Purpose: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. Methods: An international evidence-based consensus provided definitions and recommendations.

Tip position of a central venous access is of paramount importance and should be verified before starting infusion. Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only approximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out (example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion). In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become the preferential method for confirming the tip position during PICC insertion.

Due to the low diagnostic capability of clinical variables, PCR amplifications in CSF, especially for EBV-DNA and for JCV-DNA, represent, in most cases, an essential step in the differential diagnosis of AIDS-related FBL. This is particularly true in patients with FBL without mass effect or with mass effect and who are either seronegative or undergoing anti-Toxoplasma prophylaxis. Brain biopsy remains a necessary procedure in EBV-DNA-positive cases and in seronegative patients with FBL displaying a mass effect. Positive JCV-DNA testing may obviate the need for brain biopsy in patients with FBL without mass effect. An advanced diagnostic strategy based on combined clinical criteria and PCR tests may allow rapid and accurate identification of patients for prompt brain biopsy or specific therapy.

IntroductionIn the ICU, peripherally inserted central catheters (PICCs) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome with the use of power-injectable catheters.MethodsWe retrospectively reviewed all of the power-injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance.ResultsWe collected 89 power-injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related bloodstream infection. Non-infective complications during management were not clinically significant. There was one episode of symptomatic thrombosis during the stay in the ICU and one episode after transfer of a patient to a non-intensive ward.ConclusionPower-injectable PICCs have many advantages in the ICU: they can be used as multipurpose central lines for any type of infusion including high-flow infusion, for hemodynamic monitoring, and for high-pressure injection of contrast media during radiological procedures. Their insertion is successful in 100% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infective and non-infective complications.

The actual value of heparinization for non-dialysis catheters should be reconsidered. Also, the use of lock with substances with anti-bacterial and anti-biofilm activity (such as citrate or taurolidine) should be taken into consideration in selected populations of patients.

BackgroundAcutely ill patients admitted to the emergency department (ED) constantly require at least one fast and reliable peripheral intravenous (PIV) access. In many conditions (morbid obesity, underweight state, chronic diseases, intravenous drug abuse, adverse local conditions, etc.), PIV placement may be challenging.Ultrasound guidance is a useful tool for obtaining a peripheral intravenous access in the emergency department, particularly when superficial veins are difficult to identify by palpation and direct visualization, though standard peripheral intravenous cannulas are not ideal for this technique of insertion and may have limited duration.Long polyurethane catheters inserted with ultrasound guidance and direct Seldinger technique appear to have several advantages over short cannulas in terms of success of insertion and of duration.MethodsA retrospective analysis was conducted on all the ultrasound-guided peripheral venous accesses obtained by insertion of long polyurethane catheters in patients admitted to the emergency department of our university hospital during 1 year. The main indication to the procedure was the urgent need of a peripheral venous access in patients with superficial veins difficult to palpate and/or visualize. All relevant data concerning the insertion and the maintenance of these peripheral lines were collected from the chart.ResultsSeventy-six patients were included in this review. The success rate of insertion was 100 %, with an average of 1.57 punctures per each successful cannulation. The mean time needed for the complete procedure was 9.5 min. In 73 % of patients, the catheter was used for more than 1 week; a minority of catheters were removed prematurely for end of use. No major infective or thrombotic complication was reported.ConclusionsIn our experience, 8- to 10-cm-long polyurethane catheters may offer a fast and reliable peripheral venous access in the emergency department, if placed by ultrasound guidance and with the Seldinger technique. Further studies with prospective, randomized, and controlled design are warranted to confirm our results.

The presence of 'ghost' could be an independent predictor of mortality after TLE, thus identifying a subgroup of patients who need closer clinical surveillance to promptly detect any complications.

The 2020 COVID pandemic has forced everyone to update the usual medical procedures and adapt them to a new situation characterized by a high risk of contamination of the health operator. The placement of a venous access device is no exception. In the experience of the vascular access team of our hospital, hit by the COVID epidemic in March 2020, the safety of both the patient and the staff can be ensured by an insertion bundle of few smart strategies, which include choice of long dwelling peripheral catheters (midline catheters) rather than short venous cannulas; use of power injectable peripherally inserted central catheters in the COVID patients in intensive care unit requiring a central line; use of wireless probes-easy to carry, easy to clean-for ultrasound guided venipuncture; avoidance of x-rays, using alternative methods for tip location such as intracavitary electrocardiography or trans-thoracic echocardiography; strict adoption of the barrier precautions recommended by the international guidelines.