Analysis of Tip Malposition and Correction in Peripherally Inserted Central Catheters Placed at Bedside by a Dedicated Nursing Team

Analysis of tip malposition and correction of peripherally inserted central catheters under ultrasound-guidance: 5-year outcomes from a single center

BACKGROUND

Peripherally inserted central catheter (PICC) has become a common procedure. Although ultrasound (US)-guidance has improved success rates, a small percentage of malposition is inevitable. The purpose of our study is to evaluate malposition rates of US-guided bedside PICC catheter insertion, and the clinical factors associated with malposition.

METHODS

This is a retrospective cohort study evaluating 5981 patients who had undergone ultrasound-guided bedside PICC placement from January 2017 to December 2021 at a single tertiary center. Final tip location was confirmed on chest radiograph.

RESULTS

Patients were categorized into optimal, suboptimal, and malposition groups according to final tip location. 4866 cases (81.7%) showed optimal tip position, 790 (13.3%) were suboptimal, and 299 (5.0%) were malpositioned. Logistic regression analysis identified six variables associated with tip malposition; height (odds ratio (OR) 1.044; 95% confidence interval (CI), 1.028-1.061; p < 0.001), body mass index (BMI) (OR 1.051; 95% CI, 1.017-1.087; p = 0.003), prior failure at accessing peripheral intravenous (IV) access (OR 1.718; 95% CI, 1.215-2.428; p = 0.002), side of the arm (OR 3.467; 95% CI, 2.457-4.891; p < 0.001), length of the catheter (OR 0.763; 95% CI, 0.734-0.794; p < 0.001), and number of previous central catheter insertions (OR 1.069; 95% CI, 1.004-1.140; p = 0.038). Malpositioned catheters were corrected by either bedside repositioning, bedside reinsertion, fluoroscopic reinsertion, switching to jugular catheters or catheter removal. No patient related factors were significantly associated with malposition or success of reposition.

CONCLUSION

US-guidance can help reduce catheter malposition during bedside PICC insertion. Patients with risk factors such as multiple previous central vein insertions, failed peripheral line insertions, left arm insertion, or high BMI should undergo thorough sonographic evaluation of the arm vessels to prevent malposition.

A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement

BACKGROUND

Malpositioned central venous access devices (CVADs) can lead to significant patient injury including central vein thrombosis and dysrhythmias. Intra-cavitary electrocardiography (IC ECG) has been recommended by peak professional bodies as an accurate alternative for bedside CVAD insertion, to reduce risk of malposition and allowing immediate use of the device. Our objective was to compare the effect of IC ECG on CVAD malposition compared to traditional institutional practice for CVAD placement.

METHODS

Randomised controlled trial of IC ECG CVAD insertion verses traditional CVAD insertion (surface landmark measurement with post insertion x ray). Patient recruitment was from December 2016 to July 2018. The setting was a 900-bed tertiary referral hospital based in South Western Sydney, Australia. Three hundred and forty-four adult patients requiring CVAD insertion for intravenous therapy, were enrolled and randomly allocated (1:1 ratio) to either IC-ECG (n = 172) or traditional (n = 172) CVAD insertion. Our primary outcome of interest was the rate of catheters not requiring repositioning after insertion (ready for use). Secondary outcomes were comparison of procedure time and cost.

RESULTS

Of the 172 patients allocated to the IC ECG method, 170 (99%) were ready for use immediately compared to 139 of the 172 (81%) in the traditional insertion group (difference, 95% confidence interval (CI): 18%, 11.9-24.1%). The total procedure time was mean 15 min (SD 8 min) for IC ECG and mean 36 min (SD 17 min) for traditional CVAD insertion (difference-19.9 min (95% CI-14.6 to -34.4). IC ECG guided CVAD insertion had a cost reduction of AUD $62.00 per procedure.

CONCLUSIONS

Using IC-ECG resulted in nearly no requirement for post-insertion repositioning of CVADs resulting in savings in time and cost and virtually eliminating the need for radiographic confirmation.

TRIAL REGISTRATION

This trial is registered at the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au). The registration number is ACTRN12620000919910.

Assessment of dysfunctional tunneled hemodialysis catheters and outcome of endovascular salvage techniques: a simple solution to a complex problem

Objective

The aim of this study was to evaluate the causes of the dysfunctional tunneled cuffed catheters (TCCs) using multi-spiral computed tomography venography (MSCTV), and to analyze the outcomes of endovascular salvage techniques.

Material and methods

This retrospective review data from 27 patients who experienced TCC dysfunction between July 1, 2016 and January 31, 2021 was conducted. Patients' demographic data, clinical signs and symptoms, and imaging data were collected from interventional radiology database.

Results

MSCTV showed a range of abnormalities in the hemodialysis (HD) patients, including central venous occlusion (n = 4), fibrin sheath formation (n = 3), malposition of the catheter tips (n = 4), central venous perforation (n = 1), thrombus formation (n = 12), regular catheter exchange without determined lesions (n = 3). Interventional catheter salvage procedures were performed, such as catheter exchange, balloon disruption of a fibrin sheath, angioplasty for central vein stenosis, and stent deployment. The technical success rate for catheter insertions was 100%, and no procedure-related severe complications were observed. The 30-day catheter patency for all assessable catheters was 85.2%.

Conclusion

The use of MSCTV showed abnormal findings in almost 88.9% of cases concerning dysfunctional TCC. In this study, the examined appropriate endovascular techniques were found to be safe and technically successful, with a low incidence of procedure-related complications.

