Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis

Thrombosis and infections associated with PICC in onco-hematological patients, what is their relevance?

PURPOSE

Peripherally inserted central venous catheters (PICC) in the onco-hematological patients may be associated with thrombosis or infections that may have short- to medium-term repercussions.

MATERIAL AND METHODS

Single-centre retrospective analysis of a prospectively collected cohort. Primary objective was to establish the PICC-thrombosis and infections incidence. Secondary objectives were to analyze profile of patients suffering from these complications and variables associated with an increased likelihood of developing these events.

RESULTS

549 patients were recruited. 58.5% (n = 321) were oncology patients and 41.5% (n = 228) hematology patients. The incidence of PICC-associated thrombosis was 3.5% (n = 19). Thrombosis was associated with progression of the underlying malignant pathology in 10.6% (n = 2) of cases. No association was found between clinical variables analysed and development of thrombosis. Incidence of PICC-associated infections was 7.65% (n = 42). In the 30 days prior to PICC infection, 57.1% (n = 24) had a febrile syndrome of another focus, 73.8% (n = 11) had been hospitalized, 49.5% (n = 25) had a neutrophil count of 0-500 cells/mm3 and 47.6% (n = 20) had an episode of neutropenic fever. Variables significantly associated with the development of infection were hematological patients, high-flow PICC, 3-lm PICC or PICC insertion because of administration of vesicant therapy.

CONCLUSIONS

Incidence of PICC-associated thrombosis is low and apparently less prognostically aggressive than other forms of thrombosis associated with cancer, without identify predictive factors. Infection was more prevalent and the identification of risk factors in our series could facilitate its prevention.

Safety and effectiveness of tunneled peripherally inserted central catheters versus conventional PICC in adult cancer patients

OBJECTIVES

This study aimed to compare the safety and effectiveness of tunneled peripherally inserted central catheters (T-PICC) vs. conventional PICCs (C-PICC) in adult cancer patients.

METHODS

A multicentre randomized controlled trial was conducted between April 2021 and January 2022 in seven hospitals in China. 564 participants were randomly assigned to T-PICC or C-PICC. These data were collected and compared: the baseline characteristics and catheterization-related characteristics, periprocedural complications, and long-term complications.

RESULTS

Five-hundred fifty-three participants (aged, 52.6 ± 12.3 years; female, 39.1%) were ultimately analyzed. No significant differences in periprocedural complications were found between the T-PICC and C-PICC groups (all p > 0.05). Compared with C-PICC, T-PICC significantly reduced the incidence of long-term complications (26.4% vs. 39.9%, p < 0.001). Specifically, reduced complications were found in central line-associated bloodstream infection (1.8% vs. 5.1%, p = 0.04), thrombosis (1.1% vs. 4.0%, p = 0.03), catheter dislodgement (4.7% vs. 10.1%, p = 0.01), non-infectious oozing (17.3% vs. 28.6%, p = 0.002), local infection (3.6% vs. 7.6%, p = 0.04), skin irritation (6.1% vs. 10.9%, p = 0.046), and reduced unplanned catheter removal (2.2% vs. 7.2%, p = 0.005). No significant differences were found between T-PICC and C-PICC regarding catheter occlusion (6.5% vs. 5.8%, p = 0.73) or skin damage (2.2% vs. 2.9%, p = 0.58).

CONCLUSION

T-PICC is safe and effectively reduces long-term complications.

CLINICAL RELEVANCE STATEMENT

The tunneled technique is effective in reducing PICC-related long-term complications. Thus, it is recommended for cancer patients at high risk of PICC-related complications.

TRIAL REGISTRATION

The registration number on https://www.chictr.org.cn/ is ChiCTR2100044632. The name of the trial registry is "A multicenter randomized controlled study of clinical use of tunneled vs. non-tunneled PICC".

KEY POINTS

Cather-related complications are associated with the technique of catheterization. Compared with conventional PICC, tunneled PICC reduced catheter-related long-term complications. Tunneled PICC placement provides an alternative catheterization method for cancer patients.

Quality appraisal of clinical guidelines for peripherally inserted central catheter-related thrombosis prophylaxis in patients: a systematic review

OBJECTIVES

To evaluate and analyse the quality of clinical practice guidelines for Peripherally Inserted Central Catheter-related thrombosis (PICC-related thrombosis) to identify the most current and effective prophylactic measures recommended in the guidelines.

DESIGN

Scoring and analysis of the guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

DATA SOURCES

Cochrane Library, PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Chinese databases (China National Knowledge Infrastructure and Wan Fang) and the relevant websites of the guideline were searched through 8 August 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies that primarily clinical practice guidelines on the prevention of PICC-related thrombosis were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the searched items and extracted data and scored documents using AGREE II. Findings were summarised in Grading of Recommendation, Assessment, Development and Evaluation (GRADE) evidence profiles and synthesised qualitatively.

RESULTS

The analysis incorporated a total of nine guidelines, all rated as 'recommended' or 'recommended with modifications'. Standardised scores revealed elevated performance in the domains of Scope and Purpose, Clarity of Presentation and Editorial Independence. Conversely, the Stakeholder Involvement and Applicability domains yielded the lowest average standardised scores. Disparities in standardised scores across guidelines were particularly evident in the domains of Rigour of Development, Stakeholder Involvement and Applicability. The agreement between the two appraisers was almost perfect (intraclass correlation coefficients higher than 0.80). A considerable proportion of recommendations relied on evidence of low-quality, in certain instances, were derived from expert opinions within working groups.

CONCLUSIONS

The review reveals that a significant portion of recommendations relies on low-quality evidence. Guideline developers are urged to prioritise methodological quality, with a specific focus on refining Stakeholder Involvement and Applicability domains. Addressing these aspects will enhance the overall quality and reliability of PICC-related thrombosis prevention guidelines. One potential way to mitigate these challenges is to endorse a standardised approach to guideline development and to synthesise reliable clinical evidence to reduce variation in recommendations.

PROSPERO REGISTRATION NUMBER

CRD42023495519.

Guidelines for the Prevention, Diagnosis, and Management of Urinary Tract Infections in Pediatrics and Adults: A WikiGuidelines Group Consensus Statement

Importance

Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.

Objective

To create a clinical guideline for the diagnosis and management of urinary tract infections that addresses the gap between the evidence and recommendation strength.

Evidence Review

This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In May 2023, new and existing members were solicited for questions on urinary tract infection prevention, diagnosis, and management. For each topic, literature searches were conducted up until early 2024 in any language. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were developed discussing the available literature and associated risks and benefits of various approaches.

Findings

A total of 54 members representing 12 countries reviewed 914 articles and submitted information relevant to 5 sections: prophylaxis and prevention (7 questions), diagnosis and diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment and antimicrobial stewardship (10 questions), and special populations and genitourinary syndromes (10 questions). Of 37 unique questions, a clear recommendation could be provided for 6 questions. In 3 of the remaining questions, a clear recommendation could only be provided for certain aspects of the question. Clinical reviews were generated for the remaining questions and aspects of questions not meeting criteria for a clear recommendation.

Conclusions and Relevance

In this consensus statement that applied the WikiGuidelines method for clinical guideline development, the majority of topics relating to prevention, diagnosis, and treatment of urinary tract infections lack high-quality prospective data and clear recommendations could not be made. Randomized clinical trials are underway to address some of these gaps; however further research is of utmost importance to inform true evidence-based, rather than eminence-based practice.

A multi-center big-data approach for precise PICC-RVT prognosis and identification of major risk factors in clinical practice

Background

The Peripherally Inserted Central Catheter (PICC) is a widely used technique for delivering intravenous fluids and medications, especially in critical care units. PICC may induce venous thrombosis (PICC-RVT), which is a frequent and serious complication. In clinical practice, Color Doppler Flow Imaging (CDFI) is regarded as the gold standard for diagnosing PICC-RVT. However, CDFI not only requires prominent time and effort from experienced healthcare professionals, but also relies on the formation and development of PICC-RVT, especially at early stages of PICC-RVT, when PICC-RVT is not apparent. A prognosis tool for PICC-RVT is crucial to bridge the gap between its diagnosis and treatment, especially in resource-limited settings, such as remote healthcare facilities.

Objective

Evaluate over 14,885 models from various machine learning techniques to identify an effective prognostic model (referred to as PRAD - PICC-RVT Assessment via Deep-learning) for quantifying the risks associated with PICC-RVT.

Methods

To tackle the challenges associated with PICC-RVT diagnosis, we gathered a comprehensive dataset of 5,272 patients from 27 healthcare centers across China. From a pool of 14885 models from various machine learning techniques, we systematically screened a data-driven prognostic model to quantify the risks associated with PICC-RVT. This model aims to provide objective evidence, and facilitate timely interventions.

Results

The proposed model displayed exceptional predictive accuracy, achieving an accuracy of 86.4 % and an AUC of 0.837. Based on the prognosis model, we further incorporated a weight analysis to identify the major contributing factors for PICC-RVT risk during catheterization. Albumin levels, primary diagnosis, hemoglobin levels, platelet levels, and education level are emphasized as important risk factors.

