PICC nel paziente in insufficienza renale -...
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PICC nel paziente in insufficienza renale
Giuseppe Capozzoli
ASDAA, azienda sanitaria dell’Alto AdigeOspedale di Bolzano
1° Servizio di Anestesia e Rianimazione
X PICC Day
Roma,30 novembre 2016
Fistola arterovenosa di alta qualità 2
• Revisione sistematica ostacoli
• Mantenere l’integrità dei vasi
• dispositivi intravascolari nella medicina moderna
FLEBITE, SCLEROSI, STENOSI, TROMBOSI
Obiettivi:1. Identificazione dei
pazienti in IRC2. Algoritmi per la
scelta dell’accesso vascolare ottimale in questi pazienti
FAV autologa > graft protesico > catetere venoso atriale LT
1. Hoggard J et al. Guidelines for venous access in patients with chronic kidney disease. Semin Dial.2008;21(2):186-191.
2. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice. Recommendations forVascular Access. Am J Kidney Dis. 2006: S176–322.
Fistola radio-cefalica: I scelta
Studi che hanno verificato le complicanze dovute ai cateterismi vascolari nei pazienti nefropatici
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PICC
CVC DIALISI
PACEMAKER-ICD
3.2X > incidenza malfunzionamento fistola in pazienti con storia di PICC
+32% stenosi vena centrale con
CICC dialisi in succlavia vs
giugulare interna
Shingarev R et al, Peripherally Inserted Central Catheters andOther Intravascular Devices: How Safe Are They for HemodialysisPatients? Am J Kidney Dis. 2012 October ; 60(4): 510–513
Linee guida: PICC e nefropatie croniche 4
1. Marnejon T et al. Risk factors for upper extremity venous thrombosis associated with peripherally insertedcentral venous catheters. J Vasc Access. 2012; 13:231–238.
2. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice. Recommendations forVascular Access. Am J Kidney Dis. 2006: S176–322.
3. UK Renal Association. Preservation of sites for native vascular access (guidelines 2.1-2.2). In: Clinical practiceguideline: vascular access for haemodialysis. 6th ed. 2015 http://www.renal.org/docs/
In patients with CKD stage 4 or 5, forearm and upper-arm veins suitable forplacement of vascular access should not be used for venipuncture or for theplacement of intravenous (IV) catheters, subclavian catheters, or peripherallyinserted central catheter lines (PICCs).
For patients with chronic kidney disease, avoid unnecessary venipunctureof peripheral veins in the upper extremity intended for future vascularaccess. Avoid PICCs in patients with chronic kidney disease due to therisks of central vein stenosis and occlusion, as well as resultant venousdepletion preventing future fistula construction. Venepuncture of cephalicveins of non-dominant arm should be prohibited, wearing of Medic alertbracelets may be helpful in preserving veins for future access creation.
Preservation of peripheral veins for vascular access: we suggest that allpatients that may require haemodialysis should have education on forearmvein preservation (2C). Avoiding vessel injury: we suggest thathealthcare workers should avoid unnecessary venepunctures ofperipheral venous access in the upper limb intended for creation ofvascular access.
• Rischio di trombosi venosa associato ai picc è 2X nei nefropatici cronici
Linee guida: PICC e nefropatie croniche II5
Don’t place peripherally inserted centralcatheters (PICC) in stage III-V CKD patientswithout consulting nephrology.Excessive venous puncture damages veins,destroying potential AVF sites. PICC lines andsubclavian vein puncture can cause venous thrombosisand central vein stenosis. Early nephrologyconsultation increases AVF use at hemodialysisinitiation and may avoid unnecessary PICC lines orcentral/peripheral vein puncture.
American Society of
Nephrology (1)
1. Nephrology ASo, Medicine ABoI, 2012. Available from: http://www.choosingwisely.org/societies/american-socie-ty-of-nephrology/2. Hoggard J et al. Guidelines for venous access in patients with chronic kidney disease. Semin Dial.2008;21(2):186-191.
American Society of Diagnostic and
Interventional Nephrology (2)
Limiti degli Studi
• Associazione fra picc e FAV non funzionante (NON CAUSALITA’)
• Scarsa qualità dei vasi e per questo hanno posizionato PICC
• Non etico uno studio randomizzato in cui posizionare picc a pazienti inIRC (tendenza dei picc a creare trombosi nelle vene utilizzate perl’anastomosi)
• Malfunzionamento primitivo della FAV (non maturazione della venadrenante per mancata dilatazione) o tardivo
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Stenosi venosa centrale
• Vena ascellare, succlavia ebrachiocefaliche sono espostealla terminazione prossimaledei midline e (dei picc).
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PICC 7% pacemaker 10-64% CICC dialisi giugulari 41%
Indicazioni al posizionamento dei PICC nei pazienti con nefropatia terminale
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El Ters M et al. Association Between Prior Peripherally Inserted Central Catheters and Lack of FunctioningArteriovenous Fistulas: A Case-Control Study in Hemodialysis Patients. Am J Kidney Dis. 2012.
Appropriatezza dei PICC nei pazienti con nefropatia cronica: guida MAGIC
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PICC INDICAZIONI
GENERALI
Consulenza nefrologica
PRESERVARE LE VENE!
1) National Kidney Foundation/Kidney Disease Outcomes Quality Initiative. KDOQI 2012 clinical practice guidelines for chronic kidney disease. Kidney Int. 2013;(Suppl 3):1-150.
2) Chopra V et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015 Sep 15;163(6 Suppl):S1-40
1)
Perché i PICC vengono posizionati anche nei pazienti con malattia renale allo stadio terminale?
