Prospective follow-up of complications related to peripherally inserted central catheters

Peripherally Inserted Central Venous Catheter-Related Complications in Adult Patients with Haematological Malignancy

Background

Peripherally inserted central venous catheters (PICC) are widely used in patients with haematological malignancies owing to the requirement for prolonged intravenous therapy. However, the growing use of PICCs has resulted in a multitude of complications such as infections and thrombosis, leading to prolonged hospitalisation periods and increased morbidity. This study aimed to determine the incidence of and factors associated with PICC-related complications in patients with haematological malignancies.

Methods

This prospective cohort study was conducted at a single academic institution. The inclusion criteria involved all adult patients with haematological malignancies who had newly inserted PICCs. The patients were observed for a minimum duration of 60 days to evaluate the incidence of PICC-related infections and thrombosis, as well as mechanical complications.

Results

A total of 119 PICCs were implanted in 85 patients. Among them, more than half of the patients were diagnosed with lymphoma (55.0%). The median dwell time was 61 days (interquartile range: 98 days). The incidence of PICC-related complications was 58.0% (6.9 per 1,000 catheter-days). Specifically, 43 PICCs (36.1%, 4.3 per 1,000 catheter-days) experienced infective complications, 25 (21.1%, 2.5 per 1,000 catheter-days) encountered mechanical complications and 1 (0.8%, 0.1 per 1,000 catheter-days) exhibited thrombotic complications. Furthermore, an underlying diagnosis of acute leukaemia was significantly associated with a higher incidence of PICC-related infections.

Conclusion

Our study revealed higher incidence rates of PICC-related complications in adult patients with haematological malignancies compared to the finding of other studies. Notably, patients with underlying acute leukaemia displayed a higher incidence of PICC-related infections. These findings underscore the importance of implementing appropriate interventions and conducting thorough root cause analyses to effectively mitigate this complication and improve patient outcomes.

Peripherally Inserted Central Catheters-associated blood stream infections-occurrence, risk factors, and pathogens, a single center study

Background

Peripherally inserted central catheters (PICCs) are central venous catheters inserted peripherally but terminate in great vessels. PICCs are widely used for patients requiring long-term intravenous therapy in both in-patient and out-patient settings.

Aim

This study was carried out to understand PICC-related complications, specifically infections and causal pathogens, in a tertiary care hospital in Kerala, South India.

Methods

A retrospective analysis of PICC insertions and follow-up during a 9 years period to look at patient demographics and infections related to PICC was carried out.

Results

The overall PICC-related complication rate is 28.1% (4.98 per 1000 PICC days). Commonest complication was thrombosis followed by infection, either PICC-associated bloodstream infection (PABSI) or local infection (LI). PABSI noted in this study was 1.34 per 1000 catheter days. The majority (85%) of PABSI were due to Gram-negative rods. The average duration of PICC days for occurrence of PABSI was 14 days and the majority occurred in in-patients.

Conclusion

Thrombosis and infection were the commonest PICC-related complications. PABSI rate was comparable to that of previous studies.

Peripheral Insertion of Pediatric Central Venous Catheters in Adults with Difficult I.V. Access

BACKGROUND

Difficult intravenous access is a frequent occurrence in critical care and emergency medicine. Prior intravenous access, chemotherapy use, and obesity are a few factors associated with difficult access. Alternatives to peripheral access are often contraindicated, not feasible, or not readily available.

OBJECTIVES

To describe the feasibility and safety of peripheral insertion of peripherally inserted pediatric central venous catheters (PIPCVC) in a cohort of adult critical care patients with difficult intravenous access.

METHODS

Prospective observational study of adult patients with difficult intravenous access who underwent peripheral insertion of pediatric PIPCVCs at a large university hospital.

RESULTS

During a 1-year period, 46 patients were evaluated for PIPCVC; 40 catheters were placed successfully. The median age of the patients was 59 years (range 19-95 years) and 20 (50%) were female. The median body mass index was 27.2 (range 17.1-41.8). The basilic vein was accessed in 25/40 (63%) patients, the cephalic in 10/40 (25%), and the accessed vessel was missing in 5/40 (13%) cases. The PIPCVCs were in place for a median of 8 days (range 1-32). One superficial thrombosis and one deep occurred; pulmonary embolism did not occur.

CONCLUSIONS

PIPCVC placement seems to be a feasible option in patients in whom peripheral intravenous access is difficult. The safety of this technique needs to be evaluated in prospective studies.

