Zito - PICC nel bambino

(1)

Verona

2-3-4 Dicembre December 2nd_-3rd_-4th

2019

XI

11

TH

Congresso

GAVeCeLT

Congress

2-3 DicembreDecember 2nd_{- 3}rd

II

2

ND

Convegno

GAVePed

Conference

3 DicembreDecember 3rd

XIII

13

TH

PICC

Day

4 Dicembre December 4th

Verona

2-3-4 Dicembre

December 2

nd

-3

rd

-4

th

2019

XI

11 TH

Congresso

GAVeCeLT

Congress

2-3 Dicembre

December 2

nd

- 3

rd

II

2 ND

Convegno

GAVePed

Conference

3 Dicembre

December 3

rd

XIII

13 TH

PICC

Day

4 Dicembre

December 4

th

(2)

T

h

e

A

l

p

h

a

b

e

t

S

t

r

e

t

Verona 2-3-4 Dicembre December 2nd-3rd-4th 2019 XI 11TH Congresso GAVeCeLT Congress 2-3 DicembreDecember 2nd- 3rd II 2 NDConvegno GAVePed Conference 3 DicembreDecember 3rd XIII 13THPICC Day

IL PICC ACCESSO VENOSO CENTRALE

(3)

A

PPROCCIO

A

PPROPRIATO

APPROPRIATEZZA

SCELTA RAZIONALE

A

B

C

BRACCIO - BASILICA

CUORE - COMPLICANZE

IL PICC ACCESSO VENOSO CENTRALE

(4)

A

PPROCCIO

A

PPROPRIATO

APPROPRIATEZZA

SCELTA RAZIONALE

A

C

BEST PRACTICE

CUORE - COMPLICANZE

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

(5)

APPROPRIATEZZA

APProccio alla Vena APPropriata

Rapid Peripheral Vein Assessment

La scelta del LATO e VENA un passaggio essenziale per un impianto efficace

e a basso rischio di complicanze

E’fondamentale una accurata esplorazione ecografica di entrambe le braccia

IL PICC ACCESSO VENOSO CENTRALE

(6)

RAPEVA

APPROPRIATEZZA

APProccio alla Vena APPropriata

IL PICC ACCESSO VENOSO CENTRALE

(7)

APPROPRIATEZZA

APProccio alla Vena APPropriata

Rapid Peripheral Vein Assessment

Un protocollo ben definito e sistematico per

l’esame delle vene del braccio e della

zona sopra/ sottoclaveare

IL PICC ACCESSO VENOSO CENTRALE

(8)

RAPEVA

APPROPRIATEZZA

APProccio alla Vena APPropriata

Rapid Peripheral Vein Assessment

Un protocollo ben definito e sistematico per

l’esame delle vene del braccio e della

zona sopra/ sottoclaveare

7 “Fermate”

IL PICC ACCESSO VENOSO CENTRALE

(9)

1

2

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(10)

1 V Cefalica al gomito

1

2

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(11)

1

2

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(12)

1

2

2 Aa eVv Brachiali al gomito

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(13)

1

2

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(14)

1

2

3

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(15)

1

2

3

3 Vena Basilica

4

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(16)

1

2

3

3 Vena Basilica

4

4 Fascio Nervo-Vascolare

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(17)

1

2

3

3 Vena Basilica

4

4 Fascio Nervo-Vascolare

5 Vena Cefalica

5

6

7 IL PICC ACCESSO VENOSO CENTRALE

(18)

1

2

3

3 Vena Basilica

4

4 Fascio Nervo-Vascolare

5 Vena Cefalica

5

6 Vena Ascellare

7

6

7 IL PICC ACCESSO VENOSO CENTRALE

(19)

1

2

3

3 Vena Basilica

4

4 Fascio Nervo-Vascolare

5 Vena Cefalica

5

6 Vena Ascellare

7 _{Vv Giugulare}

VSucclavia

6

7 IL PICC ACCESSO VENOSO CENTRALE

(20)

