Prospective evaluation of systematic use of peripherally inserted central catheters (PICC lines) for the home care after allogeneic hematopoietic stem cells transplantation

Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review

BACKGROUND

Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation.

METHODS

A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data.

RESULTS

From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies.

CONCLUSION

Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

The incidence and risk of venous thromboembolism associated with peripherally inserted central venous catheters in hospitalized patients: A systematic review and meta-analysis

Background

Venous thromboembolism (VTE) can be fatal if not treated promptly, and individual studies have reported wide variability in rates of VTE associated with peripherally inserted central catheters (PICC). We thus conducted this meta-analysis to investigate the overall incidence and risk of developing PICC-related VTE in hospitalized patients.

Methods

We searched PubMed, Embase, Scopus, and Web of Science databases from inception until January 26, 2022. In studies with a non-comparison arm, the pooled incidence of PICC-related VTE was calculated. The pooled odds ratio (OR) was calculated to assess the risk of VTE in the studies that compared PICC to the central venous catheter (CVC). The Newcastle-Ottawa Scale was used to assess methodological quality.

Results

A total of 75 articles (58 without a comparison arm and 17 with), including 109292 patients, were included in the meta-analysis. The overall pooled incidence of symptomatic VTE was 3.7% (95% CI: 3.1–4.4) in non-comparative studies. In the subgroup meta-analysis, the incidence of VTE was highest in patients who were in a critical care setting (10.6%; 95% CI: 5.0–17.7). Meta-analysis of comparative studies revealed that PICC was associated with a statistically significant increase in the odds of VTE events compared with CVC (OR, 2.48; 95% CI, 1.83–3.37; P < 0.01). However, in subgroup analysis stratified by the study design, there was no significant difference in VTE events between the PICC and CVC in randomized controlled trials (OR, 2.28; 95% CI, 0.77–6.74; P = 0.13).

Conclusion

Best practice standards such as PICC tip verification and VTE prophylaxis can help reduce the incidence and risk of PICC-related VTE. The risk-benefit of inserting PICC should be carefully weighed, especially in critically ill patients. Cautious interpretation of our results is important owing to substantial heterogeneity among the studies included in this study.

Vascular Access in Pediatric Oncology and Hematology: State of the Art

Management and successful use of vascular access are critical issues in pediatric patients affected by malignancies. Prolonged course of disease, complex and various treatment protocols require long-lasting vascular access providing adequate tools to administrate those therapies and to collect routine blood sampling without painful and repeated venipuncture. For these reasons, central venous catheters are currently an important component in pediatric onco-hematological care, with a direct influence on outcome. Indeed, there are peculiar issues (techniques of insertion, management, complications etc.) which must be well-known in order to improve the outcome and the quality of life of children with cancer.

Dual-lumen power injectable peripherally inserted central catheters in allogeneic hematopoietic stem cell transplantation: A prospective observational study

AIMS AND OBJECTIVES

To explore whether dual-lumen power injectable peripherally inserted central catheters (PICCs) could be effectively and safely applied in allogeneic hematopoietic stem cell transplantation (allo-HSCT) and for serum cyclosporine level monitoring.

BACKGROUND

Compared to conventional central venous access devices, PICC provides a feasible route not only for fluid infusion, but also for blood sample collection in patients undergoing oncological treatments.

DESIGN

A prospective observational study was conducted according to the STROBE guidelines.

METHODS

We prospectively evaluated the applications and complications of power injectable PICCs in 52 consecutive allo-HSCT recipients. We also compared the cyclosporine levels in 188 paired blood samples, simultaneously obtained via power injectable PICCs and percutaneous venous puncture, to investigate whether power injectable PICC is a feasible route for cyclosporine concentration monitoring in allo-HSCT.

RESULTS

The median PICC placement duration was 29 days. The insertion-site blood oozing and central line-associated bloodstream infection rates were 36.5% (19/52) and 26.9% (14/52), respectively, indicating the feasibility of these PICCs for various applications in allo-HSCT. No power injectable PICC-related thrombotic adverse events were identified; 90.4% (47/52) of cases with power injectable PICC removal occurred because of lack of medical utility, suggesting that power injectable PICC-related complications were manageable. However, cyclosporine levels in samples obtained via these PICCs were significantly higher than those in samples obtained via percutaneous venous puncture (261.5 ± 139.2 vs. 232.4 ± 253.6 ng/ml; p = 0.019 [set 1]; 254.8 ± 89.3 vs. 225.1 ± 233.3 ng/ml; p<0.001 [set 2]; 283.6 ± 103.9 vs. 238.0 ± 254.7 ng/ml; p = 0.006 [set 3]; 291.0 ± 94.9 vs. 266.0 ± 274.7 ng/ml; p = 0.016 [set 4]).

