A new trend in venous access programs:PICC first

Mauro PittirutiCatholic University, Rome - Italy

PICC first

• A new worldwide strategy which is changing the world of venous access– PICC has become the first choice for both intra-

hospital and extra-hospital central venous access

Something’s changed after 2001…

…with regards to PICC insertion:– HOW ? – US-guidance, EKG-guidance !– WHY ? – safety and cost-effectiveness !– WHEN ? – for any central line !– BY WHOM ? – nurses !

HOW

PICC insertion

HOW ?

Ultrasound guidanceMicrointroducer techniqueIntracavitary EKG method

Ultrasound have changed the fundamental features of PICCs• Traditional PICCs vs US-guided PICCs:

– Two radically different devices, in terms of:• Indication• Technique of insertion• Rate of complications at insertion• Rate of late complications• Patient’s comfort

PICC in XX century:‘blind’ insertion

Basilic or cephalic vein in the antecubital fussa (veins which can be seen or palpated)

“blind” PICC insertion

• Catheter through needle (breakaway needle)

• Catheter through cannula• Catheter over guidewire

(Seldinger diretto)• Catheter through

introducer (Seldinger ‘indiretto’)

PICC in the XX centurywere inserted exclusively without US

• HIGH INCIDENCE OF COMPLICATIONS AT INSERTION• Failure (even 30% !)• Malpositions ( > 20%)

• HIGH INCIDENCE OF LATE COMPLICATIONS• Infection• Venous thrombosis

• MINIMAL PATIENT COMFORT

From 2001 on:

Micro-introducer

US Guidance

US-guided insertion of PICC• Puncture of deep peripheral veins

located at the upper midarm• Exit site: above the antecubital fussa

1. INSERTION IN ANY PATIENT (even in patients with ‘no veins’)

2. VERY LOW INCIDENCE OF COMPLICATIONS AT INSERTION

3. VERY LOW INCIDENCE OF LATE COMPLICATIONS

4. OPTIMAL PATIENT COMFORT

Which veins ?1.BASILIC vein

First choiceAdequate diameter (3 – 6 mm.)Not in proximity of arteries or nerves

2.BRACHIAL veinsSecond choiceClose to brachial artery and median nerve

3.CEPHALIC veinsOnly in selected patients (obese, etc,)Too superficialToo many valvesNon-linear trajectory

US anatomy • training required• Few, simple notions

Vein:Round, empty circle

Vein:- Easy to collapse- No pulsation

1. Basilic vein1 - 2 cm

3 – 6 mm

2. Brachial veins

• “mickey mouse”Brachial vein

brachial vein

Brachial artery

Basilic vein

2. Brachial veins

3. Cephalic vein

• Third choice• Not a ‘deep’ vein• Enters the axillary vein at 90°• Higher risk of thrombosis• Higher risk di malpositions• Useful in morbidly obese patients

Traditional method for estimation of the distance between puncture site and cavo-atrial junction

Before PICC insertionMidclav.

Distance between midclavicular point and 3°

intercostal space

Distance between puncture site and

midclavicular point

Alternative method (Ocado) for estimation of the distance between puncture site and cavo-atrial junction

Before PICC insertionNotch

Add 10 cm (right) or 15 cm (left)

Distance between puncture site and

suprasternal notch

Technical choices

• Relationship between vein and probe– Short axis vs. long axis

• Relationship between vein and needle direction– ‘In plane’ puncture vs. ‘out of plane’ puncture

• Needle guide– Needle-guide vs. free hand

in short axis

Out of plane

in long axis

‘Free hand’

Needle guide

Technical choices

• Routine recommendations:– Vein visualization in short axis (transversal,

panoramic view of all crucial structures)– ‘Out of plane’ puncture (needle’s trajectory not

included in the plane of the probe)– Free hand technique (more versatile and effective)

• needle guide only during training

US Guidance + microintroducer technique

Modified Seldinger

Minimal trauma

Microintroducer

US guidance is the state of the art for CVC insertion

US guidance is the state of the art, not only for CVCs, also for PICCs

AHRQ recommendations

2013

2013

But US-guidance is not enough

• Successful puncture and cannulation of the vein is not enough

• We need proper placement of the tip of the central line:

EKG guidance

EKG-guide is becoming the state of the art, not only for CVCs, also for PICCs

Intracavitary ECG (lead II)

The intracavitary electrode is the tip of the catheter

Based on changes of P wave during the progression of the catheter into the central veins

CAVO-ATRIAL JUNCTION:maximal peak of the P wave (Stas, Yeon, Schummer, Pittiruti, La Greca, etc,)( = CRISTA TERMINALIS)

IC-EKG method

P increasing

Maximal P

P decreasing and/or diphasic

A very old method…

Von Hellerstein HK Recording of intracavitary potentials through a single-lumen saline filled cardiac catheter. Proc Soc Exp Biol Med 71:58-60, 1949

…which has come back.