A

PPROCCIO

A

PPROPRIATO

APPROPRIATEZZA

SCELTA RAZIONALE

A

B

C

BRACCIO - BASILICA

CUORE - COMPLICANZE

IL PICC ACCESSO VENOSO CENTRALE

(21)

A

B

C

IL PICC ACCESSO VENOSO CENTRALE

(22)

A

B

C

IL PICC ACCESSO VENOSO CENTRALE

(23)

A

B

C

IL PICC ACCESSO VENOSO CENTRALE

(24)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

(25)

A

PPROCCIO

A

PPROPRIATO

APPROPRIATEZZA

SCELTA RAZIONALE

A

B

C

BRACCIO - BASILICA

CUORE - COMPLICANZE

IL PICC ACCESSO VENOSO CENTRALE

(26)

C

CUORE - CENTRALE

IL PICC ACCESSO VENOSO CENTRALE

(27)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

ECG INTRACAVITARIO NEI NEONATI E NEI BAMBINI

Accuratezza 95,8% - 98,8 %

(28)

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

https://pedecho.org/library/normal/echocardiogram/sub-long-atrial-septum-p4c

#1 S

ubcostal 4c

IL PICC ACCESSO VENOSO CENTRALE

(29)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(30)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(31)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(32)

https://pedecho.org/library/normal/echocardiogram/sub-short-svc-and-ivc-p4d

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

E

chocardiography

#2 S

ubcostal

Bicaval

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(33)

https://pedecho.org/library/normal/echocardiogram/sub-short-svc-and-ivc-p4d

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

(34)

https://pedecho.org/library/normal/echocardiogram/sub-short-svc-and-ivc-p4d

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

(35)

https://pedecho.org/library/normal/echocardiogram/sub-short-svc-and-ivc-p4d

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

(36)

https://pedecho.org/library/normal/echocardiogram/a4c-p3a

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

#3 A

pical 4C

IL PICC ACCESSO VENOSO CENTRALE

(37)

https://pedecho.org/library/normal/echocardiogram/a4c-p3a

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

#3 A

pical 4C

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(38)

https://pedecho.org/library/normal/echocardiogram/a4c-p3a

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

#3 A

pical 4C

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(39)

https://pedecho.org/library/normal/echocardiogram/a4c-p3a

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

#3 A

pical 4C

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(40)

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

#4 R

ight

(41)

https://pedecho.org/library/normal/echocardiogram/hrp-svc-septum-p6

#4 R

ight

Parasternal

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(42)

https://pedecho.org/library/normal/echocardiogram/hrp-svc-septum-p6

#4 R

ight

Parasternal

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(43)

https://pedecho.org/library/normal/echocardiogram/hrp-svc-septum-p6

#4 R

ight

Parasternal

E

chocardiography

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(44)

E

chocardiography

C

linical

Cases

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(45)

E

chocardiography

C

linical

Cases

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(46)

E

chocardiography

C

linical

Cases

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

(47)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(48)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(49)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Cardiac Imaging

RULE OUT COMPLICATION

TIP LOCATION

C

E

chocardiography

(50)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

(51)

C

CUORE - CENTRALE

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Consistent adoption of

SIP protocol

as proposed by

GAVeCeLT since 2010:

1 – hand washing, maximal barrier protection, 2% chlorhexidine

2 – US scan of all veins before starting the procedure (RaPeVA)

3 – choice of vein matched with cath diameter (3:1)

4 – individuation of brachial artery and median nerve

5 – US-guided puncture and cannulation

6 – tip navigation by US

7 – tip verification by intracavitary EKG

(52)

IL PICC ACCESSO VENOSO CENTRALE

DI PRIMA SCELTA IN ETA’ PEDIATRICA

Feb 2008 - Apr 2014

1660 Devices

138 CVC

157 PICC

retrospective single center study

Increased Risk of Thrombosis Associated with Peripherally Inserted

Central Catheters Compared with Conventional Central Venous Catheters

in Children with Leukemia

Pierre-Amaël Noailly Charny, MD1,2_{, Nathalie Bleyzac, MD}1_{, Robin Ohannessian, MD, MPH}2_{, Edouard Aubert, MD}3_,

Yves Bertand, MD, PhD1,2_{, and Cecile Renard, MD}1

ObjectiveTo study the risk of catheter-associated thrombosis (CAT) between peripherally inserted central cath-eters (PICCs) and tunneled central venous cathcath-eters in children with leukemia.