Conclusions

Our method excels in predicting early PICC-RVT risks, especially in asymptomatic patients. The findings in this paper offers insights into controllable PICC risk factors that could benefit vast patients and reduce disease burden through stratification and early intervention.

A 12-Year Review of Upper Extremity Deep Vein Thrombosis-Are They the Same as Lower Extremity Deep Vein Thrombosis?

Background: Upper extremity deep vein thrombosis (UEDVT) is uncommon but not insignificant. The current literature is limited, and the management is largely extrapolated from the treatment of lower extremity DVTs (LEDVT). Methods: A retrospective review was conducted on patients diagnosed with UEDVT at Northern Health, Victoria, Australia, between December 2010 and December 2022. Medical records were reviewed to assess baseline characteristics and treatment outcomes. The results were compared to our previously collected data for LEDVTs. Results: 137 patients with UEDVT were identified (52.6% females; median age 62 years, IQR 46-74 years). A total of 105 patients (76.6%) had at least one provoking factor at the time of diagnosis, most commonly malignancy (45.7%) and/or indwelling venous devices (58.1%). Fourteen patients (10.1%) were subsequently diagnosed with Paget-Schroetter syndrome, with nine receiving endovascular or surgical intervention. A total of 109 patients (79.6%) received limited therapeutic anticoagulation (median 3 months, IQR 1.5-6.0 months) with enoxaparin, the most common anticoagulant used. Six patients had major bleeding (5.2/100-patient-years), and seven developed clot progression while on anticoagulation (6.0/100-patient-years). Ten patients had recurrent VTE following anticoagulation cessation (4.6/100-patient-years). There were no significant differences seen in the complication rate between catheter-related UEDVT and other UEDVTs. Compared to LEDVT, UEDVT was more likely provoked with comparable complication rates. Conclusions: UEDVTs were commonly associated with a provoking factor, with indwelling catheters and/or malignancies being the most common. Interestingly, catheter-related UEDVT had comparable clot progression/recurrence and major bleeding compared to other UEDVTs and LEDVTs, which may be confounded by relatively high rates of malignancy.

Systematic review and meta-analysis of the association between ABCA7 common variants and Alzheimer's disease in non-Hispanic White and Asian cohorts

Background and aims

The relationship between the ABCA7 gene and Alzheimer's disease (AD) has been widely studied across various populations. However, the results have been inconsistent. This meta-analysis aimed to evaluate the association of ABCA7 polymorphisms with AD risk, including specific subtypes such as late-onset Alzheimer's disease (LOAD).

Methods

Relevant studies were identified through comprehensive database searches, and the quality of each study was assessed using the Newcastle-Ottawa Scale (NOS). Allele and genotype frequencies were extracted from the included studies. The pooled odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated using random-effects or fixed-effects models. Multiple testing corrections were conducted using the false discovery rate (FDR) method. The Cochran Q statistic and I2 metric were used to evaluate heterogeneity between studies, while Egger's test and funnel plots were employed to assess publication bias.

Results

A total of 36 studies, covering 21 polymorphisms and involving 31,809 AD cases and 44,994 controls, were included in this meta-analysis. NOS scores ranged from 7 to 9, indicating high-quality studies. A total of 11 SNPs (rs3764650, rs3752246, rs4147929, rs3752232, rs3752243, rs3764645, rs4147934, rs200538373, rs4147914, rs4147915, and rs115550680) in ABCA7 were significantly associated with AD risk. Among these SNPs, two (rs3764650 and rs3752246) were also found to be related to the late-onset AD (LOAD) subtype. In addition, two SNPs (rs4147929 and rs4147934) were associated with the susceptibility to AD only in non-Hispanic White populations. A total of 10 SNPs (rs3764647, rs3752229, rs3752237, rs4147932, rs113809142, rs3745842, rs3752239, rs4147918, rs74176364, and rs117187003) showed no significant relationship with AD risk. Sensitivity analyses confirmed the reliability of the original results, and heterogeneity was largely attributed to deviations from Hardy-Weinberg equilibrium, ethnicity, and variations between individual studies.

Conclusion

The available evidence suggests that specific ABCA7 SNPs may be associated with AD risk. Future studies with larger sample sizes will be necessary to confirm these results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42024540539.

Incidence and risk factors for central venous access device failure in hospitalized adults: A multivariable analysis of 1892 catheters

BACKGROUND

Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion.

OBJECTIVE

To quantify CVAD failure and complications; and identify risk factors.

DESIGNS, SETTINGS, AND PARTICIPANTS

Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations.

RESULTS

In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24-5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68-6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31-6.68), and diabetes (HR 3.25, 95%CI 1.40-7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08-0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14-0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48-33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08-6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk.

Development and evaluation of a PICC virtual simulator in neonatal nursing: A randomized controlled trial

BACKGROUND

Peripherally Inserted Central Catheter (PICC) is essential in neonatal care, especially for critically ill infants. Traditional training for neonatal PICC insertion faces challenges such as high costs and limited practice opportunities. Virtual simulation technology has emerged as a potential training tool, providing a realistic, risk-free learning environment.

OBJECTIVES

The study aimed to assess the effectiveness of a virtual simulation teaching system in neonatal PICC care training, focusing on improving nursing students' knowledge， skills and interest in pediatric nursing.

DESIGN

A quasi-experimental design was used, with assessments conducted before and after the activity.

PARTICIPANTS

The study involved 58 graduate nursing students from China Medical University, divided into experimental and control groups.

METHODS

The System Usability Scale (SUS) was utilized to assess teachers' experiences with the PICC virtual simulation software. Students' perceptions of the software and their interest in pediatric nursing were measured using Self-Administered Questionnaires. Furthermore, Theoretical and Operational Assessments were applied to determine the extent of students' knowledge and practical skills before and after experimentation.

RESULTS

Teachers and students have favorably evaluated the software system, with notable improvements in theoretical scores following testing. While the virtual simulation system does not enhance practical skills, it does increase student interest in pediatric nursing and employment.

CONCLUSIONS

This neonatal virtual simulation software serves as a complement to, rather than a replacement for, traditional clinical training. Its integration into educational programs significantly enhances learning outcomes.

Prevention of complications for hospitalized patients receiving parenteral nutrition: A narrative review

Hospitalized patients may benefit from parenteral nutrition to address their compromised nutrition status attributed to limited oral/enteral intake and increased nutrient/energy requirement during acute illness. Parenteral nutrition, however, can be associated with many complications that can negatively impact patient outcomes. In this review, we focus on potential metabolic and catheter-related complications associated with parenteral nutrition use. We report on potential risk factors for such complications and highlight strategies for prevention and early recognition. To optimize outcomes, key findings include the creation and implementation of evidence-based protocols with proven efficacy. For each hospital unit delivering parenteral nutrition to patients, tracking compliance with established protocols and patient outcomes is crucial for ongoing improvement through identification of gaps, proper reeducation and training, and ongoing refinement of care protocols. Establishment of specialized inpatient nutrition support teams should be considered.

Performance and safety of PowerPICC catheters and accessories: a prospective observational study

OBJECTIVE

This study aimed to evaluate the safety and performance of PowerPICC catheters in a real-world setting.

DESIGN

Prospective, observational, multicentre study.

SETTING

Nine European countries, involving 14 centres.

PARTICIPANTS

General patient population.

INTERVENTION

PowerPICC catheter inserted by the clinician as standard of care with routinely collected outcomes followed through device removal or 180 days postinsertion.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Safety and performance outcomes were assessed for PowerPICC, PowerPICC SOLO 2 and PowerGroshong PICC. The primary safety endpoint was the incidence of symptomatic venous thrombosis (VT), and secondary safety endpoints included phlebitis, extravasation, vessel laceration, vessel perforation local infection, accidental dislodgment and catheter-related bloodstream infection (CRBSI). The primary performance endpoint was the percentage of patients whose PowerPICC device remained in place through the completion of therapy. The secondary performance endpoints included catheter patency, placement success in a single attempt and usability.

RESULTS

The enrolled patients (N=451) received either PowerPICC, PowerPICC SOLO 2 or PowerGroshong PICC catheters. Across all devices, 1.6% of patients developed symptomatic VT, and CRBSI occurred in 1.6% of patients. There were no cases of phlebitis or extravasation and only three cases of vein laceration or vein perforation. The catheters showed high success rates in completing therapy (81.8%), maintaining patency (93.9%) and achieving successful placement in a single attempt (90.4%). Clinicians overwhelmingly agreed that both the guidewire and stylet (93.3% and 94.4%, respectively) were easy or very easy to use.

CONCLUSIONS

This study demonstrates the safety and performance of PowerPICC catheters across diverse settings and patient cohorts in real-world hospital settings across Europe. The findings indicate that these catheters are safe and can be effectively used in the general patient setting and when inserted by a variety of clinicians. The low incidence of complications and high success rates further support the clinical utility of these catheters.

TRIAL REGISTRATION NUMBER

NCT04263649.

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

The safety of peripherally inserted central venous catheters in critically ill patients: A retrospective observational study

BACKGROUND

Centrally inserted central venous catheters (CICCs) are commonly placed in critically ill patients who require a central venous catheter (CVC). Recently, peripherally inserted central venous catheters (PICCs) have been widely used on general wards. However, the safety of PICCs in critically ill patients remains unclear.

