Abstracts from the 3rd World Congress on Vascular Access, WoCoVA 2014, 18-20 June 2014, Berlin, Germany.

J Vasc Access 2014 ; 15 ( 3): 193 - 239 DOI: 10.5301/jva.5000275

Abstracts from WoCoVA 2014, Berlin - Germany, 18-20 June 2014

3rd World Congress on Vascular Access WoCoVA 2014 Berlin - Germany 18-20 June 2014

Oral Presentations O-001 Nurse assisted CVC insertion. An example of physiciansnurses collaboration H Rosay1, M Cellupica1, C Thoumazet1, A-L Boiza1, C Galvez2 1 Leon Berard Center, Department of Anesthesiology, Lyon, France 2 Leon Berard Center, General Nurse Direction, Lyon, France French nurses have been trained to insert CVC (PICC and PORT) with efficiency without complication in our hospital dedicated to the management of cancer patients. In August 2013, the Rhône-Alpes Health Authority passed an act to validate this procedure and potentially export it to other hospitals. Over the 3 years, 4087 CVC (2517 PICC, 1440 PORTS and 130 internal jugular catheters) were inserted by nurses under the supervision of anesthesiologists, following a strict procedure. Punctures were realized under ultrasound guidance (Bard Site Rite5 equiped with a needle guide) and an anesthesiologist was to be called after. 3 unsuccessful attempts or in case of unexpected difficulties. Up to now no complication of this collaboration has been reported and we started the training of external nurses to export our procedure to other hospitals. Type of CVC

PICC

Internal jugular Vein(CCI et KT)

Number of CVC

2517

1570

% of arteriel puncture

0.04%

0.19%

% of pneumothorax

-

0%

% of single puncture

87,6%

89,4%

recently developed the SICA protocol (Safe Insertion of Central Access) which includes six recommendations for an appropriate technique of CVC insertion. Method: (1) appropriate choice of the vein to access after a systematic ultrasound exam of the central veins (according to the RaCeVA - Rapid Central Vein Assessment), considering the diameter of the vein and balancing the advantages of an insertion site at low risk for early mechanical complications vs. the advantages of an exit site at low risk of late complications (possible option of tunneling the catheter in selected cases); (2) appropriate aseptic technique, including hand washing, maximal barrier precautions and skin antisepsis with 2% chlorhexidine; (3) ultrasound guided venipuncture (preferably by the ‘in plane’ technique’) + ultrasound control of the direction of the guidewire + ultrasound scan of the pleura, so to rule out pneumothorax; (4) real time verification of the central position of the tip by the intracavitary ECG method, whenever possible; (5) protection of the exit site with cyanoacrylate glue (in patients at risk for bleeding) or with chlohexidine-releasing sponge (in patients at risk for infection); (6) securement and stabilization of the catheter with sutureless device and transparent adhesive semipermeable dressing. Implications: The bundle is currently under evaluation both as a clinical tool for reducing catheter-related complications and as an educational tool in GAVeCeLT courses on central venous access. Our preliminary data suggest that it is easy to learn, simple to perform, effective in focusing the operator on the prevention of early and late complications associated with central venous catheters. O-003 Improvement of patient safety access for CVC – Aggregation of CVC insertion and license system at Central Venous Catheterization (CVC) center

Percentage of arterial punctures, of pneumothorax, of success with first attemp for cannulation

O-002 The SICA protocol: a bundle of interventions for the safe insertion of central venous catheters in adult patients M Pittiruti1, G Scoppettuolo2, A LaGreca1 Catholic University Hospital, Surgery, Roma, Italy 2 Catholic University Hospital, Infective Disease, Roma, Italy 1

Introduction: In most Italian hospitals the insertion of short term central venous catheters is still performed ignoring the evidence-based recommendations of international guidelines (ultrasound guidance is not consistently adopted, maximal barrier precautions are often forgotten, catheters are frequently secured by stitches, etc.). Thus, GAVeCeLT has

J Oda1, H Fukui2, H Nishi3, K Okazaki4, I Nakamura5, A Shimizu6, M Uramatsu7, Y Nakajima8, K Ishii8 1 Tokyo Medical University, CV Line Center/Department of Emergence and CCM, Tokyo, Japan 2 CV Line Center/Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan 3 Tokyo Medical University, CV Line Center/Department of Gynecology, Tokyo, Japan 4 Tokyo Medical University, Department of Radiology, Tokyo, Japan 5 Tokyo Medical University, CV Line Center/Department of Infectious disease medicine, Tokyo, Japan 6 Tokyo Medical University, CV Line Center/Department of otorhinology, Tokyo, Japan 7 Tokyo Medical University, CV Line Center/Department of Health Care Safety Management, Tokyo, Japan

© 2014 Wichtig Publishing - ISSN 1129-7298

193


Tokyo Medical University, CV Line Center/Department of Nursing, Tokyo, Japan

8

Introduction: There are approximately 3,000 central venous line (CVL) placements being conducted annually in a 1,000 bed scale hospital (University hospital and flagship hospital) in Japan. In our university hospital with 1,015 beds, we had 2 serious complications with CV catheterization between 2003 and 2004; therefore, we established a CV Catheterization Center and also introduced a license system for CVC placements in order to prevent reoccurrence of serious complication. Method: We organized a multidisciplinary CV catheterization management committee for the purpose of management, analyzing current state, collecting evidence for patient safety, establishing rule of catheterization and checking all catheterization procedures. We defined guideline for catheterization for entire hospital, and catheterization center for all patients in entire hospital except ER, OR, and ICU. We also started lecture, skill test, and instituted license/registration system. Our guideline required operators to use ultrasonography to confirm the vein, to catheterize using fluoroscope, to check blood gas analysis of catheter blood, to confirm backflow, and conduct 2 X-ray exams soon after and 4-6 hours after catheterization. We restricted the placers from puncturing the vein to 3 times, at maximum. The format for informed consent was standardized. Results: The number of catheterizations decreased from approximately 3,000 to 1,200 per year. On the other hand, number of PICC catheterizations increased to 200 per year. Only 8% of patients were catheterized in general ward; of the 8%, 90% of them were emergency catheterization, 10% were very severe or infected patients. The rules set within the university hospital were complied to. Less than 4.2% of patients suffered from minor complications. Incidence of complication with accident level 3b or more reduced to 0.05% of all patients. There was correlation between number of punctures and incidence of complications. Discussion and Conclusion: Aggregation into CV Catheterization center, education, and license system improve patient safety access for CVC. O-004 A descriptive study of nerve Injury related to upper arm PICC line placement L Zhao Sir Run Run Shaw Hospital, IV Team, Hangzhou, China Objective: Determine the incidence and causative factors related to nerve injury in order to create steps for prevention. Methods: A review was conducted for patients receiving PICC lines during a 7 month time period. The time period was January, 2013 to July 2013). A total of 739 PICC line patients medical records were reviewed retrospectively. The review process included distribution characteristics of looking at nerve injury by site, vein, arm to determine a pattern of occurrence. Results: A total of 739 PICC line placements were reviewed resulting in the identification of 6 cases of PICC line insertion related nerve injury. The rate of nerve injury as a complication for insertion was 0.8%. Breakdown of the cases demonstrated that 2 cases were upper left arm and 4 cases were upper right arm. No significant difference was seen with arm choice (χ2=0.109, P>0.05). Vein choice impacted the likelihood of nerve injury. All 6 cases were the result of a brachial vein as the insertion versus the basilica or cephalic vein sites. (χ2=50.8, P0.05). Conclusions: In order to avoid nerve injury of the upper arm during PICC line placement it is best to avoid the brachial vein and choose the basilic vein as a first choice. It is important to utilize ultrasound visualization when performing a PICC line insertion in the upper arm to identify nerves bundles. Should a nerve be accidently injured in the insertion process one must immediately remove the needle when the patient is complaining of “tingling and stinging” during the insertion procedure. Assess the neurovascular status of the extremity if the patient has experienced any of the symptoms of nerve injury.