Effect of exercise therapy on PICC-associated venous thromboembolism: A meta-analysis

BACKGROUND

Peripherally inserted central catheter (PICC) is widely used in clinical practice because of its long retention time and easy maintenance. However, PICC-associated venous thromboembolism (VTE) is the most serious complication of PICC. Guidelines recommend exercise therapy to prevent PICC-associated VTE. However, inconsistent findings have been reported across the literature. This study conducted a meta-analysis to further evaluate the effect of exercise therapy on PICC-associated VTE.

METHODS

We searched CNKI, Wanfang database, Chinese Science and Technology Journal Full Text Database, PubMed, Embase, Web of Science and Cochrane Library databases and included all randomized controlled trials (RCTs) of exercise therapy for the prevention of PICC-associated VTE. Two investigators independently screened the literature, extracted information, and evaluated the risk of bias for eligible RCTs. Meta-analysis was conducted by RevMan5.4 software.

RESULTS

Eleven RCTs were included, including 1919 patients. Meta-analysis showed that the incidence of PICC-associated VTE was lower in the exercise therapy group than in the usual care group (RR = 0.30, 95% CI: 0.22-0.41, p < 0.00001).Exercise therapy increased the axillary vein maximum velocity (SMD = 0.93, 95% CI: 0.58-1.28, p < 0.00001) and the axillary vein time-mean flow velocity (SMD = 0.86, 95% CI: 0.53-1.20, p < 0.00001). Subgroup analysis showed statistically significant differences for the incidence of PICC-associated VTE for intervention times<4 weeks (RR = 0.26, 95% CI: 0.17-0.40, p < 0.00001) and intervention times≥4 weeks (RR = 0.35, 95% CI: 0.22-0.54, p < 0.00001). For axillary vein maximum velocity, the difference was statistically significant for both intervention time <4 weeks (SMD = 0.73, 95% CI: 0.55-0.91, p < 0.00001) and intervention time ≥4 weeks (SMD = 1.18, 95% CI: 0.18-2.19, p = 0.02). For axillary vein time-mean flow velocity, the intervention time <4 weeks (SMD = 0.75, 95% CI: 0.46-1.04, p < 0.00001), and the difference was statistically significant; while ≥4 weeks, the difference was not statistically significant (SMD = 1.14, 95% CI: -0.07 to 2.35, p = 0.06).

CONCLUSIONS

Exercise therapy improved venous blood flow velocity and effectively reduced the incidence of PICC-associated VTE. However, RCTs with large samples and high quality are needed to further evaluate the effectiveness of exercise therapy in PICC patients.

Clinical factors associated with peripherally inserted central catheters (PICC) related bloodstream infections: a single centre retrospective cohort

BACKGROUND

Despite their spread in daily practice, few data is available on clinical factors associated with peripherally inserted central catheter (PICC)-related bloodstream infections (PR-BSI). We aimed to assess the PR-BSI incidence, microbiology, and factors associated with PR-BSI with a focus on clinical symptoms.

METHODS

We conducted a retrospective cohort study in a French university hospital. We screened all PICC insertions performed from April 1st, 2018, to April 1st, 2019, and included PICC insertions in adult patients. We assessed the PR-BSI incidence, the factors associated with PR-BSI using a Cox model, and negative and positive predictive values (NPVs and PPVs) of each clinical sign for PR-BSI.

RESULTS

Of the 901 PICCs inserted in 783 patients (38,320 catheters days), 214 PICCs (24%) presented with a complication. The most prevalent complication was PR-BSI (1.9 per 1000 catheter days; 8.1% of inserted PICCs ). Enterobacterales (N = 27, 37%) and coagulase negative Staphylococci (N = 24, 33%), were the main microorganisms responsible for PR-BSI. Factors independently associated with occurrence of PR-BSI were fever (hazard ratio 13.21, 95% confidence interval 6.00-29.11, p < 0.001) and chills (HR 3.66, 95%CI 1.92-6.99, p < 0.001). All clinical signs and a duration of PICC maintenance ≥ 28 days, had a low PPVs (≤ 67.1%) but high NPVs (≥ 92.5%) for PR-BSI.

CONCLUSIONS

Monitoring of clinical signs, especially fever and chills, with caution and limitation of device maintenance duration, could improve PICC management.

Subcutaneously anchored securement for peripherally inserted central catheters: Immediate, early, and late complications

BACKGROUND

An adequate stabilization of a vascular device is an important part of insertion bundles and is an effective strategy in reducing complications. Dislodgment has a relevant clinical impact and an increase in healthcare costs.

METHOD

We have retrospectively investigated the safety and efficacy of Subcutaneously Anchored Securement (SAS) for Peripherally Inserted Central Catheters (PICC) in cancer patients.