METHOD

We conducted a retrospective observational study at a mixed intensive care unit (ICU). Adult patients (⩾18 years) who were emergently admitted to the ICU and underwent CVC insertion between April 2019 and March 2021 were enrolled. We compared the safety of PICCs and CICCs. The primary outcome was the overall rate of catheter-related complications, including bloodstream infections, thrombosis, insertional trauma, catheter malfunction, and accidental removal. We used a stabilized inverse probability weighting (sIPW) model to estimate the effects of PICC use.

RESULTS

A total of 239 CVCs (PICCs, 53; CICCs, 186) were inserted into 229 patients. Although the severity of illness did not differ significantly between the groups, the length of hospital stay and mean indwelling catheter duration were significantly longer in the PICC group. There was no significant intergroup difference in the overall rate of catheter-related complications (PICC: 9.4% vs CICC: 3.8%; odds ratio [OR]: 2.65; 95% confidence interval [CI]: 0.63-10.2, p = 0.145), and there were 7.7 and 9.0 complications per 1000 catheter days in the PICC and CICC groups, respectively (hazard ratio [HR]: 0.61; 95% CI: 0.14-2.65, p = 0.513). After adjustment using the sIPW model, PICC use was not found to be associated with a reduction in catheter-related complications (adjusted OR: 3.10; 95% CI: 0.90-10.7; adjusted HR: 0.53; 95% CI: 0.14-1.97).

CONCLUSION

We found no significant differences in catheter-related complications between patients treated using CICCs and those treated using PICCs after emergency ICU admission. Our findings imply that PICCs may be an alternative to CICCs in critically ill patients.

The effect of introducing a nurse-practitioner-led peripherally inserted central venous catheter placement program on the utilization of central venous access device: A retrospective study in Japan

BACKGROUND

Nurse-led peripherally inserted central venous catheter (PICC) placement teams are common in western hospitals, but they are still in their infancy in Japan. Although implementing a dedicated program may improve ongoing vascular-access management, the direct hospital-level effects of launching a nurse-led PICC team on specific outcomes have not been formally investigated.

OBJECTIVES

To evaluate the effect of introducing a nurse practitioner (NP)-led PICC-placement program on subsequent utilization of centrally inserted central catheters (CICCs) and to contrast the quality of PICC placements conducted by physicians and NPs.

MATERIALS AND METHODS

Patients who underwent central venous access devices (CVADs) between 2014 and 2020 at a university hospital in Japan were evaluated retrospectively using an interrupted time-series analysis on the trend for monthly CVAD utilization and logistic regression and propensity score-based analyses for PICC-related complications.

RESULTS

Among 6007 CVAD placements, 2230 PICCs were inserted into 1658 patients (725 by physicians and 1505 by NPs). The monthly number of CICC utilization fell from 58 in April 2014 to 38 in March 2020, while PICC placements by the NP PICC team increased from 0 to 104. The implementation of the NP PICC program reduced the immediate rate (by 35.5; 95% confidence interval [CI]: 24.1-46.9; p < 0.001) and post-intervention trend (by 2.3; 95% CI: 1.1-3.5; p < 0.001) of monthly CICC utilization. Overall immediate complication rates were lower in the NP group than the physician group (1.5% vs 5.1%; adjusted odds ratio = 0.31; 95% CI: 0.17-0.59; p < 0.001). The cumulative incidences of central line-associated bloodstream infections were comparable between the NP and physician groups (5.9% vs 7.2%; adjusted hazard ratio = 0.96; 95% CI: 0.53-1.75; p = .90).

CONCLUSIONS

This NP-led PICC program reduced CICC utilization without affecting the quality of PICC placement or complication rate.

Infiltration and Extravasation Risk with Midline Catheters: A Narrative Literature Review

Midline catheters have recently gained popularity in clinical use, with a common reason being the reduction of central venous catheter use and central line-associated bloodstream infections. At the same time, the number of nononcology vesicant medications has increased, and midline catheters are frequently being used for infusions of vesicant medications. The Infusion Nurses Society (INS) Vesicant Task Force identified midline catheter use as a possible risk factor for extravasation and concluded that a thorough literature review was necessary. This review highlights the variations in catheter terminology and tip locations, the frequency of infiltration and extravasation in published studies, and case reports of infiltration and extravasation from midline catheters. It also examines the many clinical issues requiring evidence-based decision-making for the most appropriate type of vascular access devices. After more than 30 years of clinical practice with midline catheters and what appears to be a significant number of studies, evidence is still insufficient to answer questions about infusion of vesicant and irritant medications through midline catheters. Given the absence of consensus on tip location, inadequate evidence of clinical outcomes, and importance of patient safety, the continuous infusion of vesicants, all parenteral nutrition formulas, and infusates with extremes in pH and osmolarity should be avoided through midline catheters.

Effectiveness of a nurse-led peripherally inserted central catheter service: A retrospective cohort study

BACKGROUND

A multitude of challenges arises from the growing utilisation of peripherally inserted central catheters (PICCs), including the ability to provide timely, effective and safe insertion, which must be ensured and prioritised in patient care. A nurse-led model of care has become more prevalent as PICCs become extensively needed due to their applications. However, despite their widespread use, such intervention is yet in its inception in Saudi Arabia, and thereby, evaluating the outcomes of this service is of utmost importance to support patient safety initiatives and quality of care.

PURPOSE

This research aims to assess the effectiveness of a nurse-led PICC placement service.

METHODS

A quantitative retrospective cohort design was used. The sample of this study was 333 random subsets of records on PICC insertion for adult patients between 1st April 2019 and 31st March 2023 in a tertiary medical facility in Riyadh, Saudi Arabia.

RESULTS

A nurse-led PICC service demonstrated an overall successful placement of 330 cases (99.1%), out of which 323 PICCs (97%) were successfully inserted under intra-cavitary electrocardiogram (IC-ECG) guidance, while 7 PICCs (2.1%) were successfully inserted with fluoroscopy. The overall complication rate was 2.35 occurrences per 1000 CL days, whereas the complication rate within the first 10 days after PICC insertion was 0.42 per 1000 CL days.

CONCLUSION

A nurse-led model for PICC insertion has remarkably high success rates and low rates of complication, highlighting the pivotal role of a specialised PICC team. This service boasted a commendable track record of achieving a high rate of success in its implementation, implying that a nurse-led PICC service operates effectively to improve the patient experience by delivering timely and high-quality healthcare service.

A Monocentric Analysis of Implantable Ports in Cancer Treatment: Five-Year Efficacy and Safety Evaluation

BACKGROUND

Daily clinical practice requires repeated and prolonged venous access for delivering chemotherapy, antibiotics, antivirals, parenteral nutrition, or blood transfusions. This study aimed to investigate the performance and the safety of totally implantable vascular access devices (TIVADs) over a 5-year follow-up period through a standardized well-trained surgical technique and patient management under local anesthesia.

METHODS

In a retrospective, observational, and monocentric study, 70 patients receiving POLYSITE® TIVADs for chemotherapy were included. The safety endpoints focused on the rate of perioperative, short-term, and long-term complications. The performance endpoints included vein identification for device insertion and procedural success rate.

RESULTS

The study demonstrated no perioperative or short-term complications related to the TIVADs. One (1.4%) complication related to device manipulation was identified as catheter flipping, which led to catheter adjustment 56 days post-placement. Moreover, one (1.4%) infection due to usage conditions was observed, leading to TIVAD removal 3 years and 4 months post-surgery. Catheter placement occurred in cephalic veins (71.4%), subclavian veins (20%), and internal jugular veins (8.6%). The procedural success rate was 100%. Overall, the implantable ports typically remained in place for an average of 22.4 months.

CONCLUSIONS

This study confirmed the TIVADs' performance and safety, underscored by low complication rates compared to published data, thereby emphasizing its potential and compelling significance for enhancing routine clinical practice using a standardized well-trained surgical technique and patient management.

A GAVeCeLT consensus on the indication, insertion, and management of central venous access devices in the critically ill

Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions).

Long-term intravenous devices: a narrative review of their placement

PURPOSE OF REVIEW

This review summarizes the latest findings and recommendations about the characteristics, indications and use of peripheral and central long-term venous access devices.The various complications inherent in these devices are becoming better known, and their contributing factors determined, which could make it possible to reduce their incidence.

RECENT FINDINGS

Some measures are integrated into recommendations for good practice, such as appropriate selection of devices, the preferential use of the thinnest catheters, and cyanoacrylate glue and dressings impregnated with chlorhexidine.

SUMMARY

Improving understanding of the phenomena leading to infectious and thrombotic complications, as well as better knowing the differences between intravenous devices and their respective indications, should lead to improvement of in-hospital and out-of-hospital care.

Implementation contexts and strategies for alternative peripherally inserted central catheter material and design selection: A qualitative exploration using CFIR/ERIC approach

AIM

To explore the implementation contexts and strategies that influence the uptake and selection of alternative peripherally inserted central catheter (PICC) materials and design.

DESIGN

Qualitative evaluation of end user perspectives within a randomized control trial of different PICC materials and design.

