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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.
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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
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Annetta MG, Marche B, Ortiz Miluy G, Pittiruti M. Totally implanted central venous access devices inserted by the femoral route: A narrative review and the proposal of a novel approach, the FICC-port. J Vasc Access 2024:11297298241236816. [PMID: 38708819 DOI: 10.1177/11297298241236816] [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 ports are used in patients with indication to a totally implanted venous access device but with contraindication to chest-ports and brachial ports because of obstruction of the superior vena cava. In the last three decades, femoral ports have been implanted almost exclusively by cannulation of the common femoral vein at the groin, while the position of the tip has been assessed by X-ray. METHODS We report our experience with a new approach to femoral ports, which includes recent methods and techniques developed in the last few years. These novel femoral ports, which we call "FICC-ports," are characterized by (a) long femoral 5 Fr polyurethane catheter inserted by ultrasound-guided puncture of the superficial femoral vein at mid-thigh; (b) intraprocedural location of the tip in the sub-diaphragmatic inferior vena cava, using ultrasound visualization by the transhepatic and/or the subcostal view; (c) low-profile or very low-profile reservoir implanted above the quadriceps muscle, at mid-thigh. RESULTS In the last 3 years, we have implanted 47 FICC-ports in young adults with mediastinal lymphoma compressing the superior vena cava. We had no immediate/early complication, and only three late complications (one kinking of the catheter in the subcutaneous tissue; one tip migration with secondary venous thrombosis; one persistent withdrawal occlusion due to fibroblastic sleeve). CONCLUSION If there is indication to a femoral port, the implantation of a "FICC-port"-as described above-is to be strongly considered in terms of safety, effectiveness, and cost-effectiveness: no immediate-early complications, minimal late complications, no X-ray exposure, low invasiveness, low cost.
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Affiliation(s)
- Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Policlinico Universitario "A.Gemelli," Rome, Lazio, Italy
| | - Bruno Marche
- Department of Hematology, Policlinico Universitario "A.Gemelli," Rome, Lazio, Italy
| | | | - Mauro Pittiruti
- Department of Surgery, Policlinico Universitario "A.Gemelli," Rome, Lazio, Italy
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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.
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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
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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.
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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
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Gidaro A, Samartin F, Salvi E, Casella F, Cogliati C, Giustivi D, Lugli F, Trione C, Melchionda C, Bartoli A, Foschi A, Schiavini M, Schiuma M, Castelli R, Calloni M. Midline peripheral catheters inserted in the superficial femoral vein at mid-thigh: Wise choice in COVID-19 acute hypoxemic respiratory failure patients with helmet continuous positive airway pressure. J Vasc Access 2023; 24:1469-1476. [PMID: 35502147 DOI: 10.1177/11297298221085450] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND During coronavirus disease 2019 (COVID-19) pandemic, Helmet Continuous Positive Airway Pressure (h-CPAP) has been widely used to treat Acute Hypoxemic Respiratory Failure (AHRF). In COVID-19 patients undergoing h-CPAP a simple short peripheral catheter could be insufficient. According to the European Recommendations for Proper Indication and Use of Peripheral venous access consensus, a stable peripheral Vascular Access Device is indicated for intravenous treatment compatible with the peripheral route scheduled for more than 1 week. OBJECTIVE The aim of this prospective study was to evaluate the performance and the potential complications of superficial femoral midline catheters (SFMC) inserted in the Superficial Femoral Vein by direct Seldinger technique with peripheral tip (Arrow®, Teleflex; 20 cm length four FR single lumen and seven FR dual lumen) in AHRF COVID-19 patient. Complications were divided in early (accidental puncture of superficial femoral artery (APSFA); accidental saphenous nerve puncture (ASNP); bleeding) and late (Catheter Related Thrombosis (CRT); Catheter-Related Bloodstream Infections (CRBSI); Accidental Removal (AR); persistent withdrawal occlusion (PWO)). METHODS From 1st October 2020 to 30th June 2021 we conducted a prospective observational study in COVID-19 sub-intensive wards at Luigi Sacco Hospital (Milan). RESULTS Hundred seventy five SFMC (mean dwell time 11.1 ± 9.8 days) were implanted in COVID-19 patients, 107 (61.1%) during h-CPAP treatment (10.5 ± 8.9 days), the remaining 68 (38.9%) in patients with severe disease. We recorded two minor immediate/early complications (APSFA without sequelae) and no major complications.The long-term follow-up registered four CRBSI (2.3%-2.5/1000 catheters days (CD)), five CRT (2.9%: 2.6/1000 CD), 22 AR (12.6%; 11.4/1000 CD), 38 PWO (36.5%), 34 of which occurred due to fibroblastic sleeve (32.7%). CONCLUSIONS SFMC proved to be safe, easy and time-saving. It could be implemented, after a careful benefits and risks evaluation, in particular settings such as h-CPAP, delirium, bleeding risk factors and palliative care patients.
