Peter Frykholm, Docent och överläkare Anestesi- och intensivvårdskliniken Akademiska Sjukhuset

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1 Peter Frykholm, Docent och överläkare Anestesi- och intensivvårdskliniken Akademiska Sjukhuset

2 Vad? Komplikationer Säker (eller osäker) inläggningsteknik Handläggning av komplikationer Kvalitetssäkring

3 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: Artärkateter: PICC: 4.4% 2.7 per 1000 IVDD 0.8% 1.7 per 1000 IVDD 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 (9):

4 Thrombo-embolic complications Fibrin sheath Asymptomatic thrombosis Symptomatic thrombo-embolism

5 Miscellaneous complications Catheter migration Rupture Port migration The pinch-off syndrome ( %) Catheter fracture/embolization Munck et al. Eur Respir J 2004; Mirza B et al. Am Surg 2004; 70:

6 The Uppsala Vascular Access Centre - audit Cohort study Port insertions April 2009 August ports Follow-up period 12 months catheter days

7 The Uppsala Vascular Access Unit Started October 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

8 The Uppsala Vascular Access Unit audit of early complications Complication Absolute number Rate Other centres Arterial puncture % 0 6.0% Perioperative pain % - Technical problems % - Haematoma % % Miscellaneous % - 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

9 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!

10 Overall complications: subclavian vs internal jugular vein Subclavian Internal jugular number percent number percent Arterial puncture % 4 2.3% Perioperative pain % 8 4.7% Pneumothorax 6 0.6% 0 0 number per 1000 d number per 1000 d Temporary occlusion p=0,06 Thrombo- embolism p=0,76

11 Reasons for premature removal of port Number Rate Other centres Total 40 3% 1-15% Infection % % Occlusion/poor function % 0-9.3% Thrombo- embolism % % Miscellaneous 6 15% -

12 The Uppsala Vascular Access Unit lessons learned Teaching the procedure: How many procedures does it take? Teaching residents Teaching consultants

13 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

14 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

15 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?

16 Choice of vessel Bilateral pre-operative US scan: Vascular anomalies? Thrombosis? Tumors? Which part of the vessel provides optimal access? (eg SCV vs AxV)

17 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.

18 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

19 Choice of port and catheter Size matters Use only power ports - ready for high pressure infusions Silicon vs polyurethane catheter

20 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:

21 Silberzweig JE et al J Vasc Interv Radiol 14(9):S Dede D et al Surg Oncol 34(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.

22 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!

23 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:

24 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

25 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