Peripherally Inserted Central Venous Catheters Are Not Superior to Central Venous Catheters in the Acute Care of Surgical Patients on the Ward

ACR Appropriateness Criteria® Central Venous Access Device and Site Selection

The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Comparing Complication Rates of Midline Catheter vs Peripherally Inserted Central Catheter. A Systematic Review and Meta-analysis

Background

Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach.

Results

Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15-0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48-3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes.

Conclusions

Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

An Information-Based Nursing Quality Evaluation Model of Daily PICC Work in Outpatient Clinics

Our purpose of this study was to analyze the application value of the information-based nursing quality evaluation model in improving the daily work quality of the PICC room in the outpatient department. From January 2020 to December 2020, 465 patients who received PICC treatment were selected as the research objects and divided into the observation group (265 cases, July 2020–December 2020, information-based nursing quality evaluation model after implementation) and the control group (200 cases, January 2020–June 2020, before the implementation of the information-based nursing quality assessment model). Compared with the control group, the children and their families in the observation group had higher PICC health knowledge and compliance scores, longer mean time for catheter placement, lower overall complication rate, and higher overall satisfaction rate after the intervention. The information-based nursing quality evaluation model can improve the daily work quality of the PICC room in the outpatient clinic, improve the clinical efficacy of PICC in patients, and reduce the incidence of complications such as catheter shedding. It is worthy of clinical application.

Safe central venous catheters for esophageal cancer treatment

 Introduction : Central venous catheter (CVC) use is essential for treating esophageal cancer. Peripherally inserted central catheters (PICC) are commonly used recently for improved patient comfort and safety. We compared centrally inserted central catheters (CICC) and PICC insertions and examined their safety. Methods : We retrospectively investigated complications at the catheter insertion and post-insertion for 199 patients' esophageal cancer treatment (CICC : 45, PICC : 154) from 2013 to 2018. In addition, we summarized the results of catheter tip culture. Results : No serious complications occurred at the catheter insertion in either group. The rate of complications at catheter insertion was 5.8% for PICC and 6.7% for CICC patients. Post-insertion complications were observed in 6.5% and 11.1% of patients with PICC and CICC, respectively, and this difference was not significant. The incidence of catheter-related blood stream infection (CRBSI) was significantly lower in PICC than CICC patients (0.3 vs. 1.8 / 1,000 catheter-days ; p = 0.029). Catheter-related thrombosis was observed in PICC : 0.5 and CICC : 0.6, and occlusion due to blood flow reversal was observed in PICC : 0.5 and CICC : 0.6. Conclusion : PICCs are safer and more effective than CICCs for the treatment of esophageal cancer, and reduce the incidence of CRBSI. We hope to standardize the insertion procedures, conventionalize techniques, and establish training systems. J. Med. Invest. 67 : 298-303, August, 2020.

Catheterization of PICC through a superficial femoral vein for patients with superior vena cava syndrome using ECG positioning and ultrasound-guided technologies

OBJECTIVE

We herein demonstrate the efficacy of PICC placement through a superficial femoral vein in patients with superior vena cava syndrome using ultrasound guidance and electrocardiographic localization. The treatment of PICC disconnection was also discussed.

METHODS

The study enrolled 51 patients with superior vena cava syndrome. Ultrasound-guided technology and ECG positioning technology are employed to help these patients in catheterization. The puncture time, the number of punctures, and catheter tip position were recorded. The patient was followed up for at least 2 years. The complications and treatment during follow-up were recorded.

RESULT

The average puncture time was 32.13 ± 3.91 min. A total of 49 patients were successfully punctured once, while 2 patients failed in the first puncture. The main reason for puncture failure is that the inability of a guide wire to pass through. After the nurse removed the needle and pressed the puncture point until no rebleeding occurred, the puncture above the original puncture point was successful. X-ray examination revealed that the catheter tip was located in the inferior vena cava, above the diaphragm, near the right atrium. The success rate of catheterization was 100%. The visual analog scale (VAS) score was (2.44 ± 0.73) at the time of puncture, which was tolerable during the operation, and the patient did not complain of obvious pain following the operation. One patient developed complications of broken tube half a year after the puncture. Interventional physicians utilized angiography to locate the broken catheter.

CONCLUSION

It is safe and feasible to place PICC through a superficial femoral vein under ultrasound combined with ECG positioning technology in patients with superior vena cava syndrome.

Effects of indwelling centrally inserted central catheter on tip location of peripherally inserted central catheter with intracavitary electrocardiogram guidance: A retrospective case-control study

BACKGROUND

Intracavity electrocardiogram (IC-ECG) guidance is an effective technology for monitoring the tip locations of centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs). However, for patients with an indwelling CICC, there has been no study on whether the CICC affects PICC tip positioning with IC-ECG guidance.

METHODS

Thirty people with a CICC requiring PICC insertion, matched with age to controls without a CICC. The stability of IC-ECG waveforms, the amplitude of P-waves, and the accuracy of PICC tip location were compared.

RESULTS

There was no significant difference in the stability of the IC-ECG waveforms (χ² = 0.22, p = 0.64). The amplitudes of baseline P-waves and ideal P-waves also showed no significant difference (t1 = 0.06, p1 = 0.96, t2 = 0.80, p2 = 0.43). Neither the accuracy of tip location (χ² = 1.40, p = 0.50) nor the distance of PICC tip (t = -0.03, p = 0.98) were significantly different.

CONCLUSION

For patients with an indwelling CICC, the position of PICC tip can be accurately determined by the dynamic changes in the P-wave amplitude.

A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial

OBJECTIVE

The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU).

METHODS

This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate.

RESULTS

One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24).

CONCLUSIONS

PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

Comparing catheter related bloodstream infection rate between cuffed tunnelled and non-cuffed tunnelled peripherally inserted central catheter

OBJECTIVE

To compare catheter related blood stream infection (CRBSI) rate between cuffed tunnelled and non-cuffed tunnelled PICC.

METHODS

We prospectively followed 100 patients (50:50 cuffed and non-cuffed PICC) and compared CRBSI rate between these groups. Daily review and similar catheter care were performed until a PICC-related complication, completion of therapy, death or defined end-of-study date necessitate removal. CRBSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of infection and from peripheral blood cultures.

