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ARTICLES: Maurizio Gallieni, Mauro Pittiruti, and Roberto Biffi Vascular Access in Oncology Patients CA Cancer J Clin 2008; 58: 323-346 [Abstract] [Full text] [PDF]

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Response to Luptak

Maurizio Gallieni, MD, Mauro Pittiruti, MD; Roberto Biffi, MD   (23 January 2009)

Vascular Access

Patricia Luptak RN, BSEd, MS, OCN   (23 January 2009)

Response to Luptak 23 January 2009
Maurizio Gallieni, MD, Researcher University of Milano School of Medicine, Mauro Pittiruti, MD; Roberto Biffi, MD Send letter to journal: Re: Response to Luptak maurizio.gallieni{at}fastwebnet.it Maurizio Gallieni, MD, et al.	We thank Patricia Luptak for her comments on our article regarding vascular access in oncology patients [1]. We certainly agree that due to its great clinical importance, this issue should be intensely studied. We tried to summarize the most relevant aspects of clinical care in this area, which was a rather difficult task considering the number of open issues. We realize that many of these aspects remain open to discussions, and we welcome different inputs and suggestions. Regarding the number of lines placed in the US every year, we agree that the 1995 reference [2] underestimates the number of catheters used in oncology patients, but we could not find more recent and specific data. Indeed, even the references suggested by Ms. Luptak [3, 4] do not specifically address the prevalence of catheters use in oncology patients. However, we all agree that the number of catheters is in the order of millions. The issue of the tip position of midline catheters should be clarified. We stated that their tip is not “central”, i.e., is not located in the superior vena cava but in the axillary vein or in the subclavian vein, while Ms. Luptak suggests that the tip should not extend beyond the head of the humerus in the arm. We believe that clinically the most relevant distinction should be between central and peripheral catheters, as correctly suggested, where a central catheter has its tip in the distal third of the superior vena cava or at the caval atrial junction. Only a central venous access is indicated for the administration of solutions with pH < 5 or pH > 9; of drugs with osmolarity > 500 mOsm/L; of hyperosmolar parenteral nutrition; and of vesicant drugs. When a typical midline catheter is inserted under ultrasound guidance in the mid arm (which is currently the most common approach), in most of the patients the tip will be either in the axillary or in the subclavian vein. We would like to underscore the fact that this is still to be considered a peripheral catheter. Finally, we agree that PICC lines with proper maintenance can stay in patients longer than 3 months if needed. Indeed, there is no evidence allowing us to establish a specific duration of PICC lines. We also had patients who kept their PICC for over 12 months. However, while it can be reasonable not to change a well functioning and not infected PICC in the single patient, the cut-off of 3 months could be used for the choice of the correct vascular access in the first place. If it is anticipated that treatment will be required for more than 3 months, it could be better to insert a tunnelled or a totally implanted catheter. Maurizio Gallieni, MD Mauro Pittiruti, MD Roberto Biffi, MD References 1. Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology patients. CA Cancer J Clin. 2008;58:323-346. 2. Ryder M. Peripheral access options. Surg Oncol Clin N Am 1995;4:395-427. 3. Richardson D. Vascular access nursing - standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12:19-27. 4. Brown M. The impact of safety product use on catheter-related infections. J Infus Nurs. 2004;27:245-50.
Vascular Access 23 January 2009
Patricia Luptak RN, BSEd, MS, OCN, Director Oncology/Infusion Services Jefferson Regional Medical Center, Pittsburgh, PA Send letter to journal: Re: Vascular Access Patricia.Luptak{at}jeffersonregional.com Patricia Luptak RN, BSEd, MS, OCN	Dear Editor, As a nurse for 37 years, most of it in Vascular Access and the past 20 in Oncology, I think the article addressing Vascular Access in Oncology Patients was certainly long overdue. Some of the physicians references were very old such as his very first statement about the number of lines placed in the US every year. That reference was from 1995! Current references show us that the number of central venous catheters placed in the US each year is closer to 7 million used in both chronic and acute care [1, 2]. Also, one correction is that in our country by our standards, midlines do not extend beyond the head of the humerus in the arm, therefore would never be in the axillary or subclavian vein. That is not standard placement by INS standards which most facilities go by. That would be midclavicular, which we do not approve of for therapies. It is either a midline which is peripheral or a central line which is the distal one third of the SVC or caval atrial junction placement. Another fact is that PICC lines with proper maintenance can stay in patients longer than 3 months if needed. Documented PICC lines have been left in patients as long as 2 years with proper care and maintenance. I had a PICC line for 5 months myself. There is very good information in this article and maybe the difference is that the author is from another country, but I wanted to clear up some inconsistencies with some of the facts printed. I have been lecturing and educating on Vascular Access Devices for almost 10 years and want everyone to be on the same page. Thank You, Patricia Luptak RN, BSEd, MS, OCN Director Oncology/Infusion Services Jefferson Regional Medical Center Pittsburgh, PA 412-469-7129 Fax 412-469-7338 References 1. Richardson D. Vascular access nursing - standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12:19-27. 2. Brown M. The impact of safety product use on catheter-related infections. J Infus Nurs. 2004;27:245-50.