RESULTS

We analyzed 639 patients who had a PICC inserted and secured with SAS, over the past 3 years (2018-2020). No immediate complications during SAS placement were reported. In the first 24-48 h, a slight local ecchymosis was reported in 24 cases with rapid spontaneous resolution. No cases of bleeding or hematoma of the exit site were reported. The total number of catheter days was 93078. Dislodgment occurred only in seven cases (1.1%). In 16 patients, the PICC was removed because of catheter-related bloodstream infection (CRBSI): the overall incidence of CRBSI was 0.17 per 1000 catheter days. Symptomatic venous thrombosis was documented in 12 patients (1.9%) and treated with low molecular weight heparin without PICC removal. We had no cases of irreversible lumen occlusion. In 17 patients, local discomfort-including device-related pressure ulcers and painful inflammation-was reported: these cases were treated without SAS removal or PICC removal.

CONCLUSION

In this retrospective analysis, subcutaneously anchored securement of PICCs was a safe and effective strategy for reducing the risk of dislodgment.

An analysis of 90-day emergency department visits after peripherally inserted central catheter (PICC) placement for prosthetic joint infection

OBJECTIVE

Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA.

METHODS

We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center.

RESULTS

The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7-95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3-89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24-4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95-1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation.

CONCLUSIONS

PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.

Facilitation as a component of evidence implementation: a multinational perspective

BACKGROUND

Facilitation is a key component of JBI's approach to evidence implementation along with context analysis and evaluation of process and outcomes. Although the role of facilitation is recognized as a critical component of evidence implementation, what constitutes effective facilitation is poorly understood.

AIM

This article presents a descriptive exploration of facilitation as it occurs in evidence implementation initiatives conducted in various healthcare and geographical contexts. All projects used the JBI approach to evidence implementation.

METHODS

To provide a multinational perspective on how facilitation was operationalized to promote positive changes in clinical practice and health outcomes, five case studies of evidence implementation projects are presented.

RESULTS

The cases highlighted that facilitation is a multifaceted process that can be met through a variety of roles that address aspects of education and capacity building, partnerships, action planning, problem solving and evaluation. Facilitation in all cases appeared to be collaborative, with multiple 'players' within and outside of the health organization being involved in the process. Although there are similarities in activities, facilitation involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case. Numerous contextual factors influenced the success of the implementation initiative.

CONCLUSION

The cases emphasized the complex nature of facilitation as a strategy for evidence implementation, indicating that contextual attributes and features define the range of knowledge, skills, and activities that should take place in order for facilitation to be effective. Although there appears to be some core components, tailoring and adaptation of the facilitation process (or roles) is required.

Peripherally Inserted Central Catheter by Interventional Nephrologists: Experiences from a Single Center

Purpose

As the number of patients with chronic kidney disease increases, nephrologist activities are gradually expanding. This study evaluated the safety and success of peripherally inserted central catheter (PICC) performed by nephrologists.

Patients and Methods

We retrospectively analyzed the medical records of a medical center. All patients underwent a PICC procedure by two nephrologists. The reasons for catheter removal were classified as accidental removal; treatment termination; catheter occlusion; vessel thrombosis; catheter-related infection, or patient death. Overall catheter complications were defined as catheter occlusion, vessel thrombosis, or catheter-related infection.

Results

A total of 335 catheterizations among 286 patients were performed. Overall, catheter removal was required during follow-up in 251 of 335 cases. The catheter was removed in 48 out of 251 (19.1%) cases with catheter-related complications. In univariate and multivariate analyses, diabetes mellitus was associated with catheter-related infection. The catheter survival rates were 85.3% at 1 month. In univariate and multivariate analyses, diabetes mellitus and fluoroscopy-guided insertion were associated with favorable catheter survival.

Conclusion

The results of our study showed high success and low complication rates for PICC insertion by nephrologists. These findings indicate that interventional nephrologists already skilled in other procedures can expand their field of activity and profit.

Broad-Spectrum Antibiotics for Breast Expander/Implant Infection: Treatment-Related Adverse Events and Outcomes

BACKGROUND

Despite best practices, infection remains the most common complication after breast reconstruction with expanders and implants, ranging from 2% to 29%. Empiric broad-spectrum antibiotics are frequently used in nonsurgical treatment of implant-associated infections in an effort to salvage the reconstruction. Pitfalls of antibiotherapy include adverse events, vascular access site complications, and drug resistance. Our goals were to describe management of implant infections with broad-spectrum antibiotics, review treatment related adverse events, and report on outcomes of therapy.

PATIENTS AND METHODS

A retrospective review was carried out to identify patients who were treated with intravenous (IV) antibiotics for periprosthetic infection. Patient characteristics, surgical details, and antibiotic therapy-related adverse events were collected. Eventual outcome related to expander/implant salvage was noted.