RESULTS

A total of 50 cuffed PICC were placed for 1864 catheter-days. Of these, 12 patients (24%) developed infection, for which 5 patients (10%) had a CRBSI for a rate of 2.7 per 1000 catheter-days. Another 50 tunnelled non-cuffed PICCs were placed for 2057 catheter-days. Of these, 7 patients (14%) developed infection, for which 3 patients (6%) had a CRBSI. for a rate of 1.5 per 1000 catheter-days. The mean time to development of infection is 24 days in cuffed and 19 days in non-cuffed groups. The mean duration of utilization was significantly longer in non-cuffed than in cuffed group (43 days in non-cuffed vs 37 days in cuffed group, p = 0.008).

CONCLUSIONS

Cuffed PICC does not further reduce the rate of local or bloodstream infection. Tunnelled non-cuffed PICC is shown to be as effective if not better at reducing risk of CRBSI and providing longer catheter dwell time compared to cuffed PICC.

Safe use of Peripherally Inserted Central Catheters for chemotherapy of solid malignancies in adult patients: A 1-year monocentric, prospectively-assessed, unselected cohort of 482 patients

INTRODUCTION

Aim of this study was to analyze the overall complication and failure rates of Peripherally Inserted Central Catheters (PICCs), in a 1-year consecutive unselected cohort of 482 adult patients, affected by non-hematological malignancies undergoing chemotherapy.

METHODS

Adult outpatients (aged 18-75 years), with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, bearing solid tumors and candidates for intravenous chemotherapy were eligible for the study. Exclusion criteria were active infections, coagulopathy (defined as platelet count <50,000/μL and/or prothrombin time more than 18 s), life expectancy <6 months, or inability to give written informed consent. Devices were all implanted in an outpatients' hospital facility, following predefined evidence-based institutional guidelines and protocols by a PICC-dedicated team at the European Institute of Oncology in Milan, Italy, during the 12-month period from January 1 to December 31, 2019.

RESULTS

Five-hundred PICCs were implanted in a cohort of 482 patients during the time interval of this study. Thirty devices were overall removed (6.2%), 23 as a consequence of a complication occurred, and seven inadvertently. The inserted PICCs accounted for a total of 49,718 catheter days in situ, median duration was 85.5 days [interquartile range (IQR): 56-146]. Overall there were 42 (8.7%) complications, corresponding to 0.84 catheter-adverse events (CAE)/1000 PICC-days (95% CI: 0.61-1.14). There were N = 13 (2.7%) thromboses, N = 11 (2.3%) irreversible occlusions, N = 7 (1.5%) accidental removals, N = 5 (1.0%) infections [two Catheter Related Blood Stream Infection (CRBSI) and three exit site/local infection], N = 3 (0.6%) ruptures and N = 3 (0.6%) primary or secondary malpositions.

CONCLUSION

This large prospective study supports the increasing use of PICCs in adult oncology outpatients treated in specialized centers with chemotherapy for non-hematological malignancies. In this clinical setting, PICC failure occurred in 6% only of the inserted devices.

A comparison of hydrophobic polyurethane and polyurethane peripherally inserted central catheter: results from a feasibility randomized controlled trial

Background

To evaluate the feasibility of an efficacy trial comparing a hydrophobic polyurethane peripherally inserted central catheter (PICC) with a standard polyurethane PICC.

Methods

This pilot randomised controlled trial (RCT) was conducted between May 2017 and February 2018. Adult participants (n = 111) were assigned to hydrophobic polyurethane PICC with proximal valve (intervention) or a polyurethane PICC with external clamp (standard care). Primary outcome was trial feasibility including PICC failure. Secondary outcomes were central line-associated bloodstream infection, local infection, occlusion, thrombosis, fracture and dislodgement, phlebitis, local or systemic allergic reaction, and PICC dwell time.

Results

All feasibility outcomes were achieved, apart from eligibility criteria. In total, 338 patients were screened, 138 were eligible (41%), and of these 111 were randomised (80%). Patients received the allocated PICC in 106 (95%) insertions. No patients withdrew from the study and there was no missing data. PICC failure was 24% (13/55) in the intervention group and 22% (12/55) in the standard care group (p = 0.820). PICC failure per 1000 PICC days was 16.3 in the intervention group and 18.4 in the control group (p = 0.755). The average dwell time was 12 days in the intervention and 8 days in the control group.

Conclusions

This study demonstrates the feasibility of an efficacy trial of PICC materials in an adult population, once adjustments were made to include not only in-patients, but also patients being discharged to the Hospital in the Home service.

Trial registration

Australia and New Zealand Clinical Trials Registry ACTRN12616001578493. Prospectively registered on 16 November 2016. The trial protocol was published a priori (Kleidon et al., Vasc Access 3:15–21, 2017).

Peripherally inserted central catheter versus central venous catheter for intravenous access: A protocol for systematic review and meta-analysis

BACKGROUND

Since the first description of the central venous catheter (CVC) in 1952, it has been used for the rapid administration of drugs, chemotherapy, as a route for nutritional support, blood components, monitoring patients, or combinations of these. When CVC is used in the traditional routes (eg, subclavian, jugular, and femoral veins), the complication rates range up to 15% and are mainly due to mechanical dysfunction, infection, and thrombosis. The peripherally inserted central catheter (PICC) is an alternative option for CVC access. However, the clinical evidence for PICC compared to CVC is still under discussion. In this setting, this systematic review (SR) aims to assess the effects of PICC compared to CVC for intravenous access.

METHODS

We will perform a comprehensive search for randomised controlled trials (RCTs), which compare PICC and traditional CVC for intravenous access. The search strategy will consider free text terms and controlled vocabulary (eg, MeSH and Entree) related to "peripherally inserted central venous catheter," "central venous access," "central venous catheter," "catheterisation, peripheral," "vascular access devices," "infusions, intravenous," "administration, intravenous," and "injections, intravenous." Searches will be carried out in these databases: MEDLINE (via PubMed), EMBASE (via Elsevier), Cochrane CENTRAL (via Wiley), IBECS, and LILACS (both via Virtual Health Library). We will consider catheter-related deep venous thrombosis and overall successful insertion rates as primary outcomes and haematoma, venous thromboembolism, reintervention derived from catheter dysfunction, catheter-related infections, and quality of life as secondary outcomes. Where results are not appropriate for a meta-analysis using RevMan 5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed.