194

O-005 A Global Prevalence Study on Peripheral CatheTers (The OMG-PIVC Study) E Alexandrou University of Western Sydney, School of Nursing and Midwifery, Penrith - New South Wales, Australia Introduction: It is estimated that approximately half of all patients admitted to hospital require the insertion of an intravenous cannula. It is the most common invasive clinical procedure performed in hospitals worldwide. Peripheral intravenous cannulae (PIVC) have been associated with both local and systemic complications that contribute to increased risk of morbidity, mortality, and prolonged hospitalisation. This study is the first of its kind to evaluate and compare the current state of PIVC use and practices from hospitals across the world to identify evidence-practice gaps. Method: This is a worldwide, multi-centre observational investigation. The study will be undertaken in a number of hospitals internationally. PIVC characteristics recorded will include: device type (manufacturer), device gauge/size, location of device on the body, length of PIVC dwell time, insertion site assessment, dressing quality assessment, securement technique. The current reason for use of the PIVC will be documented. This will include intravenous fluids or medications administered on the day of the survey. Results: The study will include evaluation of adult and paediatric hospitals in patients with a PIVC in situ on a given date. The multiple sites worldwide will provide an opportunity to capture an unprecedented amount of information about the use of PIVCs in a broad population. All PIVCs in situ at the participating hospitals on the day of the prevalence study will be included in the data analysis. Within country and between country variability in PIVC use and management practice will be examined. Data will be presented from a pilot study across 14 countries along with preliminary data from the main study. Discussion and Conclusion: PIVCs are a vital and ubiquitous medical device, with millions used around the world each year. Consequently, reliable evidence that informs safe, effective use of these devices is of the utmost importance to patients, nurses, doctors, and the community. The bulk of research about PIVCs to date has been conducted in more economically developed nations. The state of care and management of PIVCs in less economically developed nations is largely unknown. This prevalence study will have international significance in documenting and comparing the prevalence of PIVC use and their complications, worldwide. O-006 The Emergency Department and PERIPHERAL CANNULATION P Carr1, J Rippey1, C Rickard2 The University of Western Australia, Emergency Medicine School of Primary, Aboriginal and Rural Health Care Faculty of Medicine, Dentistry and Health Services, Australia 2 Griffith University, Australian Vascular Access Teaching and Research Group | NHMRC Centre of Research Excellence in Nursing Interventions | Griffith Health Institute Centre for Health Practice Innovation | Royal Brisbane & Women’s Hospital | Princess Alexandra Hospital | The Prince Charles Hospital, Australia

1

Introduction: Vascular access is indispensable in emergency departments (EDs) and assist with diagnostic (blood sampling and monitoring) and interventional practice (intravenous therapy). In our ED, two distinct healthcare professions - nursing and medicine - share the insertion of peripheral intravenous cannulae (PIVC). Successful first time PIVC insertion may depend on a variety of factors such as; clinical presentation, body mass, skin shade, a visible and/or palpable vessel, number of cannulation sites, vein measurement, rationale for insertion, inserter confidence among others, but these are poorly studied. Method: Clinical audit and quality improvement initiative to measure preand post insertion factors associated with successful PIVC insertion in a busy metropolitan ED.



Results: A total of n=734 PIVC insertions were recorded. A first time insertion success of 86% was achieved and was associated with clinician’s pre-insertion confidence of 85%. Unsuccessful first time insertions were associated with levels of clinician pre-insertion confidence of 63%. Greater inserter experience in performing cannulation, and patient body size of ‘average’ (rather than ‘obese’ or ‘emaciated’) significantly predicted first time success (both p20% of observations), while the PVC assess, Rittenberg and VIP scales were the most restrictive (no phlebitis detected). Only ‘tenderness’ and ‘erythema’, and the Catney and Lanbeck scales had acceptable (>two-thirds, 66.7%) levels of inter-rater agreement. Discussion and Conclusion: Inter-rater agreement for current phlebitis assessment symptoms and scales is generally low and of concern given the many nursing hours used for documentation. Poor agreement likely contributes to the high degree of variability in phlebitis rates in the literature. We


195


recommend further research into agreement for infrequent symptoms, into the Catney or Lanbeck scales, and to exploring new approaches to evaluating vein irritation that are practical, valid, reliable and based on evidence that they really predict clinical complications. O-010 4 Fr polYurethane mid-clavicular lines inserted with ultrasound guided technique: incidence of adverse events and unexpected removal M A Tomás-López1, V Armenteros-Yeguas1, I Moraza-Dulanto1, I MorazaDulanto1, L Garate-Echenique1, E Miranda-Serrano2, B Moreno-de Gusmao1 1 Osakidetza- Basque Health Service, Araba University Hospital, VitoriaGasteiz, Spain 2 Basque Country Health Department, Araba Research Unit, Vitoria-Gasteiz, Spain Introduction: The intravenous therapy team has developed a new insertion technique of 4 Fr polyurethane mid-clavicular venous device. The cost of this catheter in the hospital is half the cost of one PICC (97 € vs 45 €). The main characteristics of this technique are: ultrasound guided, bedside insertion, subclavian or braquiocefalic vein positioning of the catheter tip. The insertion is done following the CDC (2011) recommendations. This study aims to evaluate the clinical outcomes of the midclavicular lines inserted in patiens admitted at tertiary hospital in Spain. Method: Observational and prospective design. Sample includes every inpatient with a mid-clavicular line indwelled during study period (March 2012-September 2013). This device is indicated for patients meeting one of the following criteria: a) >6 days long iv therapy and not irritant drugs, b) venous access depletion, c) clinical condition contraindicates PICC. The primary outcomes were the incidence of adverse event (AE) and the unexpected removal proportion. The follow up period was from insertion date to catheter removal. Incidence rates were calculated for 1,000 catheter days. Results: 285 patients who had 317 mid-clavicular catheters were included. Patients were 71,0 years (SD 15,3). Midline catheters were in place for a mean of 17,3 days (SD 13,7). The AE incidence rate was 4,5/1,000 catheter days. There were no phlebitis, infiltrations or bacteriemias. There was one case of deep venous thrombosis. 14,4% of the catheters were removed unexpectedly and the main reason was accidental dislodgment (n=11). The incidence of unexpected removal was 8,3/1,000 catheter days. Discussion and Conclusion: 4 Fr polyurethane mid-clavicular venous access device can be safely inserted using ultrasound guided technique at bedside and positioning the tip in subclavian or braquiocefalic veins. This technical development has provided patients a mid-term catheter which has low risk of adverse events and high probability of reaching the end of treatment. O-011 Replacement after standard versus prolonged use of administration set for arterial catheter in an Australian intensive care unit: a feasibility RCT A Daud1, M Cooke2, C Rickard2 International Islamic University Malaysia, Faculty of Nursing, Kuantan, Malaysia 2 Griffith University, School of Nursing and Midwifery, Nathan, Australia

1

Introduction: The prevalence of administration sets (AS) used for peripheral arterial catheter (PAC) of critically ill patients is not known, however, approximately six million PACs were placed yearly in the USA (Gowardman et al., 2010) which can estimate the use of AS for PAC to be at least the same number. Most recent research has investigated the prolonged use of AS associated with the incidence of CVC related BSIs with no recent studies on replacement of AS for PAC. Purpose: To rigorously test the efficacy or equivalence of AS replacement for PAC at 4 days versus 7 days. Method: The 13 months recruitment of patients was undertaken at The Prince Charles Hospital, Queensland. Recruitment was from July 2011