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Affiliation(s)
- Antonio Gidaro
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Federica Samartin
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Emanuele Salvi
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Francesco Casella
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Cogliati
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | | | - Francesca Lugli
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Trione
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Melchionda
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Arianna Bartoli
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Antonella Foschi
- Department of Infectious Diseases, Luigi Sacco Hospital, Milan, Italy
| | - Monica Schiavini
- Department of Infectious Diseases, Luigi Sacco Hospital, Milan, Italy
| | - Marco Schiuma
- Department of Infectious Diseases, Luigi Sacco Hospital, Milan, Italy
| | - Roberto Castelli
- University of Sassari Department of Medical, Surgical and Experimental Science University Hospital of Sassari, Sassari, Italy
| | - Maria Calloni
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
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Brescia F, Pittiruti M, Ostroff M, Spencer TR, Dawson RB. The SIF protocol: A seven-step strategy to minimize complications potentially related to the insertion of femorally inserted central catheters. J Vasc Access 2023; 24:527-534. [PMID: 34459295 DOI: 10.1177/11297298211041442] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The insertion of central venous catheters through the femoral veins is not uncommon and is potentially associated with the risk of immediate puncture-related complications and severe late complications as infection and thrombosis. As for other central venous access devices, the use of a standardized protocol of insertion and the correct application of evidence-based strategies are beneficial in reducing the risk of complications. We proposed a standardized protocol (S.I.F.: Safe Insertion of Femorally Inserted Central Catheters) consisting of seven strategies that should be part of vascular cannulation and should be adopted during the insertion of femoral venous catheters, aiming to minimize immediate, early and late insertion-related complications. These strategies include: preprocedural evaluation of the patient history and of the veins, appropriate aseptic technique, ultrasound guided puncture and cannulation of the vein, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and appropriate coverage of the exit site.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | | | - Robert B Dawson
- DNP, MSA, APRN, ACNP-BC, VA-BC Hospital Medicine and Vascular Access, Catholic Medical Center-Upper Connecticut Valley Hospital, Colebrook, NH, USA
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Ostroff M, Aberger K, Moureau N. Case report: End of life care via a mid-thigh femoral midline catheter. J Vasc Access 2023; 24:809-812. [PMID: 34463188 DOI: 10.1177/11297298211043410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Maintaining peripheral vascular access represents a major challenge for medical providers and patients leading to the emergence of ultrasound guided vascular access teams. Upper extremity peripheral vascular access options are often limited in the chronically ill patient population with end stage cancer, patients with severe contractures, tracheostomies, and feeding tubes and patients referred for palliative care are just some examples of patients who live with difficult access. The following is a case description of a mid-thigh superficial femoral vein midline catheter for comfort care medications in a patient with exhausted peripheral vasculature on hospice.
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Affiliation(s)
| | - Kate Aberger
- St. Joseph Regional Medical Center, Paterson, NJ, USA
| | - Nancy Moureau
- PICC Excellence, Inc, Chief Executive Officer, Hartwell, GA, USA
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Abdullaev AM, Davtyan KV, Kharlap MS. Alternative vascular accesses in electrophysiological operating rooms: focus on the quality of life in the early postoperative period. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Atrial fibrillation is the most common arrhythmia, the incidence of which increases in parallel with the progressive aging of the population. Atrial fibrillation worsens the prognosis of patients and significantly reduces the quality of life. Improvement of the technical and methodological aspects of catheter procedures leads to their widespread introduction into clinical practice both for the prevention of embolic events and for rhythm control. The need to provide access to the main vessels, more often to the femoral veins, the use of large bore introducers, as well as aggressive regimens of antithrombotic therapy in the postoperative period, bring to the fore local complications of catheter procedures and necessitates to maintain a horizontal position to achieve stable hemostasis. The use of ultrasound imaging can significantly reduce the number of vascular events. However, long-term immobilization often leads to back pain, urinary retention, and infectious complications, which is more pronounced in the older patient population. In order to reduce the immobilization time, many hemostasis systems have been developed, which have disadvantages and require additional costs for the treatment of patients. In this regard, the development and introduction into clinical practice of novel vascular access types to improve the quality of life in the early postoperative period seems relevant. For this purpose, a randomized study is conducted, which compares the efficacy and safety of the distal femoral access, which makes it possible to activate patients as soon as possible after surgery.
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Affiliation(s)
- A. M. Abdullaev
- National Medical Research Center for Therapy and Preventive Medicine
| | - K. V. Davtyan
- National Medical Research Center for Therapy and Preventive Medicine
| | - M. S. Kharlap
- National Medical Research Center for Therapy and Preventive Medicine
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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.
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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
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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.
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