dilantin pH 12 Dobutamine pH 2.5 Phenergan pH 4.0 Potassium pH 4.0 hypertonic Rocephin mixed hypertonic Tobramycin pH3.0 TPN and PPN hypertonic > 600m Osm Vancomycin pH 2.4 Doxycycline pH 1.8 Erythromycin irritant Gancyclovir pH 11 Lidocaine Morphine pH 2.5 Nafcillin pH 10 Dopamine pH 2.5 Pentamidine pH 4.09 Contraindications • Sepsis: if a patient has a positive blood culture, it may be indicated to treat the patient with peripheral antibiotics for 48 to 72 hours and confirm a negative blood culture before a PICC is placed. Contraindications • Peripheral neuropathy, • Circulatory impairment, burns, or radiation to the insertion site or along the intended path of the catheter. History of thrombosis • Dermatitis, hematomas, or burns that would prevent peripheral or antecubital access. Contraindications • Injury or infection to the extremity: if a patient has osteomyelitis of the left shoulder, you should not place a PICC in the left extremity. Avoid PICCs in an extremity with an injury or infection. Advantages for Pediatric Surgeons 1. BETTER CARE 2. MORE TIME TO WORK AS PEDIATRIC SURGEONS 3. REDUCE ANXIETY AND STRESS 4. HAPPIER NURSES 5. HAPPIER PARENTS Peripheral IV cannula Vs PICC ☻ Conventional IV cannula - life ☻ Access sites 1-3 days. rapidly exhausted. ☻Pain inflicted by repeated cannulation. ☻Rate of phlebitis and catheter associated infection higher. ☻Cost-benefit ratio unfavorable. West J Med. 1994 Jan;160(1):25-30 PICC vs PIV Phlebitis – PICC 9,9% – PIV34,5% • Catheter Sepsis – PICC 4,6% – PIV 9% • More duration – PICC 11days – PIV1,2 a 2,9 days Efficacy of peripherally inserted central venous catheters placed in noncentral veins. Arch. Pediatr Adolesc Med. 1998. May;152(5):436-9 PICC vs PIV • PICC insertion is successful in the great majority of cases. Lower risk of infection than multiple i-v line insertion in VLBW • Take into account the pain due to multiple punctures Liossis G, Bardin C, Papageorgiou A, Comparison of risks from percutaneous central venous catheters and peripheral lines in infants of extremely low birth weight: a cohort controlled study of infants < 1000 g. J Matern Fetal Neonatal Med. 2003 Mar; 13 (3) :171-4 Review of literature – PICC Vs CL • Much safer Can be inserted by registered nurses at the . bedside. • Lower rate of mechanical complications - pneumothorax, haemothorax. • Practically no contraindications. • Cheaper, Easier to maintain, have a longer dwell time. • Smaller and more comfortable for the child. • Allows early discharge and outpatient continuation of therapy Singapore Med J 2003 Vol 44(10) : 531-535 IRC according to NEO-KISS January 2000 – December 2004 VLBW < 500g Bacteriemia associated to catheters Central venous line 14.2 PICC 9.6 <1.000 g and 1000-1499 g Bacteriemia associated to catheters Central venous line 11,1 PICC 7,8 (Number of infections x 1000 patients/day) Peter Heeg 2006 CVLine + hemothorax Tunneled CVL Versus PICC Lines • The pediatric surgeon places them!!... At the femoral vein… • There is no difference in efficacy or associated complications between the two groups. • Journal of Perinatology 2001; 21:525–530. But…. 24-gauge Quick Cath catheter ? Again no materials……. Umbilical venous catheters • Very sick newborn or very inmature during the first 48 H of life • For exchange transfusion • Any type of drugs can be infused, blood and byproducts (except platelets) • In VLBW could last from 7-14 days J.Perinatal 1996;16:461-6 Complications Umbilical Artery Ischemia Massive bleeding Distal necrosis. Thrombosis Umbilical Vein Air Embolism Pulmonary Bleeding Embolism Thrombosis Arterial spasm After manipulation of umbilical catheters arterial & venous NB 27 WGA. 2º day of life.PDA. • • • • • • • • • • • • • 1 Paulson PR, Miller KM Neonatal peripherally inserted central catheters: recommendations for prevention of insertion and postinsertion complications. Neonatal Netw. 2008 Jul-Aug; 27(4):245-57 2 López Sastre J B, Fernández Colomer B, Coto Collado G D y Ramos Aparicio A. Estudio prospectivo sobre catéteres epicutáneos en neonatos. Grupo de Hospitales Castrillo. Anales Españoles de Pediatréa. 2000 ; 53 ( 2). 3 Cartwright D W.. Central venous lines in neonates: a study of 2186 catheter. Arch Dis Child Fetal Neonatal Ed 2004; 89: F504 – F508. 4 Pettit, J. Technological advances for PICC placement and management. Advances in Neonatal Care. 2007; 7: 122–131. 5 Pettit J. Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the most frequently occurring complications. Adv Neonatal Care. 2002 Dec;2(6):304-15. 6 Pettit J. Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less frequently occurring complications. Adv Neonatal care, 2003, February; 3(1):14-26. • • • • • • • • • • • • 7 Amerasekera SS, Jones CM, Patel R, Cleasby MJ. Imaging of the complications of peripherally inserted central venous catheters. Clin Radiol. 2009 Aug;64(8):832-40. Epub 2009 Jun 16. 8 Todd T. Nowlen, Geoffrey L. Rosenthal, Gregory L. Johnson, Deborah J. Tom and Thomas A. Vargo. Pericardial Effusion and Tamponade in Infants With Central Catheters. Pediatrics 2002;110;137-142. Downloaded from www.pediatrics.org by on March 9, 2010 9 Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999; 282:867-74. Metaanálisis 10 O 'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Reuniones y talleres de educación continua: efectos sobre los resultados en la práctica profesional y la asistencia sanitaria. Base de Datos Cochrane de Revisiones Sistemáticas (Cochrane Database of Systematic Reviews) 2001, 11 Filston HC,Jhonson DG.Percutaneous venous canulation in neonates and infants.A method of catethe Shaw, J.C.L. Parenteral Nutrition in the Management of Sck Low Birthweight Infants.Pediatric Clinics of NorthAmerica 1973 29 (2) 333-358 A14 13 García-Alix A, Pérez J, Serrano M, López JC, Quero J. Retained central venous lines in the newborn: Report of one case and systematic review of the literature. Neonatal Networ March/April 2007. Vol. 26, Nº 2, 14 Bueno T M, A. I. Diz, P. Q. Cervera, J. Pérez-Rodríguez, J. Quero. Peripheral insertion of double-lumen central venous catheter using the Seldinger technique in newborn. Journal of Perinatology 2008; 28(4), 282– 286. 15 Goñi Orayen C., R. Ruiz Cano, M. C. Carrascosa Romero, M. S. Vázquez García, A. Martínez Gutiérrez. Accesos venosos centrales por técnica de Seldinger en Neonatología. Cir Pediatr 1999; 12: 165-167. 16 Mickler PA. Neonatal and Pediatric Perspectives in PICC Placement. J Infus Nurs. 2008 SepOct;31(5):282-5. Upper Versus Lower Extremity Insertion. Pediatrics 2008 May; 121(5):e1152-9. Not even ONE article that proved the superiority of CUT-DOWNS over PICCs. Cut-down technique for intravenous infusion in infants. Wright JE. 1972 Med J Aust. Jun 3;1(23):1203-6. No abstract available. We need a transition Shifting from open surgical cut down to ultrasound-guided percutaneous central venous catheterization in children: learning curve and related complications Pediatric Surgery International 2010 Aug;26(8):819-24. Epub 2010 Jun 20. PICC lines were excluded from the study Percentage of CVCP-related complications in the 4 monthly data grouping. Learning curve to achieve appropriate levels of competence in US-guided CVCP positioning may explain the progressive decrease in complication rate especially in the second part of the study Pediatric Surgery International 2010 Aug;26(8):819-24. Epub 2010 Jun 20 Profesional staff • Training of nurses in charge of indication, insertion y maintenance Egginamp p ,et al. Lancet 2000; 355 : 1864-8 • Make sure that the staff acts according to general policies Meta-análisis JAMA 1999; 282:867-74 • Appropriate number of nurses: 1-2 patients / nurse Vein Selection Vein Selection TIPS 1. Right arm basilic vein First OPTION 2. Scalp veins DILATE easily and do not have valves 3. External jugular: Bleeds, risk of gas embolism, hard to compress, fix, position. Close to airway. 4. Lower limbs LESS INFECTIONS Hoang V, Sills J, Chandler M, Busalani E, Clifton-Koeppel R and Modanlou H D. Percutaneously Inserted Central Catheter for Total Parenteral Nutrition in Neonates: Complications Rates Related to Upper Versus Lower Extremity Insertion. Pediatrics 2008 May; 121(5):e1152-9. Vein Selection TIPS 1. Saphenous access gives more phlebitis Giraldo I, Quirós A, Mejía LA.Manejo de catéteres centrales de inserción periférica en recién nacidos. Aquichan. 2008; Vol. 8, Nº. 2:257-265 2. Popliteal access is more difficult to reach a central vein 3. Femoral vein too deep ¿PICC in lower limbs? • Less infection than the ones inserted at upper limbs • Complications take longer to detect • Less cholestasis in spite of long lasting TPN Lower limbs can be used for PICC insertion Hoang V, Sills J, Chandler M, Busalani E, Clifton-Koeppel R, Modanlou HD Percutaneously inserted central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower extremity insertion. Pediatrics. 2008 May;121(5):e1152-9. PICC COMPLICATIONS 25% of total lines PICC COMPLICATIONS INSERTION COMPLICATIONS POST-INSERTION COMPLICATIONS PICC COMPLICATIONS ALL COMPLICATIONS ARE MANAGEABLE INSERTION COMPLICATIONS 1. PAIN (Sacarose 2ml 24% BEST )Taddio A, Shah V, Hancock R, Smith RW, Stephens D, Atenafu E, Beyene J, Koren G, Stevens B, Katz J. Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures. CMAJ. 2008 Jul 1;179(1):37-43. 2. HEMORRAGE (introducer TOO BIG) 3. Arterial puncture (polyurethane) 4. Cardiac Arrhythmia 5. Nerve injury 6. Difficulty with advancing catheter Complications • Other complications – Arritmias – Carciac perforation(0,25%). Pericardiac effussion Cardiac tamponade • More incidence in PVC catheters – Rupture & catheter migration – Difficult in catheter removal • More incidence in silicone catheters Serrano M, García-Alix A, López JC, Pérez J, Quero J. Retained central venous lines in the newborn: report of one case and systematic review of the literature. Neonatal Netw. 2007 Mar-Apr;26(2):105-10 Difficulty with advancing catheter • Specially in children with chronic pathologies • Long time with i-v therapy • Massage, limb reposition and flushing helps POST-INSERTION COMPLICATIONS 1. 2. 3. 4. 5. 6. 7. 8. Phlebitis Occlusion and Clotting Hemorrhage Thrombosis and Deep Vein Thrombosis Infection Emboli, Air Emboli, Catheter Catheter Malpositioning and Migration Most common catheter-related complications 1. Catheter-related blood-stream infection (CRBSI; incidence: 8.3 per 1000 catheter days), 2. Catheter occlusion (4.0 per 1000 catheter days), 3. Catheter site inflammation (3.5 per 1000 catheter days), 4. Phlebitis (3.1 per 1000 catheter days). The most common pathogen of CRBSI was coagulase-negative staphylococcus (40.1%) Neonatol. 2010 Dec;51(6):336-42. Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous catheters in very low birth weight infants: a center's experience in Taiwan. Hsu JF, Tsai MH, Huang HR, Lien R, Chu SM, Huang CB. Risk factors of CRBSI • 1. Catheters inserted at femoral sites (increased risk of CRBSI compared with nonfemoral catheters: 1.76; 95% confidence interval, 1.013.07, p = 0.045) • 2. Longer duration of PICC placement (p < 0.001). • A low birth body weight and gestational age were not found to significantly affect the risk of CRBSI. Neonatol. 2010 Dec;51(6):336-42. Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous catheters in very low birth weight infants: a center's experience in Taiwan. Hsu JF, Tsai MH, Huang HR, Lien R, Chu SM, Huang CB. • PICCs have an infection rate of only 0.4% per 1,000 patient days, whereas acute care noncuffed, noncoated, and nontunneled catheters had an infection rate of 1,000 patient days. 2.2% per Journal of Infusion Nursing Issue: Volume 28(1), January/February 2005, p 45–53 Occlusion and Clotting • Partial occlusion • One-way occlusion • Total occlusion PREVENTION IS THE MOST IMPORTANT Catheter malposition Catheter malposition Catheter malposition Catheter malposition Catheter malposition Catheter malposition Catheter malposition Type of complications: Central versus Non central Complications Central n=1096 Non central n=170 P Value Phlebitis 16 (1.5%) 17 (10%) <.001 Occlusion 19 (1.7%) 11 (6.5%) <.001 Rupture 1 (.1%) 19 (11.2%) <.001 Mechanic 4 (.3%) 2 (1.2%) .187 Infection 2 (.2%) 0 1.000 Total 42 (3.8%) 49 (28.8%) <.001 Jhon M. Ricardio, Darcy A. Doellman y cols. Pediatric Peripherally Inserted Central Catheters: Complication Rates Related to Catheter tip localition . Pediatrics 2001;107;28 The two most serious complications are infection and thrombosis. Infection rates with PICCs continue to be low (in one study as low as .4/1000 catheter days) but varies with differing age groups Prevention is the key to maintaining a low complication rate When shall we remove the catheter? The catheter should be removed when • Its use can be no longer justified • Bacteraemia and/or clinical symptoms persisting beyond 48-72 hours despite appropriate antibiotic therapy • Septicaemia due to fungal infection • Evidence of septic emboli or endocarditis • Limb becomes increasingly oedematous Position the patient in a supine position. Apply sterile gloves. Remove the dressing. Grasp the catheter and have sterile gauze ready in your other hand. Pull with gentle, steady pressure but stop the removal if there is resistance. • Contact the physician, apply heat, reposition the limb and consider trying removal again later or the next day. • Do not pull against resistance. In conclusion The lack of correct vascular access Raises morbidity and mortality Prolongs hospitalization Raises the sanitary expenditure . (Pratt et al. 2001; EPIC) So… Isn’t it worth to give a try with PICCs? Thank you