RESULTS

A total of 101 patients (111 treatment episodes) were identified. Mean duration of antibiotic treatment was 18 days (range, 1-40 days). The most commonly used parenteral treatment was a combination of daptomycin with piperacillin-tazobactam (65%) or an alternative agent (16%). Fifty-nine percent of treatment episodes resulted in salvage of the expander or implant. Thirty-five percent treatment episodes were associated with 1 or more adverse events: diarrhea (12.6%), rash (10%), vaginal candidiasis (3.6%), agranulocytosis/neutropenic fever (3.6%), nausea (3.6%), urinary complaint (0.9%), myositis (0.9%), headache (0.9%), vascular line occlusion (1.8%), deep vein thrombosis (1.8%), and finger numbness (0.9%). No patients developed Clostridium difficile colitis. Five episodes (4%) needed discontinuation of antibiotics because of severe adverse events. The prosthesis was explanted in 3 of the cases of discontinued treatment.

CONCLUSIONS

Our findings show favorable outcomes and well-tolerated adverse effects with broad-spectrum parenteral antibiotherapy for periprosthetic infection. However, every effort should be made to deescalate therapy by narrowing the spectrum or limiting the duration, to minimize adverse events and development of bacterial resistance. Treating surgeons need to carefully weigh benefits of therapy and be aware of potential complications that might necessitate discontinuation of treatment.

Oral Antibiotic Management of Acute Osteomyelitis of the Hand: Outcomes and Cost Comparison to Standard Intravenous Regimen

Background: Acute, direct inoculation osteomyelitis of the hand has traditionally been managed by intravenous antibiotics. With proven high levels of bone and joint penetration, specific oral antimicrobials may deliver clinical efficacy but at substantially lower cost. Methods: Sixty-nine adult patients with surgically proven acute, direct inoculation osteomyelitis of the hand were evaluated for clinical response on a 6-week postdebridement regimen of susceptibility-matched oral antibiotics. Inclusion required gross purulence and bone loss demonstrated at the initial debridement and radiographic evidence of bone loss. Excluded were 2 patients with extreme medical comorbidities. There were 53 men and 16 women with a mean age of 46 years. Mean follow-up was 16 weeks (±10). The cost model for the outpatient oral antibiotic treatment was intentionally maximized using Walgreen's undiscounted cash price. The cost model for the traditional intravenous treatment regimen was intentionally minimized using the fully discounted Medicare fee schedule. Results: All patients achieved resolution of osteomyelitis by clinical and radiographic criteria. In addition, 7 patients underwent successful subsequent osteosynthesis procedures at the previously affected site without reactivation. The mean postdebridement direct cost of care per patient in the study cohort was $482.85, the cost of the antibiotic alone. The postdebridement direct cost of care per patient on a regimen of vancomycin 1.5 g every 12 hours via peripherally inserted central catheter line was $21 646.90. Conclusions: Acute, direct inoculation osteomyelitis of the hand can be successfully managed on oral antibiotic agents with substantial direct and indirect cost savings.

From hospitalisation to primary care: integrative model of clinical pharmacy with patients implanted with a PICC line-research protocol for a prospective before-after study

INTRODUCTION

Clinical pharmacy improves patient safety and secures drug management using information, education and good clinical practices. However, medical device management is still unexplored, and proof of effectiveness is needed. A PICC line (peripherally inserted central catheter) is a medical device for infusion. It accesses the central venous system after being implanted in a peripheral vein. However, complications after implantation often interfere with smooth execution of the treatment. We hypothesise that clinical pharmacy for medical devices could be as effective as clinical pharmacy for medications. The main objective is to assess the effectiveness of clinical pharmacy activities on the complication rate after PICC line implantation.

METHODS AND ANALYSIS

This is a before-after prospective study. The study will begin with an observational period without clinical pharmacy activities, followed by an interventional period where pharmacists will intervene on drug and medical device management and provide personalised follow-up and advice. Sixty-nine adult patients will be recruited in each 6-month period from all traditional care units. The main inclusion criteria will be the implantation of a PICC line. The primary outcome is the decrease in the number of complications per patient and per month. Secondary outcomes are the consultation and hospital readmission rates, the acceptance rate of pharmaceutical interventions, the patients' quality of life, the direct hospital induced or avoided costs and the participants' satisfaction. Data will be collected using case report forms during hospitalisation and telephone follow-up after discharge. The analysis will compare these criteria during the two periods.

