A Randomized Trial of Central Venous Catheter Type and Thrombosis in Critically Ill Neurologic Patients

Complications after peripherally inserted central catheter versus central venous catheter implantation in intensive care unit: propensity score analysis using a nationwide database

BACKGROUND

It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups.

RESEARCH DESIGN AND METHODS

Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses.

RESULTS

We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32-2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38-3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16-2.99), and phlebitis (OR, 1.72; 95% CI, 1.27-2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39-3.04).

CONCLUSIONS

Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications.

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.

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.

Peripherally Inserted Central Catheter lines for Intensive Care Unit and onco-hematologic patients: A systematic review and meta-analysis

BACKGROUND

It is unclear whether Peripherally Inserted Central Catheter (PICC) lines are associated with lower complication rates as compared to conventional Central Venous Catheters (CVCs), especially in high risk patients.

OBJECTIVE

To compare Central Line Associated Bloodstream Infection (CLABSI) and catheter-related thrombosis rates in Intensive Care Unit (ICU) and onco-hematologic patients with PICC lines and CVCs.

METHODS

We systematically reviewed the PubMed, Cochrane and Google Scholar databases to identify relevant studies. Study quality was evaluated using appropriate assessment tools and the pooled odds ratio (OR) and confidence interval (CI) were calculated. Sensitivity analyses were performed based on meta-analysis method, type of study and prophylaxis implementation.

RESULTS

Thirteen studies were included in our meta-analysis. PICC lines were associated with a significantly higher rate of thrombosis in ICU [OR (95%CI): 2.58(1.80,3.70); P_z<0.00001] and onco-hematologic [OR (95%CI): 2.91(2.11,4.02); P_z<0.00001] patients. CLABSI rates with PICC lines were not significantly different in ICU patients [OR (95%CI): 1.65(0.91,2.99); P_z= 0.1], but significantly lower CLABSI rates were observed in onco-hematologic patients [OR (95%CI): 0.38(0.16,0.91); P_z=0.03]. Sensitivity analyses verified the robustness of our results.

CONCLUSIONS

PICC lines are associated with higher rates of thrombotic events. However, they might be suitable for onco-hematologic patients due to lower CLABSI rates.

Peripherally inserted central catheters inserted with current best practices have low deep vein thrombosis and central line–associated bloodstream infection risk compared with centrally inserted central catheters: A contemporary meta-analysis

Background:

Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines.

Methods:

Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006–2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line–associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle–Ottawa and Cochrane Risk of Bias scales.

Results:

Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line–associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30–0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47–2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients ( p = 0.064). Patient outcomes favored peripherally inserted central catheters.

Conclusion:

When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.

Complication and Failures of Central Vascular Access Device in Adult Critical Care Settings

OBJECTIVES

To examine the proportion and rate of central venous access device failure and complications across central venous access device types in adult intensive care.

DATA SOURCES

A systematic search was undertaken in the electronic databases Cochrane Central Register of Controlled Trials, Embase, U.S. National Library of Medicine National Institutes of Health, and Cumulative Index to Nursing and Allied Health in September 2017.

STUDY SELECTION

Included studies were of observational (prospective and retrospective) or interventional design and reported central venous access device failure and complications in adult ICU settings. Studies were excluded if they were published prior to November 2006 or not reported in English. Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias.

DATA EXTRACTION

Data were extracted on the primary outcome, central venous access device failure, and secondary outcomes: central venous access device complications (central line-associated bloodstream infection, catheter-related bloodstream infection, catheter-related thrombosis, occlusion, catheter removal due to suspected infection, dislodgement, breakage, and local infection). Patient and device data and study details to assess the study quality were also extracted.

DATA SYNTHESIS

A total of 63 studies involving 50,000 central venous access devices (396,951 catheter days) were included. Central venous access device failure was 5% (95% CI, 3-6%), with the highest rates and proportion of failure in hemodialysis catheters. Overall central line-associated bloodstream infection rate was 4.59 per 1,000 catheter days (95% CI, 2.31-6.86), with the highest rate in nontunneled central venous access devices. Removal of central venous access device due to suspected infection was high (17%; 20.4 per 1,000 catheter days; 95% CI, 15.7-25.2).

CONCLUSIONS

Central venous access device complications and device failure is a prevalent and significant problem in the adult ICU, leading to substantial patient harm and increased healthcare costs. The high proportion of central venous access devices removed due to suspicion of infection, despite low overall central line-associated bloodstream infection and catheter-related bloodstream infection rates, indicates a need for robust practice guidelines to inform decision-making surrounding removal of central venous access devices suspected of infection.

Venous Thromboembolism in Neurocritical Care Patients

BACKGROUND

Venous thromboembolism (VTE) is a potentially life-threatening complication among critically ill patients. Neurocritical care patients are presumed to be at high risk for VTE; however, data regarding risk factors in this population are limited. We designed this study to evaluate the frequency, risk factors, and clinical impact of VTE in neurocritical care patients.

METHODS

We obtained data from the electronic medical record of all adult patients admitted to neurological intensive care unit (NICU) at Henry Ford Hospital between January 2015 and March 2018. Venous thromboembolism was defined as deep vein thrombosis, pulmonary embolism, or both diagnosed by Doppler, chest computed tomography (CT) angiography or ventilation-perfusion scan >24 hours after admission. Patients with ICU length of stay <24 hours or who received therapeutic anticoagulants or were diagnosed with VTE within 24 hours of admission were excluded.

RESULTS

Among 2188 consecutive NICU patients, 63 (2.9%) developed VTE. Prophylactic anticoagulant use was similar in patients with and without VTE (95% vs 92%; P = .482). Venous thromboembolism was associated with higher mortality (24% vs 13%, P = .019), and longer ICU (12 [interquartile range, IQR 5-23] vs 3 [IQR 2-8] days, P < .001) and hospital (22 [IQR 15-36] vs 8 [IQR 5-15] days, P < .001) length of stay. In a multivariable analysis, potentially modifiable predictors of VTE included central venous catheterization (odds ratio [OR] 3.01; 95% confidence interval [CI], 1.69-5.38; P < .001) and longer duration of immobilization (Braden activity score <3, OR 1.07 per day; 95% CI, 1.05-1.09; P < .001). Nonmodifiable predictors included higher International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) scores (which accounts for age >60, prior VTE, cancer and thrombophilia; OR 1.66; 95% CI, 1.40-1.97; P < .001) and body mass index (OR 1.05; 95% CI, 1.01-1.08; P = .007).

CONCLUSIONS

Despite chemoprophylaxis, VTE still occurred in 2.9% of neurocritical care patients. Longer duration of immobilization and central venous catheterization are potentially modifiable risk factors for VTE in critically ill neurological patients.

Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals

OBJECTIVES

To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward.

DESIGN

Retrospective cohort study.

SETTING

Fifty-two hospital Michigan quality collaborative.

PATIENTS

Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria.

CONCLUSIONS

Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.

A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.

[Catheter-related thrombosis during intravascular temperature management]

We report on a case of catheter-related thrombosis after 7‑day catheter placement during intravascular temperature management (IVTM), in spite of the use of prophylactic anticoagulants. There were no clinical sequelae. According to the literature, occult thrombosis during ITVM could be more frequent than previously reported and dedicated monitoring for potential thrombosis may be indicated. However, a study comparing IVTM with surface cooling found no differences in clinical outcome. Therefore, n either of the methods can be recommended over the other. Further studies should evaluate the rate of occult thrombosis during the use of both cooling methods.