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Becton, Dickinson and — MDS20 EU (April 2020)
39 slides from Becton, Dickinson and's conference presentation, April 2020
Slide 1: Presenter disclaimer
These presentations were developed by the respective presenter(s), and the findings, interpretations, and conclusions contained or expressed with them do not necessarily reflect the views of BD. To the extent these presentations relate to specific products, such products should always be used in acc
Slide 2: Effectiveness and sustainability of the PICC in ICU
Effectiveness and sustainability of the PICC in ICU: EBM approach, Review of the literature and sharing of experiences. Fulvio Pinelli, MD Careggi University Hospital Florence, Italy
Slide 3: VADs needs in the critically ill
VADs NEEDS IN THE CRITICALLY ILL • Solutions with pH <5 or pH>9 (vasoactive drugs, atb., etc.) • Continuous multiple infusates (fluids, blood, electrolytes, drugs, etc.) • Parenteral Nutrition >800 mOsm/l • Hemodynamic Monitoring (CVP; CO; MvO2Sat) • Frequent blood samples INS 2016
Slide 4: Which VAD ensures the required performance?
WHICH VAD ENSURES THE REQUIRED PERFORMANCE? CVADs. • 43–80% of patients in the ICU require central access. • The CVAD most commonly inserted in ICU are nontunneled CVADs (CICC), PICCs, and hemo-dialysis catheters. Takashima CCM 2018
Slide 5: CICC or PICC in the Critically Ill?
CICC or PICC in the Critically Ill?
Slide 6: PICC drawbacks
CICC or PICC in the Critically Ill? PICC Drawbacks • «Time consuming» procedure • Hemodynamic monitoring • Increased risk of CRT (?) • Reduced catheter flow rates • Single/dual lumen
Slide 7: PICC: technological improvements
PICC: TECHNOLOGICAL IMPROVEMENTS III GENERATION PUR DESIGN INCREASED STRENGTH; SOFTNESS; PLIABILITY; THINNER WALLS; LARGER INTERNAL DIAMETER POWER INJECTABILITY High flows, Multiple infusions, Contrast Media
Slide 8: 5Fr Power Triple Lumen PICC
5FrPICC 3-lumen Power Triple Lumen PICC: in ICU High flows, Multiple Infusions, Contrast Media
Slide 9: PICC and hemodynamic monitoring: CVP
PICC and HEMODYNAMIC MONITORING: CVP Black CCM 2000 Polyurethane McLemore AVS 2006 Open ended catheters Latham BMC 2010 Yun Korean J Anesth 2011 Accurate measurements Sanfilippo JVA 2017
Slide 10: PICC implant technique improvements
CICC or PICC in the Critically Ill? PICC IMPLANT TECHNIQUE IMPROVEMENTS • CHOICE OF THE VEIN (diameter, position, depht) • ASEPTIC TECHNIQUE ISP PROTOCOL • ULTRASOUND GUIDANCE • INTRAPROCEDURAL TIP LOCATION Gavecelt 2010 • STABILIZATION OF THE DEVICE
Slide 11: Risk of infection, risk of thrombosis
CICC or PICC in the Critically Ill? ❑ RISK OF INFECTION ❑ RISK OF THROMBOSIS
Slide 12: Risk of infection
CICC or PICC in the Critically Ill? ❑ RISK OF INFECTION
Slide 13: PICC are theoretically associated with lower risk of infection
PICC are theoretically associated with lower risk of infection Why ? - Exit site is distant from nasal/oral/tracheal secretions - Low contamination of arm skin - Physical characteristics of arm skin (dry, thin) - Exit site allows better cleaning and better stabilization of the dressing - PICCs are i
Slide 14: PICC with insertion protocol have low risk of infection
PICC inserted according to a well-defined insertion protocol have low risk of infection - 0.4/1000 days (Pittiruti 2006 – pts on PN) - 0/1000 days (Harnage 2006) - 0.3/1000 days (Scoppettuolo 2010 – infect. dis. pts) - 0/1000 days (Cotogni 2013 – cancer pts on HPN) - 0.3/1000 days (Zerla 2015 – hosp
Slide 15: 63 studies involving 50,000 CVADs
63 studies involving 50,000 CVADs (396,951 catheter days) Takashima CCM 2018
Slide 16: CRBSI and CLABSI in ICU adults
ADULTS IN ICU NO OF COMPLICATIONS PER 1000 CATHETER DAYS CRBSI CLABSI Takashima CCM 2018
Slide 17: CICC is the better choice in
CICC is the better choice in: • Emergency situations • More than 3 lumen required • Arm veins unavailable or too small • Arm plegia • CHRONIC KIDNEY DISEASE (AV fistula) • Sedation IS NOT a contraindication to PICC INS 2016
Slide 18: Wouldn't a PICC have been a better choice?
Wouldn’t a PICC have been a better choice?
Slide 19: Wouldn't a PICC have been a better choice?