CONCLUSION

The power injectable PICC is a feasible venous access device for allo-HSCT.

RELEVANCE TO CLINICAL PRACTICE

The dual-lumen power injectable PICCs provided a reliable access for blood sample collection, decreasing the number of blind percutaneous venous punctures in allo-HSCT. However, its application in cyclosporine level monitoring needs further investigation.

Peripherally inserted central catheters in allogeneic hematopoietic stem cell transplant recipients

BACKGROUND

Central venous catheters (CVC) are essential for the management of patients with hematologic malignancies, facilitating chemotherapy infusion, antibiotics, parenteral nutrition, blood products, and blood samples collection. In this population, peripherally inserted central catheters (PICC) seem to be associated with lower complications, compared with conventional percutaneously inserted devices (CICC). Data on the PICC in allogeneic hematopoietic stem cell recipients (allo-HSCT) are limited.

METHODS

We have prospectively evaluated the safety and efficacy of 100 polyurethanes or silicone PICC, inserted into 100 adult allo-HSCT recipients, at the Hematology of Sapienza University of Rome (Italy), between October 2012 and August 2017.

RESULTS

The median duration of PICC placement was 117 days. Overall, 68% of patients maintained the device for the entire transplant procedure and PICC were removed after day 100 from allo-HSCT; of these, 44% did not experienced any PICC-related complications. Catheter-related bloodstream infections (CRBSI) occurred in 32% of patients (2.5/1000 PICC days), associated with thrombosis in 8 cases. CRBSI were observed in 42% of patients with polyurethane and 20% with silicone PICC (p = 0.02). Catheter-related thrombosis occurred in 9% of patients, never requiring anticipated PICC removal. Mechanical complications occurred in 15% of cases (1.2/1000 PICC days). On the whole, adverse events were manageable and did not affect transplant outcome. No deaths related to PICC-complications were observed.

CONCLUSIONS

PICC are a safe and reliable long-term venous access in allo-HSCT recipients.

Early mortality attributable to PICC-lines in 4 public hospitals of Marseille from 2010 to 2016 (Revised V3)

INTRODUCTION

Peripherally inserted central catheters (PICC-line) are devices inserted through peripheral venous access. In our institution, this technology has been rapidly adopted by physicians in their routine practice. Bacteremia on catheters remains an important public health issue in France. However, the mortality attributable to bacteremia on PICC-line remains poorly evaluated in France and in the literature in general. We report in our study an exhaustive inventory of bacteremia on PICC-line and their 30 days mortality, over a 7 years period.

MATERIAL AND METHODS

From January 2010 to December 2016, we retrospectively matched PICC-line registers of the radiology department, blood culture records of the microbiology laboratory and medical records from the Hospital Information Systems.

RESULTS

The 11,334 hospital stays during which a PICC-line was inserted were included over a period of 7 years. Among them, 258 episodes of PICC-line-associated bacteremia were recorded, resulting in a prevalence of 2.27%. Hematology units: 20/324 (6.17%), oncology units: 55/1375 (4%) and hepato-gastro-enterology units: 42/1142 (3.66%) had the highest prevalence of PICC-line related bacteremia. The correlation analysis, when adjusted by exposure and year, shows that the unit profile explains 72% of the variability in the rate of bacteremia with a P = .023. Early bacteremia, occurring within 21 days of insertion, represented 75% of cases. The crude death ratio at 30 days, among patients PICC-line associated bacteremia was 57/11 334 (0.50%). The overall 30-day mortality of patients with PICC-line with and without bacteremia was 1369/11334 (12.07%). On day 30, mortality of patients with bacteremia associated PICC-line was 57/258 or 22.09% of cases, compared to a mortality rate of 1311/11076, or 11.83% in the control group (P < .05, RR 2.066 [1.54-2.75]). Kaplan-Meier survival analysis revealed a statistically significant excess mortality between patients with PICC-line associated bacteremia and PICC-line carriers without bacteremia (P < .0007, hazard ratio 1.89 [1307-2709]).