RESULTS

Our SR will be conducted according to the Cochrane Handbook of Systematic Reviews of Interventions and the findings will be reported in compliance with PRISMA.

CONCLUSION

Our study will provide evidence for the effects of PICC versus CVC for venous access.

ETHICS AND DISSEMINATION

This SR has obtained formal ethical approval and was prospectively registered in Open Science Framework. The findings of this SR will be disseminated through peer-reviewed publications or conference presentations. REGISTRATION:: osf.io/xvhzf.

ETHICAL APPROVAL

69003717.2.0000.5505.

Patient experiences with peripherally inserted venous catheters- A cross-sectional, multicentre study in Norway

Aim

To investigate patient experiences with peripherally inserted venous catheters, namely PICC lines and Midlines, as well as the influence of socio-demographic variables, length of stay, comorbidity and complications on these experiences.

Design

The study had a descriptive, multicentre, cross-sectional design.

Methods

We used a questionnaire to investigate patient experiences (N = 359).

Results

Patients experiences were not optimal on each of the items in the questionnaire. Nevertheless, few respondents would have preferred a traditional peripheral venous catheter instead. Moreover, free-text answers indicated that patients were very satisfied with their catheter. Results also indicate that the hospitals have different approach when selecting a PICC line or a Midline as route of choice. The only factor associated with patient experiences was "complications."

Conclusion

Even though patients reported of several disadvantages with the PICC line/Midline, findings indicate that they would have chosen this again. PICC lines and Midlines are beneficial from the patients' perspective, even though they have disadvantages.

Management of peripherally inserted central catheter use in an intensive care unit of a teaching hospital in Brazil: a best practice implementation project

OBJECTIVE

This project aimed to promote evidence-based practice in the management of peripherally inserted central venous catheters (PICCs) in pediatric and adult patients in an intensive care unit (ICU).

INTRODUCTION

A PICC provides secure vascular access to medication, blood and nutrition administration. However, their use in the ICU is limited. Gaps in training and education in the use of these catheters are barriers to improving practice and safety.

METHODS

The project was conducted in an ICU of a cardiology teaching hospital in São Paulo, Brazil. The Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used. A baseline audit of the management of PICCs in pediatric and adult patients was conducted, with a sample size of 22 patients and 180 nursing staff. After an educational program, a follow-up audit involving 14 patients and 180 nursing staff was conducted using the same audit criteria.

RESULTS

The baseline audit indicated that PICC management concerning flushing had poor compliance of 2-20%. The results of the criteria related to the change in administration sets, including secondary sets and add-on devices, had better results, with moderate (65%) to high (100%) compliance. The follow-up audit showed improvement in all 10 criteria. Criteria related to flushing achieved 83% to 89% compliance; criteria related to dressing and change of administration sets achieved 100% compliance.

CONCLUSIONS

Increased compliance with evidence-based best practices was achieved in all assessed audit criteria. The criteria that reached the highest compliance with best practice recommendations were related to the prevention of bloodstream infection and loss of the PICC due to obstruction. Future audits are planned to ensure sustainability.

Incidence of and risk factors for totally implantable vascular access device complications in patients with gastric cancer: A retrospective analysis

Totally implantable vascular access devices (TIVADs) are often used to administer chemotherapy by prolonged intravenous infusion. The objective of the present study was to investigate the incidence of long-term complications and identify risk factors associated with TIVAD placement in patients with gastric cancer. A total of 121 patients with gastric cancer who had undergone 150 TIVAD placement procedures for chemotherapy or supportive care were enrolled in the present retrospective cohort study. A number of risk factors were analyzed, including age, sex, hypertension, diabetes mellitus, history of thrombosis, body mass index, disease stage, and site and purpose of TIVAD. In total, 40 TIVADs (26.7%) developed long-term complications, of which 27 (18.0%) were infections, seven (4.7%) were catheter-related deep vein thrombosis (CR-DVT), and six (4.0%) were obstructions. Chemotherapy was associated with an increased rate of infectious adverse events (odds ratio 2.925; 95% CI, 1.104-7.750; P=0.031) according to the multivariate analysis. CR-DVT occurred more frequently in upper arm ports than in chest wall ports; however, this difference was not statistically significant (7.5 vs. 0.0%; P=0.084) according to the univariable analysis. All CR-DVTs developed in the upper arm sites. Chemotherapy and the upper arm site were associated with long-term complications in patients with TIVAD. However, further studies are needed to confirm the findings of the present study and to determine the reasons for the high incidence of long-term complications in these patients.

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.

Comparison of Complication Rates of Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters in Pediatric Patients

OBJECTIVES

The purpose of our study is to compare the rate of central line-associated blood stream infections and venous thromboembolism in central venous catheters versus peripherally inserted central catheters in hospitalized children. There is a growing body of literature in adults describing an increased rate of venous thromboembolisms and similar rates of central line-associated blood stream infection associated with peripherally inserted central catheters versus central venous catheters. It is not known if the rate of central line-associated blood stream infection and venous thromboembolism differs between peripherally inserted central catheters and central venous catheters in children. Based on current adult literature, we hypothesize that central line-associated blood stream infection rates for peripherally inserted central catheters and central venous catheters will be similar, and the rate of venous thromboembolism will be higher for peripherally inserted central catheters versus central venous catheters.

DESIGN

This is a cohort study using retrospective review of medical records and prospectively collected hospital quality improvement databases.

SETTING

Quaternary-care pediatric hospital from October 2012 to March 2016.

