Peter Frykholm, Docent och överläkare Anestesi- och intensivvårdskliniken

Akademiska Sjukhuset

Vad?

� Komplikationer � Säker (eller osäker) inläggningsteknik � Handläggning av komplikationer � Kvalitetssäkring

Rate of catheter-related blood stream infection(CRBSI) vs device type �  Perifer venkateter: 0.1%* 0.5 per 1000 IVDD ** �  Midline cath: 0.4% 0.2 per 1000 IVDD �  Standard CVC: 4.4% 2.7 per 1000 IVDD �  Artärkateter: 0.8% 1.7 per 1000 IVDD �  PICC: 2.4% 2.1 per 1000 IVDD �  Kuffad, tunnel. CVK: 22.5% 1.6 per 1000 IVDD �  SVPort: 3.6% 0.1 per 1000 IVDD

�  *total, **per 1000 days with resp catheter type

Maki et al. Mayo Clin Proc 2006 81(9):1159-71

Thrombo-embolic complications

�  Fibrin sheath � Asymptomatic thrombosis � Symptomatic thrombo-embolism

Miscellaneous complications

� Catheter migration � Rupture � Port migration �  The pinch-off syndrome (0.1-2.1%) � Catheter fracture/embolization

Munck et al. Eur Respir J 2004; 430–4 Mirza B et al. Am Surg 2004; 70: 635–44.

The Uppsala Vascular Access Centre - audit � Cohort study � Port insertions April 2009 – August 2011 �  1216 ports �  Follow-up period 12 months �  292472 catheter days

The Uppsala Vascular Access Unit

�  Started October 2006 �  700 – 800 procedures per year �  Ports, PICCs and tunneled CVCs (Hickman) �  A dedicated team of 6 – 8 anaesthesiologists,

4 nurses and one secretary �  The OR team: 1 anesthesiologist + one nurse

�  high output, low cost! �  Open weekdays 8 – 4 pm. Routine 4

scheduled procedures per day, but room for 1-4 extras.

�  Goal: Manage > 95% of referrals within 24 h

The Uppsala Vascular Access Unit – audit of early complications  

Complication   Absolute  number   Rate   Other  centres  Arterial  puncture   58   4.8%   0  –  6.0%  Perioperative  pain   48   3.9%   -­‐  Technical  problems   15   1.2%   -­‐  Haematoma   15   1.2%   0.2-­‐8.2%  Miscellaneous   11   0.9%   -­‐  

Pneumothorax   6   0.5%   0-­‐2.3%  Early  infection   4   0.3%   0  –  2.8%  Suture  insufIiciency   2   0.2%   -­‐  Hemothorax   1   0.1%   -­‐  

Early complications: diagnosed within two weeks of insertion

Fallbeskrivning: arteriellt läge

�  60 årig kvinna, svår RA, Cushingoid �  Indikation för SVP: anti-RA terapi � V subclavia sin �  ”semi-blind” puncture � Genomlysning: svårt att följa ledarens

väg pga svår skolios och svårdefinierade landmärken

� Dilator insertion: arteriellt läge!

Overall  complications:  subclavian  vs  internal  jugular  vein  

Subclavian   Internal  jugular  number   percent   number   percent  

Arterial  puncture   54   5.2%   4   2.3%  Perioperative  pain   39   3.8%   8   4.7%  Pneumothorax   6   0.6%   0   0  

number   per  1000  d     number   per  1000  d  

Temporary  occlusion   76   0.30   18   0.49   p=0,06  

Thrombo-­‐embolism   21   0.08   2   0.05   p=0,76  

Reasons  for  premature  removal  of  port  

Number   Rate   Other  centres  Total   40   3%   1-­‐15%  

Infection   24   60.0  %   0  -­‐  69.4%  Occlusion/poor  function   7   17.5  %   0  -­‐  9.3%  Thrombo-­‐embolism   3   7.5  %   0  -­‐  14.5%  Miscellaneous   6   15%   -­‐  

The Uppsala Vascular Access Unit – lessons learned

Teaching the procedure: � How many procedures does it take? �  Teaching residents �  Teaching consultants

The Uppsala Vascular Access Unit – lessons learned

� Dedicated theatre � Dedicated staff � Capacity for urgent cases � Budget and organisation for support

function � Art and the human side

Safe practice – patient preparation �  Information �  Is starvation a good thing? �  Prophylactic antibiotics? �  Chlorhexidine skin disinfection

�  Shower the night before �  Shower the same morning �  Local pre-operative scrub

�  Which lab tests do we need? �  Coagulation tests? �  WBC? Neutrofils?

�  Repeat procedure: consider CT angiography

Val av kärl �  Patient factors

�  Strålning �  Lymfödem pga bröstkirurgi �  Njurinsufficiens – framtida dialysbehov? �  Estetiska skäl/patientens önskemål

�  Internal Jugular Vein (IJV) vs Subclavian Vein (SCV)

�  V scl vs v axillaris �  Right vs Left side �  V femoralis?

Choice of vessel

Bilateral pre-operative US scan: � Vascular anomalies? �  Thrombosis? �  Tumors? � Which part of the vessel provides

optimal access? (eg SCV vs AxV)

Choice of vessel

To summarize: �  For long term access, use the right

internal jugular vein as the first choice! � Other sites may be chosen in individual

patients – the operator should be skilled in US guided insertion via all central veins.

Port implantation site

�  Female patients �  The obese patient �  The very thin patient �  The ”invisible” port – lateral thoracic site � Port placement for the femoral vein

�  to be avoided if possible

Choice of port and catheter

� Size matters � Use only ”power” ports - ready for high

pressure infusions � Silicon vs polyurethane catheter

Ultrasound

� Reduces number of attempts and the rate of puncture-related complications

� Saves time and money! �  The in-plane approach

�  Steep learning curve � Greater versatility �  Total control of needle position

Hind et al BMJ 2003 Fragou M et al CCM 2011;39:1607-12

Catheter tip position �  Fluoroscopy – an easy choice

�  Safe insertion of dilator �  Redirect deviating guidewire or catheter �  Find the correct tip position �  No need for routine post-op chest x-ray

�  Aim for the lower SVC/upper part of the RA

�  Paediatric long-term access – consider fluoroscopy with contrast. Post-op CXR prudent.

Silberzweig JE et al. 2003. J Vasc Interv Radiol 14(9):S443-52 Dede D et al. 2008. Surg Oncol 34(12):1340-3 www.sfai.se

Case report: arterial cannulation?

�  65 year old male (hunter) with myeloma � Chemotherapy planned �  Left subclavian approach � Easy ultrasound-guided cannulation � Guidewire going the right direction � Catheter going the un-right direction � Gravity test: iv. Blood gas: arterial!

Management of thrombosis

� Asymtomatic thrombosis: no indication for removal

� Symtomatic thrombo-embolism: LMWH treatment until port no longer needed, then consider removal

Debourdeau P et al 2009 Annals of Oncology 20: 1459–1471

Take-home messages

� Styr upp hygienrutinerna – gärna med hjälp av checklista

�  1. lär dig ultraljud. 2. använd ultraljud � Höger jugularis interna säkrast för

långtidsaccess �  Fixa ett kvalitetssäkringssystem

Anna Söderberg, medical student The staff at Uppsala Vascular Access Centre: Gunnar Enlund, Philip Staun Anna Holma, Anna-Greta Jansson, Soile Sundbaum, Ann-Sofie Eriksson, Veronica Barahona-Reyes

Peter Frykholm