METHODS

Semi-structured interviews with key stakeholders were undertaken via an adapted, rapid-analytic approach using the Consolidated Framework for Implementation Research. Outcomes were mapped against the Expert Recommendations for Implementing Change (ERIC) tool for strategies to guide innovation in PICC practice.

RESULTS

Participants (n = 23) represented a combination of users and inserters/purchasers, from adult and paediatric settings. Dominant themes included intervention characteristics (intervention source), inner setting (structural characteristics) and individuals involved (self-efficacy). Strategies emerging to support a change from ERIC mapping (n = 16) included promotion of intervention adaptability, inclusion of staff and consumer perspectives and sufficient funding. Implementation contexts such as inner setting and individuals involved equally impacted PICC success and implementation effectiveness and enabled a greater understanding of barriers and facilitators to intervention implementation in this trial.

CONCLUSION

Trial evidence is important, but healthcare decision-making requires consideration of local contexts especially resourcing. Implementation contexts for Australian healthcare settings include a practical, strategic toolkit for the implementation of alternative PICC materials and designs.

REPORTING METHOD

This study adhered to COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The association between ABO blood types and peripherally inserted central catheter-related venous thrombosis for patients with cancer: A retrospective 7-year single-center experience and meta-analysis

BACKGROUND

This meta-analysis evaluated the association of ABO blood type on central venous catheter-related thrombosis (CRT).

METHODS

Data were derived from 8477 patients at Sichuan Cancer Hospital from January 2015 to December 2021 and articles previously published in Chinese and English databases. Data from our hospital were collected by reviewing electronic medical records. Searched databases included CNKI, VIP, Wan Fang, China Biomedical, PubMed, Cochrane Library, Web of Science, EMBASE, CINAHL, and OVID (up to July 2023). All statistical analyses were performed using SPSS 22.0 and Revman 5.3. The Bonferroni method was used to adjust the α test level for reducing the risk of I errors in the multiple comparisons. A P-value < 0.05 was considered statistically significant. Continuous variables were analyzed using a two-independent sample T test. The chi-squared test was used to analyze categorical data.

RESULTS

A total of 818 studies were identified in the search. However, only four studies met the inclusion criteria. Combined with data from our hospital, five studies were included with a total of 18407 cases. Those studies only focused on peripherally inserted central catheter (PICC). According to the data from our hospital, logistic regression revealed that myelosuppression [odds ratio (OR), 1.473; P = 0.005) and radiotherapy(OR, 1.524; P<0.001) were independent risk factors for symptomatic PICC- VTE. Blood types A (OR, 1.404; P = 0.008), B (OR, 1.393; P = 0.016), and AB (OR, 1.861; P<0.001) were associated with a significantly higher risk of symptomatic PICC-VTE than blood type O. And the hematologic tumor has a significantly higher risk of PICC-VTE than breast cancer (OR, 0.149; P < 0.001), and gynecological tumor (OR, 0.386; P = 0.002). In the meta-analysis of the association between ABO blood type and PICC related thrombosis, the I2 statistic was not significant in any of the pairwise comparisons, and a fixed-effects model was subsequently used for all analyses. The meta-analysis indicated that the incidence of symptomatic PICC related thrombosis was significantly lower in individuals with the O blood type (3.30%) than in those with the A (4.92%), B (5.20%), or AB (6.58%) blood types (all P < 0.0083). However, in the pairwise comparisons among A, B, and AB, the differences were nonsignificant (P > 0.0083).

CONCLUSIONS

According to the results from our single center analysis, we found that myelosuppression, radiotherapy, hematologic tumor, and non-O blood type were independent risk factors for symptomatic PICC related thrombosis. In the meta-analysis of further exploration of ABO blood type and PICC related thrombosis, we found that ABO blood type may influence PICC related thrombosis, and individuals with the O blood type had a lower risk of PICC related thrombosis than those with non-O blood type.

Risk assessment models for PICC-related venous thrombosis in adult patients with cancer: A network meta-analysis

OBJECTIVES

This review aims to compare the performance of available risk assessment models (RAMs) for predicting peripherally inserted central catheter-related venous thrombosis (PICC-RVT) in adult patients with cancer.

METHODS

A systematic search was conducted across ten databases from inception to October 20, 2023. Studies were eligible if they compared the accuracy of a RAM to that of another RAM for predicting the risk of PICC-RVT in adult patients with cancer. Two reviewers independently performed the study selection, data extraction and risk of bias assessments. A Bayesian network meta-analysis (NMA) was used to evaluate the performance of the RAMs.

RESULTS

A total of 1931 studies were screened, and 7 studies with 10 RAMs were included in the review. The most widely used RAMs were the Caprini (4 studies), Padua prediction score (3 studies), Autar (3 studies), Michigan risk score (2 studies) and Seeley score (2 studies). The sensitivity, specificity and accuracy varied markedly between the models. Notably, the Caprini score achieved higher sensitivity than 4 RAMs (Wells, Revised Geneva, modified MRS, MRS). The Michigan risk score had greater specificity than did the other 6 RAMs (Caprini, Autar, Padua, Seeley, the novel RAM, Wells). The predictive accuracy of the MRS is significantly greater than that of the Caprini and Autar RAM.

CONCLUSION

The MRS could be the most accurate RAM for identifying patients at high risk of PICC-RVT. However, as limited studies are available, more rigorous studies should be conducted to examine the accuracy of the Michigan risk score for PICC-RVT in different contexts.

Peripherally inserted central catheter design and material for reducing catheter failure and complications

BACKGROUND

Peripherally inserted central catheters (PICCs) facilitate diagnostic and therapeutic interventions in health care. PICCs can fail due to infective and non-infective complications, which PICC materials and design may contribute to, leading to negative sequelae for patients and healthcare systems.

OBJECTIVES

To assess the effectiveness of PICC material and design in reducing catheter failure and complications.

SEARCH METHODS

The University of Queensland and Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the WHO ICTRP and ClinicalTrials.gov trials registers to 16 May 2023. We aimed to identify other potentially eligible trials or ancillary publications by searching the reference lists of retrieved included trials, as well as relevant systematic reviews, meta-analyses, and health technology assessment reports. We contacted experts in the field to ascertain additional relevant information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating PICC design and materials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were venous thromboembolism (VTE), PICC-associated bloodstream infection (BSI), occlusion, and all-cause mortality. Secondary outcomes were catheter failure, PICC-related BSI, catheter breakage, PICC dwell time, and safety endpoints. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 12 RCTs involving approximately 2913 participants (one multi-arm study). All studies except one had a high risk of bias in one or more risk of bias domain. Integrated valve technology compared to no valve technology for peripherally inserted central catheter design Integrated valve technology may make little or no difference to VTE risk when compared with PICCs with no valve (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.19 to 2.63; I² = 0%; 3 studies; 437 participants; low certainty evidence). We are uncertain whether integrated valve technology reduces PICC-associated BSI risk, as the certainty of the evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Integrated valve technology may make little or no difference to occlusion risk when compared with PICCs with no valve (RR 0.86, 95% CI 0.53 to 1.38; I² = 0%; 5 studies; 900 participants; low certainty evidence). We are uncertain whether use of integrated valve technology reduces all-cause mortality risk, as the certainty of evidence is very low (RR 0.85, 95% CI 0.44 to 1.64; I² = 0%; 2 studies; 473 participants). Integrated valve technology may make little or no difference to catheter failure risk when compared with PICCs with no valve (RR 0.80, 95% CI 0.62 to 1.03; I² = 0%; 4 studies; 720 participants; low certainty evidence). We are uncertain whether integrated-valve technology reduces PICC-related BSI risk (RR 0.51, 95% CI 0.19 to 1.32; I² = not applicable; 2 studies (no events in 1 study); 542 participants) or catheter breakage, as the certainty of evidence is very low (RR 1.05, 95% CI 0.22 to 5.06; I² = 20%; 4 studies; 799 participants). Anti-thrombogenic surface modification compared to no anti-thrombogenic surface modification for peripherally inserted central catheter design We are uncertain whether use of anti-thrombogenic surface modified catheters reduces risk of VTE (RR 0.67, 95% CI 0.13 to 3.54; I² = 15%; 2 studies; 257 participants) or PICC-associated BSI, as the certainty of evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces occlusion (RR 0.69, 95% CI 0.04 to 11.22; I² = 70%; 2 studies; 257 participants) or all-cause mortality risk, as the certainty of evidence is very low (RR 0.49, 95% CI 0.05 to 5.26; I² = not applicable; 1 study; 111 participants). Use of anti-thrombogenic surface modified catheters may make little or no difference to risk of catheter failure (RR 0.76, 95% CI 0.37 to 1.54; I² = 46%; 2 studies; 257 participants; low certainty evidence). No PICC-related BSIs were reported in one study (111 participants). As such, we are uncertain whether use of anti-thrombogenic surface modified catheters reduces PICC-related BSI risk (RR not estimable; I² = not applicable; very low certainty evidence). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces the risk of catheter breakage, as the certainty of evidence is very low (RR 0.15, 95% CI 0.01 to 2.79; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Antimicrobial impregnation compared to non-antimicrobial impregnation for peripherally inserted central catheter design We are uncertain whether use of antimicrobial-impregnated catheters reduces VTE risk (RR 0.54, 95% CI 0.05 to 5.88; I² = not applicable; 1 study; 167 participants) or PICC-associated BSI risk, as the certainty of evidence is very low (RR 2.17, 95% CI 0.20 to 23.53; I² = not applicable; 1 study; 167 participants). Antimicrobial-impregnated catheters probably make little or no difference to occlusion risk (RR 1.00, 95% CI 0.57 to 1.74; I² = 0%; 2 studies; 1025 participants; moderate certainty evidence) or all-cause mortality (RR 1.12, 95% CI 0.71 to 1.75; I² = 0%; 2 studies; 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter failure (RR 1.04, 95% CI 0.82 to 1.30; I² = not applicable; 1 study; 221 participants; low certainty evidence). Antimicrobial-impregnated catheters probably make little or no difference to PICC-related BSI risk (RR 1.05, 95% CI 0.71 to 1.55; I² = not applicable; 2 studies (no events in 1 study); 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter breakage (RR 0.86, 95% CI 0.19 to 3.83; I² = not applicable; 1 study; 804 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