196

until July 2012. The researcher screened patients admitted to the ICU in relation to the inclusion criteria. Patients were randomised into two treatment groups; the control group had the PAC-AS replaced every four days and the experimental group had the PAC-AS replaced every seventh days. The study was approved by the Human Research Ethics Committees of the University and the Queensland Health multi- centre committee protocol member. Results: 100 patients were randomised, 50 in the 4-day group and 50 in the 7-day group. Of the 50 patients in each group, 90% in the 4-day group and 60% in the 7-day group had the AS changed for the first time. There was zero percentage of CRBSI of the AS replacement for PAC at 4 days and 7 days. Discussion: Information derived from this study provides clinicians the need for high quality evidence on the impact of extended, AS use for PAC beyond 4 days in the form of RCT is required Conclusion: There is limited evidence to suggest changing AS at 96 hours or more effects the risk of CRBSI among critically ill patients, indicating that large randomised trials of high quality are needed. O-012 Sterile versus aseptic non-touch technique when changing the bung on a central venous access device: A retrospective cohort study J Flynn, S Keogh, N Gavin Australian Vascular Access Training and Research group, Griffith University & Cancer Care Services, RBWH, Brisbane, Australia, Nursing & Midwifery, Australia Introduction: Central Venous Access Devices (CVAD) are routinely used in patients undergoing a Bone Marrow Transplant (BMT) for the administration of medications including immuno-suppressants, chemotherapy, blood products, total parenteral nutrition, and blood sampling. While CVADs are essential, they come with unwanted side effects such as infections associated with their use and maintenance. BMT patients also have an increased risk of infection due to neutropenia as a result of their treatment. This study aimed to assess whether a change in practice from and aseptic non-touch technique (AnTT) to a sterile technique when changing the bungs on a CVAD had any impact on infection rates in the BMT population. Methods: This descriptive exploratory study used a retrospective chart audit of patients undergoing a BMT from September 2009 to November 2010 at the Royal Brisbane & Women’s Hospital (7 months AnTT and 7 months sterile technique). Inclusion criteria: haematological malignancy; Hickman line inserted for the BMT procedure; male or female; and any age. The primary end point was the rate of catheter related blood stream infection between groups. Results: One hundred and fifty six patients were audited, with 79/156 (51%) in the AnTT group and 77/156 (49%) in the sterile technique group. Overall demographics were males 98/156 (63%), mean age 51 y.o. (18.10 SD), with 49% (77/156) receiving an autologous BMT. Blood cultures were collected from 43/79 (54%) in the AnTT group and 47/77 (61%) in the sterile technique group. The number of Hickman lines removed for suspected catheter related bloodstream infections was 17/79 (22%) in the AnTT group and 18/77 (23%) in the sterile technique group. Conclusion: It is difficult to draw firm conclusions from this small, descriptive study. However, the results revealed no change in infection rate between groups. Given that it is impossible to achieve a truly sterile environment, ‘asepsis’ appears to be an acceptable, safe and cost effective standard for procedures on patients in the general clinical environment. O-013 Safety, cost effectiveness and efficiency of the use of onestep 2% Chlorhexidine in 70% Isopropyl Alcohol (CHX-OH) compared to 4-step Povidone Iodine (PVI) with 5% Ethanol (PVI-OH) for preventing early port-related infections D Vanjak1, A Cotel2, A Pelloquin3, M-C Escande4, A-M Beneteau2, I Kriegel5 1 Institut curie, Infection Control Unit/Anesthesiology, Paris, France 2 Institut curie, Infection Control Unit, Paris, France



Institut curie, Pharmacy, Paris, France Institut curie, Microbiology, Paris, France Institut Curie, Anesthesiology, Paris, France

3 4 5

Introduction: French recommendations advocate the use of a 4-step skin preparation (scrub, rinse, dry and antisepsis) and the use of alcoholic products. Alcoholic Chlorhexidine >0.5% is recommended by CDC guidelines as a first choice. The aim of this study is to evaluate the use of a one –step 2% CHX-OH for preventing early VAD-related infections. Methods: On two successive periods of 15 months through a computerized monitoring database, all local and systemic infections occurred within 30 days after port insertion were recorded. The diagnosis of portrelated infection was based on the positive blood culture with differential growth and/or culture of the VAD (port and catheter tip). During the first period (July 2010-September 2011), a procedure 5 step (scrub, rinse, dry, antiseptic first application carried out by the nurse and surgical antiseptic second application carried out by the operator just before the draping) PVI-OH was performed, then during a second period (October 2011December 2012), CHX- OH simple disinfection in one step before draping was used. In both periods, a Povidone-iodine pre-operative shower was recommended to patients. Results: The incidence of early infections was for the first and second periods respectively 15 infections for 1648 consecutive insertions (0.91%) and 8 infections for 1423 insertions (0.56%) that is respectively 0.30 and 0.18 infections per 1,000 days catheters. Gram positive cocci were involved respectively in 76% of cases (PVI-OH) and 87% of cases (CHX- OH). Discussion: The incidence of infection is low and comparable to the literature. The use of one-step CHX-OH does not increase the risk of infection. It shortens installation time without increasing costs (products and preparation skin sets). A bias, in this study, is the continued use of PVI-OH for the VAD maintenance during the first month use. Conclusion: This work leads us to start evaluating the use of one-step 2% CHX-OH for the VAD maintenance, in particular the placement of the Huber needle to test if a significant decrease of infection incidence could be obtained. O-014 Bacterial Communities on Inner and Outer Surfaces of Peripheral Venous Catheters L Zhang1, C Rickard1, N Marsh2, M Morrison3, G Nimmo4 1 Griffith University, Australian Vascular Access and Teaching Research Group (AVATAR), Centre for Health Practice Innovation, Brisbane, Australia 2 Royal Brisbane and Women’s Hospital, Centre for Clinical Nursing, Brisbane, Australia 3 University of Queensland, Diamantina Institute, Brisbane, Australia 4 Pathology Queensland Central, Division of Microbiology, Brisbane, Australia

taxonomic groups (HInner surface = 3.05±0.35, HOuter surface = 2.95±0.22; p=0.365). In addition, bacterial communities on PVCs from antibiotic treated patients were significantly different from untreated patients (HAntibiotic = 2.85±0.30, HNoantibiotic = 3.13±0.21; p=0.005). These findings raise the possibility that low level colonization of PVCs is the norm and changes in bacterial composition favouring the expansion of population of pathogens or opportunity pathogens such as Staphylococcus spp. might trigger the process of clinically significant bacterial colonization and BSI. Further investigation should be undertaken to determine whether these potential pathogens represent non-pathogenic variants or simply do not cause infection despite being present on PVC samples. O-015 Effectiveness interventions to reduce bloodstream infection and vascular acCess infection in a Hemodialysis Unit in Brazil R Lobo1, C Luders2, H Cristofalo2, G Elias2, I Sousa2, M Hernandes2, C Fabrega3, M Corradi1, M B Dias1 1 Hospital Sirio Libanes, Infection control, Sao Paulo, Brazil 2 Hospital Sirio Libanês, hemodialysis center, Sao Paulo, Brazil Introduction: Patients undergoing hemodialysis are at risk for bloodstream infections (BSIs) and vascular access infection (AIV) and preventing these infections in this high-risk population is a priority. In spite of having low BSI and AIV rates in our institution, we conducted an intervention study with the objective of improving those rates. Methods: The study was a quasi-experimental study conducted in a Hemodialysis unit located in a private teaching hospital. The service performs 3 hemodialysis sessions a day and has 20 hemodialysis machines with 60 patients. Until 2012, the unit protocols included the use of antimicrobial ointment in catheter exit sites, use of heparin to catheter lock and the use of sterile dressing to cover the catheter. In 2013, we implemented an evidenced-based intervention package that included: the use of alcoholic chlorhexidine during manipulation; the use of citrate to lock the catheter, the use of chlorhexidine impregnated sponge dressings and the implementation of feedback of infection rates to staff. Results: Modeled rates decreased to zero for BSI in 2013 and 53% for AIV infection after intervention implementation when compared to 2012. Discussion and Conclusion: These findings suggest that improved implementation of evidence-based practices can reduce BSIs and AIV in hemodialysis centers. O-016 Effect of a vascular access team on central-line associated bloodstream infections in infants admitted to a neonatal intensive care unit; a systematic review M Legemaat1, I Jongerden2, R Van Rens3, M Zielman1, A Van den Hoogen4 Utrecht University, Nursing Science, Utrecht, Netherlands 2 University Medical Center Utrecht, Intensive Care Medicine, Utrecht, Netherlands 3 Hamad Medical Corporation, Neonatology, Doha, Qatar 4 Wilhelmina Children’s Hospital, University Medical Center, Neonatology, Utrecht, Netherlands