ETHICS AND DISSEMINATION

The study has received the approval of our Ethics Committee (Clermont-Ferrand Southeast VI, France, number AU1586). Results will be made available to the patients or their caregivers, the sponsor and other researchers when asked, as described in the consent form.

TRIAL REGISTRATION NUMBER

NCT04359056.

Novel high-strength thromboresistant poly(vinyl alcohol)-based hydrogel for vascular access applications

Adherence of proteins, cells, and microorganisms to the surface of biomaterials used for vascular access contribute to device failure by thrombosis, occlusions, and infections. Current technologies for inhibiting these complications are limited to coatings and additives that are limited in duration of efficacy and often induce adverse side effects. In this work, we developed a novel composite hydrogel structure comprising of a porous poly(vinyl alcohol) (PVA) that is impregnated with poly(acrylic acid) (PAA) and heat treated to create a physically cross-linked high-strength hydrogel material. The swelling and mechanical properties can be controlled by the temperature and duration of heat treatment to increase the cross-link density of the matrix. The heat treated composite PVA/PAA hydrogel exhibits both the mechanical strength and durability of thermoplastic polyurethanes (TPUs) and the inherently non-thrombogenic surface functionality of PVA-based hydrogels without the use of chemical cross-linking agents. The composite hydrogels were found to maintain their mechanical integrity and surface functionality after accelerated aging in a simulated-use in vitro model for 162.5 days real-time equivalent. Relative to commercial catheter materials, the composite PVA/PAA hydrogel exhibited up to an average of 97% reduction in platelet adhesion when exposed to an in vitro blood loop model and a lower rate of tip occlusion due to thrombosis. This high-strength thromboresistant hydrogel could have a major impact as a novel biomaterial for use in vascular access applications to improve patient health.

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

OBJECTIVE

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thrombotic risk factors in patients with superior vena cava syndrome undergoing chemotherapy via femoral inserted central catheter

OBJECTIVE

Our study aimed to scrutinize the incidence and risk factors of femoral inserted central catheter (FICC)-related thrombosis in patients with superior vena cava syndrome (SVCS) undergoing chemotherapy.

METHODS

A retrospective analysis of patients with SVCS undergoing chemotherapy who received FICC catheterization at the Xiangya Hospital, Central South University, Changsha City, Hunan Province between May 2012 and February 2019 was performed. Both asymptomatic thrombosis and symptomatic thrombosis were diagnosed by color doppler ultrasound (CDUS). Univariate and multivariate logistic regression analyses were performed to identify patient-, insertion-, and catheter-related factors.

RESULTS

Eight hundred and seventy-four patients with SVCS undergoing chemotherapy, with a total of 157,180 catheter days were enrolled in our study. FICC-related thrombosis was detected in 144 patients, and yielding an overall incidence of 16.47% or 0.92 events per 1000 catheter days. Of these, 19(2.17%) patients had symptomatic thrombosis. The mean time interval between FICC insertion and thrombosis onset was (10.40 ± 6.32) days and the mean catheter indwelling time was (179.84 ± 46.15) days. The history of deep venous thrombosis, treatment with vascular endothelial growth factor (VEGF) inhibitor (bevacizumab), puncture site (mid-thigh, groin), tip position and catheter size showed association with FICC-related thrombosis. Treatment with VEGF inhibitor [odds ratio (OR) = 2.779; 95%confidence interval (CI): 1.860-4.153; P < 0.001] and puncture site at the groin (OR = 10.843; 95%CI: 6.575-17.881; P < 0.001) were identified as independent risk factors of FICC-related thrombosis.

CONCLUSION

Treatment with VEGF inhibitor and puncture site at the groin during FICC catheterization were considered as high-risk factors in FICC-related thrombosis.

Peripheral Inserted Central Catheter Use and Related Infections in Clinical Practice: A Literature Update

Peripherally inserted central catheter (PICC) lines are commonly used by clinicians in daily practice. This strategy has been established the latest years as a common approach in many clinical conditions. Apart from their usefulness, PICC use is related to some complications. Aim of this review is to summarize all relevant publications regarding the PICC-related infection, as sepsis remains a high mortality syndrome. We conducted a PubMed search to identify all relevant publications referring to infective complications after insertion and use of PICC lines in hospitalized adult patients. A great number of publications suggest that PICC lines are widely used in the management of patients. The use of peripheral inserted central lines is related with a few complications, including bloodstream infections. Existing data mainly support their use in specific clinical conditions because of the low infectious rates. Some conflicting data also exist regarding PICC use, due to an unclear benefit from their use compared to other commonly used strategies. Although a number of complications, including bloodstream infections are related with insertion of PICC lines, their use has a promising role and can be used when indicated in a wide variety of clinical conditions, especially in specific categories of patients and prolonged periods.