There is limited high-quality RCT evidence available to inform clinician decision-making for PICC materials and design. Limitations of the current evidence include small sample sizes, infrequent events, and risk of bias. There may be little to no difference in the risk of VTE, PICC-associated BSI, occlusion, or mortality across PICC materials and designs. Further rigorous RCTs are needed to reduce uncertainty.

Use of peripherally inserted central venous catheters and midline catheters for palliative care in patients with cancer: a systematic review

BACKGROUND

Peripherally inserted central catheters (PICCs) and midline catheters (MCs) may offer convenient intravenous access, but evidence to support their place in palliative care is limited. This review aimed to assess catheter indications, utilization, complications, dwell time, and patient experiences in cancer patients receiving palliative care.

METHODS

A systematic search for studies on catheter utilization for supportive or symptom treatment was conducted in Medline, Embase, CINAHL, Web of Science, Cochrane, and CENTRAL databases. Studies with a study population or a subgroup of palliative care cancer patients were included. Study quality was assessed using the Effective Public Health Practice Quality assessment tool.

RESULTS

Of 7631 unique titles, 17 articles were examined in detail, all published between 2002 and 2022. Median catheter dwell time varied from 15 to 194 days, the longest when utilized for home parenteral nutrition. For pain and symptom management, the typical duration was 2-4 weeks, often until the patient's death. Complication rates were minimal, with thrombosis, infections, and occlusion ranging from 0 to 2.46 incidents per 1000 catheter days. In studies from palliative care services, patients reported minimal distress during procedures and high user satisfaction. Quality of life assessments post-procedure improved, possibly influenced by concurrent specialist palliative care provision. All studies were assessed to be of moderate or weak quality.

CONCLUSION

PICC and MC are safe and valuable tools in palliative care cancer patients who would benefit from intravenous access for symptom management. Further studies are needed to clarify indications for PICC or MC in palliative care.

Prevalence of PICC-related thrombosis in patients with hematological malignancies: a systematic review

PURPOSE

To estimate the prevalence of peripherally inserted central catheter (PICC)-related venous thrombosis in patients with hematological malignancies.

METHODS

A systematic review of observational studies that evaluated the occurrence of PICC-related venous thrombosis in children, adults, and older people with hematological malignancies was conducted. Searches were carried out on June 12th, 2023 on PubMed, CINAHL, Embase, Web of Science Core Collection, Scopus, and LILACS, and to gray literature on Google Scholar, and ProQuest Dissertations and Theses Global. Eligibility criteria were applied independently by two reviewers, first on the titles and abstracts on the Rayyan platform and then on the full text of eligible studies. Risk of bias was assessed by the JBI checklist. Data were summarized descriptively, and the meta-analysis was carried out using the MetaXL 5.3 software. The review followed JBI guidelines and PRISMA for reporting.

RESULTS

In the 40 studies included, prevalence of PICC-related venous thrombosis was 9% in general, 9% in adults, and 6% in children with hematological malignancies. Most studies only evaluated cases of symptomatic thrombosis (n = 25; 64%).

CONCLUSION

Patients with hematological malignancies using PICC have an estimated prevalence of PICC-related venous thrombosis of 9%, and this rate may be underestimated due to the consideration of mostly symptomatic cases.

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis

BACKGROUND

Peripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF.

METHODS

A retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal.

RESULTS

During the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively.

CONCLUSIONS

Many adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

Optimizing Intravenous Access for Long-Term Parenteral Nutrition

PURPOSE OF REVIEW

Securing safe and effective intravenous (IV) access is of utmost importance for administering parenteral nutrition (PN). Sustaining this access can indeed pose challenges, especially when dealing with the risk of complications associated with long-term PN. This review emphasizes best practices to optimize intravenous access and reviews the current evidence-based recommendations and consensus guidelines.

RECENT FINDINGS

An individualized approach when selecting central venous catheters (CVC) is recommended, considering the estimated duration of need for IV access and the number of lumens needed. Established and novel approaches to minimize complications, including infection and thrombosis, are recognized. These include placement and positioning of the catheter tip under sonographic guidance and the use of antimicrobial lock therapies. Moreover, when possible, salvaging CVCs can reduce the risk of vascular access loss. CVC selection for patients requiring PN depends on several factors. Carefully reviewing an individual patient's clinical characteristics and discussing options is important. Given the increased infection risk, CVC lumens should be minimized. For long-term PN beyond 6 months, using CVCs with skin barriers and larger diameters should be considered.

Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil

INTRODUCTION

Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion.

OBJECTIVE

To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients.

METHODS

We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT.

RESULTS

The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99).

CONCLUSION

PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

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

BACKGROUND

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of positive airway pressure on basilic vein diameter and venous flow velocity in healthy volunteers

INTRODUCTION

The placement of vascular catheters of adequate size in accordance to catheter-to-vein ratio (CVR) recommendations represents one of the cornerstones of catheter-related upper vein thrombosis prevention. However there is scarcity of data on its effect on the venous dynamics of the basilic vein, a common site for long-term catheter placement. This study investigates the effects of the application of positive airway pressure on the diameter and blood flow velocity of basilic vein. We also measured the effects of under-armpit straps, a device commonly used to keep continuous positive airway pressure (CPAP) helmets in place.

METHODS

We enrolled 28 healthy volunteers. Basilic vein diameter and minimum/maximum blood flow velocity, according to respiratory venous flow oscillation, were measured by ultrasound on the midpoint of their dominant arm during spontaneous breathing and during breathing in a CPAP helmet with 10 cm H2O of airway pressure applied, with the helmet kept in place either through armpit straps or by tying the helmet to the bed.

RESULTS

The application of 10 cm H2O of positive airway pressure significantly increased basilic vein diameter by 0.9 ± 0.2 mm, while reducing minimum blood flow velocity by 1.8 ± 0.4 cm/s. These effects were amplified by the application of under armpit straps.

CONCLUSIONS

Breathing with positive airway pressure increases basilic vein diameter while reducing blood flow-velocity. This phenomenon might lead to an incorrect assessment of CVR, misleading the operator into choosing improperly large catheters.

Identification of predictive patient characteristics for assessing the probability of COVID-19 in-hospital mortality

As the world emerges from the COVID-19 pandemic, there is an urgent need to understand patient factors that may be used to predict the occurrence of severe cases and patient mortality. Approximately 20% of SARS-CoV-2 infections lead to acute respiratory distress syndrome caused by the harmful actions of inflammatory mediators. Patients with severe COVID-19 are often afflicted with neurologic symptoms, and individuals with pre-existing neurodegenerative disease have an increased risk of severe COVID-19. Although collectively, these observations point to a bidirectional relationship between severe COVID-19 and neurologic disorders, little is known about the underlying mechanisms. Here, we analyzed the electronic health records of 471 patients with severe COVID-19 to identify clinical characteristics most predictive of mortality. Feature discovery was conducted by training a regularized logistic regression classifier that serves as a machine-learning model with an embedded feature selection capability. SHAP analysis using the trained classifier revealed that a small ensemble of readily observable clinical features, including characteristics associated with cognitive impairment, could predict in-hospital mortality with an accuracy greater than 0.85 (expressed as the area under the ROC curve of the classifier). These findings have important implications for the prioritization of clinical measures used to identify patients with COVID-19 (and, potentially, other forms of acute respiratory distress syndrome) having an elevated risk of death.

Comparison of different machine learning classification models for predicting deep vein thrombosis in lower extremity fractures

Deep vein thrombosis (DVT) is a common complication in patients with lower extremity fractures. Once it occurs, it will seriously affect the quality of life and postoperative recovery of patients. Therefore, early prediction and prevention of DVT can effectively improve the prognosis of patients. This study constructed different machine learning models to explore their effectiveness in predicting DVT. Five prediction models were applied to the study, including Extreme Gradient Boosting (XGBoost) model, Logistic Regression (LR) model, RandomForest (RF) model, Multilayer Perceptron (MLP) model, and Support Vector Machine (SVM) model. Afterwards, the performance of the obtained prediction models was evaluated by area under the curve (AUC), accuracy, sensitivity, specificity, F1 score, and Kappa. The prediction performances of the models based on machine learning are as follows: XGBoost model (AUC = 0.979, accuracy = 0.931), LR model (AUC = 0.821, accuracy = 0.758), RF model (AUC = 0.970, accuracy = 0.921), MLP model (AUC = 0.830, accuracy = 0.756), SVM model (AUC = 0.713, accuracy = 0.661). On our data set, the XGBoost model has the best performance. However, the model still needs external verification research before clinical application.