1

Introduction: Peripheral venous catheters (PVCs) are some of the most widely used medical devices in hospitals worldwide. PVC-related infections increased morbidity and treatment costs. Inner surfaces of PVCs are rarely examined for population structure of bacteria as it is generally believed that bacteria at this niche are less than those on the external surface of PVC. Method: Inner and outer surfaces of PVCs from 15 patients were examined by 454 GS FLX Titanium 16S rRNA sequencing and the culture method. Results: None of the PVCs were colonized according to the culture method and none of patients had a bacteraemia. From a total of 127,536 high quality sequence reads, 14 bacterial phyla and 268 diverse bacterial genera were detected. The number of Operational Taxonomic Units (bacterial group) for each sample was in the range of 86-157 even though 60% of patients had received antibiotic treatment. Discussion and Conclusion: Stenotrophomonas maltophilia was the predominant bacterial species in all examined PVC samples. There were noticeable but not statistically significant differences between the inner and outer surfaces of PVCs in terms of the distribution of the

Introduction: Central line-associated bloodstream infections (CLABSI) occur frequently within a neonatal intensive care unit (NICU) with incidences of 11.6 to 35.2 per 1,000 catheter days. Premature infants are particularly vulnerable to bloodstream infections. Many strategies have been developed to decrease CLABSI. One of the strategies is proper placement and maintenance of central lines by a specialized vascular access team. We systematically reviewed the effect of a vascular access team on the incidence of CLABSI in infants admitted to a NICU. Method: A systematic review was conducted according to the Prisma Statement. Medline, Cinahl, Embase, Web-of-Science and the Cochrane Library were searched up to December 2013. Incidence rates of CLABSI were extracted as well as data on vascular access team tasks and team composition (Table I).


197


Results: Seven studies were included: These studies involved 136 to 414 participants, and 161 to 2039 catheter insertions. Vascular access teams decreased CLABSI with 45% to 79% (Table II). The most important tasks of a vascular access team are the insertion and maintenance of central lines, staff education on optimizing sterile techniques and trouble shooting of catheter problems. Discussion and Conclusion: Included studies reveal that central line-associated bloodstream infections can be reduced by limiting the insertion and maintenance of central venous catheters to a small group of dedicated and specially trained specialists. Despite several concurrent interventions in all studies, the implementation of a vascular access team seems promising in decreasing CLABSI in infants admitted to a neonatal intensive care unit. Neonatal intensive care units struggling to decrease central line-associated bloodstream infections may benefit from the establishment of a dedicated vascular access team.

TABLE II Author

Infection rates before and after the intervention

Patients

Cooley and Grady, 2009

6.3/1000 catheter days 1.3/1000 catheter days

Neonates with peripherally inserted central catheters

Curry et al, 2009

CABSI 3.1/1000 catheter days 1.7/1000 catheter days

Neonates with peripherally inserted central catheters or Broviac catheters

Golombek et al, 2002

CRI’s 15.8/1000 catheters 5.1/1000 catheters (p6 were used as reference for Systematic-Review. We used the study “Complications associated with peripheral or central routes for central venous cannulation” (Pikwer, Akeson, Lindgren et al., 2012) as the main-reference. Cost-utility analysis demonstrate that 1CICC is dominant respect to 1PICC. However, comparing 2CICC vs 1PICC, the effectiveness becomes comparable and the cost of 2CICC is still lower than a PICC. When we consider the use of 3 or 4 CICC vs 1PICC, PICC options became dominant (less cost and more QALYs). Probabilistic Sensitivity analysis demonstrates high variability over the effectiveness data. Discussion and Conclusion: The low impact of the PICC positioning, the difference indication of use, the importance of needs of the patient and the duration of the therapy are supported by the analysis of cost effectiveness.

O-026 Nursing and Midwifery intravenous device flushing practice: A cross sectional survey S Keogh, J Flynn, N Marsh, N Higgins, K Davies, C Rickard Australian Vascular Access Training and Research group, Griffith University & Centre for Clinical Nursing, RBWH, Nursing and Midwifery, Brisbane, Australia Introduction: There is limited evidence informing intravenous device (IVD) flushing practice and little is known about the current status of flushing. Complications such as thrombosis, dislodgement, infiltration and infection can lead to delayed treatment, increased cost and increased mortality. The aim of this study is to gain an understanding of current IVD flushing practice to improve patient outcomes. Method: A cross sectional survey of nurses and midwives working in Queensland was conducted using 25 item electronic survey. Distribution was via the Queensland Nurses Union membership database. Results: One thousand two hundred and three nurses responded to the online survey. Only 1178 were fully completed and analysed with n=1068 using peripheral intravenous catheter (PIVC) group and n=584 in the central venous catheter (CVC) group. The majority of respondents, 72% (PVC 742/1028) and 80% (CVC 451/566), were aware of their facility’s policies on flushing of IVDs to maintain patency. Most nurses reported using Sodium Chloride 0.9% for flushing both the PVC (96%, 987/1028) and CVC (75%, 423/566). Some form of heparin-saline combination was used in 25% of CVC cases. A 10 ml syringe was used by most respondents for flushing PIVCs and CVCs, however 24% of respondents used smaller syringes in the PIVC group. Use of prefilled syringes was limited to 10% and 11% respectively for each group. Frequency of flushing varied widely with the most common responses being for PRN (23% PVC and 21% CVC) and 6th hourly (23% PVC and 22% CVC). Approximately half of respondents in both groups stated that there was no medical order or documentation for device flushing. Conclusions: Flushing practice for IVDs appears to vary widely. Specific areas of practice warrant further investigation include the use of heparin-saline in CVC flushing, the use of smaller than recommended syringes, the minimal use of prefilled syringes, the varied frequency of flushes, and the lack of documentation of flush orders and administration. O-027 Occlusion Management Guidelines of CVADs D Broadhurst Medical Pharmacies, Education, Ottawa, Canada Introduction: In 2012, a Canadian professional association of vascular access and infusion therapy clinicians recognized a lack of standardized practice across the country for management of occlusions of central venous access devices (CVADs), leading to variances in practice. Key queries presented to the association included the management of multiple lumen occlusions, occluded non-tunneled percutaneous catheters and persistent withdrawal occlusions. Method: A national task force of Canadian vascular access experts was formed to review the published literature and develop a clinical guideline for management of catheter occlusions. Recommendations for evidence-base practice strategies were developed, with a modified Delphi consensus approach for areas with a lack of published evidence. The strength of each recommendation and quality of supporting evidence is graded. External peer review feedback was provided by leading physician, pharmacy, administrative and nursing leaders. Recommendations address the assessment, management and prevention of catheter occlusions. Results: This 32-page clinical practice guideline has been published in a peer-reviewed Canadian journal. Clinical practice tools, such as an occlusion management algorithm and templates, including a medical directive, pre-printed order and competency validation checklist, are available online in open access to facilitate implementation of these recommendations. Conclusion: These national peer-reviewed evidence-based guidelines provide strategies to safely, effectively and promptly manage CVAD