Validation of the PICC length prediction formula based on anteroposterior chest radiographs for bedside ultrasound-guided placement

This study aimed to validate the accuracy of the peripherally inserted central catheter (PICC) length prediction formula using only anteroposterior chest radiographs (AP-CXR) and the technical feasibility of bedside ultrasound-guided PICC placement. This study included 156 Asian adult patients who underwent bedside PICC placement at three hospitals from September 2021 to March 2022. The shortest straight-line distance from the cubital crease to the puncture point (CP) was measured first. Using the formula of a previous study, the CP + estimated PICC length (eCL) was calculated with the parameters measured on AP-CXR. The formula was as follows: 19.409 + 0.424 × (MHTD, maximal horizontal thoracic diameter) + 0.287 × (CL, clavicle length) + 0.203 × (DTV, distance of thoracic vertebrae) + (2VBUs, two vertebral body units below the carina inferior border) (if from the left, 3.063cm was added; if female, 0.997cm was subtracted). Catheters were pretrimmed according to calculated eCL prior to the procedure. Technical success was evaluated, and the validation success of catheter length prediction was classified according to the catheter tip position as follows: optimal position or suboptimal position. Technical success was achieved in 153 cases (98.1%). Evaluation of validation success revealed that the position was “optimal” in 108 cases (70.6%) and “suboptimal” in 45 cases (29.4%). There was no validation failure. There was no case where the catheter was inserted too deep as to wedge into the right atrial wall. In conclusion, the PICC could be positioned accurately using the formula based on only AP-CXR. Furthermore, this bedside procedure was technically feasible.

Diagnostic accuracy of ultrasound for localising peripherally inserted central catheter tips in infants in the neonatal intensive care unit: a systematic review and meta-analysis

BACKGROUND

Chest radiography after peripherally inserted central catheter insertion in infants is the reference standard method for verifying catheter tip position. The utilisation of ultrasound (US) for catheter placement confirmation in the neonatal and paediatric population has been the focus of many recent studies.

OBJECTIVE

In this systematic review we investigated the diagnostic accuracy of US for peripherally inserted central catheter tip confirmation in infants in the neonatal intensive care unit (NICU) MATERIALS AND METHODS: We conducted a systematic literature search of multiple databases. The study selection yielded eight articles, all of which had acceptable quality and homogeneity for inclusion in the meta-analysis. Sensitivity and specificity values were reported together with their respective 95% confidence intervals (CI).

RESULTS

After synthesising the eligible studies, we found that US had a sensitivity of 95.2% (95% CI 91.9-97.4%) and specificity of 71.4% (95% CI 59.4-81.6%) for confirming catheter tip position.

CONCLUSION

Analyses indicated that US is an excellent imaging test for localising catheter tip position in the NICU when compared to radiography. Ultrasonography is a sensitive, specific and timely imaging modality for confirming PICC tip position. In cases where US is unable to locate malpositioned PICC tips, a chest or combined chest-abdominal radiograph should be performed.

Developing Echogenic Materials as Catheters for Use with Ultrasound

Patients with peripherally inserted central catheters (PICCs) are routinely discharged with the catheters in place. These patients experience complications due to undetected thrombosis or accidental dislodgement, with tracking through limited X-ray imaging. Developing catheters with the capability to be tracked without the need for X-ray imaging would greatly benefit these patients by decreasing patient stress, reducing time to diagnosis, and increasing nursing home capabilities. This study reports on the incorporation of echogenic microspheres into catheters to produce bulk echogenic effects for developments in the field of real-time ultrasound tracking of polymeric medical devices. The impact on elastic modulus, ultrasound contrast, and cytocompatibility of the polymer was analyzed when incorporating up to 10 wt % glass microspheres. Up to this loading level, the elastic modulus was found to remain constant. However, at 10 wt %, extrusion defects due to agglomeration, air bubbles, and shearing were numerous and deemed detrimental to ultrasound imaging. Successful, defect-free samples were produced with 5 wt % microsphere loading and when embedded in a soft tissue phantom revealed a significant increase in the signal-to-noise ratio as compared to the polymer alone. Preliminary results have shown a successful increase in polymer's echogenic properties, without undermining its mechanical and cytocompatibility properties.

Unusual malposition of a peripherally inserted central catheter into the left pericardiophrenic vein: A case report

We report a case of primary malposition of a PICC inserted by guidewire replacement in the emergency room. Intraprocedural tip location by intracavitary electrocardiography was not feasible because the patient had atrial fibrillation; intraprocedural tip location by ultrasound (using the so-called "bubble test") showed that the tip was not in the superior vena cava or in the right atrium. A post-procedural chest X-ray confirmed the malposition but could not precise the location of the tip. A CT scan (scheduled for other purposes) finally visualized the tip in a very unusual location, the left pericardiophrenic vein.

Supraclavicular ultrasonographic real-time guidance of peripherally inserted central catheters - A feasibility study

BACKGROUND

Mispositioning is common during insertion of peripherally inserted central catheters. Ultrasonographic visualization of anatomical structures may enable continuous guidance during insertion. The aim was to investigate the feasibility of ultrasonographic real-time guidance of peripherally inserted central catheter placement using the supraclavicular fossa view.

METHODS

An observational quality control study was performed including 20 patients. Ultrasonography was performed via the right supraclavicular fossa using a microconvex probe identifying the junction between the right internal jugular- and the subclavian vein forming the right brachiocephalic vein. The wire guide tip was identified at the junction allowing estimation of catheter length. The catheter stiffening wire was followed in real-time into the right brachiocephalic vein towards the superior vena cava. Mispositions and the ability to redirect in real-time were detected. Final catheter tip positions were evaluated by either fluoroscopy or a chest radiograph.

RESULTS

Catheters were successfully placed in 19/20 patients. In all patients the junction and the right brachiocephalic vein was identified. Two thrombi were identified in the right brachiocephalic vein and left-sided insertions were performed. In 16 of 17 right-sided insertions, wire guide and catheter stiffening wire were visible. Of the 16 visual catheters, 15 could be followed into the right brachiocephalic vein. Real-time mispositioning was identified in eight cases and optimal redirection was successful in seven. All ultrasound-guided catheter length estimations were adequate.

CONCLUSIONS

Supraclavicular ultrasonographic real-time guidance for peripherally inserted central catheter placement was feasible and enabled successful placement together with detection and redirection of mispositioned catheters without delay.

