Vascular access in neonates: - PowerPoint Presentation

Slide1

Vascular access in neonates:what we have vs. what we could have

Dr. Diana N. DiazAssistant Professor of Pediatric SurgeryZUMS

Vs.Slide2

Nurses assume much responsibility for

the administration of intravenous therapy…Slide3

With these consequences…Slide4
Slide5
Slide6
Slide7

General surgeons feel overconfident when dealing with children…Slide8

With these consequences…Slide9
Slide10
Slide11

Neither residents of Pediatrics nor Neonatology fellows get formal training in i-v line placementSlide12

Just blood sampling….Slide13

Necrotic handSlide14

In the end, the pediatric Surgeon is called……….Slide15

…..just for thisSlide16

…and what do we have?Loneliness

Inadequate materialsMoribund patientsSlide17

The materialsSlide18

List of venous access devices (CHOP, April 2009)Slide19

List of venous access devices (CHOP, April 2009)Slide20

MaterialsSlide21

Our setting

Sick neonate

Peripheral i

-v line

If unsuccessful

CUT-DOWN

Intraosseous

lineSlide22

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.Slide23

So...Slide24

What do we need?Slide25

Cooperation = TEAM WORK2. Adequate materials =

PICC (?)3. Patients in better shape = THINK AHEADSlide26

The importance of a VASCULAR ACCESS SERVICESlide27

VAS team is multidisciplinaryi-v teamInterventional Radiology nurses

TechnologistsPhysicians, NEONATOLOGISTS!Infection/prevention control specialistsInformation systems control personnelJPSN Vol.11, Number 4, October,2006Slide28

i-v teamCriteria for team membershipNICU 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 22–29Slide29

Training of the TeamReview of PICC manufacturer guidelines,Insertion and dressing techniques,

Radiographic confirmation of placement, Recognition and management of complicationsSlide30

Clinical practicum 5 successful insertions, initially supervised Groups of 2 nurses trained at a timeSlide31

Catheter Care CommitteeOncologistPediatric SurgeonAdvanced Practice Nurse manager

Infection prevention and control specialistsMaterials management personnelQuality practice specialistPatient safety specialistJPSN Vol.11, Number 4, October,2006Slide32

PICCP

eripherally Inserted C

entral

C

athetersSlide33

PICCSince 1971 showed to be superior

to CUT-DOWNSFilston

HC,Jhonson

DG.Percutaneous venous

canulation

in neonates and

infants.A

method of

catether

insertion without cut-

down.Pediatrics

1971 ;48 896-901Slide34

Although a PICC is inserted peripherally, the tip terminates in the superior vena cavaSlide35

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), Slide36

Indications1. 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 drugsSlide37

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

Slide38

Indications (cont.)10. VLBW patients who cannot be fed for more than 7 days11. Inadequate peripheral access

12. Patient in need of more than one peripheral vascular accessSlide39

Acyclovir pH 10.5 Penicillin pH 10Amphotericin B irritant Bactrim pH 10

Cipropraxin pH 3.3 Dilantin pH 12Dobutamine 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

Medications that are considered irritants due to chemical structure, pH or

osmolaritySlide40

ContraindicationsSepsis: 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.Slide41

ContraindicationsPeripheral 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.Slide42

ContraindicationsInjury 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.Slide43

Advantages for Pediatric Surgeons BETTER CARE

MORE TIME TO WORK AS PEDIATRIC SURGEONSREDUCE ANXIETY AND STRESS

HAPPIER NURSES

HAPPIER PARENTSSlide44

Peripheral IV cannula Vs PICC ☻ Conventional IV

cannula - life 1-3 days.☻ Access sites 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):25-30Slide45

PICC vs PIV Phlebitis

PICC 9,9%PIV34,5%Catheter SepsisPICC 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):436-9Slide46

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

PICC vs PIVSlide47

Review of literature – PICC Vs CLMuch 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) : 531-535Slide48

IRC according to

NEO-KISSJanuary 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

Peter

Heeg

2006

(

Number

of

infections

x 1000

patients

/

day

)

Slide49

CVLine + hemothoraxSlide50

Tunneled CVL Versus PICC LinesThe 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.Slide51

But….Slide52

24-gauge Quick Cath catheter

?Again no materials…….Slide53

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;16:461-6Slide54

Complications Slide55

Arterial spasmSlide56

After

manipulation

of umbilical

catheters

arterial

&

venous

NB 27 WGA. 2º

day

of life.PDA. Slide57

1 Paulson PR, Miller KM Neonatal peripherally inserted central catheters: recommendations for preventionof insertion and postinsertion complications. Neonatal Netw. 2008 Jul-Aug; 27(4):245-572 López Sastre J B, Fernández