JVA 2011

…which has come back.

JVA 2012

It can be done with any ECG monitor…

… and different types of connections

Applicability

- The IC-EKG method is applicable to any central venous access, valved or not, peripherally inserted or not, independently from the access technique.- Current limit of IC-EKG method: it is applicable only in patients with evident P wave in the surface ECG

This excludes 7 – 9 % of patients: atrial fibrillation, pacemaker (if constantly active), so called ‘junctional rhythm’, atrial flutter, etc.

Feasibility

Feasibility = in which % of cases do we get an ‘atrial P’ in the intracavitary EKG? •GAVeCeLT multicenter study 2012:

– 1440 patients, any type of VAD– All pts with evident P on basal ECG– Both saline technique and guidewire technique– Overall feasibility 99.3 %

• Feasibility with the saline technique 99.9 %• Feasibility with the guidewire technique 98.6 %

Feasibility

0.7 % of failure (not feasibility) depends on:Technical problems of the connection between monitor and catheterTechnical problems of the ECG monitorExperience of the operator (ability to recognize P changes)Low signal (catheter < 3Fr)

Accuracy

Accuracy = in which % the ‘atrial P’ corresponds to the cavo-atrial junction?

Almost 99%

IC-EKG - Is it accurate?

In the last two decades, many clinical studies have proved the accuracy of the EKG method:

- Compared with radiological methods- Compared with trans-esophageal echocardiography (TEE)

Accuracy

Very high for echocardiography: TTE or TEESpecially: TTE + CEUS

(contrast-enhanced ultrasonography)

Very low for fluoroscopy and chest x-raySubjective interpretationNo common criteria for CAJ‘Interpretation of shadows’ (M.Costantino)

TEE vs IC-EKG

Cavoatrial junction = maximal P wave (EKG)Cavoatrial junction = crista terminalis (TEE)

100% accuracy - In 30 patients, EKG = TEE

2004

[12] International Anesthesia Research Journal

Tip at the cavoatrial junction

TIP in lower 1/3 of SVC

Tip in middle 1/3 of SVC

TEE vs. IC-EKG

54 patients Cavoatrial junction = crista terminalis

2006

IC-EKG vs. X-Ray

147 pts – correct tip positioning in 96 % 2007

[10] Journal of Anesthesia and Analgesia

TEE vs. IC-EKG vs. X-Ray

200 patients - accuracy 99% for EKG, 88% for X-ray2009

GAVeCeLT Multicenter Study2012

GAVeCeLT Multicenter Study

8 hospitals, 1440 patientsAny type of central VADIntra-procedural IC- EKG vs. post-procedural X-RayX-ray criteria for CAJ:

CAJ = 3 cm below the carinaLower 1/3 SVC = 1-3 cm below the carinaUpper 1/3 RA = 3-5 cm below the carina

2012

GAVeCeLT Multicenter Study

IC-EKG (intra-op.) vs. Chest X-Ray (postop.)Total Match (Accuracy): 95,4 %Mismatch EKG/Xray = 3.8 % (55 cases)

in 44/55 cases, tip was higher on X-Ray … but in most of these patients post-op- Chest X-Ray had been performed in standing position

GAVeCeLT Multicenter Study

IC-EKG (intraop.) vs. Chest X-Ray (postop.)…considering the confounding factor that IC-EKG had been performed in supine position and Chest X-Ray in standing position:Match (Accuracy): 99 %

Safety

YesGAVeCeLT Multicenter Study 2012:

1440 patients, any type of VADNo complication - directly or indirectly related to the EKG method – was reportedThe overall incidence of arrhythmias was low (0.7%)

GAVeCeLT Pediatric Multicenter Study 2013:309 children, any type of VADNo complication - directly or indirectly related to the EKG method – was reported

Easiness

Easy to performEasy to teachEasy to learn

New defibrillators/ECG monitor: terrific for the EKG method…..

