1
|
McManus C, Mifflin N, Rivera R, Vause S, Tran T, Ostroff M, Harrowell L, Frost S, Alexandrou E. Comparison of outcomes from tunnelled femorally inserted central catheters and peripherally inserted central catheters: a propensity score-matched cohort study. BMJ Open 2024; 14:e081749. [PMID: 38760049 PMCID: PMC11103188 DOI: 10.1136/bmjopen-2023-081749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/14/2024] [Indexed: 05/19/2024] Open
Abstract
OBJECTIVES To compare catheter-related outcomes of individuals who received a tunnelled femorally inserted central catheter (tFICC) with those who received a peripherally inserted central catheter (PICC) in the upper extremities. DESIGN A propensity-score matched cohort study. SETTING A 980-bed tertiary referral hospital in South West Sydney, Australia. PARTICIPANTS In-patients referred to the hospital central venous access service for the insertion of a central venous access device. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome of interest was the incidence of all-cause catheter failure. Secondary outcomes included the rates of catheters removed because of suspected or confirmed catheter-associated infection, catheter dwell and confirmed upper or lower extremity deep vein thrombosis (DVT). RESULTS The overall rate of all-cause catheter failure in the matched tFICC and PICC cohort was 2.4/1000 catheter days (95% CI 1.1 to 4.4) and 3.0/1000 catheter days (95% CI 2.3 to 3.9), respectively, and when compared, no difference was observed (difference -0.63/1000 catheter days, 95% CI -2.32 to 1.06). We found no differences in catheter dwell (mean difference of 14.2 days, 95% CI -6.6 to 35.0, p=0.910); or in the cumulative probability of failure between the two groups within the first month of dwell (p=0.358). No significant differences were observed in the rate of catheters requiring removal for confirmed central line-associated bloodstream infection (difference 0.13/1000 catheter day, 95% CI -0.36 to 0.63, p=0.896). Similarly, no significant differences were found between the groups for confirmed catheter-related DVT (difference -0.11 per 1000 catheter days, 95% CI -0.26 to 0.04, p=1.00). CONCLUSION There were no differences in catheter-related outcomes between the matched cohort of tFICC and PICC patients, suggesting that tFICCs are a possible alternative for vascular access when the veins of the upper extremities or thoracic region are not viable for catheterisation.
Collapse
Affiliation(s)
- Craig McManus
- Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Nicholas Mifflin
- Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Renz Rivera
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sophie Vause
- Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ton Tran
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Matthew Ostroff
- St Joseph's Health and Medical Centre, Emerson, New Jersey, USA
| | - Lorenza Harrowell
- Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Nursing, University of Wollongong, Faculty of Science Medicine and Health, Wollongong, New South Wales, Australia
| | - Steven Frost
- School of Nursing, University of Wollongong, Faculty of Science Medicine and Health, Wollongong, New South Wales, Australia
| | - Evan Alexandrou
- Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Nursing, University of Wollongong, Faculty of Science Medicine and Health, Wollongong, New South Wales, Australia
| |
Collapse
|
2
|
Ostroff M, Elzomor H, Weite TA, Garcia D, Ahn J, Stanko O, Anderson K, Winborne A, Alexandrou E. Femoral to abdomen tunneling at the bedside for medium/long term venous access. J Vasc Access 2024:11297298241251510. [PMID: 38708830 DOI: 10.1177/11297298241251510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Femoral to abdomen tunneling of small-bore central venous catheters is a bedside technique for patients with contraindications to a thoracic approach, or as an alternative to a lower extremity catheter exit site. METHOD A femoral to abdomen tunneling technique was implemented for patients receiving medium and long-term intravenous treatments with contraindications to the thoracic venous approach or as an alternative to a lower extremity catheter exit site. All venous access devices were inserted with ultrasound guidance under local anesthesia, and catheter tip placement assessed by post procedural radiography. RESULTS In this case series, from January 2020 to January 2023, a total of eight FTA-tunneled venous access devices were inserted. There were seven ambulatory patients and one bedbound patient. The median length of the subcutaneous tunnel was 20 cm, ranging from 15 to 27 cm. The median length of the intravenous catheter to the terminal tip was 31 cm, ranging from 23 to 40 cm. Tip location was confirmed by post-procedural abdominal radiograph. The catheter tip locations were interpreted to be at the level of T8-T9 (2), T12 (1), L4 (2), L2 (2), L1(1).No insertion or post insertion related complication was reported. Six patients completed the scheduled intravenous treatment. One patient was unable to be tracked due to transfer to an outside facility. One catheter initially demonstrated to be coiled over the left common iliac vessel was repositioned using a high flow flush technique. There was one reported catheter dislodgment by the nurse providing care and maintenance. The overall implant days were 961, with a median dwell time of 125 days ranging from 20 to 399 days. CONCLUSION Femoral to abdomen tunneling provides an alternative exit site useful in select patients with complex intravenous access. The data of this small retrospective review suggests this a safe and minimally invasive bedside procedure.
