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Pinelli F, Pittiruti M, Annetta MG, Barbani F, Bertoglio S, Biasucci DG, Bolis D, Brescia F, Capozzoli G, D'Arrigo S, Deganello E, Elli S, Fabiani A, Fabiani F, Gidaro A, Giustivi D, Iacobone E, La Greca A, Longo F, Lucchini A, Marche B, Romagnoli S, Scoppettuolo G, Selmi V, Vailati D, Villa G, Pepe G. A GAVeCeLT consensus on the indication, insertion, and management of central venous access devices in the critically ill. J Vasc Access 2024:11297298241262932. [PMID: 39097780 DOI: 10.1177/11297298241262932] [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: 08/05/2024] Open
Abstract
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).
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Affiliation(s)
- Fulvio Pinelli
- Department of Anesthesia and Critical Care, University of Florence, "Careggi" Hospital, Florence, Italy
| | - Mauro Pittiruti
- Department of Surgery, Policlinico Universitario "A.Gemelli," Rome, Italy
| | | | - Francesco Barbani
- Department of Anesthesia and Critical Care, University of Florence, "Careggi" Hospital, Florence, Italy
| | | | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
| | - Denise Bolis
- Intensive Care Unit, Hospital "A.Manzoni," Lecco, Italy
| | - Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Giuseppe Capozzoli
- Department of Anesthesiology, Hospital of Bolzano, Lehr-Krankenhaus der Paracelsus Medizinischen Privatuniversität, Bolzano, Italy
| | - Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Policlinico Universitario "A.Gemelli," Rome, Italy
| | - Elisa Deganello
- Anaesthesia and Intensive Care, Ospedali Riuniti Padova Sud, Monselice, Italy
| | - Stefano Elli
- Vascular Access Team, Fondazione "San Gerardo dei Tintori," Monza, Italy
| | - Adam Fabiani
- Cardiac Surgery Intensive Care Unit, Vascular Access Team, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste, Italy
| | - Fabio Fabiani
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences, University of Milan, "Luigi Sacco" Hospital, Milan, Italy
| | - Davide Giustivi
- Post-Anesthesia Care Unit and Vascular Access Team, Lodi, Italy
| | - Emanuele Iacobone
- Anesthesia and Intensive Care, Hospital of Macerata, Macerata, Italy
| | - Antonio La Greca
- Department of Surgery, Policlinico Universitario "A.Gemelli," Rome, Italy
| | | | - Alberto Lucchini
- Adult and Pediatric Intensive Care Unit, Fondazione "San Gerardo dei Tintori," Monza, Italy
| | - Bruno Marche
- Department of Hematology, Policlinico Universitario "A.Gemelli," Rome, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Critical Care, University of Florence, "Careggi" Hospital, Florence, Italy
| | | | - Valentina Selmi
- Vascular Access Team, Department of Anesthesia and Critical Care, University of Florence, "Careggi" Hospital, Florence, Italy
| | - Davide Vailati
- Department of Anesthesia and Intensive Care, Melegnano Hospital, Milano, Italy
| | - Gianluca Villa
- Department of Anesthesia and Critical Care, University of Florence, "Careggi" Hospital, Florence, Italy
| | - Gilda Pepe
- Department of Surgery, Policlinico Universitario "A.Gemelli," Rome, Italy
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Pinelli F, Muzzi M, Pittiruti M. Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal? J Vasc Access 2024; 25:697-702. [PMID: 36163680 DOI: 10.1177/11297298221125965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite several effective preventive strategies peripherally inserted central catheters (PICCs)-as much as centrally inserted central catheters and femorally inserted central catheters-are inevitably associated with the potential development of catheter-related thrombosis. This complication may be symptomatic or-more often-asymptomatic. Even if remote, the chance that PICC removal may mobilize an asymptomatic thrombus and cause pulmonary embolism, is theoretically possible. On the other hand, the diffuse adoption of an ultrasound scan aiming at detecting an asymptomatic catheter-related thrombosis may be logistically difficult and expensive. No clear evidence-based recommendations exist on this issue and whether perform an ultrasound scan before PICC removal in asymptomatic patients remains a matter of debate. For these reasons, the authors propose few common sense recommendations that may help clinicians in weighing the clinical advantages of the exam (optimal safety for the patient) versus its practical disadvantages (logistic cost).
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Affiliation(s)
- Fulvio Pinelli
- AOUC, Anesthesia and Intensive Care, Florence, Tuscany, Italy
| | - Mirko Muzzi
- School of Human Health Science, University of Florence, Florence, Italy
| | - Mauro Pittiruti
- Department of Surgery, University Hospital Agostino Gemelli, Rome, Lazio, Italy
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van Ommen CH, Luijnenburg SE. Anticoagulation of pediatric patients with venous thromboembolism in 2023. Thromb Res 2024; 235:186-193. [PMID: 38378308 DOI: 10.1016/j.thromres.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/24/2023] [Accepted: 12/24/2023] [Indexed: 02/22/2024]
Abstract
Venous thromboembolism (VTE) is a rare and heterozygous disease in children. Management of VTE in children is complicated by age-related differences in epidemiology, recurrent VTE and bleeding risk, hemostatic proteins and pharmacokinetics of anticoagulants. Recently, the choice of anticoagulation has expanded to oral factor IIa and Xa inhibitors, which have been authorized for children for treatment of acute VTE and extended secondary prevention. These drugs have several properties that make them extremely suitable for use in children, including oral administration, antithrombin independence, less interactions with food and drugs and no need for monitoring. Unfortunately, the phase 3 studies had many exclusion criteria, and only a few term neonates and infants were included in these studies. Additional real-world data is needed to make evidence-based recommendations in these age and patient groups, as well.