CONCLUSION

Patients with PICC-line associated bacteremia have a significant excess mortality. The implementation of a PICC-line should remain the last resort after a careful assessment of the benefit/risk ratio by a senior doctor.

Management of Hospital In The Home (HITH) Peripherally Inserted Central Catheters: A Retrospective Cohort Study

Worldwide, there has been a shift in health care delivery, with an increasing emphasis on avoiding hospital admissions and providing treatment such as intravenous antibiotics for patients at home, using peripherally inserted central catheters (PICCs). However, there is inadequate data to demonstrate if rates of PICC failure are similar for hospital inpatients, currently understood to be between 7% and 36%, than those cared for at home. The objective of this study was to identify prevalence, dwell time, and complications associated with PICCs in the home setting. This single-center, retrospective cohort study of adults treated by the “Hospital in the Home” (HITH) program in Queensland, was conducted between June 1, 2017 and June 15, 2018. Clinical data were collected for patient and PICC characteristics. Variables were described as frequencies and proportions, means and standard deviations, or medians and interquartile ranges. In total, 304 patients treated by HITH during this timeframe, and 164 (54%) patients with 181 PICCs were included in this study. These patients were predominately male (n = 105, 64%), with a mean age of 54 years. The most common reason for admission was a wound infection and/or bone infection (n = 120, 33%). Most PICCs were single lumen (n = 120; 67%), inserted in the basilic vein (n = 137; 80%) by nurses (n = 122; 67%). Peripherally inserted central catheter failure occurred in 10% (n = 19); the most common complications were dislodgement (n = 9; 5%) and thrombosis (n = 4; 2%). There were no confirmed catheter-related blood stream infections. Peripherally inserted central catheter failure rates are similar between hospitalized inpatients and those cared for at home.

Peripherally inserted central catheter–related thrombosis rate in modern vascular access era—when insertion technique matters: A systematic review and meta-analysis

Background:

Technical factors at the moment of catheter insertion might have a role in peripherally inserted central catheter–related thrombotic risk. We performed a systematic review and meta-analysis to define the actual rate of peripherally inserted central catheter–related symptomatic deep vein thrombosis in patients in whom catheter insertion was performed according to ultrasound guidance, appropriate catheter size choice, and proper verification of tip location.

Methods:

We searched Medline, Embase, and Cochrane Library. Only prospective observational studies published in peer-reviewed journals after 2010 up to November 2018 reporting peripherally inserted central catheter–related deep vein thrombosis rate were included. All studies were of adult patients who underwent peripherally inserted central catheter insertion. Results were restricted to those studies which included in their methods ultrasound guidance for venipuncture, catheter tip location, and a catheter size selection strategy. Random-effect meta-analyses and arcsine transformation for binomial data were performed to pool deep vein thrombosis weighted frequencies.

Results:

Of the 1441 studies identified, 15 studies involving 5420 patients and 5914 peripherally inserted central catheters fulfilled our inclusion criteria. The weighted frequency of peripherally inserted central catheter–related deep vein thrombosis was 2.4% (95% confidence interval = 1.5–3.3) and remained low in oncologic patients (2.2%, 95% confidence interval = 0.6–3.9). Thrombotic rate was higher in onco-hematologic patients (5.9%, 95% confidence interval = 1.2–10). Considerable heterogeneity (I2 = 74.9) was observed and all studies were considered at high risk of attrition bias.

Conclusions:

A proper technique is crucial at the moment of peripherally inserted central catheter insertion. Peripherally inserted central catheter–related deep vein thrombosis rate appears to be low when evidence-based technical factors are taken into consideration during the insertion procedure.

A Model to Predict Central-Line-Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score

BACKGROUND Peripherally inserted central catheters (PICCs) are associated with central-line-associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed. OBJECTIVE To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual's risk of PICC-CLABSI prior to device placement. METHODS Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values. RESULTS Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56-1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration. CONCLUSION The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary. Infect Control Hosp Epidemiol 2017;38:1155-1166.