Collapse
Affiliation(s)
- Matt Ostroff
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | | | | | - Daniel Garcia
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | - Jane Ahn
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | - Olena Stanko
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | | | | | | |
Collapse
|
3
|
Annetta MG, Elli S, Marche B, Pinelli F, Pittiruti M. Femoral venous access: State of the art and future perspectives. J Vasc Access 2023:11297298231209253. [PMID: 37953601 DOI: 10.1177/11297298231209253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
In the past 5 years, non-dialysis femoral venous access has changed in terms of indications, techniques of insertion, and expected incidence of complications. To the traditional non-emergency indication for femoral catheters-obstruction of the superior vena cava-many other indications have been added, both in intensive and non-intensive care. The insertion technique has evolved, thanks to ultrasound guided venipuncture, tunneling, and ultrasound based intraprocedural tip location. Insertion of femorally inserted central catheters may be today regarded as a procedure with an extremely low intraprocedural and post-procedural risk. The risk of infection is reduced by the possibility of the exit site at mid-thigh, by the use of cyanoacrylate glue for sealing the exit site, and by appropriate intraprocedural strategies of infection prevention. The risk of catheter-related thrombosis is low, due to several concomitant strategies: a proper match between vein diameter and catheter caliber; an accurate intraprocedural assessment of tip location by ultrasound and/or intracavitary ECG; the consistent use of ultrasound guided venipuncture and micro-introducer kits; an adequate stabilization of the catheter at the exit site. The risk of mechanical complications and the risk of lumen occlusion are minimized when using polyurethane, power injectable catheters. All these novelties have brought a revolution in the field of femoral venous access, so that this route may be considered as safe and effective as other approaches to central venous catheterization.
Collapse
Affiliation(s)
| | - Stefano Elli
- ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Bruno Marche
- Vascular Access Team, Fondazione Policlinico Universitario "A Gemelli," Roma, Italy
| | - Fulvio Pinelli
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mauro Pittiruti
- Vascular Access Team, Fondazione Policlinico Universitario "A Gemelli," Roma, Italy
| |
Collapse
|
4
|
Ostroff M, Hafez N, Ann Weite T. A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia. J Vasc Access 2023; 24:162-164. [PMID: 34148396 DOI: 10.1177/11297298211026820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.
