Impatto della guida ecografica sulle complicanze immediate del cateterismo venoso centrale P. Della Vigna

Legge di Murphy: Se qualcosa puo' andar male, lo fara' Corollari: Se c'e' una possibilita' che varie cose vadano male, quella che causa il danno maggiore sara' la prima a farlo. Se si prevedono quattro possibili modi in cui qualcosa puo' andare male, e si prevengono, immediatamente se ne rivelera' un quinto.

Paz 77 aa Svuotamento laterocervicale in pregresso ca lingua Posizionato CVC transucclavio sn NPT attraverso il CVC TIA

Le complicanze possono interessare il dispositivo nella sua interezza, oppure i singoli componenti, il catetere ed il reservoir Le complicanze, inoltre, possono essere sia infettive che di natura meccanica Infezioni ed occlusioni del dispositivo possono coinvolgere qualsiasi componente del port Fratture ed embolizzazione sono complicanze strettamente correlate al catetere Complicanze correlate con il reservoir: difficoltà di accesso danneggiamento del reservoir stravaso dell’infusione soluzione di continuo della cute soprastante il reservoir

Le complicanze possono essere di duplice natura Precoci : strettamente correlate con l’impianto del dispositivo (tecnica d’impianto) Failure PNX Emotorace Pinch-off Kinking Embolia aerea Aritmia Ematoma Malposizionamento Tardive : correlate con l’impianto e l’impiego del dispositivo Infezioni Trombosi Rottura del catetere Fibrin sleeve

Accesso venoso centrale: “the radiological point of view” “ it’s better to see what you are doing than not!”

Corretta visualizzazione del vaso Pervietà del vaso Accesso venoso centrale: “the radiological point of view”

Ultrasound guided CVC placement: technique

unsuccessful catheter placement –previous major surgery –radiation therapy in the region –prior catheterization –prior attempts at catheterization –a high body-mass index –Dvt Accesso venoso centrale: “the radiological point of view”

Complications –arterial puncture –pneumothorax –mediastinal hematoma –Hemothorax –Pinch off syndrome 5 % to 19 % of cases –Sznajder JL, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rate by three percutaneous approaches. Arch Intern Med 1986;146: –Mansfield PF, Hohn DC, Fornage BD, et al.Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331: –Merrer J, De Jonghe B, Golliot F, et al.Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286:700-7 Accesso venoso centrale: “the radiological point of view”

number of needle attemps are associated with the rate of complications US GUIDANCE: continuous visualization of needle and vessel is accomplished patient-dependent risk factors, such as obesity, limited neck mobility, etc, can be almost completely compensated US guidance: the puncture of only the anterior wall of the vein without penetration of the posterior wall Accesso venoso centrale: “the radiological point of view”

With longitudinal plane –entire length of the needle –Avoid inadvertent arterial inadvertent pleural puncture distal approach also when subclavian artery and/or lung was close to the subclavian vein and arterial branches were in the course of needle entry. Accesso venoso centrale: “the radiological point of view”

Denys BG. Circulation 1993; 87: Caridi JG. AJR 1998; 171: Objective: determine relative effectiveness of US to place CVC compared with use of landmark alone Data Synthesis: 18 trials identified Significant reduction in failure rate, n° of attempts and arterial puncture Increase of successful first attempt cannulations No difference in time to insertion US guided vs. Blind technique

Between december 1996 and august 2006, 203 CVC were placed under US guidance, 197 in subclavian vein and 6 in jugular internal vein In 1 patient we observed superficial bleeding treated with digital compression for less than 10 minutes 100% technical success; 100% single wall pass of the needle CVC placement in hemostasis failure patients: our experience In 92 procedures patients had PLT ≤ (range ) and or INR ≥ 1.3

conclusions safer faster When US is used with the right technique, CV access is Due to “no complications” and “hi-experience”, we usually perform “bed-side” CVC placement easy

COMO “Il Broletto”