Colomer B, Coto Collado G D y Ramos Aparicio A. Estudio prospectivosobre 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 lessfrequently occurring complications. Adv Neonatal care, 2003, February; 3(1):14-26.Slide58

7 Amerasekera SS, Jones CM, Patel R, Cleasby MJ. Imaging of the complications of peripherally insertedcentral 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, 20109 Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuingmedical education: do conferences, workshops, rounds, and other traditional continuing educationactivities change physician behavior or health care outcomes? JAMA 1999; 282:867-74. Meta-análisis

10 O 'Brien MA,

Freemantle N, Oxman AD, Wolf F, Davis DA,

Herrin J. Reuniones y talleres de educacióncontinua: 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

catetheSlide59

Shaw, J.C.L. Parenteral Nutrition in the Management of Sck Low Birthweight Infants.Pediatric Clinics ofNorthAmerica 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, Nº2,14 Bueno T M, A. I. Diz, P. Q.

Cervera, J. Pérez-Rodríguez, J.

Quero. Peripheral insertion of double-lumen central venous catheterusing 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 Sep-

Oct;31(5):282-5.

Upper Versus Lower Extremity Insertion. Pediatrics 2008 May; 121(5):e1152-9.Slide60

Not even ONE article that proved the superiority of CUT-DOWNS over PICCs.Slide61

Cut-down technique for intravenous infusion in infants.Wright JE.

Med J Aust. 1972 Jun 3;1(23):1203-6. No abstract available. Slide62

We need a transitionSlide63

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 studySlide64

Pediatric Surgery International 2010 Aug;26(8):819-24.

Epub 2010 Jun 20Percentage 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 Slide65

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

/ nurseSlide66

Vein SelectionSlide67
Slide68
Slide69

Vein SelectionTIPSRight arm

basilic vein First OPTION2. Scalp veins DILATE easily and do not have valves3. 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.Slide70

Vein SelectionTIPSSaphenous 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 vein3. Femoral vein too deepSlide71

¿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. Slide72

PICC COMPLICATIONS25% of total linesSlide73

PICC COMPLICATIONSINSERTION COMPLICATIONSPOST-INSERTION COMPLICATIONSSlide74

PICC COMPLICATIONSALL COMPLICATIONS ARE MANAGEABLESlide75

INSERTION COMPLICATIONS1. 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 catheterSlide76
Slide77

ComplicationsOther

complications ArritmiasCarciac perforation(0,25%).

Pericard

iac

effussion

Cardiac

tamponade

More

incidence

in PVC

catheters

Rupture

&

catheter

migration

Difficult

i

n

catheter

removal

More

incidence

i

n

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):105-10Slide78

Difficulty with advancing catheterSpecially in children with

chronic pathologiesLong time with i-v therapy

Massage, limb reposition and flushing helpsSlide79

POST-INSERTION COMPLICATIONSPhlebitis

Occlusion and ClottingHemorrhageThrombosis and Deep Vein ThrombosisInfectionEmboli, AirEmboli, Catheter

Catheter

Malpositioning and MigrationSlide80

Most common catheter-related complications1.

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. P

hlebitis (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

.Slide81

Risk factors of CRBSI1. Catheters inserted at femoral sites (increased risk of CRBSI compared with nonfemoral

catheters: 1.76; 95% confidence interval, 1.01-3.07, 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

.Slide82

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 2.2% per 1,000 patient days.

Journal of Infusion Nursing Issue: Volume 28(1), January/February 2005, p 45–53Slide83

Occlusion and ClottingPartial occlusionOne-way occlusion

Total occlusionPREVENTION IS THE MOST IMPORTANTSlide84

Catheter malpositionSlide85

Catheter malpositionSlide86

Catheter malpositionSlide87

Catheter malpositionSlide88

Catheter malpositionSlide89

Catheter malpositionSlide90

Catheter malpositionSlide91

Type of complications:

Central versus Non central

Complica

t

ions

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;28Slide92

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 rateSlide93

When shall we remove the catheter?Slide94

The catheter should be removed when Its use can be no longer justified B

acteraemia 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  Slide95

􀂄 Position the patient in a supine position.􀂄 Apply sterile gloves.􀂄 Remove the dressing.

􀂄 Grasp the catheter and have sterile gauzeready in your other hand.􀂄 Pull with gentle, steady pressure but stop theremoval if there is resistance. Slide96

Contact the physician, apply heat, reposition the limb and consider trying removal again later or the next day.Do not pull against resistance.Slide97

In conclusionThe lack of correct vascular access

Raises morbidity and mortalityProlongs hospitalization Raises

the

sanitary

expenditure

.

(

Pratt

et al. 2001; EPIC)

Slide98

So…Slide99

Isn’t it worth to give a try with PICCs?Slide100

Thank you