Appraising the quality standard of clinical practice guidelines related to central venous catheter-related thrombosis prevention: a systematic review of clinical practice guidelines

OBJECTIVE

To evaluate the quality and analyse the content of clinical practice guidelines regarding central venous catheter-related thrombosis (CRT) to provide evidence for formulating an evidence-based practice protocol and a risk assessment scale to prevent it.

DESIGN

Scoring and analysis of the guidelines using the AGREE II and AGREE REX scales.

DATA SOURCES

Pubmed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and the Chinese Biomedical Literature, and the relevant websites of the guideline, were searched from 1 January 2017 to 26 March 2022.

ELIGIBILITY CRITERIA

Guidelines covering CRT treatment, prevention, or management were included from 1 January 2017 to 26 March 2022.

DATA EXTRACTION AND SYNTHESIS

Three independent reviewers systematically trained in using the AGREE II and AGREE REX scales were selected to evaluate these guidelines.

RESULTS

Nine guidelines were included, and the quality grade results showed that three were at A-level and six were at B-level. The included guidelines mainly recommended the prevention measure of central venous CRT from three aspects: risk screening, prevention strategies, and knowledge training, with a total of 22 suggestions being recommended.

CONCLUSION

The overall quality of the guidelines is high, but there are few preventive measures for central venous CRT involved in the guidelines. All preventive measures have yet to be systematically integrated and evaluated, and no risk assessment scale dedicated to this field has been recommended. Therefore, developing an evidence-based practice protocol and a risk assessment scale to prevent it is urgent.

Use of Peripheral Intravenous Access in Patients Undergoing Chemotherapy for Testicular Cancer

PURPOSE

Systemic chemotherapy, depending on the regimen, can be administered through peripheral intravenous (pIV) access or through central venous access devices (CVADs). There is no current best practice regarding optimal access for chemotherapy for patients with testicular cancer (TC). We retrospectively evaluated patients undergoing systemic chemotherapy for TC and compared baseline characteristics and complications of patients using pIV versus CVADs.

METHODS

We included patients with TC who underwent first-line systemic chemotherapy at the University of Colorado Hospitals from 2005 to 2020. Data were collected on demographics, cancer characteristics, type, duration of chemotherapy, pIV or CVAD use, and associated complication rates. We then performed univariate and multivariate regression analyses to compare complication rates and risk factors for each group.

RESULTS

One hundred fifty-four patients met inclusion criteria. Ninety-two (60%) patients used CVADs, and 62 patients (40%) used pIV for their initial treatment. Only six (9.7%) of 62 patients transitioned from pIV to CVADs during therapy. Similarly, 10 of 92 (10.9%) patients with initial CVAD needed to transition to a different type of CVAD or to pIV (P = .81). There were a greater number of venous access-related complications (48 of 92 patients, 52.2%) and overall thrombotic events (33 of 92 patients, 35.9%) for the CVAD group (P > .001) when compared with the pIV group. We observed an association between the following factors and venous access-related complications during chemotherapy: higher stage TC, increased total chemotherapy cycles, and delayed therapy.

CONCLUSION

Peripheral IV use for first-line nonvesicant chemotherapy in patients with TC appears to be well tolerated with high rates of therapy completion and lower rates of complications when compared with CVADs. These data support our preferred treatment approach and provide evidence that pIV access is a safe and effective way to deliver chemotherapy for patients with TC.

The Global and Regional Prevalence of Hospital-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection: A Systematic Review and Meta-analysis

Background

Due to scarce therapeutic options, hospital-acquired infections caused by Klebsiella pneumoniae (KP), particularly carbapenem-resistant KP (CRKP), pose enormous threat to patients' health worldwide. This study aimed to characterize the epidemiology and risk factors of CRKP among nosocomial KP infections.

Method

MEDLINE, Embase, PubMed, and Google Scholar were searched for studies reporting CRKP prevalence from inception to 30 March 2023. Data from eligible publications were extracted and subjected to meta-analysis to obtain global, regional, and country-specific estimates. To determine the cause of heterogeneity among the selected studies, prespecified subgroup analyses and meta-regression were also performed. Odds ratios of CRKP-associated risk factors were pooled by a DerSimonian and Laird random-effects method.

Results

We retained 61 articles across 14 countries and territories. The global prevalence of CRKP among patients with KP infections was 28.69% (95% CI, 26.53%-30.86%). South Asia had the highest CRKP prevalence at 66.04% (95% CI, 54.22%-77.85%), while high-income North America had the lowest prevalence at 14.29% (95% CI, 6.50%-22.0%). In the country/territory level, Greece had the highest prevalence at 70.61% (95% CI, 56.77%-84.45%), followed by India at 67.62% (95% CI, 53.74%-81.79%) and Taiwan at 67.54% (95% CI, 58.65%-76.14%). Hospital-acquired CRKP infections were associated with the following factors: hematologic malignancies, corticosteroid therapies, intensive care unit stays, mechanical ventilations, central venous catheter implantations, previous hospitalization, and antibiotic-related exposures (antifungals, carbapenems, quinolones, and cephalosporins).

Conclusions

Study findings highlight the importance of routine surveillance to control carbapenem resistance and suggest that patients with nosocomial KP infection have a very high prevalence of CRKP.

Implementation of a vascular access team and an intravenous therapy programme: A first-year activity analysis

BACKGROUND

Creating Vascular Access Teams (VAT) provides an expert nursing role that contributes to the training and continuous improvement of healthcare personnel. They can offer greater clinical safety, reducing complications and costs. Peripherally inserted central catheters (PICCs) and midline catheters (ML) can be safe and cost-effective alternatives to other types of venous access (VA). The aim of the study was to analyse our centre's VAT first 12 months of activity. The primary outcome was reported complications. Secondary outcomes were cause of catheter removal, consultancy activity and economic impact of VAT implantation.

METHODOLOGY

A longitudinal, descriptive study was carried out from March 2019 to March 2020. Using consecutive sampling, all VA inserted, and all consults received were included. Patients under 18 years of age were excluded.

RESULTS

The VAT inserted 1257 catheters into 1056 patients (291 MLs, 966 PICCs). The mean dwell time was 14.9 days for MLs and 59.07 days for PICCs. The main reason for removing VA was end of treatment (80.7%). During VA follow-up confirmed infection was detected in 1 ML (0.3%) and nine PICCs (0.9%). Symptomatic thrombosis was reported in 2 MLs (0.7%) and 16 PICCs (1.7%). The VAT received 367 consultations, and the main reason for consultation was to resolve doubts regarding the management of VA (80.9%). The insertion of ML and PICC catheters represented annual estimated economic savings of €867,688.44€.

CONCLUSIONS

Our study provides a detailed analysis of VAT's activity, its relevance to clinical safety, and to efficient resource management within our hospital. It demonstrates how VAT establishment can be a safe and efficient intervention that enhances care quality.

Types of peripherally inserted central catheters and the risk of unplanned removals in patients: A prospective cohort study

BACKGROUND

Peripherally inserted central catheters are widely used in clinical practice. Despite the many advantages of peripherally inserted central catheters, unplanned removals can occur owing to irreversible complications and may have adverse consequences for patients. However, the relationship between peripherally inserted central catheter type and the incidence of unplanned removal is unclear.

OBJECTIVE

To investigate the association between the type of peripherally inserted central catheter and unplanned catheter removal.

DESIGN

A multicenter prospective cohort study.

SETTINGS

Sixty hospitals located in 30 cities across seven provinces in China.

PARTICIPANTS

Three thousand two hundred and twenty-two patients aged 18 years or older with one peripherally inserted central catheter inserted for treatment were enrolled, and 3166 (98.3 %) patients with follow-up data were included in the final analysis.

METHODS

The included participants had peripherally inserted central catheters that either had a proximal valve (n = 2436) or were open-ended (n = 730). A competing risk Cox regression model was used, and both univariate and multivariate analyses were conducted. A sub-distribution hazard model was applied to test the validity of the results.

RESULTS

Of the 2436 peripherally inserted central catheters with a proximal valve and 730 that were open-ended, 272 (11.2 %) and 46 (6.3 %) were removed unplanned, respectively. The whole incidence of unplanned removal was 10.04 %; multivariate Cox regression was conducted and it was determined that unplanned removal was statistically significantly associated with the proximal valve peripherally inserted central catheter type (hazard ratio: 1.86, 95 % confidence interval: 1.28 to 2.70, p = 0.001). In patients without cancer, the risk of unplanned removal of peripherally inserted central catheters with a proximal valve was 8.14 times higher than that of open-ended peripherally inserted central catheters (p < 0.001).