PATIENTS

All patients age 1 day to 18 years old with central venous catheters and peripherally inserted central catheters placed during hospital admission over the study dates were included. Central venous catheters that were present upon hospital admission were excluded. The primary outcomes were rate of central line-associated blood stream infection and rate of venous thromboembolism.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,709 catheters included in the study, 1,126 were peripherally inserted central catheters and 1,583 were central venous catheters. Peripherally inserted central catheters demonstrated a higher rate of both infection and venous thromboembolism than central venous catheters in all reported measures. In multivariable analysis, peripherally inserted central catheters had increased association with central line-associated blood stream infection (odds ratio of 3.15; 95% CI, 1.74-5.71; p = 0.0002) and increased association with venous thromboembolism (odds ratio of 2.71; 95% CI, 1.65-4.45; p < 0.0001) compared with central venous catheters.

CONCLUSIONS

Rates of central line-associated blood stream infection and venous thromboembolism were higher in hospitalized pediatric patients with peripherally inserted central catheters as compared to central venous catheters. Our study confirms the need for further investigation into the safety of central access devices to assist in proper catheter selection.

Chlorhexidine-coated peripherally inserted central catheters reduce fibroblastic sleeve formation in an in vivo ovine model

Purpose:

This study compared an antimicrobial and anti-thrombogenic peripherally inserted central catheter treated with a chlorhexidine-based technology, a peripherally inserted central catheter with bulk distributed fluoro-oligomers, and a poly 2-methoxyethyl acrylate–based peripherally inserted central catheter to an untreated peripherally inserted central catheter (control) in an ovine model at 14 and 30 days post-implant.

Methods:

One of four types of peripherally inserted central catheters was surgically implanted into the left jugular vein of each of 18 sheep for 14 or 30 days. Blood analysis consisted of complete blood counts, serum chemistries, and coagulation (fibrinogen, prothrombin time, and partial thromboplastin time) profiles. Sheep were sacrificed to examine the vein and thorax. Histological analysis was performed on serial catheter sections using standard microscopy on hematoxylin and eosin–stained tissues.

Results:

All catheters developed fibroblastic sleeves at both 14 and 30 days. The chlorhexidine-peripherally inserted central catheter showed a 64% lower mean fibroblastic sleeve weight and a 66% shorter mean fibroblastic sleeve length compared to the untreated control at 14 days. By 30 days, compared to untreated control, the chlorhexidine-peripherally inserted central catheter showed 81% lower mean fibroblastic sleeve weight with 75% shorter mean fibroblastic sleeve length, the fluoro-oligomer-peripherally inserted central catheter showed 54% lower mean sheath weight with 40% shorter mean fibroblastic sleeve length, and the poly 2-methoxyethyl acrylate-peripherally inserted central catheter had 41% lower mean fibroblastic sleeve weight with 57% lower fibroblastic sleeve length.

Conclusion:

Among the three anti-thrombogenic peripherally inserted central catheter technologies, the chlorhexidine-peripherally inserted central catheter had the smallest fibroblastic sleeves, followed by the fluoro-oligomer-peripherally inserted central catheter, poly 2-methoxyethyl acrylate-peripherally inserted central catheter, and control peripherally inserted central catheter.

ACR Appropriateness Criteria® Radiologic Management of Central Venous Access

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Efficacy and safety of peripherally inserted central venous catheters in acute cardiac care management

PURPOSE

Patients admitted to cardiac intensive care unit need administration of drugs intravenously often in concomitance of therapeutic techniques such as non-invasive ventilation, continuous renal replacement therapy and intra-aortic balloon counterpulsation. Therefore, the insertion of central venous catheters provides a reliable access for delivering medications, laboratory testing and hemodynamic monitoring, but it is associated with the risk of important complications. In our study, we tested the efficacy and safety of peripherally inserted central catheters to manage cardiac intensive care.

METHODS

All patients admitted to cardiac intensive care unit with indication for elective central venous access were checked by venous arm ultrasound for peripherally inserted central catheter's implantation. Peripherally inserted central catheters were inserted by ultrasound-guided puncture. After 7 days from the catheter's placement and at the removal, vascular ultrasound examination was performed searching signs of upper extremity deep venous thrombosis. In case of sepsis, blood cultures peripherally from the catheter and direct culture of the tip of the catheter were done to establish a catheter-related blood stream infection.

RESULTS

In our cardiac intensive care unit, 137 peripherally inserted central catheters were placed: 80.3% of patients eligible for a peripherally inserted central catheter were implanted. The rate of symptomatic catheter-related peripheral venous thrombosis was 1.4%. Catheter-related blood stream infection was diagnosed in one patient (0.7%; 5.7 × 1000 peripherally inserted central catheter days). All peripherally inserted central catheters were inserted successfully without other major complications.

CONCLUSIONS

In patients admitted to cardiac intensive care unit, peripherally inserted central catheters' insertion was feasible in a high percentage of patients and was associated with low infective complications and clinical thrombosis rate.

Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study

BACKGROUND

The guidelines for peripherally inserted central catheters (PICCs) recommend avoiding insertion if the anticipated duration of use is =5 days. However, short-term PICC use is common in hospitals. We sought to identify patient, provider, and device characteristics and the clinical outcomes associated with short-term PICCs.

METHODS

Between January 2014 and June 2016, trained abstractors at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites collected data from medical records of adults that received PICCs during hospitalization. Patients were prospectively followed until PICC removal, death, or 70 days after insertion. Multivariable logistic regression models were fit to identify factors associated with short-term PICCs, defined as dwell time of =5 days. Complications associated with short-term use, including major (eg, venous thromboembolism [VTE] or central lineassociated bloodstream infection [CLABSI]) or minor (eg, catheter occlusion, tip migration) events were assessed.

RESULTS

Of the 15,397 PICCs placed, 3902 (25.3%) had a dwell time of =5 days. Most (95.5%) short-term PICCs were removed during hospitalization. Compared to PICCs placed for >5 days, variables associated with short-term PICCs included difficult venous access (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.40-1.69), multilumen devices (OR, 1.53; 95% CI, 1.39-1.69), and teaching hospitals (OR, 1.25; 95% CI, 1.04-1.52). Among those with short-term PICCs, 374 (9.6%) experienced a complication, including 99 (2.5%) experiencing VTE and 17 (0.4%) experiencing CLABSI events. The most common minor complications were catheter occlusion (4%) and tip migration (2.2%).