• Accessi convenienti
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• Percezione di profilo di sicurezza maggiore
(complicanze ridotte)
• Richiesti da NON-nefrologi
• Non conoscenza delle linee guida
• Alternative ai piccpoco conosciute (Proline, CICC
tunnellizzati 4-7F)
• Rapidadimissibilità
extraospedaliera
Nephrology ASo, Medicine ABoI, 2012. Available from: http://www.choosingwisely.org/societies/american-socie-ty-of-nephrology/
• alternative: Groshong, Leonard, Hickman 5-12F, (PICC 3-6F)
Quale accesso venoso nei pazienti con GFR<45 ml/min?11
1. Sasadeusz KJ et al. Tunneled jugular small-bore central catheters as an alternative to peripherally insertedcentral catheters for intermediate-term venous access in patients with hemodialysis and chronic renalinsufficiency. Radiology. 1999;213:303-6.
2. Chopra V et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From aMultispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015 Sep 15;163(6Suppl):S1-40
per <= 5 giorni >5 giorni o per infusioni non compatibili
con le vene periferiche
AGOCANNULE PERIFERICHE
SUL DORSO DELLA MANO
CICC piccolo calibro 4-5F e tunnellizzati sul torace ,
anche bilume
Se il paziente viene dializzato discutere con
nefrologo della possibilità di somministrare i farmaci durante o subito dopo la
dialisi
Alternative ai PICC12
• alternative note: Groshong, Leonard,
Hickman 5-12F (PICC 3-6F)
• alternative poco conosciute (Proline, CICC tunnellizzati 4-7F)
Sasadeusz KJ, Trerotola SO. Tunneled Jugular small bore central catheters as an alternative to periferally insertedcentral catheters for intermediate-term Venous access in patients with Hemodialysis and chronic renal insufficiency.Radiology 1999; 213: 303-306.
CICC piccolo calibro tunnellizzati: vantaggi
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1) Bhutani G. Evaluating safety of tunneled small bore central venous catheters in chronic kidney diseasepopulation: A quality improvement initiative.Hemodialysis International 2016.2) Timsit JF. Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients.JAMA 1996; 276: 1416-1420.3) Andrivet P. Lack of clinical benefit from subcutaneous tunnel insertion of central venous catheters inimmunocompromised patients. Clin Infect Dis 1994; 18: 199-206.
Sepsi catetere correlate e tunnellizzazione dei CICC (2,3)
Rapporto diametro catetere / diametro vena
• Nei pazienti in IRC rischio di
trombosi venosa catetere correlata (1,2)
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1. Marnejon T et al Risk factors for upper extremity venous thrombosis associated with peripherally inserted centralvenous catheters. J Vasc Access. 2012; 13:231–238.
2. Infusion Therapy Standards of Practice Funded by Supplement to January/February 2016 Volume 39, Number 1SISSN 1533-1458
3. Cotogni P, Pittiruti M et al Catheter-related complications in cancer patients on home parenteral nutrition: Aprospective study of over 51,000 catheter days. JPEN J Parenter Enteral Nutr. 2013; 37:375–383.
4. Toure A, Duchamp A, Peraldi C, et al. A comparative study of peripherally-inserted and Broviac cathetercomplications in home parenteral nutrition patients. Clinical Nutrition 2014; 34:49–52.
Infezioni nei CVC
tunnellizzatiper nutrizione parenterale cronica (3,4)
Altri fattori PICC correlati predisponenti alla trombosi venosa vs CICC tunnellizzati di piccolo calibro
• Lunghezza del catetere: ampia superficie di contatto catetere-vena
• Trauma locale nelle vene del braccio target dell’accesso per la dialisi
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pei pazienti in IRC o nefropatia stadio finale
es. PROLINE 7F con cuffia in dacron
CICC in vena ascellare• Stenosi
• > rischio di sanguinamento
• trombosi >50% per i CICC da dialisi vs <10% per la giugulare interna (2)
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1) Bodenham A.R. Central Venous Catheters 2009 Wiley &Sons, Ltd. P111.2) Sasadeusz KJ et al. Tunneled jugular small-bore central catheters as an alternative to peripherally insertedcentral catheters for intermediate-term venous access in patients with hemodialysis and chronic renal insufficiency.Radiology. 1999;213:303-6
CICC tunnellizzati di piccolo calibro cuffiati
VANTAGGI
• Rimozioni meno frequenti• Infezioni (?)
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SVANTAGGI
• Posizionamento complesso• Rimozione complessa
Come regolare ed ottimizzare l’impianto dei picc nei pazienti nefropatici?
Stadio 1-3 (VFG >45 ml/min)
• SI’ PICC e midline di piccolo calibro
• Regole generali
• Consulenza nefrologica se dubbi
• Utilizzare arto dominante (3)
• Vene brachiali
Stadio 3b-5(VFG <45 ml/min)
• NO PICC e midline
• Cateteri tunnellizzati dipiccolo diametro in venagiugulare interna
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1) Chopra V et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From aMultispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015 Sep 15;163(6Suppl):S1-40.2) Sasadeusz KJ et al. Tunneled jugular small-bore central catheters as an alternative to peripherally insertedcentral catheters for intermediate-term venous access in patients with hemodialysis and chronic renal insufficiency.Radiology. 1999;213:303-6.3) El Ters M et al. Association Between Prior Peripherally Inserted Central Catheters and Lack of FunctioningArteriovenous Fistulas: A Case-Control Study in Hemodialysis Patients. Am J Kidney Dis. 2012;