Small, portable ECG monitors

Nautilus

The method is easy… even easier with a dedicated monitor

The future: Wireless IC-ECG

Cost effectivenessLow cost method ‘low cost’ trainingApplicable even when X-Ray is contraindicated or difficult or expensive (pregnancy, morbid obesity, hospice, home care, etc.)‘real time’ verificationi.v. treatment can start immediately afterSave money (cost of X-Ray, cost of repositioning)

65

Cost effectivenessIn its basic form: IC-EKG is inexpensive (connection cables cost few euros)Big saving comes from:

Avoiding expensive equipment (fluoroscopy, TEE)Avoiding x-ray expenses (direct and indirect)Avoiding delay due to post-procedural chest x-ray or post-procedural TEE/TTE)Avoiding need for reposition (it may happen with post-procedural chest x-ray or post-procedural TEE/TTE)

In conclusion: IC-EKG

• Applicable in 91-93% of adults and 99% of children

• Feasible in 99%• Safety 100%• Accurate (maximal P = CAJ) in 91-99% of cases

– ‘real’ accuracy (IC-EKG vs TEE): 99%– ‘standard ‘ accuracy (IC-EKG vs Xray): 91-98%

Raccomandazioni AHRQ

2013

US-PICC = a new venous access device

PICCVery selected indicationsHigh rate of failure at insertionHigh rate of malpositionsHigh rate of late complications (infection, thrombosis)No comfort for the patient

US-PICCWide indicationsSuccess rate at insertion close to 100%No malposition (IC-EKG)Very low incidence of late complications (infection, thrombosis)Maximal patient compliance

US-guided, EKG-guided insertion

Necessità di accesso venoso in paziente con neoplasia avanzata del rinofaringe

Rimozione dell’introduttore

Verifica della posizione della punta: assenza del catetere in giugulare

Key to uneventful insertion:

Use a bundle of evidence-based, cost-effective strategies:US assessmentUS guidanceIntracavitary EKG guidemicrointroducer techniquesutureless securement…….

The SIP protocol

A GAVeCeLT bundle for the safe implantation of PICCs

The SIP protocol1. Hand washing, aseptic technique and maximal barrier

protection2. Bilateral US scan of all veins at arm and neck3. Choice of the appropriate vein at midarm (vein mm = or

> cath Fr)4. Clear identification of median nerve and brachial artery 5. Ultrasound guided venipuncture6. US scan of IJV during introduction of the PICC7. EKG method for assessing tip position8. Securing the PICC with a sutureless device

1 - Hand washing, aseptic technique and maximal barrier protection

• Maximal barrier protection include sterile gloves, mask, hat, sterile gown and vast body drape over the patient

• Clorhexidine 2% in alcoholic solution should be preferred for skin preparation before PICC insertion

2 - Bilateral US scan of all veins at arm and neck

• Before deciding the vein to be cannulated, a complete bilateral scan of most deep veins of the arm (basilic, brachial) and the neck (axillary, subclavian, internal jugular, brachio-cephalic) should be performed, so to exclude major abnormalities, to rule out pre-existing venous thrombosis, and to choose the most appropriate vein

• The deep veins of the arm should be evaluated with and without tourniquet

3 - Choice of the appropriate vein at midarm (vein mm = or > cath Fr)

• To minimize the risk of local ‘peripheral’ venous thrombosis, catheters should be inserted in veins whose diameter is at least three times larger than the catheter itself:– 3 Fr catheter: 9 Fr (3 mm) vein or larger– 4 Fr catheter: 12 Fr (4 mm) vein or larger– 5 Fr catheter: 15 Fr (5 mm) vein or larger– 6 Fr catheter: 18 Fr (6 mm) vein or larger

4 - Clear identification of median nerve and brachial artery

• The most effective method to avoid accidental nerve injury is the direct visualization of the nerve before and during venipuncture

• The most effective method to avoid accidental arterial puncture is to identify and visualize the brachial artery before and during any venipuncture

5 - Ultrasound guided venipuncture

• Real time ultrasound guided venipuncture of a deep vein (basilic or brachial) at midarm is the preferred choice

• A micro-introducer kit is recommended, preferably with a small gauge (21G) echogenic needle and a 0.018” soft straight tip nitinol guidewire

6 - US scan of IJV during introduction of the PICC

• While inserting the catheter into the introducer, the ipsilateral internal jugular vein should be compressed by the US probe, so to facilitate the passage of the catheter from the subclavian vein into the brachio-cephalic vein

• After the maneuvre, evidence of absence of the catheter in the internal jugular veins of both sides should be obtained by US scan

7 - EKG method for assessing tip position

• The EKG method is an inexpensive, effective, simple and safe methodology for a real time assessment of the position of the tip of the catheter during the procedure itself.