CONCLUSION

Short-term use of PICCs is common and associated with patient, provider, and device factors. As PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary.

Chest wall-parallel vs. conventional subclavian venous catheterization in cancer chemotherapy: A comparison of complication rates

The incidence of complications such as pneumothorax and hematoma between the chest wall-parallel and conventional subclavian venous catheterization in cancer chemotherapy was compared. From December 2011 to March 2016, a total of 314 patients undergoing chemotherapy for cancer in the Guizhou Provincial People's Hospital were assigned to either the Chest Wall-parallel (n=155) or the conventional subclavian venous catheterization group (n=159) in order to observe the primary success rate for catheterization and to assess the incidence of complications such as pneumothorax, hemothorax, hematoma, and internal jugular venous injury. The primary success rates for catheterization were not significantly different between the conventional and chest wall-parallel subclavian venous catheterization groups (94.3% vs. 96.8%, P>0.05), with a total catheterization success rate of 100% in both groups. However, the incidence of pneumothorax was significantly different between the groups (6.29% in conventional vs. 0% in chest wall-parallel subclavian venous catheterization group, P<0.05). Therefore, compared to conventional subclavian venous catheterization, the chest wall-parallel approach could reduce the risk of or even totally prevent pneumothorax and other venipunctures and is, thus, a relatively safe and effective technique that could have wide applications in clinical settings.

Complications with peripherally inserted central catheters (PICCs) used in hospitalized patients and outpatients: a prospective cohort study

Background

Peripherally Inserted Central Catheters (PICCs) are widely used for hospitalized patients and among outpatients. Despite many advantages, PICC-related complications can occur such as infection, thrombosis or mechanical complications.

We aimed to evaluate rates and nature of PICC-related complications from insertion to removal and analyze risk factors of complications at baseline and during healthcare.

Methods

We performed a prospective cohort study looking at PICC-related complication rates in the inpatient and outpatient settings of 163 patients over a 7-month period. Pertinent patient demographics as well as catheter-related factors were collected. The data were analyzed to identify catheter-related complications using univariate and multivariate analysis.

Results

One hundred ninety-two PICCs were monitored for a total of 5218 PICC-days (3337 PICC-days for inpatients, 1881 PICC-days for outpatients). The overall complication rate was 30.2% (11.1 per 1000 PICC-days) with a mean time to onset of 16.1 days. Complications included occlusion (8.9%), accidental withdrawal (8.9%), infections (6.3%) including 9 local infections (4.7%) and 3 bloodstream infections (1.6%), venous thrombosis (1.6%) and hematoma (1%). Complication rate was higher in the hospitalization setting (36.1%; 14.38 per 1000 PICC-days) than in the outpatient setting (19.4%; 3.19 per 1000 PICC-days). Multivariate logistic regression analysis showed that the occurrence of occlusion was significantly associated with an age > 65 years (OR = 4.19; 95% CI [1.1–15.81]) and the presence of a pre-occlusive event the week before PICC removal (OR = 76.35; 95% CI [9.36–622.97]).

Conclusions

PICCs appear safe in the inpatient and outpatient settings with low rates of infectious or thrombotic complications. Occlusion and accidental withdrawal were the most common complications, with age > 65 and catheter pre-occlusive event associated with an increased likelihood of catheter occlusion.

A novel infection prevention approach: Leveraging a mandatory electronic communication tool to decrease peripherally inserted central catheter infections, complications, and cost

BACKGROUND

Peripherally inserted central catheters (PICCs) removed prematurely for unconfirmed infection or thrombosis lead to subsequent reinsertions and associated complications. To improve clinical quality, a mandatory electronic communication tool (MECT) based on clinical practice guidelines was mandated for all inpatient adult PICCs in an academically affiliated tertiary medical center. This MECT facilitated early communication and specialized evaluation with the PICC team for any complications related to PICCs.

METHODS

A historical cohort study was conducted. Quality and cost measurements for 200 PICCs postinstitution of a MECT were compared with 200 PICCs 12 months prior. PICC removal and complication rates were compared for the 2 cohorts.

RESULTS

Significant outcomes included a central-line associated blood stream infection rate that changed from 1.38/1,000 catheter days to 0/1,000 catheter days, 0 provider-led premature PICC removals, an overall 84% decrease in premature PICC removals (from 16%-2.5%; P < .0001), a decrease in the total complication rate from 45.5%-24% (P < .0001), and 25% reduction in radiology costs.

CONCLUSION

A novel infection prevention approach leveraging a MECT resulted in 0 central line-associated bloodstream infections and provider-led premature PICC removals.

[Application of ultrasonography in central venous catheterization; access sites and procedure techniques]

Central venous catheterization is commonly performed in clinical practice. Traditional procedural technique is based on anatomical landmarks, but is associated with a high risk of failure and complications. To decrease their incidence European and American societies recommend application of ultrasonography. Preliminary ultrasonographic examination allows for assessment of local anatomical relations as well as vessel morphology (diameter, patency), while real-time ultrasonography increases chances of successful needle insertion. This paper presents the most common venous access sites and procedure techniques.

Peripherally inserted central catheters (PICCs) in cancer patients under chemotherapy: A prospective study on the incidence of complications and overall failures

BACKGROUND AND OBJECTIVES

The increasing use of peripherally inserted central venous catheters (PICCs) for chemotherapy has led to the observation of an elevated risk of complications and failures. This study investigates PICC failures in cancer patients.

METHODS

A prospective study was conducted at a single cancer institution on 291 PICC placement for chemotherapy. The primary study outcome was PICC failure.

RESULTS

Median follow-up was 119 days. PICC complications occurred in 72 patients (24.7%) and failures with removal in 44 (15.1%). Reasons for failures were upper extremity deep venous thrombosis (UEDVT) 12 (4.1%), central line associate bloodstream infection (CLABSI) 5 (1.7%) with an infection rate of 0.95 per 1,000 catheter days, exit site infection 9 (3.1%) with a rate of 1.46 per 1,000 catheter days, catheter dislodgment 11 (3.8%), and occlusion 7 (2.4%). Statistically significant risk factors were previous DVT (HR 2.95, 95%CI 1.33-6.53), reason for PICC implant (HR 3.65, 95%CI 1.12-10.34) and 5-fluorouracil, oxaliplatin and bevacizumab based chemotherapy (HR 3.11, 95%CI 1.17-8.26).