201


occlusions. Recommendations are now available to guide clinicians reinforcing published literature findings and presenting novel approaches, including the use of thrombolytics as infusions, for management of multiple lumen occlusions and in the alternate care settings. O-028 Valved versus non-valved PICCs in hospital in the home (HITH) – A multi-site national study M Loewenthal1, P Dobson1, N Collins2, Y Harbort3, Y Harbort3, D Kuzmich4, G Van Popering5, T Hecimovic6, F Beaumont7, A Ellis8, J King9, B Ong10, J Masters10, N Hawkins11 1 John Hunter Hospital, Immunology & Infectious Diseases Unit, Newcastle, Australia 2 Sydney South West Local Health District, Macarthur Ambulatory Care Service, Sydney, Australia 3 Gosford Hospital, Acute Post Acute Care (APAC), Gosford, Australia 4 Prince of Wales Hospital, Post Acute Care Service, Sydney, Australia 5 Goulburn Valley Health, Hospital in the Home (HITH), Shepparton, Australia 6 Fairfield Hospital, Fairfield Ambulatory Care, Sydney, Australia 7 St John of God Health Choices, Hospital in the Home, Ballarat, Australia 8 Wide Bay Health Service, Hospital in the Home, Bundaberg, Australia 9 Canberra Hospital, Hospital in the Home, Canberra, Australia 10 Bankstown/Lidcombe Hospital, Ambulatory Care, Bankstown, Australia 11 Sir Charles Gairdner Hospital, Homelink, Perth, Australia Introduction: The Multi-site HITH PICC Study is an ongoing study to determine outcomes in peripherally inserted central catheters managed in the home setting for hospital in the home patients in Australia by examining patient and catheter variables. Twelve sites have been recruited since 2011. Methods: Demographic data – patient age, sex, HITH condition, PICC type, lumen number and gauge, date inserted, date removed, and reason for removal were collected by each service. All sites submitted data to the lead researchers ML & PD. Data was analyzed using survival analysis techniques. Services were coded in random order so they cannot be identified in any publication. Results: Data on 5456 PICCs representing 126,329 catheter days and more than 345 patient years of observation were available. PICCs were insitu for a median of 21 days (range 1 - 525). The majority of PICCs were valved, single lumen, and 3fr gauge. The rate of removal for any complication was 3.4/1000 line days. PICC infection was low 0.15 episodes/1000 line days. Between valved and non-valved PICCs there was no significant difference in PICCs removed for blockage. Valved PICCs were 37 times more likely to be removed due to catheter damage (p=18 year receiving tunneled and temporary catheters for hemodialysis We realized a descriptive retrospective study analyzing and summarizing of data from all catheters that required the use of locking agents. Results: A total of 38 patients, 20 required placement more than a catheter during the year. The locking agents used were: TaurolockTM-U25.000, TaurolockTM-hep 500, Citra-LockTM, heparin 1%, heparin 5%, urokinase, vancomicynheparin 5%. There were 5 catheter-related infections (all related with vancomicyn-hep 5% locking and femoral catheters),16 malfunctions overall flow problems and obstruction (37,5% with urokinase and vancomicyn-heparin, 16% with heparin 1%, 18,75% with heparin 5%) and 1 bacteremia (vancomicyn-hep 5% locking and in a femoral hemodialysis catheter). Average survival time was 50 days. Limitations of the study among others are the small size and different levels of nursing training in the use and management of hemodialysis catheters. Conclusions: In our experience we have observed that there were a greater number of infections in catheters sealed with vancomycinheparin 5% possibly due to the resistance created by this antibiotic but we would need a study to confirm this. In the other hand, catheters sealed with heparin 1%, heparin 5%, taurolidine/urokinase and taurolidine/ heparin like lock agent presented reflux problems. No complications with catheters sealed with citrate.

STUDY POPULATION

GENDER: n (%) Women

24 (35,82%)

Men

43 (64,17%)

TOTAL OF VASCULAR ACCESS/YEAR: n (%) FAVI PTFE Tunneled yugular catheter

TEMPORAL Right

2 (50%)

Left

2 (50%)

No. CATHETERS PATIENT/YEAR (%) 1 per year

52,50%

2-3 per year

27,5%

More than 3

20%

TABLE III - Locking agent (%) Urokinase

10,86%

Taurolock -UK 25,000

4,34%

TaurolockTM -heparin 500

13,04%

Citra-LockTM

2,17%

Heparin 1%

19,56%

Heparin 5%

19,56%

Vancomycin-heparin 5%

30,43%

TM

TABLE IV - COMPLICATIONS (%) Infection

17,24%

Malfuction

56,98%

Catheter replacement

9,67%

Exit site

6,45%

Change to another VA

3,22%

Bacteremia

3,22%

Other

3,22%

O-032 Benefits of ultrasound-guided early cannulation of AV fistulas and grafts

TABLE I - BASELINE CHARACTERISTIC VARIABLES

FEMORAL TUNNELED

33 (33,33%) 4 (4,04%) 50 (50,50%)

Tunneled femoral catheter

9 (9,09%)

Temporal catheter

3 (3,03%)

J Chua St. George’s Healthcare NHS Trust, Venous Access, London, United Kingdom Introduction: The use of real-time ultrasound guidance for vessel visualization and localization, needle guidance, and verification of ultimate needle or wire location is already widely recommended by various international guidelines and medical governing bodies. It is now routinely used by medical practitioners. Ultrasound guidance was initially adopted for the insertion of acute central venous catheters(CVCs). It later became beneficial in improving success rates in Peripherally Inserted Central Catheter (PICC) insertions. Now a growing number of medical and nursing practitioners are using ultrasound guidance to aid peripheral cannulation and this has implications for the renal population.


203


In the Renal Unit of St George’s Hospital in London, UK, the use of ultrasound guidance has been extended from central to peripheral cannulation. Recently the vascular access team has been trialing ultrasound-guided early cannulation of the newly created or re-fashioned artereo-venous fistula/graft (AVF/AVG). Method: Ultrasound-guided AVF and AVG cannulations were performed by vascular access and renal nurse practitioners on 57 patients. Over 400 AVF and AVG cannulation episodes were performed over a 5 year period. Results: All ultrasound guided AVF and AVG cannulations were successful. On occasions a more experienced practitioner was required to achieve correct placement. This meant that patients with AVF/AVG revisions or rescues no longer required temporary vascular access (e.g. a vascath or cuffed-tunneled vascular access device) to facilitate their haemodialysis treatments whilst waiting for the swelling at the operation site to subside and the AVF or AVG to be palpable. Discussion and Conclusion: As a result, newly created or re-fashioned AVFs and AVGs can be successfully and accurately cannulated. There is reduced complication risk associated with more invasive central venous access devices insertions and improved patient experience. A local policy has been developed to support real-time ultrasound guided cannulation of newly created or re-fashioned AVFs and AVGs. O-033 Effectiveness & acceptability of a novel securement device in adult & teenage cancer patients with PICCs L Simcock, N Price, S Sandeluss, B Patel, D Putensen, K McInerney University College London Hospitals NHS Foundation Trust, Central Venous Access, Cancer Services, London, United Kingdom Introduction: Migration is a common problem with PICCs. Historically 7% of PICCs in our diverse oncology and haematology patient group have had to be removed because of the tip of the PICC migrating out of the superior vena cava. In March 2013 we introduced SecurAcath® in an attempt to reduce this problem. Method: Following a pilot study we started offering SecurAcath® to all our patients in March 2013. We subsequently carried out an audit of 100 consecutive patients. A second audit and a survey of nursing attitudes to the device are now underway. Our aim is to discover the effectiveness of the device and its acceptability to patients and nurses. Results: The pilot study revealed that overall SecurAcath® was acceptable to most patients and appeared to reduce migration during dressing changes. However it also showed pain to be an issue for some patients and also that a secondary fixation device was needed to prevent dislodgement of the PICC for patients at high risk of tugging hard on the PICC (eg multiple IV tubings). The subsequent audit of 100 patients demonstrated that the device appeared to be very effective, with only one PICC migrating by 0.5cm. 88% of patients said they found SecurAcath® tolerable and would have it again. 40% of patients experienced no pain in the first two weeks after device insertion and 75% after 2 weeks. However 7% of patients stated they had severe pain. 3.6% had asked for removal of the device. 28 patients had had their PICCs removed. 46% experienced no pain on removal of the SecurAcath®, 25% mild to moderate pain and 29% severe pain. The results of the nursing survey and the second 100 patient audit will be available by the time of WoCOVA 2014. Discussion and Conclusion: (conclusions must be supported by data) SecurAcath® seems to be very effective at preventing migration during dressing changes. It does not appear to prevent migration in the event of forceful tugging on the PICC. Most patients find the device acceptable but it is associated with pain in some patients. O-034 Securing Peripheral Venous Catheters In Hospitals: can we do better at preventing catheter failure? N Marsh1, J Webster2, J Flynn3, B Hewer4, G Mihala5, C Rickard5 1 Australian Vascular Access Training and Research group, Griffith Universtiy, & Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Nusing and Midwifery, Brisbane, Australia 2 The Royal Brisbane and Women’s Hospital & Australian Vascular Access