CONCLUSIONS

In this study, peripherally inserted central catheters with a proximal valve had a higher risk of unplanned removals, especially in patients without cancer. The peripherally inserted central catheter type should be considered in advance, and clinical staff should take appropriate measures to prevent unplanned removals after insertion.

Upper extremity venous thrombosis in hospitalized patients: A prospective epidemiological study

BACKGROUND

The frequency of upper extremities vein thrombosis (UEVT) is rising with the increasing use of endovenous devices. These thromboses are particularly common among hospitalized patients. The epidemiology and risk factors for UEVT are poorly understood in a hospitalized population.

OBJECTIVE

To assess the prevalence of UEVT in hospitalized patients and study thrombosis risk factors according to their location.

METHODS

Prospective evaluation of patients hospitalized in a university hospital with clinical and Doppler ultrasound (DUS) assessment of the upper extremities.

RESULTS

Of the 400 patients included, 91(22.8 %) had UEVT including 8 (8.8 %) proximal thrombosis, 32 (35.2 %) arm venous thrombosis and 51 (56.0 %) forearm venous thrombosis; 7 (7.7 %) patients with UEVT had a concomitant symptomatic pulmonary embolism. In this population of hospitalized patients, 40 (10 %) had proximal or arm thrombosis and 51 (12.8 %) forearm thrombosis. All patients with UEVT had a venous catheter and 63 (69.2 %) of UEVT patients had therapeutic or prophylactic anticoagulation at the time of DUS evaluation. In multivariate analysis, peripheral intravenous catheter (PIVC) OR 3.71 [1.90; 7.91] (p < 0.001); MID line OR 3.58 [1.46; 8.91] (p = 0.005) and infection disease OR 2.21 [1.26; 4386] (p = 0.005) were associated with UEVT. Central venous catheter OR 66.24 [12.64; 587.03] was associated with proximal UEVT and MID line OR 12.61 [4.64; 35.77] (p < 0.001) with arm UEVT. Forearm UEVT were associated with PIVCOR 10.71[3.14; 67.37] (p = 0.001); infectious disease OR 2.87 [1.48; 5.60] (p = 0.002), iron infusion OR 3.11 [1.23; 7.47] and hospitalization for postpartum OR 4.37 [0.97; 18.06] (p = 0.04).

CONCLUSION

One in 5 hospitalized patients suffers from UEVT. Proximal venous thrombosis is uncommon. The presence of a catheter and hospitalization for infection are the factors most frequently associated with UEVT.

Clinical experience with a chlorhexidine-coated PICC: A prospective, multicenter, observational study

INTRODUCTION

This study evaluated a chlorhexidine-coated peripherally inserted central catheter (PICC) and the incidence of associated complications within both inpatient and outpatient populations.

METHODS

This IRB-approved, multicenter, prospective observational study was performed at three large teaching hospitals in the US. All adults who required a PICC for ⩾14 days were considered. Patients were monitored throughout entire catheter dwell. Duplex venous ultrasounds were performed before insertion, after 10 to 14 days of dwell time, and upon removal. Data was collected from the hospital, outpatient clinic, and patient PICC diary records.

RESULTS

A total of 103 patients, 56% male, with mean BMI 29 ± 8.8, were enrolled. The majority (79%) of patients were from high-risk groups-cancer, infectious diseases, transplant, and trauma. Primary treatment indications were antibiotics (66.99%) and chemotherapy (25.24%). Double lumen PICCs (59.2%) were favored clinically, as was basilic vein placement (71.84%). Mean catheter dwell was 47.01 ± 25.82 days. Three (3, 2.9%) central line-associated bloodstream infections (CLABSI) were reported. Four patients (4.6%) reported symptomatic catheter-related thrombosis (CRT), confirmed with ultrasound. Three patients (3.4%) had ultrasound-confirmed fibroblastic sleeve (FS). Eight patients (9.2%) who entered the study with pre-existing superficial thrombosis, had complete resolution at the time of catheter removal. The incidence of CLABSI was 0.82/1000 days. The combined CRT and FS rate was 6.9%.

CONCLUSION

Based upon the observational findings of this study, chlorhexidine-coated PICC technology may be considered for use in patient populations who are at moderate to high-risk for catheter-related complications in both inpatient and outpatient settings.

Alpha 2-Macroglobulin Polymorphisms and Susceptibility to Alzheimer's Disease: A Comprehensive Meta-Analysis Based on 62 Studies

Background

The relationship between alpha 2-macroglobulin (A2M) gene and Alzheimer's disease (AD) has been widely studied across populations; however, the results are inconsistent.

Objective

This study aimed to evaluate the association of A2M gene with AD by the application of meta-analysis.

Methods

Relevant studies were identified by comprehensive searches. The quality of each study was assessed using the Newcastle-Ottawa Scale. Allele and genotype frequencies were extracted from each of the included studies. Odds ratio (OR) with corresponding 95% confidence intervals (CI) was calculated using a random-effects or fixed-effects model. The Cochran Q statistic and I2 metric was used to evaluate heterogeneity, and Egger's test and Funnel plot were used to assess publication bias.

Results

A total of 62 studies were identified and included in the current meta-analysis. The G allele of rs226380 reduced AD risk (OR: 0.64, 95% CI: 0.47-0.87, pFDR = 0.012), but carrier with the TT genotype was more likely to develop AD in Asian populations (OR: 1.56, 95% CI: 1.12-2.19, pFDR = 0.0135). The V allele of the A2M-I/V (rs669) increased susceptibility to AD in female population (OR, 95% CI: 2.15, 1.38-3.35, pFDR = 0.0024); however, the II genotype could be a protective factor in these populations (OR, 95% CI: 0.43, 0.26-0.73, pFDR = 0.003). Sensitivity analyses confirmed the reliability of the original results.

Conclusions

Existing evidence indicate that A2M single nucleotide polymorphisms (SNPs) may be associated with AD risk in sub-populations. Future studies with larger sample sizes will be necessary to confirm the results.

Outcome of antithrombotic therapy in cancer patients with catheter-related thrombosis: a systematic review

Introduction

The guidelines' recommendations for anticoagulation in cancer patients with catheter-related thrombosis are unclear. The aim of this systematic review was to assess anticoagulation management in cancer patients with catheter-related thrombosis (CRT) based on previously published studies.

Methods

As of June 10, 2023,we searched databases including PubMed, Embase, and Cochrane and included 11 observational studies that met the criteria. We evaluated 770 adults with active cancer and objectively confirmed patients with CRT who were using drugs including warfarin, LMWH, and new oral anticoagulants as antithrombotic therapy.

Results

We extracted outcome data, including thrombosis recurrence, catheter dysfunction, major bleeding, and death, and performed a meta-analysis.

Discussion

In this study we found that the risk of VTE recurrence was higher with rivaroxaban, the risk of bleeding and death appeared to be greater with warfarin, and although the risk of catheter dysfunction due to LMWH is a concern, it is still a more reasonable option for cancer patients with catheter-related thrombosis.

Systematic Review Registration

http://www.clinicaltrials.gov, identifier (CRD42022367979).

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.

Efficacy of antimicrobial peripherally inserted central catheters in line-associated bloodstream infections: A systematic review and meta-analysis

BACKGROUND

Several studies have investigated the safety and efficacy of antimicrobial peripherally inserted central catheters (PICCs), and the results are conflicting. Therefore, in this systematic review and meta-analysis, we aimed to summarize and identify the effect of antimicrobial PICCs on central line-associated bloodstream infection (CLABSI) risk.

METHODS

A systematic search of PubMed, Ovid MEDLINE, Ovid Embase, and Web of Science was performed to identify relevant studies up to December 2022.

RESULTS

A total of 9 studies were included for analysis. There were 7 retrospective/prospective cohort studies and 2 randomized controlled trials. The 9 studies involved 51,373 patients with PICCs. Among these patients, 6,563 (12.8%) antimicrobial-coated/impregnated PICCs and 44,810 (87.2%) nonantimicrobial-impregnated PICCs were inserted. The meta-analysis showed that antimicrobial PICCs had a nonsignificant association with lower CLABSI risk compared with noncoated PICCs (relative risk [RR] = 0.67; 95% CI, 0.43-1.05). In the subgroup analysis, minocycline-rifampin-(RR = 0.30; 95% CI, 0.19-0.49) or chlorhexidine-coated (RR = 0.61; 95% CI, 0.04-8.55) PICCs showed an association with reduced risk of CLABSI. In the adult population, antimicrobial PICCs had a nonsignificant association with lower CLABSI risk (RR = 0.50; 95% CI, 0.20-1.22).

CONCLUSIONS

This systematic review and meta-analysis suggested that antimicrobial PICCs had a nonsignificant association with lower CLABSI risk compared with noncoated PICCs. Minocycline-rifampin-or chlorhexidine-coated PICCs showed an association with reduced risk of CLABSI.

Midline catheters in patients with advanced chronic kidney disease

BACKGROUND

Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD).

OBJECTIVE

This study describes current practice and acute complications associated with midlines in CKD patients.

DESIGNS, SETTING, AND PARTICIPANTS

Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization. Patients were classified as having advanced CKD if their estimated glomerular filtration rate was <45 mL/min/1.73 m2 .