CONCLUSIONS

PICC is a safe venous device for chemotherapy delivery. Nevertheless, a 15% rate of failure has to be taken in account when planning PICC insertion for chemotherapy purposes. J. Surg. Oncol. 2016;113:708-714. © 2016 Wiley Periodicals, Inc.

Peripherally inserted central venous catheter safety in burn care: a single-center retrospective cohort review

The use of peripherally inserted central catheter (PICC) line for central venous access in thermally injured patients has increased in recent years despite a lack of evidence regarding safety in this patient population. A recent survey of invasive catheter practices among 44 burn centers in the United States found that 37% of burn units use PICC lines as part of their treatment protocol. The goal of this study was to compare PICC-associated complication rates with the existing literature in both the critical care and burn settings. The methodology involved is a single institution retrospective cohort review of patients who received a PICC line during admission to a regional burn unit between 2008 and 2013. Fifty-three patients were identified with a total of seventy-three PICC lines. The primary outcome measurement for this study was indication for PICC line discontinuation. The most common reason for PICC line discontinuation was that the line was no longer indicated (45.2%). Four cases of symptomatic upper extremity deep vein thrombosis (5.5%) and three cases of central line-associated bloodstream infection (4.3%, 2.72 infections per 1000 line days) were identified. PICC lines were in situ an average of 15 days (range 1 to 49 days). We suggest that PICC line-associated complication rates are similar to those published in the critical care literature. Though these rates are higher than those published in the burn literature, they are similar to central venous catheter-associated complication rates. While PICC lines can be a useful resource in the treatment of the thermally injured patient, they are associated with significant and potentially fatal risks.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

Evaluation of PICC complications in orthopedic inpatients with bone infection for long-term intravenous antibiotics therapy

PURPOSE

The purpose of this study is to evaluate the complications of peripherally inserted central catheters (PICCs) in orthopedic patients with chronic bone orthopedic infection.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and informed consent was waived. Records of 180 consecutives PICCs placed in patients hospitalized in the orthopedic surgery department were reviewed. All patients had bones infections necessitating a long-term intravenous antibiotics therapy. All PICC complications were recorded during the patient hospitalization: infection [catheter-related bloodstream infection (CRBSI), central line associated bloodstream infection (CLABSI), exit-site infection, septic phlebitis], thrombosis, occlusion, mechanical complication (accidental withdrawal, malposition, median nerve irritation).

RESULTS

One hundred and eighty PICCs were placed in 136 patients. Mean duration of catheterization was 21 days (total 3911 PICC-days). Thirty-six PICCs (20%) were removed due to complications (9.2 complications per 1000 PICC-days): 14 (8%) infections (one CRBSI (Pseudomonas aeruginosa), one septic phlebitis (P. aeruginosa), two exit-site infections and 10 CLABSIs), 11 (6%) occlusions, and 12 (7%) mechanical complications (10 accidental withdrawals, one malposition, one median nerve irritation). One patient had two complications simultaneously. After multivariate analysis, two risk factors were significantly associated with the overall occurrence of complications: age more than 70 years [OR = 2.89 (1.06-7.89], p = 0.04] and number of lumen at least two [OR = 2.64 (1.03-6.75), p = 0.04].

CONCLUSIONS

Even in orthopedic patients with chronic orthopedic bone infection, PICCs have a low rate of complication. The increasing lumen number of the PICC is a potential risk factor in our series.

Hyperemesis gravidarum, nutritional treatment by nasogastric tube feeding: a 10-year retrospective cohort study

OBJECTIVE

To investigate maternal and fetal outcome in hyperemesis gravidarum comparing enteral tube feeding of the mothers with other fluid/nutrition regimens.

DESIGN

Retrospective hospital-based cohort.

SETTING

University hospital, Norway.

SAMPLE

All 558 women treated for hyperemesis gravidarum 2002-2011; 273 received water/electrolytes intravenously, 177 received nutritional supplements by peripheral line, 107 received enteral feeding by gastroscopically positioned nasojejunal tube and 10 received total parenteral nutrition.

METHODS

Different fluid/nutritional groups were compared by chi-squared or non-parametric tests. The influence (odds ratio) of nutritional regimens on having small-for-gestational-age infants was evaluated by binary logistic regression.

MAIN OUTCOME MEASURES

Maternal weight gain during hospitalization and pregnancy, birthweight and gestational age at delivery.

RESULTS

Women receiving enteral nutrition had significantly greater weight loss on admission (median 5.0 kg) and at start of nutrition (5.5 kg) than the other treatment groups (4.0 kg) (p < 0.001). Enteral nutrition was administered for up to 41 days (median 5 days) during hospitalization, leading to 0.8 kg weight gain (95% CI 0.5-1.0, p = 0.005). The tube-fed women achieved similar weight gain during pregnancy and experienced similar incidence of preterm birth or small-for-gestational age compared with the other treatment groups. Women with <7 kg total weight gain had increased risk of birthweight <2500 g and small-for-gestational-age infants (odds ratio 3.68, 95% CI 1.89-7.18, p < 0.001). The nutritional regimen used was not an independent risk factor.

CONCLUSION

Compared with other fluid/nutrition regimens, enteral tube feeding for women affected by severe hyperemesis gravidarum is associated with adequate maternal weight gain and favorable pregnancy outcomes.

Peripherally Inserted Central Venous Catheter–Associated Bloodstream Infections in Hospitalized Adult Patients

Background.

Limited data on the risk of peripherally inserted central venous catheter-associated bloodstream infections (PICC BSIs) in hospitalized patients are available. In 2007, dedicated intravenous therapy nurses were no longer available to place difficult peripheral intravenous catheters or provide PICC care Barnes-Jewish Hospital.

Objectives.

To determine the hospital-wide incidence of PICC BSIs and to assess the effect of discontinuing intravenous therapy service on PICC use and PICC BSI rates.

Setting.

A 1,252-bed tertiary care teaching hospital.