Collapse
Affiliation(s)
| | - Nagwa Hafez
- St. Joseph's Regional Medical Center, Paterson, NJ, USA
| | | |
Collapse
|
5
|
Annetta MG, Marche B, Dolcetti L, Taraschi C, La Greca A, Musarò A, Emoli A, Scoppettuolo G, Pittiruti M. Ultrasound-guided cannulation of the superficial femoral vein for central venous access. J Vasc Access 2021; 23:598-605. [PMID: 33749364 DOI: 10.1177/11297298211003745] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Bruno Marche
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Laura Dolcetti
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Cristina Taraschi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Antonio La Greca
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Andrea Musarò
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Alessandro Emoli
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Mauro Pittiruti
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| |
Collapse
|
6
|
Ostroff M, Ismail M, Weite T. Achieving superficial femoral venous access in a critically ill COVID-19 patient in the prone position. J Vasc Access 2021; 23:458-461. [PMID: 33567939 DOI: 10.1177/1129729821989894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 63-year-old obese male was admitted with acute respiratory failure secondary to COVID-19. Day 13 the patient decompensated, lapsing into a critical stage of severe acute respiratory distress syndrome, requiring immediate prone positioning. The Rapid Response Team managed the emergency intervention for intubation but was unable to establish central access with the patient in the prone position. A consult to the Vascular Access Team succeeded in establishing central catheter placement with an ultrasound-guided mid-thigh superficial femoral 55-centimeter triple lumen catheter. The terminal tip of the catheter was confirmed in the mid portion of the inferior vena cava.
Collapse
Affiliation(s)
| | - Mourad Ismail
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | - ToniAnn Weite
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| |
Collapse
|
7
|
Jin MF, Thompson SM, Comstock AC, Levy ER, Reisenauer CJ, McPhail IR, Takahashi EA. Technical success and safety of peripherally inserted central catheters in the great saphenous and anterior accessory great saphenous veins. J Vasc Access 2021; 23:280-285. [PMID: 33499716 DOI: 10.1177/1129729821989166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited. OBJECTIVES This study aimed to determine technical success and safety of GSV/AAGSV PICCs. MATERIALS AND METHODS This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded. RESULTS Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3-155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%). CONCLUSION Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.
Collapse
Affiliation(s)
- Mauricio F Jin
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Scott M Thompson
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ann C Comstock
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Emily R Levy
- Division of Pediatric Infectious Diseases and Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christopher J Reisenauer
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ian R McPhail
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Edwin A Takahashi
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
8
|
Ostroff MD, Goldberg D, Bauhman G, Korb AC. Venous catheter at alternate exit site in a 2-year-old requiring long-term antibiotics for osteomyelitis: A case report. J Vasc Access 2020; 22:1013-1016. [PMID: 32865114 DOI: 10.1177/1129729820954757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the pediatric population, vascular access is often challenging to secure and to maintain, especially for long-term intravenous (IV) treatment. The traditional approach for patients who require long-term IV antibiotics is placement of a peripherally inserted central catheter (PICC). The challenge in the pediatric population is the high risk of dislodgement after PICC placement, as these patients tend to pull their line out accidentally or purposefully. Current bedside options to prevent catheter dislodgement include adhesive securement devices, subcutaneous securement devices, sutures, and wrapping the site in gauze. However, these modalities often fail, leading to delay in administration of IV therapies, including life-saving antibiotics.A novel approach to this very common and serious issue is to tunnel the catheter subcutaneously, thereby placing the exit site in a location difficult for the patient to reach. Tunneled catheters generally are placed in children for long-term vascular access and insertion has primarily been reserved for surgeons in the operating room or by interventional radiologists. The following case report describes a central venous access catheter placed in the internal jugular vein and tunneled to the medial dorsal thoracic region successfully at the bedside, using intracavitary electrocardiogram (ECG) navigation under moderate sedation. Although a novel exit site, the technique of tunneling and use of the jugular vein is no different than traditional tunneling techniques therefore it was not deemed necessary to seek internal review board approval.
Collapse
Affiliation(s)
| | - David Goldberg
- St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Greg Bauhman
- St. Joseph's University Medical Center, Paterson, NJ, USA
| | - And Cheri Korb
- St. Joseph's University Medical Center, Paterson, NJ, USA
| |
Collapse
|
9
|
Ostroff MD, Pittiruti M. Alternative exit sites for central venous access: Back tunneling to the scapular region and distal tunneling to the patellar region. J Vasc Access 2020; 22:992-996. [PMID: 32644003 DOI: 10.1177/1129729820940178] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
Collapse
|