Wouldn’t a PICC have been a better choice? Courtesy of M. Pittiruti
Slide 20: At least...a tunnelled CICC...
AT LEAST...A TUNNELLED CICC...
Slide 21: Risk of infection
Risk of Infection There is no clear evidence-based difference (no RCT) between CICCs and PICCs in this regard. Though, CICC have certainly a high risk of infection: Especially: • in patients with tracheostomy; • when the emergency site of CICC's neck; • when the CICC is positioned without a proper i
Slide 22: Risk of thrombosis
CICC or PICC in the Critically Ill? ❑ RISK OF THROMBOSIS
Slide 23: Are CICC particularly at risk of CRT?
Are CICC particularly at risk of CRT ? • It depends on the caliber, the route and the technique of insertion • Larger catheters (dialysis) = more risk • Supraclavicular route = more risk • Ultrasound guided puncture = less risk • No hard data about the actual incidence, probably less than 3-5%
Slide 24: Are PICC particularly at risk of CRT?
Are PICC particularly at risk of CRT ?
Slide 25: PICC-related thrombosis rate meta-analysis, JVA 2019
Original research article Peripherally inserted central catheter-related thrombosis rate in modern vascular access era—when insertion technique matters: A systematic review and meta-analysis Paolo Balsorano!, Gianni Virgili?, Gianluca Villa?, Mauro Pittiruti‘, Stefano Romagnoli', Angelo Raffaele De
Slide 26: Meta-analysis inclusion criteria
Only prospective Insertion bundle Tip location verified Only symptomatic
Slide 27: Incidence of CRT for PICCs
Incidence of CRT for PICCs: - Onco-hematological = 5.9% - Oncological = 2.2% - Overall = 2.4%
Slide 28: What about other VADs in cancer patients?
What about other VADs in cancer patients? CRT in cancer patients with ports: 3.8 % (Decousus 2018) 2.3 % (Hong 2018)
Slide 29: Are PICC particularly at risk of CRT?
Are PICC particularly at risk of CRT ? • There is no clear evidence-based difference between CICCs and PICCs. Though, PICC have a higher risk of thrombosis: • In ICU hematologic patients (leukemia) • When PICCs are inserted in veins which are too small for the ideal catheter/vein ratio • When PICCs
Slide 30: Other advantage of PICCs: safety
OTHER • No significant risks at the insertion ADVANTAGE OF • Feasible even in «fragile» patients (cardio- PICCs: SAFETY respiratory), altered hemostasys, tracheostomy, neck and thorax abnormalities
Slide 31: Other advantages of PICCs
OTHER ADVANTAGES OF PICCs • Low cost procedure: a) by nurses; b) bedside • Best nursing of exit site • Greater patient acceptance • Medium term • The patient may be discharged with the PICC • Easy to removal, easy replacement
Slide 32: SIAARTi-SITI-GAVeCeLT Consensus on venous access
A SIAARTi-SITI-GAVeCeLT Project: a Consensus for the Choice, Implantation and Management of Venous Access in Intensive Care
Slide 33: Why a Consensus?
Why a Consensus? 1. The acute patient admitted to ICU has particular characteristics • Choice of devices, implantation techniques, management peculiar to the general population of hospitalized patients 2. The issue of vascular access in intensive care has never been specifically explored • Just in g
Slide 34: Purpose of the Consensus
Purpose of the Consensus 1. Identify the current certainties of the literature in terms of choice, implantation and management of the vascular access devices (arterial and venous) currently used in the adult patient admitted to intensive care; 2. Suggest appropriate clinical studies aimed at definin
Slide 35: Conclusion: CICC vs PICC in ICU
CONCLUSION: CICC vs PICC in ICU There is no evidence of difference between CICC and PICC in terms of infection or thrombosis. Adopting a proper insertion protocol (both for PICC and CICC), both risks can be minimized. The preference between PICC and CICC in ICU is based on other considerations.
Slide 36: Definite indication for a PICC
DEFINITE INDICATION FOR A PICC ✓ Tracheostomy ✓ High risk of infection of the exit site ✓ Coagulopathy ✓ Unavailability of the neck/clavicle area (NIV; collars, etc.) ✓ Prolonged ICU stay
Slide 37: Definite indication for a CICC
DEFINITE INDICATION FOR A CICC ✓ Emergency vascular access ✓ More than three lumens required ✓ Arm veins unavailable ✓ Arm plegia ✓ Chronic renal failure (AV fistula)
Slide 38: PICC = an important alternative option to CICC in ICU
PICC = an important alternative option to CICC in ICU 1. Specific situations in which PICC are safer and more cost-effective than CICC 2. Not for every patient (specific contraindications to PICC) 3. Maximal benefit if inserted using a well defined insertion bundle
Slide 39: Thank you
Thank you Fulvio Pinelli, MD Careggi University Hospital Florence, Italy
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