Peripherally inserted central catheter procedure at the bedside by a nephrologist is safe and successful

Background

Peripherally inserted central catheter (PICC) use among critically ill patients with or without acute kidney injury (AKI) has gradually increased. Ultrasound-guided bedside PICC insertion in intensive care units (ICU) has been reported to be safe and effective. Reports of PICC insertion by a nephrologist without fluoroscopy, however, are relatively rare.

Methods

This retrospective study included patients (n = 224) who had a PICC inserted by a single nephrologist at Samsung Changwon Hospital from January 2019 to June 2020. Group 1 patients (n = 98) had PICCs inserted under ultrasound guidance, while group 2 patients (n = 126) had PICCs inserted under fluoroscopic guidance. Success rates, multiple puncture rates, and malposition rates were compared between the two groups.

Results

Underlying comorbidities (sepsis, AKI, ventilator use, and shock) were more common in group 1 than in group 2. Success rates were comparable between the two groups (93.9% vs. 97.6%, p = 0.171). Multiple puncture rate among successful cases (4.1% vs. 0.0%, p = 0.035) was higher in group 1 than group 2. Excluding central vein occlusion cases, malposition occurred only one in group 1.

Conclusion

Bedside PICC insertion by a nephrologist is easy and safe to perform in comorbid patients who are difficult to move to the angiography room. The success rate of ultrasound-guided PICC insertions was comparable to that of PICC insertion performed under fluoroscopic guidance. In the life-threatening ICU setting, PICCs can be successfully placed by the interventional nephrologists.

New formulas to predict the length of a peripherally inserted central catheter based on anteroposterior chest radiographs

PURPOSE

To develop formulas that predict the optimal length of a peripherally inserted central catheter (PICC) from variables measured on anteroposterior (AP) chest radiography (CXR).

MATERIALS AND METHODS

A total of 134 patients who underwent PICC insertion at the angiography suites were included. Clinical information such as patient height, weight, sex, age, cubital crease to inferior carina border length (CCL), and approach side were recorded. The following variables via measurement on AP-CXR were also collected: (1) distance from the T1 to T12 vertebra (DTV), (2) maximal horizontal thoracic diameter (MHTD), and (3) clavicle length (CL).

RESULTS

Significant correlations between CCL and the following variables were identified in linear regression analyses: approach side, height, weight, sex, DTV, MHTD, and CL. Multiple regression results motivated the following two formulas: (1) with height data, estimated CCL (cm) = 12.429 + 0.113 × Height + 0.377 × MHTD (if left side, add 2.933 cm, if female, subtract 0.723 cm); (2) without height data, estimated CCL = 19.409 + 0.424 × MHTD + 0.287 × CL + 0.203 × DTV (if left side, add 3.063 cm, if female, subtract 0.997 cm). Estimated final PICC length can be calculated as (Estimated CCL, cm) + 4.0 (distance from inferior carina border to about 2.0 vertebra body unit, cm) - (distance from set cubital crease to designated puncture point, cm).

CONCLUSION

This study suggests new formulas to predict the appropriate PICC length for bedside insertion using previous AP-CXRs. With this formula, ideal positioning of the catheter's tip can be achieved in the clinical practice, avoiding or minimalizing the exposed catheter out of skin. These formulas may be helpful for patients who cannot undergo intra-hospital transport due to hemodynamic instability or who are concerned about isolation precautions due to any infectious-related contamination.

Evaluation of a radiographer-led peripherally inserted central catheter insertion service

INTRODUCTION

To evaluate a radiographer-led peripherally inserted central catheter (PICC) insertion service within an interventional radiology suite using ultrasound and fluoroscopic guidance.

METHODS

Data from 366 consecutive PICC insertions by five trained angiography-specialized radiographers were prospectively collected over a 12-month period. For each PICC insertion, patient demographics, including past medical history of cystic fibrosis (CF), number of punctures, vein used, final tip position, contrast administration and screening time were recorded. Institutional review board approval was obtained.

RESULTS

The overall PICC insertion success rate was 100%. Fifty-five (15%) had a known medical history of CF. Three hundred and thirty-one (90%) PICC insertions required a single puncture and 32 (9%) required two punctures. The remaining three insertions required three punctures. The basilic vein was most commonly used (69%) followed by the brachial vein (29%), and the cephalic vein was used only in 2%. Administration of contrast medium was necessary during 27 (7%) PICC insertions. Mean screening time was 10.7 s.

CONCLUSION

Our specifically trained, radiographer-led PICC insertion service proved to be successful. Both straightforward and complex insertions, for example in CF patients could be adequately and efficiently performed.

Outcomes of bedside peripherally inserted central catheter placement: a retrospective study at a single institution

BACKGROUND

Bedside insertion of peripherally inserted central catheters (PICCs) has higher rates of malposition than fluoroscopic-guided PICC placement. This study evaluated the success rate of bedside PICC placement, variations in tip location, and risk factors for malposition.

METHODS

This retrospective study included patients who underwent bedside PICC placement from January 2013 to September 2014 in a single institution. The procedure was conducted under ultrasound guidance or by a blind method. After PICC placement, tip location was determined by chest X-ray.

RESULTS

The overall venous access success rate with bedside PICC placement was 98.1% (1,302/ 1,327). There was no significant difference in the venous access success rate between ultrasound-guided placement (868/880, 98.6%) and a blind approach placement (434/447, 97.1%). Optimal tip position was achieved on the first attempt in 1,192 cases (91.6%). Repositioning was attempted in 65 patients; 60 PICCs were repositioned at the bedside, two PICCs were repositioned under fluoroscopic guidance, and three PICCs moved to the desired position without intervention. Final optimal tip position after repositioning was achieved in 1,229 (94.4%). In logistic regression analysis, five factors associated with tip malposition included female sex (Exp(B), 1.687; 95% confidence interval [CI], 1.180 to 2.412; P=0.004), older age (Exp(B), 1.026; 95% CI, 1.012 to 1.039; P<0.001), cancer (Exp(B), 0.650; 95% CI, 0.455 to 0.929; P=0.018), lung disease (Exp(B), 2.416; 95% CI, 1.592 to 3.666; P<0.001), and previous catheter insertions (Exp(B), 1.262; 95% CI, 1.126 to 1.414; P<0.001).