Methods.

A 31-month retrospective cohort study was performed. PICC BSIs were defined using National Healthcare Safety Network criteria.

Results.

In total, 163 PICC BSIs were identified (3.13 BSIs per 1,000 catheter-days). PICC use was higher in intensive care units (ICUs) than non-ICU areas (PICC utilization ratio, 0.109 vs 0.059 catheter-days per patient-day for ICU vs non-ICU; rate ratio [RR], 1.84 [95% confidence interval {CI}, 1.78-1.91]). PICC BSI rates were higher in ICUs (4.79 vs 2.79 episodes per 1,000 catheter-days; RR, 1.7 [95% CI, 1.10-2.61]). PICC use increased hospital-wide after the intravenous therapy service was discontinued (0.049 vs 0.097 catheter-days per patient-day; P = .01), but PICC BSI rates did not change (2.68 vs 3.63 episodes per 1,000 catheter-days; P = .06). Of PICC BSIs, 73% occurred in non-ICU patients.

Conclusions.

PICC use and PICC BSI rates were higher in ICUs; however, most of the PICC BSIs occurred in non-ICU areas. Reduction in intravenous therapy services was associated with increased PICC use across the hospital, but PICC BSI rates did not increase.

Patient- and Device-Specific Risk Factors for Peripherally Inserted Central Venous Catheter—Related Bloodstream Infections

Objective.

To determine the patient- and device-specific risk factors for hospital-acquired peripherally inserted central venous catheter–related bloodstream infections (PICC BSIs) in adult patients.

Design.

Nested case-control study.

Setting.

Barnes-Jewish Hospital, a 1,252-bed tertiary care teaching hospital.

Patients.

Adult patients with PICCs placed from January 1, 2006, through July 31, 2008.

Methods.

PICC BSI cases were identified using the National Healthcare Safety Network definition. Uninfected control patients with PICCs in place were randomly selected at a 3: 1 ratio. Patient- and device-related variables were examined using multivariate analysis.

Results.

The overall PICC BSI rate was 3.13 per 1,000 catheter-days. Independent risk factors for PICC BSIs included congestive heart failure (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.26–3.17];P= .003), intra-abdominal perforation (OR, 5.66 [95% CI, 1.76–18.19];P= .004),Clostidium difficileinfection (OR, 2.25 [95% CI, 1.17–4.33];P= .02), recent chemotherapy (OR, 3.36 [95% CI, 1.15–9.78];P= .03), presence of tracheostomy (OR, 5.88 [95% CI, 2.99–11.55];P< .001), and type of catheter (OR for double lumen, 1.89 [95% CI, 1.15–3.10];P= .01; OR for triple lumen, 2.87 [95% CI, 1.39–5.92];P= .004). Underlying chronic obstructive pulmonary disease (OR, 0.48 [95% CI, 0.29–0.78];P= .03) and admission to surgical (OR, 0.43 [95% CI, 0.24–0.79];P= .006) or oncology and orthopedic (OR, 0.35 [95% CI, 0.13–0.99];P= .05) services were less likely to be associated with having a PICC BSI.

Conclusions.

We identified several novel factors related to PICC BSIs. These factors may inform preventive measures.

Thrombotic risk factors in patients undergoing chemotherapy via peripherally inserted central catheter

Objective

To evaluate risk factors for venous thrombosis in patients undergoing chemotherapy via peripherally inserted central catheter (PICC).

Methods

Data regarding age, sex, body mass index (BMI), smoking history, diagnosis, medical history, family history of thrombosis, haemoglobin level, and white blood cell (WBC) and platelet counts were prospectively collected from consecutively recruited patients. Patients were evaluated using six thrombotic risk-assessment scales prior to PICC. Assessments of the general venous system and the catheterized vein and limb were made. Deep vein thrombosis (DVT) was diagnosed by colour Doppler ultrasonography. Thrombosis risk factors were identified by logistic regression analysis.

Results

Thrombosis occurred in 12/188 patients (6.38%). Age >60 years, BMI >25 kg/m2 and WBC >11.4 × 109/l were identified as independent risk factors for thrombosis. The incidence of thrombosis was 16.6% (12/72) in patients with one or more risk factors, and 55.5% (five of nine) in those with two or more risk factors.

Conclusions

Age >60 years, BMI >25 kg/m2 and WBC >1.4 × 109/l are major risk factors for thrombosis in Chinese patients undergoing PICC chemotherapy.

Peripherally inserted central catheters: use at a tertiary care pediatric center

PURPOSE

To examine the use of peripherally inserted central catheters (PICCs) in a tertiary care pediatric setting.

MATERIALS AND METHODS

An observational study of use and referral practices for PICCs in a tertiary care pediatric setting was performed with three distinct approaches: (i) in an institutional overview of trends, data from 2001 to 2012 were initially analyzed to identify high-level trends; (ii) an in-depth analysis of PICC referrals during 1 year was performed to determine details of referral patterns and clinical practices; and (iii) an electronic survey of the perception and understanding of referring clinical staff was conducted.

RESULTS

During the past decade, there has been a steady increase in the number of PICC insertions and a decrease in median PICC dwell times. Discrepancies were identified between the anticipated versus actual dwell times. A large proportion of patients was found to have multiple PICC insertions, short dwell times, and premature PICC removals, potentially resulting in increasing risks of short- and long-term complications. Large percentages of the staff respondents valued the role of PICCs and had a good understanding of short-term complications, but underestimated the scale of the PICC service (numbers placed, resources involved) and several long-term complications associated with PICCs.

CONCLUSIONS

The number of PICCs inserted in children is increasing while PICC dwell times are decreasing. Better postprocedure care is important to minimize premature removals and avoid repeat insertions. Associated complications are not fully appreciated by the referring pediatricians. Further education and guidelines are needed.

Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited

The supraclavicular approach was first put into clinical practice in 1965 by Yoffa and is an underused method for gaining central access. It offers several advantages over the conventional infraclavicular approach to the subclavian vein. At the insertion site, the subclavian vein is closer to the skin, and the right-sided approach offers a straighter path into the subclavian vein. Also, this site is often more accessible during CPR and surgical procedures. In patients who are obese, this anatomic area is less distorted and in patient with congestive heart failure and cervical spine instability repositioning is not required.