Study designWe analyzed all PICCs and conventional tunneled catheters placed in patients aged<18 years and admitted to our institute for leukemia treatment between February 2008 and April 2014. Cases of symptom-atic CAT were confirmed by ultrasound and treated with low-molecular-weight heparin.

ResultsDuring the study period, 157 PICCs and 138 conventional tunneled catheters were placed in 192 pa-tients with leukemia. CAT incidence was 1.5% (n= 2) in the conventional tunneled catheter group and 10.2% (n = 16) in the PICC group. The OR for CAT occurrence after PICC vs conventional tunneled catheter placement was 5.6 (95% CI, 1.2-26.5).

ConclusionOur results suggest that the use of PICCs in children with leukemia increases the risk of CAT in comparison with the use of conventional tunneled catheters. Further randomized controlled studies are needed to characterize this risk and to better define indications. (J Pediatr 2018;■■:■■-■■).

See related article, p •••

C

entral venous lines (CVLs) are important in the treatment of children with cancer, but have been shown to be strongly associated with venous thromboembolic events (VTEs) in both solid tumor1-4_{and hematologic}3-8_{malignancies. For}

example, Piovesan et al reported that 30% of VTEs in children with cancer were associated with CVLs and that these events most frequently manifested as deep vein thrombosis in the extremities.3

Peripherally inserted central catheters (PICCs) are increasingly used in patients with hematologic malignancies, both adults and children.9,10_{PICCs are inserted into a peripheral vein and advanced to place the catheter tip in the superior vena cava. This}

insertion mode causes fewer immediate complications than conventional tunneled catheters.9,11,12_{PICCs are, however,}

associ-ated with thrombosis at the insertion site,10,13,14_{particularly in patients with cancer.}13,15,16_{The authors of a meta-analysis}

pub-lished in 201313_{reported that the rate of VTEs in adult patients with cancer with PICCs ranged from 4.69% to 8.64% and that}

the probability of developing a VTE was significantly higher when PICCs were used compared with conventional tunneled cath-eters (OR, 2.55). In the general pediatric population, there seems to be no significant difference in the incidence of thrombosis between these 2 methods for establishing venous access.10_{However, to the best of our knowledge, no studies have compared}

PICCs with conventional tunneled catheters as concerns thrombosis development in children undergoing treatment for leukemia. Since 2008, the use of PICCs has increased in our pediatric hematology and oncology institute, with a concomitant decrease in that of conventional tunneled catheters. We took advantage of this evolution in practices to compare retrospectively the risks of thrombosis associated with PICC and conventional tunneled catheter placement in children diagnosed with leukemia.

Methods

We conducted a single-center, retrospective study at the Pediatric Hematology and Oncology Institute in Lyon, France. Chil-dren diagnosed with hematologic cancer between February 1, 2008, and December 31, 2013, were identified using the

ALL Acute lymphoblastic leukemia AML Acute myeloid leukemia CAT Catheter-associated thrombosis CVL Central venous line L-ASP L-asparaginase

LMWH Low-molecular-weight heparin PICC Peripherally inserted central catheter VTE Venous thromboembolic event

From the1_{Institute of Pediatric Hematology and Oncology,}

Hospices Civils de Lyon, Lyon, France;2_{University of}

Lyon Claude Bernard; and3_{Department of Anesthesia,}

Centre Léon Bérard, Lyon, France The authors declare no conflicts of interest.

https://doi.org10.1016/j.jpeds.2018.03.026

ARTICLE IN PRESS

T

HE

J

OURNAL OF

P

EDIATRICS

• www.jpeds.com

ORIGINAL

ARTICLES

1

FLA 5.5.0 DTD■ YMPD9875_proof ■ April 27, 2018

(53)