Vascular access in COVID-19 patients: smart decisions for maximal safety
1-Giancarlo Scoppettuolo,
2-Daniele G.Biasucci,
3-Mauro Pittiruti

1Dept. of Infective Diseases
2Dept. of Anesthesia and Intensive Care
3Dept. of Surgery

Fondazione Policlinico Universitario ‘A.Gemelli’, Roma, Italy

Keywords:
COVID – coronavirus – venous access device – central venous catheter – PICC – midline – tip
location – ultrasound guidance

Corresponding author:
Mauro Pittiruti

Dept. of Surgery
Fondazione Policlinico Universitario ‘A.Gemelli’
Largo Gemelli 8
00168 Roma, Italy

mauro.pittiruti@policlinicogemelli.it

Approximately one month ago, the first patient with COVID-19 was identified in Northern
Italy; thirty days later, more than 60 thousand Italians have been contaminated and more than 6
thousand have died because of this disease. The medical and nursing staff of our 1300-bed
University Hospital in Rome have been forced to change dramatically its daily routine and adapt to
this unexpected health emergency. In particular, our multi-professional, multi-disciplinary vascular
access team – that usually takes care of the insertion of most short term and all medium-long
term venous access devices (VAD) in our hospital (about 7,000 per year) – has faced the challenge
of inserting VADs in suspected or confirmed cases of COVID-19, yet maintaining the maximal
safety for both the operator and the patient. Grounded on the international recommendations of
WHO and CDC, as well as on our previous experience, we have rapidly developed a bundle of
strategies apt to minimize the risks for our team, without giving up the basic principles of good
clinical practice for reducing the potential complication associated to VAD insertion.
We report these few strategies, hoping that they might be useful to other vascular teams that are
in our same situation right now or that might be (unfortunately) in the next future.

1) Wise choice of the peripheral venous access device.
Patients with suspected COVID-19 or with confirmed COVID-19 but without need for intensive
care usually can be safely treated just with a peripheral venous access, for hydration, supportive
therapy and blood sampling. In order to reduce as much as possible the number of vascular
procedures on these patients (considering that each maneuver is associated with the use of
precious resources and some risk to the staff), we are currently adopting the policy of inserting
power injectable polyurethane midline catheters (MC) in these non-intensive care patients. We
refer to ‘standard’ midline catheters, 20-25 cm long, which have several advantages: long duration
(several weeks), high flow, low risk of dislodgment, and feasibility of blood withdrawal (1).
To optimize the function of these VAD, we use ultrasound to assess that the location of the tip is in
the axillary vein, just before the clavicle (in our experience this is the ideal position for ensuring
easy blood sampling) (2).

2) Wise choice of the central venous access device.
COVID patients in intensive care unit, on the other hand, require a central venous access device
for several purposes: fluid support, vasopressors, parenteral nutrition, hemodynamic monitoring,
repeated blood sampling. We think that the ideal central VAD in this situation is a power injectable
peripherally inserted central catheter (PICC), either 5Fr double lumen or 6Fr triple lumen. Recent
literature have shown that power injectable polyurethane, non-valved PICCs perform as good as
centrally inserted central catheters (CICCs) in intensive care unit (3-4); in particular, they tolerate
very high flow of infusion, they are appropriate for measurement of central venous pressure (5)
and for measurement of the cardiac output by thermodilution (6-7). The risk of thrombosis and
infection is similar to CICCs and – for both devices – depends mainly on the insertion technique (8).
Though, in COVID patients, PICC may have some specific advantages: its insertion and
management is more compatible with an optimal respiratory care (particularly in the patient who
wears non-invasive ventilation devices, or has a tracheostomy, or needs periodical pronation); also
the site of insertion of PICC at midarm moves the operator far from the mouth and nose of the
patient, hopefully reducing the risk of airborne contamination.