• A correct position of the tip (in the proximity of the cavo-atrial junction) reduces the risk of catheter malfunction, fibrin sleeve and catheter-related ‘central’ venous thrombosis

• Intra-procedural assessment of tip position avoids the costs and risks associated with repositioning the PICC

8 - Securing the PICC with a sutureless device

• The PICC should be secured at the exit site not by standard suture but by a sutureless device, so to decrease the risk of infection, dislocation and local thrombosis

Goals of the SIP bundle

– Minimize complications related to venipuncture:• Failure, repeated punctures, nerve injury, arterial injury

– Minimize malpositions– Minimize venous thrombosis– Minimize dislocation– Minimize infection

US- guided PICC in 3yr child, PICU

PICC in obese patients

Double lumen, power injectable PICC

3-lumen, power injectable PICC in ICU

WHY

Why should we use a PICC and not a central line ?

Advantages of US-PICCs vs. CVCs

• Absolutely safe insertion, even in fragile and high-risk patients (coagulation abnormalities, tracheostomy, cardio-respiratory disorders, etc.)

• Low cost insertion (nurse-based, bedside)• Low rate of bacteremic infections (CRBSI) • More comfortable exit site• Longer duration• Appropriate also for extrahospital management

No patient is ‘veinless’

US-PICC = low risk of infection

Why ?-Exit site is distant from nasal/oral/tracheal secretions-Low contamination of arm skin-Physical characteristics of arm skin (dry, thin)-Exit site allows better cleaning and better stabilization of the dressing

US-PICC = low risk of infection

Studies on CRBSI with ultrasound-guided PICCs-0/1000 days (Gebauer 2004 – pts on PN)-0.4/1000 days (Pittiruti 2006 – pts on PN)-0/1000 days (Harnage 2006)-0.3/1000 days (Scoppettuolo 2010 – infect.dis.pts)-0/1000 days (Cotogni 2013 – cancer pts on HPN)-0/1000 days (Botella 2013 – cancer pts on HPN)

Cost-effectiveness

• US-PICC means saving money• To compare PICC vs. CVC is not just comparing

the raw cost of two devices, but to compare the costs of two different clinical strategies:– PICCs = lower insertion cost, lower maintenance costs

due to lower rate of complications, longer duration of the line, etc.

Cost-effectiveness

Cost-effectiveness depends also on WHERE the US-PICC is inserted, HOW and by WHOM (Smith, Wisconsin University 2011):

WHO WHERE HOW

$ 5000 surgeon operating room

fluoroscopy + nurse

$ 2800 radiologist radiology suite fluoroscopy + technician

$ 1800 anaesthesist bedside no fluoro

$ 875 nurse bedside no fluoro

Cost-effectiveness

Cost-effectiveness of US PICCs (Catholic University, Rome, Italy 2011):

WHO WHERE HOW

€ 2500 surgeon operating room fluoroscopy + nurse

€ 1850 radiologist radiology suite fluoroscopy + technician

€ 280 nurse bedside IC-EKG

Myth

• ‘high incidence of thrombosis…’NO

- if we consider only US-guided PICCs- if we do a proper insertion (SIP protocol), matching the vein diameter with the PICC diameter

(Simcock 2008, ESPEN guidelines 2009)

Myth

• ‘low flow device…’NO

if we use power polyurethane PICCs, we can get up to 5 ml/sec !

Myth

• ‘high rate of lumen occlusion…’NO

- if we use power polyurethane PICCs- if we adopt a proper policy of flushing (saline only)

Myth

• ‘cannot measure the CVP…’NO

- if we use power polyurethane PICCs- if we adopt a proper policy of flushing (saline only)- if we use open-ended, non-valved PICCs

WHEN

PICC indications

• They have expanded:– Use of insertion bundles and maintenance bundles– Widespread use of power poliurethane PICCs

• High resistance• Low rate of obstruction• High flow• Available as single, double or triple lumen

– New methods, such as tunnelling

Tunnelling PICCs

US-PICCs = first-option central line in hospitalized patients

• With few exceptions:– Central line needed in the emergency room– Patients with AV-fistula – Patients with bilateral local contraindications to PICC

insertion (axillary node dissection, deep vein < 3mm, skin or bone abnormalities, deep venous thrombosis, etc.)

