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
Tardive: correlate con l’impianto
l’impianto del dispositivo (tecnica d’impianto)
e l’impiego del dispositivo
Failure
PNX
Emotorace
Pinch-off
Kinking
Embolia aerea
Aritmia
Ematoma
Malposizionamento
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!”
Accesso venoso centrale:
“the radiological point of view”
• Corretta visualizzazione del vaso
• Pervietà del vaso
Ultrasound guided CVC placement: technique
Accesso venoso centrale:
“the radiological point of view”
• 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;146:259-261
– Mansfield PF, Hohn DC, Fornage BD, et al.Complications and failures of
subclavian-vein catheterization. N Engl J Med 1994;331:1735-8
– 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”
Accesso venoso centrale:
“the radiological point of view”
US guided vs. Blind technique
Denys BG. Circulation 1993; 87:1557-62
Caridi JG. AJR 1998; 171:1259-63
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
CVC placement in hemostasis failure patients:
our experience
•Between december 1996 and august 2006, 203 CVC were
placed under US guidance, 197 in subclavian vein and 6 in jugular internal vein
•In 92 procedures patients had PLT ≤ 150000 (range 10149.000) and or INR ≥ 1.3
•100% technical success; 100% single wall pass of the needle
•In 1 patient we observed
superficial bleeding treated
with digital compression
for less than 10 minutes
conclusions
When US is used with the right
technique, CV access is
easy
safer
faster
Due to “no complications” and “hi-experience”, we
usually perform “bed-side” CVC placement
COMO
“Il Broletto”