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Affiliation(s)
- C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands.
| | - Saskia E Luijnenburg
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands
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Abbruzzese C, Guzzardella A, Consonni D, Turconi G, Bonetti C, Brioni M, Panigada M, Grasselli G. Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study. Ann Intensive Care 2023; 13:106. [PMID: 37858003 PMCID: PMC10587047 DOI: 10.1186/s13613-023-01206-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice's method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis. RESULTS Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000*cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000*cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed. CONCLUSIONS CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.
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Affiliation(s)
- Chiara Abbruzzese
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy.
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Gloria Turconi
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Claudia Bonetti
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Matteo Brioni
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Mauro Panigada
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Giacomo Grasselli
- Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza, 35, 20122, Milan, Italy
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Monagle P, Male C, Raffini L. The value of the old and the new. Blood Adv 2023; 7:3683-3685. [PMID: 36939386 PMCID: PMC10368678 DOI: 10.1182/bloodadvances.2023009723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 03/21/2023] Open
Affiliation(s)
- Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Haematology Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Leslie Raffini
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Pelizza MF, Martinato M, Rosati A, Nosadini M, Saracco P, Giordano P, Luciani M, Ilardi L, Lasagni D, Molinari AC, Bagna R, Palmieri A, Ramenghi LA, Grassi M, Magarotto M, Magnetti F, Francavilla A, Indolfi G, Suppiej A, Gentilomo C, Restelli R, Tufano A, Tormene D, Pin JN, Tona C, Meneghesso D, Rota L, Conti M, Russo G, Lorenzoni G, Gregori D, Sartori S, Simioni P. The new Italian registry of infantile thrombosis (RITI): A reflection on its journey, challenges and pitfalls. Front Pediatr 2023; 11:1094246. [PMID: 37152311 PMCID: PMC10159054 DOI: 10.3389/fped.2023.1094246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/06/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Thrombotic events in neonates and children represent a rare although severe occurrence in view of the associated risk of mortality and sequelae. Quality evidence is limited in this field, and registry studies provide an essential base for research. The aim of this paper is to present the new Italian Registry of Infantile Thrombosis (RITI), set it into the scene of international thrombosis and stroke registries, and provide some insight on the challenges associated with registry management. Methods We present the detailed structure and content of the new RITI registry, a brief overview of its main data, and a reflection on its features, pitfalls and the main challenges related to its management. Results The RITI, initially started in 2007 and officially re-launched in 2017 after structural modifications, is a non-interventional retrospective and prospective registry study collecting data on neonatal and pediatric patients (0-18 years) who experienced a systemic or cerebral thrombotic event in Italy. The RITI is managed by a multidisciplinary team with expertise in pediatric thrombosis, and participation is open to all Italian physicians, on a voluntary basis. The overall aim of the registry is to acquire new evidence to better characterize the population of children with thrombotic events and improve their management and outcome. 48 Italian pediatric and intensive care units are actively involved in the RITI, including 85 medical doctors from 16 Italian regions. A total of 1,001 neonates and children affected by cerebral or systemic thrombosis have been enrolled. Discussion The RITI is one of the largest available European registries of neonatal and pediatric thrombosis. National registries like the RITI represent a model for the study of rare conditions based on multidisciplinary and multicenter collaboration, aimed at overcoming the limitations due to small populations of patients, and creating a network of experts for patient referral and continuous education. Moreover, registry studies have a pivotal role in the research on pediatric thrombosis, due to the limited feasibility of high-quality studies. In our experience, the main critical stages, pitfalls and challenges in registry management include adequate registry designing, diffusion, data completeness and quality control.
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Affiliation(s)
- Maria Federica Pelizza
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University of Padova, Padova, Italy
| | - Matteo Martinato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Department of Statistics, Computer Science, Applications “G. Parenti”, University of Firenze, Firenze, Italy
| | - Anna Rosati
- Neuroscience Center of Excellence, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Paola Saracco
- Paediatric Haematology Unit, Department of Paediatrics, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Paola Giordano
- Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari-Giovanni XXIII Hospital, Bari, Italy
| | - Matteo Luciani
- Department of Paediatric Hemato-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, Roma, Italy
| | - Laura Ilardi
- Neonatal Intensive Care Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Donatella Lasagni
- Paediatric Unit, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic Diseases, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Rossana Bagna
- Neonatal Intensive Care Unit, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Antonella Palmieri
- Department of Paediatric Emergency, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Luca Antonio Ramenghi
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Children's Hospital, Genova, Italy
| | - Massimo Grassi
- Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari-Giovanni XXIII Hospital, Bari, Italy
| | - Mariella Magarotto
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Federica Magnetti
- Neonatal Intensive Care Unit, University Hospital “Città Della Salute e Della Scienza”, Torino, Italy
| | - Andrea Francavilla
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giuseppe Indolfi
- NEUROFARBA Department, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Agnese Suppiej
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Roberta Restelli
- Neonatal Intensive Care Unit, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Napoli, Italy
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, University Hospital of Padova, Padova, Italy
| | - Jacopo Norberto Pin
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Clarissa Tona
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Davide Meneghesso
- Paediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Lidia Rota
- Cardiovascular Prevention Centre, Humanitas Research Hospital, Milano, Italy
| | - Marta Conti
- Child Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giovanna Russo
- Unit of Pediatric Onco-Haematology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, University Hospital of Padova, Padova, Italy
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