Zagli - aspetti organizzativi

1-11-2010

1

Technical options, organization and

economic issues

Dr Giovanni Zagli

Anesthesia and Intensive Care Unit of Emergency Department (Dir. Dr A. Peris)

Careggi Teaching Hospital Florence Italy

•  Anesthesia in emergency surgery •  10-beds Intensive Care Unit •  Regional ECMO center •  Regional long-term CVC center

•  1600 CVCs (ICU, first aid, operating room) •  230 procedures for CRRT and ECMO •  450 long-term CVCs

•  200 PICCs

Our setting:

In one year:

Anesthesia and Analgesia 2010 Sep 9

•  PICCs are important devices, for the relatively easy introducing technique, for the longer in situ duration and for the possibility to be inserted by nurses

•  Operative contest can be safe and cost-effective

•  Besides these considerations, data on different operative choice are lacking •  In this contest, we tried to understand the

advantage/disadvantage of PICC and CVC use in critically ill patients

Intensive Care Medicine 2010 Sep 21

Methods

•  Prospective, controlled study

1-11-2010

2

Results

•  Groups similar in demographic and clinical characteristics

•  Total of 2747 CVC-days and 4024 PICC-days observation included in the study

Results

•  Three-fold higher risk for DVT in medical patients who underwent to CVC positioning •  Higher incidence of DVT in PICC group (27% vs 10%)

•  Two-fold higher risk for DVT in the PICC group if the left basilic vein access was used

Comments

•  Higher DVT incidence using PICCs rather than CVCs

•  All the thrombotic events in our study were asymptomatic •  Medical patients had higher risk for DTV in CVC group •  Left side present higher risk for DTV in PICC group •  Importance of I level Doppler follow up

•  Attention within the first 2 weeks after insertion •  PICCs with Groshong valve may help

PICCs are longer than CVCs Basilic veins have smaller caliber Patients were all post-critical

Comments

•  PICCs can be use for longer time than CVCs •  Who is the ideal ICU patient for PICC and CVC? •  Patient’s compliance?

•  Valved or non-valved PICC?

•  Which is the best side of insertion (depending also on patient’s anatomy and preferences)? •  Bedside I level vascular ultrasound follow-up in ALL patients with central vascular device should be part of central access activity

Conclusions

•  PICCs are the ideal for bedside positioning •  PICCs are attractive for operator but we are looking for evidence on patient’s compliance, acceptance and economic evaluations

•  We are waiting for data on impact of technique, pathology, access site and catheter characteristic on the late complication rate, rate of