– Patients needing a central line with > 3 lumens– Superior vena cava obstruction

Power polyurethane PICCs

• ideal central line for intra-hospital PN• ideal central line for ‘chronic’ ICU patients• ideal central line in the perioperative period

Other options when PICC cannot be inserted in the arm

• US-guided insertion of PICC in the axillary vein (infraclavicular exit site)

• US-guided insertion of PICC in the brachio-cephalic, subclavian or internal jugular veins (supraclavicular exit site)

• US guided insertion of PICC in the femoral vein (exit site at the groin is avoided by tunnelling)

What about non-hospitalized patients?

Power polyurethane PICC

• ideal central line for short term extra-hospital PN• ideal central line for palliative care• ideal central line for advanced-stage cancer

patients at home or in hospice

US-PICCs = first-option central line in non-hospitalized patients

• With few exceptions:– Patients needing episodic, non-frequent venous access

(1/week or less frequent)• Central PORT or PICC-PORT is recommended

– Patients needing a long term venous access for life-time home parenteral nutrition due to benign disease

• Central tunneled/cuffed catheter is recommended(though, it might be a tunneled/cuffed PICC !)

US-PICC in extrahospital setting

• Home care, Hospice, Day Hospital, etc.

• Different options– Standard PICC– Tunneled PICC– Tunneled/cuffed PICC– PICC port

Standard PICC

Tunneled PICC

Cuffed / tunneled PICC

PICC port

BY WHOM

PICC insertion

WHO ?

A well trained health operator !(physician or nurse)

Who is inserting?

• Surgeons, anesthestiologists, oncologists, radiologists, etc.

• Nurses of different areas (anesthesia, pediatrics, intensive care, oncology, etc.)

The important is:• APPROPRIATE METHODOLOGY• ADEQUATE TRAINING

Appropriate Methodology

Safety, cost-effectiveness, efficacy•THE ‘SIP’ BUNDLE

Adequate Training

See the GAVeCeLT ‘4 x 4’ training protocol (for both nurses and physicians)-4 hrs of theory-4 hrs of practice on simulators-4 insertions seen and discussed with the tutor-4 insertions done under supervision of the tutor-Learning curve ( > 25 ins., < 3 mo.)-Final audit

Nurses or physicians?

The spreading of PICC use is clearly linked to the philosophy of nurse-based venous access

The overall cost-effectiveness of PICCs may be limited if the insertion is physician-based (even worse if radiologist-based)

PICC/yr• USA 2,500,000 nurses allowed• UK 120,000• Italy 33,000• Spain 15,000• Scandinavia 13,000• France 7,000 nurses not allowed• Benelux 5,000• Germany 2,000

Italy, 2013

• Approximately 35,000 PICC/yr– Every year, approx. + 25%– 80% inserted by nurses– > 100 hospitals have an active PICC team– 100% of PICC teams are mixed nurses+physicians– Intense activity of training/education in PICCs

• University Masters, Intensive courses both universitary and/or organized by dedicated multiprofessional societies (GAVeCeLT, WINFOCUS, etc.)

Catholic University, Rome - 2013

• More than 3500 PICC/yr for both intra-hospital use (1300 beds) and extra-hospital use

• One PICC team (3 physicians + 9 nurses)• 15 nurses specifically trained and formally authorized

for US-guided PICC insertion• 90% PICCs are inserted by nurses• Insertion of PICCs in all wards (intensive and non-

intensive, pediatrics and adults, etc.)

Catholic University, Rome - 2013

• Education and training– University Master on Venous Access for nurses– University Master on Venous Access for physicians– 15 University courses (4x4) every year, focused

exclusively on PICC insertion

Education/training for both nurses and physicians

So, who is inserting?

• The answer is– THE MULTIDISCIPLINARY,

MULTIPROFESSIONAL PICC TEAM– Patient-oriented collaboration between nurses and

physicians can cover all possible aspects of venous access management (definition of indications and insertion/maintenance policies, prevention and management of any possible complication, etc.)

CONCLUSIONS

The keys to a highly effective and highly efficient venous access team

- ‘PICC first’ strategy- Specifically trained PICC team- Bedside approach- Well defined insertion bundle (SIP bundle!) including:

Ultrasound assessment and ultrasound guidanceIntracavitary EKG guidance

My venous access team…

mauro.pittiruti@rm.unicatt.it

Thank you for your attention