CVC

General Session

Q1 — General Session: PICC in 2018: Where Are We Now

Tuesday, September 18
2:00 PM - 3:00 PM
Location: Short North Ballroom
Presentation CE Credits: 1

The aim of this talk is to give an updated and honest description of the state of the art of PICCs in 2018, considering three specific aspects: (1) the current clinical indications, (2) the best technique of insertion and (3) the actual risk of PICC-related venous thrombosis.
1) Indications. The Magic paper - published two years ago - has become very popular in USA as a guide for choosing the most appropriate venous access device. While the overall intent of this consensus document is highly virtuous, some of its recommendations are contradictory and may lead to an inappropriate choice of the device. We will analyze the weak points of this consensus document and its margin of improvement, by comparing it with an analogous consensus document, the GAVeCeLT algorithm for choosing the venous access device, that is currently used in Italy.
We will also discuss the indications of PICCs in ICU. Central venous access in ICU is often mandatory because of the need of hemodynamic monitoring, repeated blood samples and infusion and non-peripherally compatible solutions. Different options are available: centrally inserted central catheters (CICCs), peripherally inserted central catheters (PICCs) and femoral inserted central catheters (FICCs): we will discuss the pros and cons of each approach and we will offer an algorithm for the choice of the most appropriate device, based on its performance and on the associated risk of complications.
(2) Insertion. Eight years ago, GAVeCeLT (The Italian Group of central venous access devices) developed an insertion bundle called SIP (Safe Insertion of PICCs) designed to minimize the complications related to PICC insertion. This bundle has been particularly successful in Itaiy and in Europe and has been adopted in a vast number of hospitals. GAVeCeLT has now developed an update of the SIP bundle - the SIP-2 - which includes some new strategies that are currently changing the practice of PICC insertion: the RaPeVA protocol (Rapid Peripheral Venous Assessment); the option of tunneling the PICC (based on Dawson's ZIM; the systematic use of ultrasound for tip navigation; the new modified intracavitary ECG technique for patients with atrial fibrillation; the alternative option of using ultrasound for tip location; the systematic use of cyanoacrylate glue for sealing the exit site (with the double goal of minimizing bleeding and protecting the exit site from bacterial contamination).
(3) Venous thrombosis. Three years ago, a number of narrative reviews published on international journals have stressed the potential risk of venous thrombosis associated with peripherally inserted central catheters (PICCs). These papers have had vast resonance and have somehow changed the general approach to the choice of central venous access, particularly in oncological patients and ICU patients. Three years later, many prospective and retrospective clinical studies have shown that the actual risk of PICC-related thrombosis may have been somehow overestimated. When a proper indication policy and a proper insertion technique are adopted, the overall rate of PICC-related venous thrombosis now appears to be below 3% (with increased rate only in leukemic patients): also, such complication appears to be much less expensive than other severe complications such as infection and is associated with no significant risk of mortality. A careful review of the most recent literature shows that the many advantages of PICCs in terms of reduction of insertion-related complications and reduction of infection overcome the disadvantage of a potential increased risk of venous thrombosis.

Learning Objectives:

Mauro Pittiruti, Surgeon

M.D.
Catholic University Hospital, Rome - Italy

Mauro Pittiruti lives in Rome, where he works as a surgeon at the Catholic University Hospital since 1979. He is one of the best known world expert in the field of venous access. He is founder and president of the Italian Group of Central Venous Access (GAVeCeLT) and collaborates with WoCoVA (World Conference on Vascular Access) as chairman of the Scientific committee. He received the Herbst Award for excellence in vascular access in 2009.

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