Central and peripheral venous lines-associated blood stream infections in the critically ill surgical patients

Critically ill surgical patients are always at increased risk of actual or potentially life-threatening health complications. Central/peripheral venous lines form a key part of their care. We review the current evidence on incidence of central and peripheral venous catheter-related bloodstream infections in critically ill surgical patients, and outline pathways for prevention and intervention. An extensive systematic electronic search was carried out on the relevant databases. Articles were considered suitable for inclusion if they investigated catheter colonisation and catheter-related bloodstream infection. Two independent reviewers engaged in selecting the appropriate articles in line with our protocol retrieved 8 articles published from 1999 to 2011. Outcomes on CVC colonisation and infections were investigated in six studies; four of which were prospective cohort studies, one prospective longitudinal study and one retrospective cohort study. Outcomes relating only to PICCs were reported in one prospective randomised trial. We identified only one study that compared CVC- and PICC-related complications in surgical intensive care units. Although our search protocol may not have yielded an exhaustive list we have identified a key deficiency in the literature, namely a paucity of studies investigating the incidence of CVC- and PICC-related bloodstream infection in exclusively critically ill surgical populations. In summary, the diverse definitions for the diagnosis of central and peripheral venous catheter-related bloodstream infections along with the vastly different sample size and extremely small PICC population size has, predictably, yielded inconsistent findings. Our current understanding is still limited; the studies we have identified do point us towards some tentative understanding that the CVC/PICC performance remains inconclusive.

Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence

The widespread use of peripherally inserted central catheters (PICCs) has transformed the care of medical and surgical patients. Whereas intravenous antibiotics, parenteral nutrition, and administration of chemotherapy once necessitated prolonged hospitalization, PICCs have eliminated the need for such practice. However, PICCs may not be as innocuous as once thought; a growing body of evidence suggests that these devices also have important risks. This review discusses the origin of PICCs and highlights reasons behind their rapid adoption in medical practice. We evaluate the evidence behind 2 important PICC-related complications--venous thrombosis and bloodstream infections--and describe how initial studies may have led to a false sense of security with respect to these outcomes. In this context, we introduce a conceptual model to understand the risk of PICC-related complications and guide the use of these devices. Through this model, we outline recommendations that clinicians may use to prevent PICC-related adverse events. We conclude by highlighting important knowledge gaps and identifying avenues for future research in this area.

Peripherally inserted central catheters are equivalent to centrally inserted catheters in intensive care unit patients for central venous pressure monitoring

To determine the equivalency of pressure measurements from peripherally inserted central catheters(PICCs) versus centrally inserted central venous catheters(CVCs) in vitro as well as in vivo. The in vitro study was performed in a clinical laboratory. Static pressure measurements from PICCs and CVCs were obtained in vitro over a physiologic range of 5–25 mmHg. Triple and dual lumen PICCs were directly compared to CVC controls.Dynamic pressure waveforms were recorded to simulate physiologic intravascular pressure variation. The in vivo study was executed in the medical intensive care unit(MICU) of a tertiary-level academic medical center. Data was collected from ten adult patients with both a PICC and a CVC in place for on-going clinical care. Measurements of central venous pressure (CVP) were recorded simultaneously from PICCs and CVCs. Duplicate measurements were taken after a stable waveform was recorded. For the in vitro study, a total of 540 pressure measurements were recorded. The average bias determined by Bland–Altman plot was 0 mmHg for the 5Fr PICC and 0.071 mmHg for the 6Fr PICC. The correlation coefficient for both catheters was 1.0 (P<0.001). Dynamic pressure waveforms revealed equivalent amplitude. During the in vivo trial, 70CVP measurements were collected. The paired CVP measurements were found to be highly reliable across subjects (r = 0.99, P<0.0001). No significance in the average difference in CVP measurement (PICC–CVC) was determined by the Wilcoxon Signed Rank test (S = 1,P = 0.93). In conclusion, PICCs are equivalent to CVCs when measuring static and dynamic pressure in vitro and CVP in ICU patients.

Clinical analysis of postoperative venous thromboembolism risk factors in lung cancer patients

BACKGROUND AND OBJECTIVES

The objective of this study is to explore clinical risk factors for venous thromboembolism (VTE) in postoperative lung cancer patients in order to provide a basis for the prevention and treatment of postoperative VTE.

METHODS

A total of 1,001 lung cancer patients were retrospectively analyzed. Each patient was confirmed with surgical pathology diagnosis and had a complete clinical and follow-up record. VTE was identified in a combination of spiral computed tomography (CT), pulmonary angiography, and color Doppler ultrasound. We used life table method to create an occurrence frequency curve of thrombosis. We also searched for high risk factors for postoperative VTE with Cox multivariate regression model and created frequency curves of thrombosis against different risk factors using Kaplan-Meier method.

RESULTS

As of July 31, 2011, the median follow-up time is 25.73 ± 0.11 months (19.23-31.37). The cumulative frequency of VTE among 1,001 lung cancer patients is 2%, 3%, 4%, 5%, and 5.3% over 1, 3, 6, 12, and 30 months after the surgery. COX regression analysis showed that the hazard ratio of VTE occurrence in patients with incomplete resection relative to ones with complete resection is 9.867 (95% CI: 5.275-18.459, P = 0.000). And the hazard ratio of VTE occurrence is 3.472 (95% CI: 1.761-6.845, P = 0.000) in patients with anti-angiogenesis treatment compared to patients without such treatment. The hazard ratio of VTE occurrence is 2.808 (95% CI: 1.439-5.479, P = 0.002) in patients with EGFR-TKI treatment relative to patients without the treatment, and 7.520 (95% CI: 3.968-14.250, P = 0.000) in patients with an increase in D-dimer level relative to normal ones

CONCLUSIONS

The highest incidence of VTE is within 1 month after lung cancer surgery. High risk factors for VTE include incomplete surgical resection, postoperative use of anti-angiogenesis drugs, EGFR-TKI application and an increase in preoperative D-dimer level.