204

Teaching and Reserach group, Griffith University, Centre for Clinical Nursing, Brisbane, Australia Australian Vascular Access Teaching and Reserach Group, Griffith University & The Royal Brisbane and Women’s Hospital, Nursing and Midwifery, Brisbane, Australia 4 Royal Brisbane and Women’s Hospital & Austalian Vascular Access Teaching and Research group, Griffith University, Vascular Access and Devices, Brisbane, Australia 5 Australian Vascular Access and Training group, Griffith University, Nursing and Midwifery, Brisbane, Australia 3

Introduction: Peripheral intravascular venous catheters (PVCs) are an essential element of modern healthcare but the failure rate of this device is unsatisfactorily high; occurring in up to 69% of PVCs. Failure often occurs before the completion of intravenous treatment, causing patient discomfort and interrupting intravenous therapy, which may result in longer hospital stays. Complications leading to PVC failure are likely attributed partly to inadequate securement of the device. PVC dressings offer some catheter stabilisation but as a secondary benefit at best - 10% of PVCs simply fall out despite having a dressing in place. Method: A single centre, four-arm, randomised controlled, non-blinded superiority trial was conducted from November 2012 to January 2013. Patients were randomised in a 1:1:1:1 ratio to the control product, standard polyurethane dressing (SPU), or the experimental arms - histoacryl glue and SPU (TA), bordered polyurethane dressing (BPU) or a sutureless securement device and SPU (SSD). The primary endpoint was PIVC failure, defined as premature device removal prior to the end of therapy because of: pain, blockage, leakage, accidental removal, local or catheter related bloodstream infection. Results: PVCs were used for an average of 2.6 days in all groups. Catheter failure was lowest in the TA group (14%) and highest in the SPU control (38%), with SSD (22%) and BPU (25%) in the mid-range. The high failure incidence in the SPU group appeared to be related to frequent occurrence of catheter blockage and/or pain. No patient was suspected of local or catheter-related bloodstream infection. Mild skin reactions were observed at TA removal in 3 (14%) patients. Discussion and Conclusion: These strong preliminary results suggest that large reductions in catheter failure could be achieved through advanced and novel technologies for catheter dressing and securement. A large multi-centre trial is now underway. O-035 Securing arterial lines effectively in the operating theatre and the ICU: A pilot trial H Reynolds1, G Mihala2, K Taraporewalla3, M Tower4, C Rickard5 (AVATAR) Griffith University/Royal Brisbane and Women’s Hospital, Anaesthesia, Brisbane, Australia 2 (AVATAR) Griffith University, Population and Social Health, Brisbane, Australia 3 University of Queensland/Royal Brisbane and Women’s Hospital, Anaesthesia, Brisbane, Australia 4 Griffith University, Nursing, Brisbane, Australia 5 (AVATAR) Griffith University, Nursing, Brisbane, Australia

1

Introduction: Arterial lines are frequently used worldwide for monitoring and blood sampling. Failure rates are unacceptably high due to inadequate securement, dislodgement, and accidental removal. This study assessed the feasibility of conducting a large RCT using advanced and novel dressing/ securement techniques, including tissue adhesive (skin glue). Methods: 123 patients undergoing elective major surgery requiring arterial lines were assigned in this parallel trial of randomised superiority design to one of four groups: control standard polyurethane, tissue adhesive Histoacryl®, bordered polyurethane Tegaderm™ Advanced, and the sutureless securement device Statlock®. Products and procedures were assessed for acceptability and feasibility measuring catheter failure rates/survival times, catheter-related blood stream infection/local infection rates, patient/staff satisfaction scores, and resource management indicators. Results: Catheter failure incident rates per 1000 catheter hours (95% CI) were control 7.94 (3.57-17.68), tissue adhesive 2.33 (0.58-9.31), bordered polyurethane 5.09 (1.91-13.56), and sutureless securement



device 6.03 (2.51-14.48). 87.5% of staff/patient satisfaction scores (1-10) were ≥7 for all interventions. Tissue adhesive was easy to apply (p=0.007) and liked by patients p=0.009). Recruitment was achievable. There were no infections or colonisation. The trial process ran effectively. Discussion: There were strong preliminary results. The study was not powered to detect statistically significant differences. Recruitment targets were met. Staff training was feasible. Costs per item were greater for the advanced products. The use of the novel product Histoacryl® tissue adhesive had favourable results. There were no safety concerns, and the product was easy to apply. It was liked by patients. It also had the lowest rate of unplanned device removal, the lowest catheter failure rate per 1000 catheter hours, and the longest catheter survival time. Conclusion: Results suggest that catheter failure may be largely reduced using these advanced products. This trial confirms the feasibility of performing a large multicentre trial to further investigate the topic. O-036 Cochrane Protocol: Vascular access specialist teams for device insertion and prevention of failure P Carr1, N Higgins2, M Cooke3, G Mihala4, C Rickard5 The University of Western Australia, Emergency Medicine School of Primary, Aboriginal and Rural Health Care Faculty of Medicine, Dentistry and Health Services, Perth, Australia 2 Griffith University, Australian Vascular Access Teaching and Research Group | NHMRC Centre of Research Excellence in Nursing Interventions | Griffith Health Institute Centre for Health Practice Innovation, Brisbane, Australia 3 Griffith University, Australian Vascular Access Training And Research (AVATAR) group Centre for Health Practice Innovation Griffith Health Institute Griffith University, Brisbane, Australia 4 Griffith University, Centre for Applied Health Economics Griffith University, School of Medicine, Brisbane, Australia 5 Griffith University, NHMRC Centre for Research Excellence in Nursing Interventions Griffith University, Brisbane, Australia