Peripherally Inserted Central Catheter Postinsertion Complications: A Retrospective Study

PICC offers safe intravenous access for medium- to long-term use with inpatients. There is no association between overall complication rates and PICC material type. Oncology status is the strongest predictor of complications.

Complications related to the insertion and maintenance of peripheral venous access central venous catheter

OBJECTIVE

To evaluate the rates and nature of the complications related to the Central Peripheral Access Catheter (CVCAP or PICC) from its insertion to its withdrawal.

METHODS

Prospective observational study. All patients older than 14 years of age with a PICC inserted in the polyvalent intensive care unit (ICU) during the period between May 1, 2015 and April 30, 2016 were included. Data collected included: demographic data, insertion details, reason for insertion and removal, maintenance unit, total dwell time, incidence of complications and related factors and infection rate.

RESULTS

144 PICCs were inserted, of which 94 corresponded to the ICU group (65.28%) and 50 (34.72%) to the non-ICU group. The most important complication was the suspicion of infection: 17.36% (rate of 15.2 per 1000 days of PICC). The total number of confirmed infections was 6.25% (5.5 per 1000 days of PICC), 1.39% (1.2 per 1000 days) being in the ICU group and 4.86% (4.2 per 1000 days) in the non-ICU group. There were 5 bacteraemias, all in the non-ICU group (3 per 1000 days). The most frequent germ was Staphylococcus epidermidis (6 cases). Phlebitis had an incidence of 9.03% (7.9 per 1000 days of PICC).

CONCLUSIONS

PICC, effective device for central venous access due to the minimal incidence of risks in implantation and to its advantages with regard to the classic central venous catheters, is a further nursing technique.

Handgrip exercise reduces peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers: A randomized controlled trial

BACKGROUND

Peripherally-inserted central catheter-related venous thrombosis has serious complications including the loss of vascular access, recurrent venous thrombosis, and post-thrombotic syndrome. Current guidelines recommend non-pharmacological strategies to prevent peripherally-inserted central catheter-related venous thrombosis. There is little evidence for the effectiveness of handgrip exercise on the prevention of peripherally-inserted central catheter-related venous thrombosis.

OBJECTIVES

To examine the effectiveness of handgrip exercise using an elastic ball to prevent peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers.

DESIGN

A randomized controlled trial.

SETTINGS

One teaching hospital in Nanjing, China.

PARTICIPANTS

In total, 120 subjects with solid cancers were eligible; each had a new peripherally-inserted central catheter. They were recruited and randomly assigned into two exercise groups and one control group.

METHODS

Subjects from exercise groups 1 and 2 performed a 3-week, 25-repetition handgrip exercise, 3 and 6 times daily, respectively. The control group subjects performed a gentle limb exercise with no frequency and intensity requirements. Ultrasound was used to detect venous thrombosis development and examine axillary vein blood flow over the three points.

RESULTS

There were 32 cases of peripherally-inserted central catheter-related venous thrombosis detected. Two venous thrombosis cases in the control group were symptomatic, but all venous thrombosis cases in the exercise groups were asymptomatic. All venous thromboses were partial. There were significant differences in the incidence of venous thrombosis among the three groups (χ² = 12.813, p = 0.002; χ² = 9.340, p = 0.009; χ² = 11.480, p = 0.003; and χ² = 10.534, p = 0.005, respectively) at days 2, 3 and 21. The incidence of venous thrombosis in the two exercise groups was lower than that in the control group over the 3 time points (all, p < 0.05). The between-group effects and interaction effect in vein maximum velocity and time-mean flow velocity showed significant differences (F = 4.180, p = 0.025; F = 4.010, p = 0.045; and F = 2.928, p = 0.025) at days 2, 3, and 21, respectively. The axillary vein blood flow parameters in the control group were lower than those in the two exercise groups at day 21 (all, p < 0.05). However, no significant differences occurred in the incidence of venous thrombosis and axillary vein blood flow parameters between the two exercise groups.

CONCLUSION

Handgrip exercise using an elastic ball daily for three weeks could decrease the incidence of peripherally-inserted central catheter-related venous thrombosis. The method is simple, with no negative consequence reported. Further studies are required to confirm this conclusion and to explore the optimal frequency of handgrip exercise.

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.