MAIN OUTCOME AND MEASURES

Midline recipients with advanced CKD were compared to those without advanced CKD by patient, provider, and device characteristics, and by the occurrence of acute complications including major (e.g., upper extremity deep vein thrombosis [UE-DVT] and catheter-related bloodstream infection [CRBSI]) or minor (e.g., catheter occlusion, catheter dislodgement, infiltration, superficial thrombophlebitis, and leaking at insertion site) events. Multivariable mixed effects logistic regression was used to evaluate the association between catheter-related complications and stage of CKD.

RESULTS

Of 21,415 midline recipients, 5272 (24.6%) had advanced CKD, while 16,143 (75.4%) did not. Most midlines were single lumen (90.5%) and remained in place for a median of 6 days. A major or minor midline complication occurred in 804 (15.3%) patients with and 2239 (14.4%) patients without advanced CKD (adjusted odds ratios = 1.04; 95% confidence interval: 0.94-1.14). Among patients with advanced CKD, CRBSI occurred in 13 patients (0.2%) and UE-DVT occurred in 65 patients (1.2%). The proportion of advanced CKD among midline recipients and the frequency of midline-related complications varied across hospitals (interquartile range [IQR] = 19.2% to 29.8% [median = 25.0%] and IQR = 11.0%-18.9% [median = 15.4%], respectively).

Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study

BACKGROUND

Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice's method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis.

RESULTS

Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000*cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000*cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed.

CONCLUSIONS

CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.

Establishment of risk nomogram prediction model for venous catheter thrombosis

BACKGROUND

Venous catheters are widely used in clinical practice, but a drawback of their usage is the increased risk of thrombosis.

AIMS

The current study explored the risk factors affecting the formation of thrombosis following venous catheterization and establishes a risk nomogram prediction model for catheter-related thrombosis.

METHODS

Univariate and multivariate logistic regression analyses were carried out to identify the independent factors involved in venous catheter thrombosis. These factors were included in the construction of a nomogram. Finally, the C-index and calibration curves were used to validate the nomogram.

RESULT

A total of 146 cases were included in the sample, of which 36 were cases of thrombosis. The results of the univariate logistic regression analysis showed that the following were significant factors: age, Acute Physiology and Chronic Health Evaluation scoring system (APACHE II) score, white blood cell (WBC), hematocrit (HCT), international normalized ratio (INR), fibrinogen (FIB), and D-dimer. Multivariate logistic regression analysis was performed, which confirmed that the factors of age (AUC: 0.677, 95% CI: 0.564-0.790), APACHE II score (AUC: 0.746, 95% CI: 0.656-0.837), INR (AUC: 0.743, 95% CI: 0.636-0.849), and D-dimer (AUC: 0.826, 95% CI: 0.750-0.902) were independent variables. Next, a nomogram was constructed using these independent variables for predicting venous catheter thrombosis. Favorable results with C-indexes (0.816; 95% CI: 0.780-0.882) and calibration curves closer to ideal curves indicated the accurate predictive ability of this nomogram.

CONCLUSION

The individualized nomogram demonstrated effective prognostic prediction for patients with venous thrombosis.

Risk and Prognosis of Upper Extremity Deep Vein Thrombosis

Objectives: We aimed to investigate the clinical features of upper extremity deep vein thrombosis (UEDVT). Methods: We retrospectively reviewed the background, thrombus site, treatment, and outcome of 76 UEDVT patients. Results: Of the 76 UEDVT patients, 44 (57.9%) were men, and 51 (67.1%) were complicated by malignancy, 44 (57.9%) had an indwelling central vein (CV) catheter, 8 (10.5%) had concomitant pulmonary embolization (PE), and 33 (43.3%) were symptomatic. Regarding the thrombus site, the right internal jugular vein was the most common, with 30 cases (35.3%). As regards the treatment method, 53 patients (69.7%) received oral anticoagulants. In 2015, when direct oral anticoagulants (DOACs) was covered by insurance, there were 44 UEDVT cases, of which 34 (77.3%) received DOACs. Outcomes at a mean observation period of 37.5±41.5 months included 40 deaths (52.6%) with a mean survival of 16.3±21.3 months. The most common cause of death was malignancy, with 33 cases (82.5%). Conclusion: In the background of UEDVT, the combination of indwelling CV catheter placement and malignancy was frequently observed. While the risk of recurrence or PE complications is low, the prognosis of UEDVT complicated by malignancy is extremely poor.

Complications and Practice Variation in the Use of Peripherally Inserted Central Venous Catheters in People With Cystic Fibrosis: The Prospective Study of Peripherally Inserted Venous Catheters in People With Cystic Fibrosis Study

BACKGROUND

Peripherally inserted central catheters (PICCs) are used commonly to administer antibiotics to people with cystic fibrosis (CF), but their use can be complicated by venous thrombosis and catheter occlusion.

RESEARCH QUESTION

Which participant-, catheter-, and catheter management-level attributes are associated with increased risk of complications of PICCs among people with CF?

STUDY DESIGN AND METHODS

This was a prospective observational study of adults and children with CF who received PICCs at 10 CF care centers in the United States. The primary end point was defined as occlusion of the catheter resulting in unplanned removal, symptomatic venous thrombosis in the extremity containing the catheter, or both. Three categories of composite secondary outcomes were identified: difficult line placement, local soft tissue or skin reactions, and catheter malfunction. Data specific to the participant, catheter placement, and catheter management were collected in a centralized database. Risk factors for primary and secondary outcomes were analyzed by multivariate logistic regression.

RESULTS

Between June 2018 and July 2021, 157 adults and 103 children older than 6 years with CF had 375 PICCs placed. Patients underwent 4,828 catheter-days of observation. Of the 375 PICCs, 334 (89%) were ≤ 4.5 F, 342 (91%) were single lumen, and 366 (98%) were placed using ultrasound guidance. The primary outcome occurred in 15 PICCs for an event rate of 3.11 per 1,000 catheter-days. No cases of catheter-related bloodstream infection occurred. Other secondary outcomes developed in 147 of 375 catheters (39%). Despite evidence of practice variation, no risk factors for the primary outcome and few risk factors for secondary outcomes were identified.

INTERPRETATION

This study affirmed the safety of contemporary approaches to inserting and using PICCs in people with CF. Given the low rate of complications in this study, observations may reflect a widespread shift to selecting smaller-diameter PICCs and using ultrasound to guide their placement.

Histologic evaluation of a catheter coated with paclitaxel PLGA nanoparticles in the internal jugular veins of rats

The aim of this study is to investigate the potential impact of catheterization on intimal hyperplasia and explore the efficacy of Paclitaxel loaded PLGA nanoparticles (PTX-NPs) in preventing stenosis at the site of venous injury. Under general anesthesia, Central Venous Catheters were inserted into the rat's right internal jugular veins (IJV) using the cut-down technique. Twenty bare catheters (C) and twenty PTX-NPs coated catheters (P) were assigned to one of four groups (C2, C4, P2, or P4) based on catheter type and expected survival time. 2 or 4 weeks after surgery, IJVs were completely harvested by formalin fixation and gelatin infusion and slides were stained with H&E (Haematoxylin and Eosin) and Masson's technique. The P2 (Paclitaxel coating, 2 weeks) group showed the most proliferation among the four groups and the P4 (Paclitaxel coating, 4 weeks) showed a tendency to decrease proliferation. Additionally, the lumen size in the P4 group was about 6% smaller than in the P2 group, and there was a lower prevalence of stenotic grade in the P4 group. Our study suggests that PTX-NPs coated catheters may be effective in preventing venous stenosis if the intended usage is prolonged, rather than for a short-term period.

Graphical abstract

Schematic representation of catheter functionalization and coating of PTX-NPs on Catheter.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-023-00282-y.

Peripherally inserted central catheters versus implantable port catheters for cancer patients: a meta-analysis

Background

The implanted vascular access ports (PORTs) were compared with peripherally inserted central catheters (PICCs) as the administration of chemotherapy regarding different clinical effects and adverse effects. Which is better is debatable. Hence, the current study was conducted to assess the safety and efficacy of these two optimal vascular access strategies.

Methods

The following electronic databases were searched: PubMed, Embase, and the Cochrane Library updated in May 2023. Studies on the differences in complication rates in patients with cancer using either PICC or PORT for chemotherapy were included. Meta-analysis Revman 5.3 software was used for statistical analysis.

Results

A total of 22 articles were retrieved. The results suggested that PORT has a superior safety profile, with lower incidences of overall adverse effects (OR=2.72, 95% CI=1.56-4.72 P=0.0004), catheter-related thrombosis (OR=2.84, 95% CI=1.97-4.11, P<0.00001), and allergic reactions (OR=6.26, 95% CI=1.86-21.09, P=0.003) than typically expected with PICC. Moreover, PICC was non-inferior to the PORT group with respect to DVT (OR=2.00, 95% CI=0.86-4.65, P=0.11) and infection (OR=1.55, 95% CI=0.75-3.22, P=0.24).

Conclusion

PORT achieved safety benefits compared with chemotherapy through PICC. Therefore, PORT is regarded as safe and effective vascular access for the administration of chemotherapy. When considering economic factors and some key elements, more high-quality research would help verify these clinical benefits.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identififier CRD42023421690.