1

We propose to systematically review the evidence for vascular access specialist teams using the Cochrane Anesthesia review group protocol. The majority of admitted patients to hospitals worldwide require a vascular access device (VAD), regardless of their admission diagnosis. VAD insertion can be difficult and device failure is common during use. Improving the patient journey with a vascular or arterial device has been argued as a priority for hospitals. A variety of healthcare professionals currently provide VAD insertion and care. Specialist health disciplines have an interest in particular types of VAD and have published their own vascular access guidelines despite their being much overlap in content. In some health services, specialist VAD inserters exist within the organisational structure as a vascular access specialist team (VAST). These tend to provide service across all medical and surgical specialties, thus having a primary focus on VAD insertion, care and outcomes, rather than this being a secondary supportive therapy to the primary diagnosis. The ideal VAST approach should: 1. Perform vascular access needs assessments so as to insert the most appropriate VAD 2. Achieve high rates of first time insertion success 3. Perform monitoring and surveillance of the VADs 4. Be economically effective 5. Reduce complication rates during the insertion procedure (e.g. pneumothorax)) 6. Reduce premature device failure (e.g. phlebitis, extravasation, infiltration, occlusion, thrombosis and/OR device dislodgement) 7. Increase patient satisfaction 8. Generate primary research data. Should healthcare facilities not adopt a VAST approach it stands to reason that they must commit to appropriate education and training to a much larger range of staff to obtain an acceptable standard of care for reliable insertion, management and surveillance of VADs. The proposed review will question whether this approach can lead to similar clinician expertise, organisational benefits and patient experiences, as to institutions using a VAST approach. An assumption underlying this review is that specialist rather than generalist inserters are likely to have better insertion success and reduce subsequent VAD failure.

O-037 The Accuracy Of An All-In-One Navigation And Tip Locating Device Based On A Real Time Analysis Of The Patients’ Physiological Data – Observational Study S Hill1, H-U Laasch2, F Hussain1 The Christie NHS Foundation Trust, Procedure Unit, Manchester, United Kingdom 2 The Christie NHS Foundation Trust, Radiology, Manchester, United Kingdom

1

Introduction: Catheter tip malposition is associated with a higher risk of complications that may occur at the time of insertion (arrhythmias) or in the post-insertion phase (malfunction, vessel erosion, venous thrombosis1). Implementing a real time navigation and tip locating device for a VA Team may be a key factor for improving efficiency and cost/effectiveness. Method: The primary aim of the study is to assess the Arrow® VPS device for positioning the tip of PICC lines in adult patients in terms of feasibility, safety and accuracy. The secondary goal is to evaluate the impact of Arrow® VPS on the cost/effectiveness of the procedure Team activity. A total of 63 CVC (60 PICCs & 3 Implantable Ports) were inserted via VPS. Patients with no identifiable P-wave were excluded. The ideal catheter tip landing zone was defined as lower one-third of the Superior Vena Cava and the junction of the SVC with the Right Atrium2. The catheter tip placement was confirmed when a stable Blue Bull’s Eye signal was illustrated on the VPS display screen. The final position was assessed by CXR read by an independent radiologist. Results: The VPS worked feasibly with the work flow of the team. The VPS was shown to be safe in practice. Overall accuracy was 95% (52% at CAJ or upper Right Atrium, 43% in SVC). In 5% of the cases the catheter tip was in Mid/Upper SVC in spite of a stable BBE. Discussion and Conclusion: The system fit with the workflow of the team; the procedure time was increased using VPS guidance, but this may be outweighed by the reduced time associated with avoiding malposition of catheters. The system proved to be safe and reliable and has shown to be relatively easy to incorporate into practice with a minimal learning curve. O-038 ECG guidance for CVC placement. CLB’s IV team expertise and decreasing of radiation exposure H Rosay1, A-L Boiza1, M Cellupica1, C Thoumazet1, C Galvez2 Leon Berard Center, Department of Anesthesiology, Lyon, France, 2 Leon Berard Center, General Nurse Direction, Lyon, France

1

Introduction: Our current Central Venous Catheter (CVC) placement protocol includes the resort to Ultrasonography (US) and requires fluoroscopy and plain radiographies throughout the CVC insertion and until the confirmation of best placement. This verification is mandatory to avoid the risks, delays and costs of tip’s repositioning, but obtaining a fluoroscopy in operating rooms can be time consuming and exposes the patient, nurses and physicians to radiations. The ECG guidance method will allow the CVC insertion without any radiation in the operating room. Method: The purpose of this paper is to describe our practice of this method in an IV team and how our knowledge was progressively acquired and performed. First step: in 2012, the devices (Nautilus - ROMEDEX) were provided in the operating room and formation was developed. Fluoroscopy were realized to confirm the best placment. Second step: In 2013, the goal to avoid fluoroscopy was notified. Fluoroscopy was realized only when difficulties of CVC’s placement were notified or lack of P wave. CVC were inserted until to obtain the maximal P wave. In cases of difficulties, we pull out the catheter and we replace it with gentle methods: deep breath, Vasalva inspiration, head rotation, ear on the shoulder… After the process, plain radiographies in radiology unit where realized. Number of PORT and PICC, with and without any fluoroscopy, the radiation level and the evolution in the years. Results: All CVC were well placed in the two periods.


205


The use of fluoroscopy decreased in the two years. The average of radiation level was decreased from the provision of the devices. Since January 2013, the policy to avoid fluoroscopy permitted to obtain a high level of perfect placement without radiation. The percentage of CVC without fluoroscopy grew up to 95% in a steady state. Discussion and Conclusion: ECG guidance is adequate means for the total placement of PICC or PORT and confirmation of tip of CVC placement and this method can be conducted safely and efficiently. O-039 Proposal of an algorithm for verification of tip location of central venous access in patients with atrial fibrillation and pace-makers minimizing the use of x-ray exposure A La Greca1, M Pittiruti1, A Emoli2, M Calabrese3, D G Biasucci3, G Scoppettuolo4 1 Catholic University - “A. Gemelli” Hospital, Surgical Sciences - Emergency Surgery and Vascular Access Unit, Roma, Italy 2 Catholic University - “A. Gemelli” Hospital, Medical Oncology, Roma, Italy 3 Catholic University - “A. Gemelli” Hospital, Dept. of Anesthesia, Roma, Italy 4 Catholic University - “A. Gemelli” Hospital, Dept. of Infectious Diseases, Roma, Italy Introduction: Correct tip location of a central venous access device (CVAD) is of paramount importance. The intracavitary electrocardiographic method (IC-ECG) is usually considered not applicable when P wave is not evident on basal ECG, such as in atrial fibrillation (AF) or in active pace-makers (APM). Though, previous studies suggested that the increase of mean amplitude of the TQ segment on IC-ECG may be used for detecting the cavo-atrial junction (CAJ) in AF. Moreover, electromagnetic tracking systems - such as Navigator (Corpak) (NAV) - and trans-esophageal (TEE) or trans-thoracic echocardiography (TTE) might be useful in selected cases. Method and results: In a pilot study on four AF patients candidate to hemodynamic monitoring via TEE + CVAD placement, the CVAD tip was placed at the CAJ under TEE guidance and this corresponded to an abrupt increase in the mean amplitude of the T-Q segment on IC-ECG. Simultaneously, NAV detected the tip below the third intercostal space on the right border of the sternum. Discussion and conclusion: Based on the results of this study and of other studies on NAV, TTE and TEE, we propose the following “advanced” algorithm, which is currently under verification in our institution: - P wave evident: o tip location by IC-ECG (peak of P wave = CAJ); o if difficulties in advancement of the catheter are anticipated or experienced during the procedure: tip navigation by NAV + tip location by IC-ECG (peak of P wave = CAJ); - P wave absent: o in AF: tip navigation by NAV, for approximated tip location (third intercostal space on the right parasternal line) + tip location by IC-ECG (abrupt change in amplitude of TQ) o in APM or other arrhythmias: tip navigation by NAV, for approximated tip location (see above) + post-procedural confirmation by chest X-Ray in adults or by TTE in children. O-040 A New Wireless Device for Tip Location Using The Intracavitary Ecg Technique M Pittiruti1, A Emoli2, S Cappuccio2, A LaGreca1 Catholic University Hospital, Surgery, Roma, Italy 2 Catholic University Hospital, Oncology, Roma, Italy

1

Introduction: The intracavitary ECG method (IC-ECG) is adopted in clinical practice as an easy, cost-effective and accurate methodology for assessing the central location of the tip of venous access devices (VAD). We report our preliminary experience with a new wireless system specifically dedicated to the IC-ECG (Handy Nautilus, Romedex), which consists of a small box connected to the ECG cables, sending data to a smartphone or a tablet by bluetooth technology. The phone/tablet is provided with a software application which allows to display both the surface and intracavitary ECG. The system can be operated by command buttons placed on the box or directly by touching the screen of the phone/tablet.