Tunneled Catheter Placement in a Pediatric Patient: A Novel Approach

Establishing venous access can be an important and often complex aspect of care for pediatric patients. When stable central venous access is required for long-term intravenous infusions, several options are available including peripherally inserted central catheters (PICC), tunneled catheters and ports. Both PICC placement and tunneled catheter placement include an exposed external segment of catheter, either in an extremity or on the chest. We present a pediatric patient with complex behavioral history who required long-term intravenous therapy. After careful review, the best option for the patient was determined to be a tunneled catheter that exited the skin in the right upper back, making it difficult to grab and pull out. The catheter was successfully placed and the patient appropriately completed his intravenous antibiotic course. Upon completion, the catheter was removed without complications. This tunneling technique to the scapular region may be useful for patients with psychiatric or neurodegenerative disorders where purposeful dislodgement may be a problem.

Impact of arm selection on the incidence of PICC complications: results of a randomized controlled trial

INTRODUCTION

The aim of this study is to determine if right arm peripherally inserted central catheters (PICCs) experienced fewer complications while controlling for gender, hand dominance, history of malignancy, dwell time and catheter size.

METHODS

This was an intention-to-treat randomized controlled trial conducted in an academic medical center on two different sites between September 2012 and September 2015. All patients older than 18 years or age without known history of previous central line, contraindication to the use of a specific arm or hospitalized in the intensive care unit regardless of coagulation status, were considered for the study. Participants were randomized to the left or right arm group and were followed until catheter removal. Data collected included: PICC characteristics, insertion details, gender, arm dominance, history of malignancy, reason for insertion/removal, incidence of a complication and total dwell time. One-tailed hypothesis testing using a univariate logistic regression with odds ratio (OR) calculation was used to analyze the results. There were 202 patients randomly assigned, totaling 7657 catheter-days; 103 patients to the right-side group and 99 patients to the left-side group.

RESULTS

Participants in both groups were statistically equivalent for right handedness, gender, oncologic status, average dwell time and total catheter days. The overall incidence of complications on the right side was 23% versus 34% on the left side, confirming the hypothesis that right-sided insertions led to fewer complications (p = 0.046). The risk of a complication was reduced by 40% with right-sided insertion (OR 0.58 (CI: 0.31-1.09).

CONCLUSIONS

This study indicated fewer complications with right-sided insertion irrespective of hand dominance.

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

Background

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

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

Methods

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

Results

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

Conclusions

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

Complications of Peripherally Inserted Central Venous Catheters: A Retrospective Cohort Study

BACKGROUND AND AIM

The use of venous catheters is a widespread practice, especially in oncological and oncohematological units. The objective of this study was to evaluate the complications associated with peripherally inserted central catheters (PICCs) in a cohort of patients.

MATERIALS AND METHODS

In this retrospective cohort study, we included all patient carrying PICCs (n = 603) inserted at our institute between October 2010 and December 2013. The main variables collected were medical diagnosis, catheter care, location, duration of catheterization, reasons for catheter removal, complications, and nursing care. Complications were classified as infection, thrombosis, phlebitis, migration, edema, and/or ecchymosis.

RESULTS

All patients were treated according to the same "nursing care" protocol. The incidence rate of complications was two cases per 1000 days of catheter duration. The most relevant complications were infection and thrombosis, both with an incidence of 0.17 cases per 1000 days of the total catheterization period. The total average duration of catheterization was 170 days [SD 6.06]. Additionally to "end of treatment" (48.42%) and "exitus", (22.53%) the most frequent cause of removal was migration (displacement towards the exterior) of the catheter (5.80%).

CONCLUSIONS

PICCs are safe devices that allow the administration of long-term treatment and preserve the integrity of the venous system of the patient. Proper care of the catheter is very important to improve the quality life of patients with oncologic and hematologic conditions. Therefore, correct training of professionals and patients as well as following the latest scientific recommendations are particularly relevant.

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

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

Evaluation of 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.

Peripherally inserted central catheter cushioning: a pilot study comparing gauze with silicone foam

A pilot study was conducted to compare gauze with silicone foam that may be left in place for as long as seven days. Adult patients who were receiving treatment via peripherally inserted central catheters were recruited and alternately assigned to either the gauze or silicone foam group. Patient-reported itch and discomfort, nurse-reported ease of removal, and skin status were recorded for four weeks at each weekly dressing change.

Assessing the economic value of avoiding hospital admissions by shifting the management of gram+ acute bacterial skin and skin-structure infections to an outpatient care setting

OBJECTIVE

To estimate, from a US payer perspective, the cost offsets of treating gram positive acute bacterial skin and skin-structure infections (ABSSSI) with varied hospital length of stay (LOS) followed by outpatient care, as well as the cost implications of avoiding hospital admission.

METHODS

Economic drivers of care were estimated using a literature-based economic model incorporating inpatient and outpatient components. The model incorporated equal efficacy, adverse events (AE), resource use, and costs from literature. Costs of once- and twice-daily outpatient infusions to achieve a 14-day treatment were analyzed. Sensitivity analyses were performed. Costs were adjusted to 2015 US$.