CONCLUSIONS

Bedside PICC placement without fluoroscopy is effective and safe in central venous catheters. Potential risk factors associated with catheter tip malposition include older age, female sex, cancer, pulmonary disease, and previous central vein catheterizations.

Comparison of intraoperative ultrasonography guidance with an open surgical method for venous port catheter placement in chemotherapy

OBJECTIVE:

One of the leading venous access methods in chemotherapy is the use of a venous port catheter (VPC). An open surgical or ultrasound-guided technique can be performed. In our study, the VPC placement via both of these techniques was compared.

METHODS:

A total of 180 consecutive patients who underwent the VPC placement procedure either via the open or ultrasound-guided methods in two centers between January 2014 and January 2016 were included in the study. Patients’ data were reviewed retrospectively. Groups were compared in terms of intervention-related complication rates, a total procedure time, and the requirement of control imaging with ionizing radiation.

RESULTS:

The mean total procedure time was significantly shorter (19.5±4.6 min, 46.7±19.6 min, p<0.001) in the ultrasound-guided group than the open method. The rate of catheter malposition was significantly less in the ultrasound-guided group than in the open group (p<0.001). The need for per-operative imaging with ionizing radiation and the need of reversion in the preferred technique were not observed in the ultrasound-guided group, whereas in the open group, they were observed in 90 (100%) and 6 (6.7%) patients, respectively (p<0.001, p=0.01).

CONCLUSION:

Intraoperative ultrasound guidance for the VPC placement shortens the processing time and eliminates the need for routine imaging methods that require the use of ionizing radiation. In accordance with the current guidelines recommendations, intraoperative ultrasonography should be preferred as much as possible during the VPC placement. However, the need for the surgical teams in centers to maintain the necessary educational processes for both techniques should not be overlooked.

The electrocardiographic method for positioning the tip of central venous access device

BACKGROUND

The electrocardiogram-based insertion method is non-radiative, allowing real-time positioning verification and reducing the need for postoperative repositioning.

METHODS

Relevant databases published from January 1990 to January 2019 in PubMed, Web of Knowledge, Medline and Ovid's database were searched, comparing the effectiveness of electrocardiogram-guided catheter tip positioning (electrocardiogram-guided group) and the landmarks-guided insertion plus chest X-ray confirmation (landmarks-guided group). The primary outcome was accurate catheter tip placement and the secondary outcomes were complications.

RESULTS

A total of 13 studies were finally included with a total of 4988 patients, of whom 2789 cases were in the electrocardiogram-guided group and 2199 cases received landmarks-guided insertion plus chest X-ray. Compared with the landmarks-guided group, our meta-analysis showed that the electrocardiogram-guided group had a higher success rate of tip placement (odds ratio = 0.21, 95% confidence interval = 0.14-0.34, p < 0.00001) and fewer total complications (odds ratio = 0.10, 95% confidence interval = 0.04-0.23, p < 0.000001).

CONCLUSION

Based on our findings, electrocardiogram-guided tip placement for central venous access device was more accurate and safer than landmarks-guided positioning, which may be considered as an alternative method to the standard radiological control of tip placement.

Repositioning of malpositioned peripherally inserted central catheter lines with the use of intracavitary electrocardiogram: A pediatric case series

INTRODUCTION

Peripherally inserted central catheter tip migration is an infrequent event that occurs in neonatal, pediatric, and adult patients. We discuss a novel technique of utilizing intracavitary electrocardiogram to help confirm proper peripherally inserted central catheter tip repositioning, thereby reducing the need for serial radiographs.

CASE PRESENTATION

A case series of four patients will be discussed. The first three patients had peripherally inserted central catheter tips that were initially appropriately positioned but had later peripherally inserted central catheter tip migration. The use of intracavitary electrocardiogram was able to confirm the appropriate repositioning of the peripherally inserted central catheters without the need for serial radiographs. The fourth patient had several central lines in place, which led to difficulty in identifying the peripherally inserted central catheter tip location. The use of intracavitary electrocardiogram confirmed proper positioning of his peripherally inserted central catheter tip when standard radiographs could not provide clarity.

DISCUSSION

Several techniques have been published on methods to reposition a migrated peripherally inserted central catheter tip back to the superior vena cava/right atrial junction. These repositioning techniques often require fluoroscopic guidance or a confirmatory radiograph to assess the appropriate peripherally inserted central catheter tip location. At times, several radiographs may be required before the tip is successfully repositioned. This novel application of intracavitary electrocardiogram can help to minimize radiographs when peripherally inserted central catheter tip repositioning is required.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Bedside Peripherally Inserted Central Catheter Tip Confirmation: A Direct Savings Analysis

Peripherally inserted central catheter use has increased dramatically over the past decade, parallel to health care costs. Traditional bedside peripherally inserted central catheter placement requires anthropometric measurements of estimated catheter length and confirmation of appropriate tip positioning via chest radiograph. Newer bedside technology, using magnet and electrocardiogram capabilities, seeks to replace the traditional method with equal efficacy but less overall cost. The need for follow-up chest radiograph can been removed, a significant cost savings in direct patient care. In this retrospective case control study, we examine costs related to these 2 tip confirmation methods while assessing overall cost savings to the health care industry.

Risk of Venous Thromboembolism Following Peripherally Inserted Central Catheter Exchange: An Analysis of 23,000 Hospitalized Patients

BACKGROUND

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.

METHODS

We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.

RESULTS

Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).

CONCLUSION

Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.

PERIPHERALLY INSERTED CENTRAL CATHETERS IN ORTHOPEDIC PATIENTS: EXPERIENCE FROM 1023 PROCEDURES

Objectives

The advantages of using a peripherally inserted central catheter (PICC) in hospitalized patients make this device very important for intravenous therapy. This study describes the use of PICCs at the Institute of Orthopedics and Traumatology at the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo over the last 10 years.