3) Wise choice of the technique of insertion
As much as all international recommendations currently recommend the use of ultrasound
guidance for choosing, puncturing and cannulating the vein (9-10), in COVID patient we found
extremely useful to adopt wireless ultrasound probes, preferably connected by wi-fi technology
with the display of a smartphone or with a tablet. We have used these devices since a few years,
mainly because they are easy to carry and more comfortable during bedside VAD insertion. Now
we have discovered that they are precious, if not mandatory, in ultrasound maneuvers on COVID
patients, since they are easily and rapidly cleaned with appropriate solution/wipes soon after the
maneuver. Of course, the wireless probe (with a linear transducer) is properly wrapped in a sterile
cover, and the display (smartphone or tablet) in a non-sterile envelope. One other relevant issue
in COVID patients is to avoid unnecessary x-rays (both as bedside x-ray in the ICU and as transport
to the radiology suite), so to reduce the chances of contamination: thus, for proper assessment of
the location of the tip of the central VAD, we use non-radiological methods such as intracavitary
electrocardiography (IC-ECG) or trans-thoracic echocardiography (TTE), which have been using
since many years and that are now recognized to be safer, more accurate and more cost-effective
than chest-x-ray (9-11). TTE can be done very rapidly using wireless probes with convex, microconvex
or sectorial probe. IC-ECG can be performed using wireless ECG devices, dedicated to this
technique, connected by Bluetooth technology to smartphones or tablets.

4) Adoption of the recommended precautions for avoiding contamination
Last but not least, insertion of MC and PICC is performed following the CDC recommendations for
vascular access in COVID patients (12): the operator must strictly adopt the ‘standard’ maximal
barrier precautions (hand hygiene, surgical mask, beret, sterile impermeable gown, sterile gloves,
wide sterile drapes over the patient, appropriate sterile cover for the ultrasound probe);
furthermore, the patient and all other persons in the room must wear a mask. The use of N95
mask is recommended for aerosol generating procedures, which is usually not the case of VAD
insertion, and in particular not when the VAD (MC or PICC) is inserted at the arm. Nonetheless, in
selected patients, a N95ions (i.e., coupled with a surgical mask).

As COVID-19 unfortun mask should be considered, and in this case it must be used according to
the CDC recommendatately continues, it is important to focus on infection control. For this
reason, we expect that more and more hospitals will have to develop local policies for vascular
access insertion in these very special patients. We hope that these few suggestions from our VAD
team can aid others to develop insertion bundles apt to minimize any possible harm to the patient
and to the staff.

1) Qin KR, Nataraja RM, Pacilli M. Long peripheral catheters: Is it time to address the confusion? J Vasc
Access. 2019; Vol. 20(5) 457–460.
2) Elli S, Pittiruti M, Pigozzo V, et al. Ultrasound-guided tip location of midline catheters. J Vasc Access.
2020 Feb 28. doi: 10.1177/1129729820907250.
3) Pittiruti M, Brutti A, Celentano D, et al. Clinical experience with power-injectable PICCs in
intensive care patients. Crit Care. 2012 Feb 4;16(1):R21. doi: 10.1186/cc11181.
4) Cotogni P, Pittiruti M. Focus on peripherally inserted central catheters in critically ill patients. World
J Crit Care Med. 2014; 3: 80–94.
5) Sanfilippo F, Noto A, Martucci G, et al. Central venous pressure monitoring via peripherally or
centrally inserted central catheters: a systematic review and meta-analysis. J Vasc Access. 2017 Jul
14;18(4):273-278.
6) D’Arrigo S, Sandroni C, Cacciola S, et al. Are Peripherally Inserted Central Catheters Suitable for
Cardiac Output Assessment With Transpulmonary Thermodilution? Crit Care Med. 2019;
47(10):1356-1361.
7) D ́Arrigo S, Sandroni C, Cacciola S et al. Single-lumen 5Fr and triple-lumen 6Fr peripherally inserted
central catheters (PICCs) for cardiac output assessment by transpulmonary thermodilution. Critical
Care 2020, 24(Suppl 1):87, P199.
8) Balsorano P, Virgili G, Villa G, et al. Peripherally inserted central catheter-related thrombosis rate in
modern vascular access era-when insertion technique matters: A systematic review and metaanalysis.
J Vasc Access, 2020;21(1):45-54.
9) Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on
ultrasound-guided vascular access. Intensive Care Med. 2012; 38: 1105–1117.
10) Gorski L, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of Practice. J Infusion Nurs. 2016;
39 (suppl.1): S1-S156.
11) Iacobone E, Elisei D, Gattari D, et al. Transthoracic echocardiography as bedside technique to verify
tip location of central venous catheters in patients with atrial arrhythmia. J Vasc Access. 2020; doi
10. 1177/12972982005200.
12) CDC – updated protocol March 19, 2020 on airborne precautions
https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

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