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