Methods

This retrospective study analyzed 1,057 medical records and included 1,023 medical files with complete information on the punctured vein, diagnosis, duration of catheterization, complications, and catheter tip positioning.

Results

Seven hundred and twenty PICCs (70.4%) were considered successfully positioned, and mean duration of catheterization was 34.3 days. The basilic vein was used in 528 (51.6%) patients, while 157 (15.4%) catheters were removed due to complications. No cases of catheter-related thrombosis or infection were found. Eight hundred and sixty-six (84.6%) patients completed their treatment with PICC in place.

Conclusion

PICC is a safe intravenous device that can be successfully utilized for medium- and long-course intravenous therapy in hospitalized and discharged orthopedic patients. Level of Evidence IV; Case series.

Malposition of Peripherally Inserted Central Catheter Into the Right Inferior Thyroid Vein: A Case Report

Patient: Female, 58

Final Diagnosis: Breast cancer

Symptoms: None

Medication: None

Clinical Procedure: Insertion of a peripherally inserted central catheter (PICC)

Specialty: Anesthesiology

Chest Radiograph Measurement Technique Facilitates Accurate Bedside Peripherally Inserted Central Catheter Placement in Children

PURPOSE

To report the chest radiograph measurement technique for placing bedside peripherally inserted central catheters (PICCs).

MATERIALS AND METHODS

Two hundred and thirty-two consecutive pediatric patients, mean age of 56.3 months (range: 0-203 months), underwent PICC placement from January 2015 to May 2017 (28 months) with a total of 232 PICCs placed. Measurements were taken from the cavoatrial junction to clavicle, clavicle to medial margin of mid-humeral head, and medial margin of mid-humeral head to mid-humerus. The difference between total radiographic measured length and actual PICC length was then calculated, and the percent difference (from actual cut length) was recorded. An equivalence test was performed using the two, one-sided test method.

RESULTS

Mean ± standard deviation cavoatrial junction to clavicle length was 5.29 ± 2.20 cm (range: 2.1-12.6 cm). Mean clavicle to shoulder length was 8.20 ± 3.59 cm (range: 3.23-19.06 cm). Mean shoulder to mid-humerus length was 7.88 ± 3.87 cm (range: 2.01-16.8 cm). Mean total radiographic measured length was 21.37 ± 9.19 cm (range: 7.42-43.6 cm). Mean actual cut PICC length was 20.64 ± 8.72 cm (range: 8.5-44 cm). The mean difference between predicted, or total radiographic measured length, and actual cut PICC length was 0.73 ± 2.51 (range: - 5.42-8.60 cm). The mean percent difference was 4.07 ± 12.65% (range: - 23.84-47.80%). An equivalence test rejected the null hypothesis of the true percent difference greater/less than ± 6.67% with a p value of 0.002.

CONCLUSION

The chest radiograph measurement technique is an accurate method to determine catheter length for PICC placement at bedside in the pediatric population.

Improving Quality of Chest Radiographs After Placement of Peripherally Inserted Central Catheters

The goal of this study was to determine the best method for localizing peripherally inserted central catheters (PICCs) in postplacement portable chest radiographs. A retrospective analysis showed no significant difference in visualization of the PICC tip between different chest radiograph projections. Modifications were made to an institutional PICC protocol to obtain anteroposterior chest views with the guidewire present only. Repeat analysis demonstrated statistically significant increases in the frequency of anteroposterior radiographs performed, the number of chest radiographs with guidewire, and the localization of the catheter. By standardizing the acquisition of PICC placement chest radiographs, fewer variant projection radiographs were performed and the catheter tip was confidently localized in more examinations.

Superior success rate of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement in patients with cancer: A randomized open-label controlled multicenter study

Background

Intracavitary electrocardiogram (IC ECG) guidance emerges as a new technique for peripherally inserted central catheters (PICCs) placement and demonstrates many potential advantages in recent observational studies.

Aims

To determine whether IC ECG-guided PICCs provide more accurate positioning of catheter tips compared to conventional anatomical landmarks in patients with cancer undergoing chemotherapy.

Methods

In this multicenter, open-label, randomized controlled study (ClinicalTrials.gov number, NCT02409589), a total of 1,007 adult patients were assigned to receive either IC ECG guidance (n = 500) or anatomical landmark guidance (n = 507) for PICC positioning. The confirmative catheter tip positioning x-ray data were centrally interpreted by independent radiologists. All reported analyses in the overall population were performed on an intention-to-treat basis. Analyses of pre-specified subgroups and a selected large subpopulation were conducted to explore consistency and accuracy.

Results

In the IC ECG-guided group, the first-attempt success rate was 89.2% (95% confidence interval [CI], 86.5% to 91.9%), which was significantly higher than 77.4% (95% CI, 73.7% to 81.0%) in the anatomical landmark group (P < 0.0001). This trend of superiority of IC ECG guidance was consistently noted in almost all prespecified patient subgroups and two selected large subpopulations, even when using optimal target rates for measurement. In contrast, the superiority nearly disappeared when PICCs were used via the left instead of right arms (interaction P-value = 0.021). No catheter-related adverse events were reported during the PICC intra-procedures in either group.

Conclusions

Our findings indicated that the IC ECG-guided method had a more favorable positioning accuracy versus traditional anatomical landmarks for PICC placement in adult patients with cancer undergoing chemotherapy. Furthermore, there were no significant safety concerns reported for catheterization using the two techniques.

Repositioning of Central Venous Access Devices using a High-Flow Flush Technique - a Clinical Practice and Cost Review

Background

Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions. The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning.

Methods

This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia. 7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions.

Results

There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition.

Conclusions

Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Time and resources of peripherally inserted central catheter insertion procedures: a comparison between blind insertion/chest X-ray and a real time tip navigation and confirmation system

BACKGROUND

The Sherlock 3CG™ Tip Confirmation System (TCS) provides real-time peripherally inserted central catheter (PICC) tip insertion information using passive magnetic navigation and patient cardiac electrical activity. It is an alternative tip confirmation method to fluoroscopy or chest X-ray for PICC tip insertion confirmation in adults. The purpose of this study was to evaluate time and cost of the Sherlock 3CG TCS and blind insertion with chest X-ray tip confirmation (BI/CXR) for PICC insertions.