RESULTS

Total non-drug medical cost for treatment of ABSSSI entirely in the outpatient setting to avoid hospital admission was the lowest among all scenarios and ranged from $4039-$4924. Total non-drug cost for ABSSSI treated in the inpatient setting ranged from $9813 (3 days LOS) to $18,014 (7 days LOS). Inpatient vs outpatient cost breakdown was: 3 days inpatient ($6657)/11 days outpatient ($3156-$3877); 7 days inpatient ($15,017)/7 days outpatient ($2495-$2997). Sensitivity analyses revealed a key outpatient cost driver to be peripherally inserted central catheter (PICC) costs (average per patient cost of $873 for placement and $205 for complications).

LIMITATIONS

Drug and indirect costs were excluded and resource use was not differentiated by ABSSSI type. It was assumed that successful ABSSSI treatment takes up to 14 days per the product labels, and that once-daily and twice-daily antibiotics have equal efficacy.

CONCLUSION

Shifting ABSSSI care to outpatient settings may result in medical cost savings greater than 53%. Typical outpatient scenarios represent 14-37% of total medical cost, with PICC accounting for 28-43% of the outpatient burden. The value of new ABSSSI therapies will be driven by eliminating the need for PICC line, reducing length of stay and the ability to completely avoid a hospital stay.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study

BACKGROUND

Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown.

OBJECTIVE

To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients.

DESIGN

Multicenter, cross-sectional study.

SETTING

3 academic medical centers in the United States.

PATIENTS

Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings.

MEASUREMENTS

To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests.

RESULTS

990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003).

LIMITATIONS

Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded.

CONCLUSION

Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted.

PRIMARY FUNDING SOURCE

None.

Non-invasive bedside assessment of central venous pressure: scanning into the future

BACKGROUND

Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign.

METHODS

Patients presenting for their regularly scheduled echocardiograms at the hospital echo department had clinical evaluations of their CVP using these non-invasive bedside techniques. The examiners were blinded to the echo results, each other's assessments, and patient history; their CVP estimates were compared to the gold standard level 3 echo-cardiographer's estimates at the completion of the study.

RESULTS

325 patients combined were examined (mean age 65, s.d. 16 years). When compared to the gold standard of central venous pressure by a level 3 echocardiographer, the JVP was the most sensitive at 86%, improving with clinical experience (p<0.01). The classic PVC technique and Anthem sign had better specificity compared to the JVP. Mini Echo estimates were comparable to physical exam assessments.

CONCLUSIONS

JVP evaluation is the most sensitive physical examination technique in CVP assessments. The PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP evaluation is problematic. Mini Echo estimates of CVPs are comparable to physical examination by trained clinicians and require less instruction. The use of Mini Echo in medical training should be further evaluated and encouraged.

The malposition of central venous catheters in children

Background

Contemporary medical care, especially in the field of pediatrics often requires central venous line (CVC – Central Venous Catheter) implantation for carrying out treatment. Some conditions are treated intravenously for several months, other require long-term venous access due to periodical administration of medications or daily nutritional supplementation.

Material/Methods

A total number of 309 CVCs were implanted at Children’s University Hospital in Cracow between January 2011 and December 2012 (24 months). Malposition of the CVC is not common. The target of our article was to present two rare cases of malposition of catheters and two displacements of catheter due to chest tumors, and to enhance the importance of differential diagnostic imaging when difficulties occur.

Results

CVC malposition was detected with different imaging modalities followed by appropriate medical procedures.

Conclusions

In case of any difficulties with central lines, it is necessary to investigate the underlying cause. The central line team at hospital cooperating with other specialists is needed to detect complications and to prevent them.

Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone?

BACKGROUND

Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT).

METHODS

We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors.

RESULTS

Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083).

CONCLUSIONS

PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.

Neonatal intestinal physiology and failure

The neonatal intestine is a complex organ that regulates the absorption of nutrients essential for growth and development. Intestinal failure results from insufficient or functionally inadequate bowel and can lead to failure of neonatal growth and development. Current literature on neonatal intestinal physiology and failure was reviewed and summarized. A homeostatic interplay of electrolytes, enzymes, and hormonal regulators is essential to achieve the physiologic balance needed for adequate intestinal performance. Physiologic consequences of intestinal failure are dependent on the length and anatomic location of the diseased or surgically resected bowel. Intestinal failure leads to disruption of normal intestinal physiology and may have long-term consequences for growth and development if inadequately treated. Parenteral nutrition remains the mainstay of treatment for neonatal intestinal failure.