Eric Desruennes

International evidence-based recommendations on ultrasound-guided vascular access

PurposeTo provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access.MethodsAn international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations.ResultsThe recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications.ConclusionsThese definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

2008 SOR guidelines for the prevention and treatment of thrombosis associated with central venous catheters in patients with cancer: report from the working group

BACKGROUND In view of the lack of recommendations on central venous catheter (CVC)-associated thrombosis in cancer patients, we established guidelines according to the well-standardized Standards, Options and Recommendations methodology. MATERIAL AND METHODS A literature review (1990-2007) on CVC-associated thrombosis was carried out. The guidelines were developed on the basis of the corresponding levels of evidence derived from analysis of the 36 of 175 publications selected. They were then peer reviewed by 65 independent experts. RESULTS For the prevention of CVC-associated thrombosis, the distal tip of the CVC should be placed at the junction between the superior cava vein and right atrium; anticoagulants are not recommended. Treatment of CVC-associated thrombosis should be based on the prolonged use of low-molecular weight heparins. Maintenance of the catheter is justified if it is mandatory, functional, in the right position, and not infected, with a favorable clinical evolution under close monitoring; anticoagulant treatment should then be continued as long as the catheter is present. CONCLUSIONS Several rigorous studies do not support the use of anticoagulants for the prevention of CVC-associated thrombosis. Treatment of CVC-associated thrombosis relies on the same principles as those applied in the treatment of established thrombosis in cancer patients.

Guidelines on the use of ultrasound guidance for vascular access

Insertion of vascular access is a common procedure with potential for iatrogenic events, some of which can be serious. The spread of ultrasound scanners in operating rooms, intensive care units and emergency departments has made ultrasound-guided catheterisation possible. The first guidelines were published a decade ago but are not always followed in France. The French Society of Anaesthesia and Intensive Care has decided to adopt a position on this issue through its Guidelines Committee in order to propose a limited number of simple guidelines. The method used was the GRADE(®) method using the most recently published meta-analyses as the source of references. The level of evidence found ranged from low to high and all the positive aspects associated with ultrasound guidance, i.e. fewer traumatic complications at puncture, probably or definitely outweigh the potential adverse consequences regardless of whether an adult or child is involved and regardless of the site of insertion.

Recommandations pour la pratique clinique 2008 : prise en charge de la thrombose veineuse chez les patients atteints de cancer (méthode SOR)

The “Standards, Options: Recommendations” (SOR) project has been initiated by the French National Federation of Cancer Centers (FNCLCC) and is now part of the French National Cancer Institute. The project aims to develop and update the evidence-based Clinical Practice Guidelines (CPG) in oncology. The SOR has elaborated national guidelines, presented here as a short report, in order to answer questions related to venous thromboembolic events (VTE) treatment and to central venous catheter thrombosis (CVCT) management in cancer patients. These guidelines result from a collaborative work with some members of three scientific societies: the Société nationale française de médecine interne (SNFMI), the Société française de médecine vasculaire (SFMV) and the Société française d’anesthésieréanimation (SFAR).RésuméCet article propose le rapport abrégé d’une recommandation pour la pratique clinique (RPC), élaborée selon la méthodologie « Standards, Options: Recommandations (SOR) », sur le traitement de la maladie thromboembolique veineuse (MTEV) et sur la prise en charge des thromboses veineuses sur cathéter central (TVKTC) chez les patients atteints de cancer. la recommandation a été réalisée en collaboration avec des membres de la Société nationale française de médecine interne (SNFMI), de la Société française de médecine vasculaire (SFMV) et de la Société française d’anesthésie-réanimation (SFAR). Le programme SOR, initié par la Fédération nationale des centres de lutte contre le cancer (FNCLCC), a pour objectif la rédaction de RPC en cancérologie et est piloté, depuis mai 2008, par l’institut national du cancer (INCa).

Wound healing delay after central venous access following DCF/VEGF-trap therapy.

SummaryHypertension, proteinuria, thromboembolic or bleeding events are well-recognized complications occurring while targeting VEGF pathway. Wound healing dysfunctions have also been described in patients undergoing major surgery. For the first time, we report wound healing delay after central venous access following DCF-VEGF-Trap. VEGF-Trap may affect both angiogenesis and reepithelialization which are necessary to the normal repair process.