METHODS

A cross-sectional, observational Time and Motion study was conducted. Data were collected at four hospitals in the US. Two hospitals used Sherlock 3CG TCS and two hospitals used BI/CXR to place/confirm successful PICC tip location. Researchers observed PICC insertions, collecting data from the beginning (ie, PICC kit opening) to catheter tip confirmation (ie, released for intravenous [IV] therapy). An economic model was developed to project outcomes for a larger population.

RESULTS

A total of 120 subjects were enrolled, with 60 subjects enrolled in each arm and 30 enrolled at each of the four US hospitals. The mean time from initiation of the PICC procedure to the time to release for IV therapy was 33.93 minutes in the Sherlock 3CG arm and 176.32 minutes in the BI/CXR arm (p < 0.001). No malpositions were observed for PICC insertions using the Sherlock 3CG TCS, while 20% of subjects in the BI/CXR arm had a malposition. BI/CXR subjects had significantly more total malpositions (mean 0.23 vs. 0, p < 0.001). For a hypothetical population of 1,000 annual patients, adoption of Sherlock 3CG TCS was predicted to be cost saving compared with BI/CXR in all three analysis years.

CONCLUSION

The results from this study demonstrate that Sherlock 3CG TCS, when compared with BI/CXR, is a superior alternative with regard to time to release subject to therapy, malposition rates, and minimization of X-ray exposure.

The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center

Background: To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.

Methods: This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.

Results: Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; σ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.

Conclusions: PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-Ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device?

BACKGROUND

Percutaneous central venous port (CVP) placement using ultrasound-guidance (USG) via right internal jugular vein is described as a safe and effective procedure. The aim of this study is to determine whether intraoperative fluoroscopy (IF) and/or postoperative chest X-ray (CXR) are required to confirm the correct position of the catheter.

METHODS

Between January 2012 and December 2014, 302 adult patients underwent elective CVP system placement under USG. The standard venous access site was the right internal jugular vein. The length of catheter was calculated based on the height of the patient. IF was always performed to confirm US findings.

RESULTS

176 patients were men and 126 were women and average height was 176.2 cm (range 154-193 cm). The average length of the catheter was 16.4 cm (range 14-18). Catheter malposition and pneumothorax were observed in 4 (1.3 %) and 3 (1 %) patients, respectively. IF confirmed the correct position of the catheter in all cases. Catheter misplacement (4 cases) was previously identified and corrected on USG. Our rates of pneumothorax are in accordance with those of the literature (0.5-3 %).

CONCLUSION

Ultrasonography has resulted in improved safety and effectiveness of port system implantation. The routine use of CXR and IF should be considered unnecessary.

Clinical effect of peripherally inserted central catheters based on modified seldinger technique under guidance of vascular ultrasound

Objective:

To observe and analyze the application effect of ultrasound-guided modified Seldinger technique (MST) in Peripherally Inserted Central Catheter (PICC) catheterization.

Methods:

Two hundred patients treated with PICC catheterization from January 2013 to December 2015 were selected and randomly divided into two groups, namely, observation group and control group. The observation group adopted ultrasound-guided MST for catheterization while the control group applied traditional puncture technique for catheterization. Then efficacy of catheterization, success rate of catheterization and incidence rates of complications were compared between two groups.

Results:

Various indicators of catheterization effects of the observation group were better than those of the control group, and the differences were statistically significant (P<0.05); one-time success rate of puncture and catheterization of the observation group was both higher than the control group (P<0.05);. Moreover, the incidence of puncture points bleeding, phlebitis and thrombus were all lower than those of the control group (P<0.05).

Conclusion:

Implementing PICC catheterization based on ultrasound-guided modified Seldinger puncture technique can increase success rate of puncture, improve the effect of catheterization, lower incidence rate of adverse effects of catheterization and improve satisfaction and comfort level of patients.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) initiative: A summary and review of peripherally inserted central catheter and venous catheter appropriate use

Peripherally inserted central catheters (PICCs) are being selected for venous access more frequently today than ever before. Often the choice of a PICC, when compared with other vascular access devices (VADs), is attractive because of perceived safety, availability, and ease of insertion. However, complications associated with PICCs exist, and there is a paucity of evidence to guide clinician choice for PICC selection and valid use. An international panel with expertise in the arena of venous access and populations associated with these devices was convened to clarify approaches for the optimal use of PICCs and VADs. Here we present for the busy hospital-based practitioner the methodology, key outcomes, and recommendations of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) panelists for the appropriate use of VADs.

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.

Simultaneous Rapid Saline Flush to Correct Catheter Malposition: A Clinical Overview

Central venous catheters and peripherally inserted central catheters are fundamental in the delivery of pharmacologic and nutrition therapies to patient populations, including individuals with cancer. Malposition and migration of these catheters outside of the superior or inferior vena cava can contribute to delays in therapy as individuals await repositioning, and in some cases replacement of the catheter. Traditional repositioning using overwire or interventional radiology techniques can be costly and may delay care. The placement and management of these catheters has increasingly become the domain of specially trained vascular access nurses. A team of specially trained vascular access nurses, in collaboration with interventional radiologists at a National Cancer Institute-designated comprehensive cancer center developed a procedure for catheter repositioning using a simultaneous rapid saline flush technique (SRSFT). We present this procedure, along with implications for cost and clinical outcomes. Clinical outcomes suggest that 68% of catheters have been successfully repositioned using this technique with no adverse events associated with the procedure noted to date. In addition, the use of the SRSFT represents a cost savings of up to 90% compared with traditional repositioning procedures. The SRSFT is identified as safe, timely, cost-conscious, and therapeutically effective, although further research is needed to formally evaluate the efficacy of repositioning using this technique compared with overwire and interventional-radiology-guided repositioning, including complications and quality outcomes.