206

Method: The IC-ECG method is performed according to the standard procedure. The identification of the peak of the P wave (corresponding to the cavo-atrial junction) is made easy by the freeze function, which can be operated either from the box or from the phone/tablet. At any time, the display can be saved and/or printed for documentation. Results: The Handy Nautilus was adopted for tip location in 18 VAD placements (10 PICCs and 8 ports). The P wave was evident on basal ECG in all patients. A peak of the P wave was easily detected in all patients. In 6 patients (3 PICCs and 3 ports), the procedure was simultaneously carried out with both standard Nautilus and Handy Nautilus: no differences were noted in terms of performance. Discussion and conclusions: This new wireless system for IC-ECG had an optimal clinical performance in terms of applicability and feasibility. Transmission of the data to the moveable device by bluetooth simplified the wire connections. Some potential advantages over other ECG monitors are: the system is light and easy to carry - which makes it ideal for bedside insertion; it can be operated by the same professional inserting the VAD; it implies no risk of electrical hazard; it can be used on a personal portable device, allowing easy storage of data and easy printing for documentation. O-041 Electrocardiographic (ECG) guidance during implantation of femoral ports E Desruennes1, P Gibault2 Gustave Roussy Cancer Campus, Anesthesiology, Villejuif, France 2 HCL Lyon Sud, Anesthesiology, Lyon, France

1

Introduction: During port implantation the catheter tip should be positioned close to the junction of superior vena cava (SVC) with right atrium (RA) to prevent venous thrombosis and catheter dysfunction. ECG guidance is an effective tool to position of catheters in the SVC (1-2). When SVC access is contraindicated, femoral access may be used and, by analogy with the SVC, the tip should be placed at the junction of inferior vena cava (IVC) with RA. The aim of this prospective study is to evaluate the effectiveness of ECG guidance when implanting femoral ports. Method: Inclusion criteria was the need for femoral port implantation. Absence of sinus rhythm or patient refusal were exclusion criteria. The femoral vein was punctured out of plane under ultrasound guidance (Sonosite M-Turbo™). After insertion of the dilator, the catheter with the guide wire inside (Celsite ECG, B. Braun) was introduced and the ECG signal was collected at the tip of the guide wire and displayed on a monitor. Saline instead of the guide wire has also been tested (Nautilus®, Perouse). Fluoroscopy was performed at each change of the P wave from IVC to RA. As recommended for SVC, the catheter was withdrawn 2 centimeters after the first P wave change, then an X-ray was performed to confirm the correct position of the catheter. Results: 18 patients were included between December 2011 and June 2013. The P wave was most often negative in the IVC, biphasic when the catheter entered RA and became giant and positive at the top of RA. When the catheter was withdraw 2 cm after the first P wave change the tip was correctly positioned in 17 patients, just below the IVC-RA junction. In one patient the P wave changes were not significant and the final position of the catheter was adjusted under fluoroscopy. Conclusion: ECG guidance is effective to assess catheter tip position during femoral port placement. 1) Stas, EJSO 2001 2) Pittiruti, JVA 2011 O-042 Prospective randomized trial comparing distal (arm port) to central (chest port) technique in ambulatory cancer patients P Y Marcy1, R Largillier2, G Poissonet3, O Dassonville3, J C Machiavello4, M Poudenx5, J Sanglier6, E Chamorey7 1 Polyclinique Les Fleurs, Interventional Radiology, Ollioules, France 2 Antoine Lacassagne Cancer Research Institute, Medical Oncology, Nice, France



Antoine Lacassagne Cancer Research Institute, Head&Neck Surgical Oncology, Nice, France Antoine Lacassagne Cancer Research Institute, Breast Oncology Surgery, Nice, France 5 Antoine Lacassagne Cancer Research Institute, Lung Cancer, Nice, France 6 Antoine Lacassagne Cancer Research Institute, Doppler Ultrasound, Nice, France 7 Antoine Lacassagne Cancer Research Institute, Biostatistics, Nice, France 3

4

Introduction: This open non- blinded prospective randomized controlled trial aims in (a) comparing two techniques of venous port device insertion: percutaneous distal (phlebography- guided arm port, group 2) versus central surgical (cephalic vein cutdown- group1control technique) insertion; and (b) determining whether central technique is superior to distal technique. Method: Among 382 cancer patients, 230 eligible ambulatory patients were randomized. Eligibility criteria included adults with solid tissue malignancy beginning a course of I.V.chemotherapy, normal hemostatic parameters, no organ failure, a life expectancy >3months, WHO status

Abstracts from the 2014 ISDE World Congress, September 22-24, 2014, Vancouver, Canada.

Abstracts of the 1st Congress of the European Academy of Neurology, Berlin, Germany, June 2015.

2014 ACAPS Congress: Abstracts.

Abstracts of the RCOG World Congress 2014, 28-30 March 2014, Hyderabad, India.

Abstracts of the WFH 2014 World Congress, May 11-15, 2014, Melbourne, Australia.

Abstracts of the IPA World Congress 2014, May 9-11, 2014, Athens, Greece.

Abstracts of the 11th European Congress on Epileptology, 29 June - 3 July, 2014, Stockholm, Sweden.

Abstracts of the 12th European Society for Pediatric Dermatology (ESPD) Congress, 12-14 June, 2014, Kiel, Germany.

Abstracts of the XXIV European Congress of Perinatal Medicine, June 4-7, 2014, Florence, Italy.

Abstracts of the ILTS 20(th) Annual International Congress, June 3-7, 2014, London, United Kingdom.

Abstracts of the Joint Congress of European Neurology, 31 May-3 June, 2014, Istanbul, Turkey.

Abstracts from the 2014 International Nitric Oxide Society Conference,June 16–20, 2014, Cleveland, Ohio.

Abstracts of the 10th International Podocyte Conference, June 4-6, 2014, Freiburg, Germany.

Abstracts of the Heart Failure Congress 2014 and the 1st World Congress on Acute Heart Failure, May 17–20, 2014, Athens, Greece.

19th World Muscle Society congress, Berlin 2014. A city of cranes and dinosaurs.

Abstracts from the European Academy of Allergy and Clinical Immunology Congress, 7-11 June, 2014, Copenhagen, Denmark.

Abstracts from the Ninth International Society for Computational Biology (ISCB) Student Council Symposium 2013, July 19, 2014, Berlin, Germany.

Abstracts of the 3rd Regional IGCS Meeting 2014, May 16-18, 2014, Cape Town, South Africa.

Abstracts of the International Academy of Cardiology Annual Scientific Sessions 2014 19th World Congress on Heart Disease, July 25-28, 2014, Boston, Massachusetts., USA, july 25-28, 2014.

ISOO Symposium, June 26-28, 2014, Miami, Florida.

Abstracts of the 2014 AWHONN Annual Convention, June 14-18, 2014, Orlando, Florida.

WoCoVA 2014: sharing best practice.

Abstracts of the 2014 NATA Annual Meeting & Clinical Symposia, June 26-28, 2014, Indianapolis, Indiana.

Abstracts of the 38th Annual Congress of the Italian Urodynamic Society, 19-21 June, 2014, Milan, Italy.