Extended subcutaneous route technique allows the creation of a subcutaneous tunnel <5 cm, without skin incision and additional manipulation. Extended subcutaneous route technique may be feasible and useful, particularly for patients with high risk of bleeding or infection.

Needleless connector is one of the main factors involved in keeping catheter patency. It is important to perform the best choice among the connectors available.An empirical reflux measurement, relative to the needleless connector and the catheter in use, can be obtained using an 18G cannula.

Background: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. Aims and objectives: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: 'armpits strap' versus 'counterweights system'. Design: This was a non-randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. Results: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0-10 scale was: 0⋅5 ± 1⋅4 at T 0 (baseline) , 1⋅5 ± 2⋅0 at T 1 (after 1 h) and 2⋅6 ± 2⋅5 at T 2 (end of cycle) (p = 0⋅023). The same analysis was performed for the counterweights fixing option. The mean score was 0⋅3 ± 0⋅6 at T 0 , 0⋅3 ± 0⋅2 at T 1 and 0⋅5 ± 0⋅7 at T 2 (p = 0⋅069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3⋅0 ± 1⋅0 and 3⋅9 ± 2⋅3 h, respectively (p < 0⋅001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0⋅23 ± 0⋅20 cm 2 . After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0⋅27 ± 0⋅21(p = 0⋅099) and 0⋅30 ± 0⋅25, respectively (p = 0⋅080). Conclusions: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. Relevance to practice: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience. Squadrone et al., 2004), but it also depends on the ventilator settings, the interfaces available (Navalesi et al., 2000) and the quality of interaction between the pulmonary ventilator and the patient's spontaneous breathing (Vignaux et al., 2009).According to Taccone et al. (2004), non-invasive CPAP should be delivered by continuous gas flow in order to avoid or minimize the mismatch of patient/ventilator interaction. Currently, in Europe, the mask interface is still the main choice, even if new trends in several countries of south Europe demonstrated that the helmet is the alternative first choice to delivering CPAP (Crimi et al., 2010).

Introduction: Midline catheters are widely used in clinical practice. Proper placement of midline catheter tip is usually assessed only by aspirating blood and flushing with normal saline without resistance. Purpose: To describe the ultrasound-guided tip location for midline catheters and its feasibility and to compare incidence of catheter-related venous thrombosis associated with or without ultrasound tip localization. Methods: The ultrasound-guided tip location is described step by step. Feasibility of the technique and incidence of catheter-related venous thrombosis were measured (study group) and compared with two historical groups: study group, 20-cm midline catheters inserted with ultrasound-guided tip location; group 1, 25-cm midline catheters inserted without ultrasound-guided tip location and group 2, 20-cm midline catheters inserted without ultrasound-guided tip location. Results: In the study group, ultrasound-guided tip location was easily feasible in 98.9% of patients. Incidence of catheter-related venous thrombosis was 2.42% in control group 1, 9% in control group 2 and 2.62% in the study group. Discussion: In the study group and control group 1, the tip was placed in the axillary vein, about 3 cm distal to the clavicle and in the subclavian vein. In control group 2, the tip was probably located at the transition between the axillary and the subclavian vein. It is possible that such position may have been associated with an increased incidence of catheter-related venous thrombosis. Conclusion: The ideal position of the tip of a midline catheter might be inside the axillary vein, about 3 cm distal to the axillary-subclavian transition or inside the subclavian vein. Ultrasound-guided tip location is safe, inexpensive, easy and potentially useful during midline catheters insertion.

Introduction: Peripherally inserted central catheters are very common devices for short, medium and long-term therapies. Their performance is strictly dependent on the correct tip location, at the junction between the upper caval vein and the right atrium. It is very important to obtain an estimated measure of the catheter, in order to reach the cavo-atrial junction and optimize the catheter length. Estimated measures are often obtained using cutaneous landmarks. Objective: Evaluate the reliability of cutaneous landmark-based length estimation during catheter insertion. Identify any patient’s related factors that may affect cutaneous landmarks reliability. Methods: We used two distinct techniques and collected data about cutaneous landmark-based length estimation, electrocardiographic guided intravascular length, age, weight and height. We studied the reliability of possible correcting factors, balancing the error average by regression models, and we found and tested two different models of prediction. Results: A total number of 519 patients were studied. The average bias, between the two studied length assessment by cutaneous landmarks and electrocardiographic guided catheter length, were 3.77 ± 2.44 cm and 3.28 ± 2.57 cm, respectively. The analysed prediction models (deviance explained 43.5%, Akaike information criterion = 1313.67% and 43.4%, Akaike information criterion = 1313.92), fitted on the validation set, showed a root mean square error of 3.07 and 3.06. Conclusion: Landmark-based length estimation for preventive catheter length assessment seems to be unreliable, when associated with post-procedural tip location. They are useful for distal trimming catheters to optimize the ‘out of skin’ portion when associated with electrocardiographic tip location. Models identified for balancing bias are probably not useful.