Evaluation of the Correct Position of Peripherally Inserted Central Catheters: Anatomical Landmark vs. Electrocardiographic Technique

Purpose

The purpose of this study is to verify as early as possible the correct positioning of the peripherally inserted central catheter (PICC) tip in order to reduce complications due to possible malpositioning. The ECG-guided technique proved to be reliable, easy to carry out, straightforward, low-cost and allows us to recognize an incorrect or a suboptimal positioning throughout the procedure. The purpose of this study is to compare two methods used during the PICC insertion so as to prevent catheter malpositioning; the first study estimates the catheter length by the landmark method (based on cutaneous anatomical landmarks, CALs) with the addition of the postprocedural verification of tip location by chest X-Ray (CxR), whereas the second method of intraprocedural tip location is based on the observation of the morphological variations of the P wave (ECG-guided technique) with the addition of the postprocedural verification by CxR.

Methods

From 2010 to 2012, 90 PICCs were positioned, 48 using the anatomical landmarks and 42 using the ECG technique.

Results

Twenty-five percent of the catheters positioned with the anatomical landmark technique did not reach the correct position of the tip in SVC; of these, 6.25% were placed in an aberrant position and others in a suboptimal position. Of the 42 PICCs positioned with the ECG technique, only in three cases (equal to 7.14%), a suboptimal position of the tip was observed, whereas there was no case of aberrant positioning.

Conclusions

The ECG technique represents an accurate, low-cost and safe technique to verify the correct positioning of the tip. The use of the ECG allowed a more correct positioning in terms of catheter tip-carina distance and catheter tip-tracheobronchial angle, and in no patient was it necessary to place a catheter again.

Management of dysfunctional catheters and tubes inserted by interventional radiology

Minimally invasive percutaneous interventions are often used for enteral nutrition, biliary and urinary diversion, intra-abdominal fluid collection drainage, and central venous access. In most cases, radiologic and endoscopic placement of catheters and tubes has replaced the comparable surgical alternative. As experience with catheters and tubes grows, it becomes increasingly evident that the interventional radiologist needs to be an expert not only on device placement but also on device management. Tube dysfunction represents the most common complication requiring repeat intervention, which can be distressing for patients and other health care professionals. This manuscript addresses the etiologies and solutions to leaking and obstructed feeding tubes, percutaneous biliary drains, percutaneous catheter nephrostomies, and drainage catheters, including abscess drains. In addition, we will address the obstructed central venous catheter.

"Peripherally inserted central catheters: our experience from a cancer research centre"

Peripherally inserted central catheter (PICC) is a modern drug delivery system utilised in oncology practice. The purpose of this study was to determine the complications associated with PICCs within a one year study period. PICCs inserted in patients registered at Dharamshila Cancer Hospital and research centre from 1st July 2012 to 30th June 2013 were studied. Data was retrieved from the procedure room records, medical records department, department of radiology and department of microbiology. Data was collected by oncology residents and procedure team. A total of 246 PICCs were inserted during the one year period. Complete data was not available in 23 patients. 223 results were included in the final analysis. USG guidance was required in 14 patients (6.3%). Optimal PICC duration was achieved in 151 patients (67.7%). 28 patient developed culture positive infective complications (12.5%). 44 patients developed mechanical complications (19.7%). Our study shows a relatively higher rate of infective complications. PICC is an acceptable means of drug delivery system.

Impact of postplacement adjustment of peripherally inserted central catheters on the risk of bloodstream infection and venous thrombus formation

OBJECTIVE

Peripherally inserted central catheter (PICC) tip malposition is potentially associated with complications, and postplacement adjustment of PICCs is widely performed. We sought to characterize the association between central line-associated bloodstream infection (CLABSI) or venous thrombus (VT) and PICC adjustment.

DESIGN

Retrospective cohort study.

SETTING

University of Michigan Health System, a large referral hospital.

PATIENTS

Patients who had PICCs placed between February 2007 and August 2007.

METHODS

The primary outcomes were development of CLABSI within 14 days or VT within 60 days of postplacement PICC adjustment, identified by review of patient electronic medical records.

RESULTS

There were 57 CLABSIs (2.69/1,000 PICC-days) and 47 VTs (1.23/1,000 PICC-days); 609 individuals had 1, 134 had 2, and 33 had 3 or more adjustments. One adjustment was protective against CLABSI (P=.04), whereas 2 or 3 or more adjustments had no association with CLABSI (P=.58 and .47, respectively). One, 2, and 3 or more adjustments had no association with VT formation (P=.59, .85, and .78, respectively). Immunosuppression (P<.01), power-injectable PICCs (P=.05), and 3 PICC lumens compared with 1 lumen (P=.02) were associated with CLABSI. Power-injectable PICCs were also associated with increased VT formation (P=.03).

CONCLUSIONS

Immunosuppression and 3 PICC lumens were associated with increased risk of CLABSI. Power-injectable PICCs were associated with increased risk of CLABSI and VT formation. Postplacement adjustment of PICCs was not associated with increased risk of CLABSI or VT.

Accurate nonfluoroscopic guidance and tip location of peripherally inserted central catheters using a conductance guidewire system

BACKGROUND

Bedside placement of peripherally inserted central catheters (PICCs) may result in navigation to undesirable locations, such as the contralateral innominate or jugular vein, instead of the superior vena cava or right atrium. Although some guidance and tip location tools exist, they have inherent limitations because of reliance on physiological measures (eg, chest landmarks, electrocardiogram, etc), instead of anatomical assessment (ie, geometric changes in the vasculature). In this study, an accurate, anatomically based, non-X-ray guidance tool placed on a novel 0.035" conductance guidewire (CGW) is validated for PICC navigation and tip location.

METHODS

The CGW system uses electrical conductance recordings to assess changes in vessel cross-sectional area to guide navigation of the PICC tip. Conductance rises and oscillates when going in the correct direction to the superior vena cava/right atrium, but drops when going in the incorrect direction away from the heart. Bench and in vivo studies in six swine were used to confirm the accuracy and repeatability of the PICC placement at various anatomical locations. The PICC tip location was confirmed by direct visualization vs the desired location.

