Peripherally inserted central catheter placement in cancer patients with profound thrombocytopaenia: a prospective analysis

Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee

BACKGROUND

Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management.

OBJECTIVES

To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)?

METHODS

Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases.

STUDY SELECTION

Independently performed by 2 reviewers, disagreements resolved by a third reviewer.

DATA EXTRACTION

Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology.

RESULTS

Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions.

CONCLUSIONS

Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care.

LEVEL OF EVIDENCE

III. This study was registered as PROSPERO 2019 CRD42019124077.

Central catheter-associated deep vein thrombosis in cancer: clinical course, prophylaxis, treatment

The adequate handling of central venous catheters is a key element in the management of patients with cancer. Catheter-associated deep vein thrombosis is frequently observed in patients with malignant diseases; however, despite being a common complication among these patients, objective information concerning its epidemiology, clinical course, prophylaxis and treatment strategies is very limited. The reported incidence of catheter-related thrombosis (CRT) is highly variable, depending on symptomatic events, or if patients are screened for asymptomatic thrombosis. Several factors have been identified as potential predisposing factors for CRT, both technical and pathological aspects. The anticoagulant of choice is still unclear; while low-molecular-weight heparin is most commonly used, recent studies assessing the role of direct oral anticoagulants in the treatment of CRT show promise as an alternative, but the evidence remains insufficient and the decision must be made on a case-by-case basis.

Management of Platelet Disorders and Platelet Transfusions in ICU Patients

Thrombocytopenia or receipt of antiplatelet drugs, with or without bleeding, is a common indication for platelet transfusions in the ICU. However, there is almost no evidence base for these practices other than expert opinion. Also common is use of platelet transfusions prior to invasive procedures or surgery in patients with thrombocytopenia. Likewise, there is no high-quality evidence that such practices are efficacious or safe. Recently, it has become clear that, whether causal or not, patients receiving prophylactic platelet transfusions experience high rates of nosocomial infection, thrombosis, organ failure, and mortality, which increase the urgency and need for randomized trials to assess these practices. Investigational methods of improving the safety and efficacy of platelet transfusions include use of alternate strategies such as antifibrinolytics; use of ABO-identical, leukoreduced, and washed platelet transfusions; and improved storage solutions.

Effects of a new device to guide venous puncture in elderly critically ill patients: results of a pilot randomized study

BACKGROUND

Novel devices based on the emission of near-infrared electromagnetic radiation (NIR) have been developed to minimize venous puncture failures. These instruments produce an "augmented reality" image, in which subcutaneous veins are depicted on a LCD display. We compared the new technique with standard venipuncture in a population of elderly patients.

METHODS

Patients admitted in Intensive Care Unit were randomized to standard or to NIR assisted procedure.

RESULTS

In the 103 enrolled patients (age 74 ± 12 years; standard venipuncture-N = 56; NIR-N = 47), no differences were found in procedure length, number of attempts, and referred pain. With NIR there was a lower incidence of hematomas and fewer anxiety and depressive symptoms.

CONCLUSIONS

The use of the novel NIR-based device is safer and more psychologically tolerable, and it is not associated to an increase of procedure length or number of attempts.

Pregnancy in fanconi anaemia with bone marrow failure: a case report and review of the literature

BACKGROUND

Fanconi anaemia is a rare inherited disease characterized by congenital abnormalities, progressive bone marrow failure and predisposition to malignancy. Successful pregnancies in transplanted patients have been reported. In this paper we will describe the pregnancy of a patient with Fanconi anaemia without transplantation.

CASE PRESENTATION

A 34-year-old nulliparous woman with Fanconi anaemia was referred to our institution. Pregnancy was complicated by progressive pancytopenia and two severe infections. C-section was performed at 36 weeks. Both infant and mother are well.

CONCLUSION

Successful pregnancy in a Fanconi anaemia patient with bone marrow failure is possible. The mode of delivery in patients with bone marrow failure should be determined by obstetric indications. The case highlights the safe outcome of the pregnancy with strict clinical and laboratory control by a multidisciplinary team.

Comparison of different platelet transfusion thresholds prior to insertion of central lines in patients with thrombocytopenia

BACKGROUND

Patients with a low platelet count (thrombocytopenia) often require the insertion of central lines (central venous catheters (CVCs)). CVCs have a number of uses; these include: administration of chemotherapy; intensive monitoring and treatment of critically-ill patients; administration of total parenteral nutrition; and long-term intermittent intravenous access for patients requiring repeated treatments. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to CVC insertion, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to CVC insertion varies significantly from country to country. This indicates significant uncertainty among clinicians of the correct management of these patients. The risk of bleeding after a central line insertion appears to be low if an ultrasound-guided technique is used. Patients may therefore be exposed to the risks of a platelet transfusion without any obvious clinical benefit.

OBJECTIVES

To assess the effects of different platelet transfusion thresholds prior to the insertion of a central line in patients with thrombocytopenia (low platelet count).

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2015, Issue 2), MEDLINE (from 1946), EMBASE (from 1974), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 23 February 2015.

SELECTION CRITERIA

We included RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in patients of any age with thrombocytopenia requiring insertion of a CVC.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

One RCT was identified that compared different platelet transfusion thresholds prior to insertion of a CVC in people with chronic liver disease. This study is still recruiting participants (expected recruitment: up to 165 participants) and is due to be completed in December 2017. There were no completed studies. There were no studies that compared no platelet transfusions to a platelet transfusion threshold.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs to determine whether platelet transfusions are required prior to central line insertion in patients with thrombocytopenia, and, if a platelet transfusion is required, what is the correct platelet transfusion threshold. Further randomised trials with robust methodology are required to develop the optimal transfusion strategy for such patients. The one ongoing RCT involving people with cirrhosis will not be able to answer this review's questions, because it is a small study that assesses one patient group and does not address all of the comparisons included in this review. To detect an increase in the proportion of participants who had major bleeding from 1 in 100 to 2 in 100 would require a study containing at least 4634 participants (80% power, 5% significance).

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.

Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors

BACKGROUND

Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome.

METHODS

This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated.

RESULTS

Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01-3.76]) and PICC gauge (HR 2.21 [95%CI 1.04-4.70] and HR 3.56 [95%CI 1.31-9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis.

CONCLUSIONS

Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.