RESULTS

CGW PICC guidance was highly accurate and repeatable with virtually no difference between actual and desired catheter tip location. The difference between the CGW PICC location vs the desired target was -0.07 ± 0.07 cm (6.6% error) on the bench and 0.04 ± 0.10 cm (5% error) in vivo. No complications or adverse events occurred during CGW usage.

CONCLUSIONS

The CGW provides an anatomically based, reproducible, and clinically significant method for PICC navigation and tip location that can improve accuracy, decrease the wait time prior to therapy delivery, decrease cost, and minimize the need for X-ray. These findings warrant clinical evaluation of this navigation tool for PICC line placement.

Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit

Peripherally inserted central catheters are increasingly used to provide access to the central venous circulation. They are commonly positioned 'blind' using a variety of anthropometric techniques and operator experience to direct insertion length. Malposition rates are poorly defined because of differing insertion techniques, difficulties defining anatomical tip position on chest radiographs, controversy over what constitutes an adequate catheter position and possible differences between patient groups. We have developed a reproducible method to define catheter positions on chest radiograph and have applied this in a retrospective analysis of 256 ICU and 243 non-ICU catheter insertions over a 6-month period. Two different definitions were used for adequate position. 'Blind' positioning of peripherally inserted central catheters was associated with a definition-dependent malposition rate of 42-76%. Malposition rates were significantly higher in ICU patients. Emerging technologies may assist in reducing these high rates.

A retrospective clinical audit of 696 central venous catheterizations at a tertiary care teaching hospital in India

Background:

Malpositions after central venous cannulation are frequently encountered and may need a change in catheter. The incidence of malpositions are varied according to various studies and depend on the experience of the operator performing the cannulation.

Aim:

To access the incidence of malpositions and related complications associated with landmark-guided central venous cannulation in a 15-bedded medical surgical ICU over a period of three years.

Settings and Design:

Retrospective analysis of records of all the central venous cannulation done in a 15- bedded medical- surgical ICU over the period of three years (April 2008 to June 2011) were evaluated for the site and side of insertion, number of attempts of puncture, arterial puncture as well as the malpositions on post procedural chest X-ray. The records were also evaluated for the experience of the operator performing cannulation and relationship between experience of operator to malpositions of catheter.

Statistical Analysis:

Analysis was done using SPSS v 17.0 for Windows. Chi-square test was applied to evaluate the statistical significance. P > 0.05 was significant.

Results:

Records of 696 cannulations were evaluated. Malpositions occurred in 40 patients. Subclavian vein cannulation resulted in increased malpositions in relation to internal jugular vein cannulation. More common with left sided cannulation. Experience of operator had positive correlation with malpositions and arterial puncture. Arterial puncture was common in 6%, while more than one attempt for cannulation was taken in 100 patients.

Conclusion:

Incidence of malpositions was low. We conclude that experience of operator improves successful catheterization with lesser number of complications.

Repositioning techniques of malpositioned peripherally inserted central catheters

AIMS AND OBJECTIVES

To describe potential repositioning techniques of malpositioned peripherally inserted central catheters.

BACKGROUND

Various repositioning methods have been applied in clinical practice in managing malpositioned peripherally inserted central catheters, and many of them are proved effective. However, little publication reviewed on those literatures describing repositioning techniques to malpositioned peripherally inserted central catheters.

DESIGN

Systematic review. The repositioning techniques were classified and concretely described according to different locations of malpositioned peripherally inserted central catheter tips.

METHODS

Literature and relevant guidelines were reviewed, focusing on malpositioned locations and incidence, as well as repositioning skills to peripherally inserted central venous catheters. Six databases were searched, including MEDLINE, web of science, CINAHL, Cochrane library, Wanfang database and Chinese National Knowledge Infrastructure. The articles (n = 21) were analysed using inductive content analysis.

RESULTS

The malpositioned locations of postplacement peripherally inserted central catheter tips mainly include right atrium, right ventricular, axillary vein, ipsilateral and contralateral internal jugular vein, subclavian vein, brachiocephalic vein, other small venous branches or catheter looped. Repositioning techniques contained automatic reposition, manual repositioning techniques, re-advancing catheters and catheters' replacement according to different malpositioned patterns.

CONCLUSIONS

The most appropriate repositioning techniques should be adopted on the basis of malpositioned locations, direction and length of the malpositioned tip, patients' integrated conditions and available medical equipments to maintain the catheter tip in the best position.

RELEVANCE TO CLINICAL PRACTICE

The repositioning techniques described in this review can be applied in clinical practice to ensure the infusion therapy through peripherally inserted central catheter more economical and safe.

Comparison of complication rates of Hickman(®) catheters versus peripherally inserted central catheters in patients with acute myeloid leukemia undergoing induction chemotherapy

Central venous access devices (CVADs) are used for intravenous therapy in patients with hematological malignancies. There are limited data comparing catheter outcomes in patients with acute myeloid leukemia (AML) undergoing induction chemotherapy. A retrospective review comparing the incidence of early and late CVAD-associated complications and their effect on CVAD removal was performed in patients with AML undergoing induction chemotherapy between 2007 and 2011. Overall, 64 Hickman(®) catheters and 84 peripherally inserted central catheters (PICCs) were inserted. There was a trend toward increasing use of PICCs. The rate of CVAD occlusion was higher in PICCs compared to Hickman catheters (48.2% vs. 3.2%), for a rate of 20.43 vs. 1.25 per 1000 CVAD-days (p = 0.0001). There was no significant difference in the rates of CVAD-associated thrombosis, premature removal, blood stream infection (BSI) and CVAD-related BSI. Importantly, there was no significant difference in the rate of CVAD removal between Hickman catheters and PICCs for the duration that the CVADs were in place. The choice of type of CVAD inserted into patients with newly diagnosed AML will depend on ease of catheter placement, cost, perception of frequency and severity of complications, and clinician preference.