The efficacy and safety of blood sampling through peripherally inserted central catheter devices in children

Artificially Elevated Tacrolimus Concentrations Obtained From a Venous Catheter Previously Used for Tacrolimus Administration in a Pediatric Patient

Intravenous (IV) administration of calcineurin inhibitors, cyclosporine (CsA) and tacrolimus (TAC), has been associated with spuriously high serum concentrations collected from central venous catheters (CVCs) used for medication administration, secondary to reversible adsorption of medication to the catheter. Thus, therapeutic drug monitoring of IV CsA and TAC via CVCs previously exposed to these agents should be interpreted cautiously and ideally avoided. The duration of this effect is poorly characterized and the risk for extension of this effect to unexposed lumens of the same central catheter remains uncertain. We describe a case of a pediatric patient with artificially elevated serum TAC concentrations obtained from previously exposed and unexposed lumens of a central catheter, 27 days after last IV TAC administration.

Impact of blood sampling technique on reproducibility of viscoelastic coagulation monitor (VCM™) system test results in the neonate

Purpose: To evaluate the reproducibility of the results of the viscoelastic coagulation test (VCT) performed with a new viscoelastic coagulation monitor (VCM™ - Entegrion) on native blood obtained by heel prick blood sampling with two different techniques compared to the standard blood collection in the newborn.Methods: Three blood samples were tested with the VCM analyzer in each of the 67 study subjects admitted to our level 3 neonatal intensive care unit. Standard blood collection (S) was performed by direct puncture of a peripheral vessel or by drawing of blood in a syringe connected to an arterial or venous catheter. Then, two more blood samples were drawn through a single heel prick. The first heel prick blood sample (HP1) was collected in the sample well through the attached metal capillary while the second (HP2) was poured directly into the sample well. Blood samples were automatically drawn into their pre-warmed cartridges and inserted into the VCM analyzers set up for analyses, which ran for one hour. VCT blood variables included clotting time (CT), clot formation time (CFT), angle alpha (α), amplitude at 10 and 20 min (A10 and A20), maximum clot firmness (MCF), and lysis indexes at 30 and 45 min (LY30 - LY45). Agreement was quantified by calculating the mean difference and SD between measurements of VCT blood variables from S, HP1 and HP2 blood samples. The 95% limits of agreement were calculated by the Bland & Altman method, using the upper or lower limit of agreement to interpret the variability of the measurements. The Kendall's τ correlation coefficient evaluated the interdependence between SD and intra-measurement mean.Results: S blood samples were easily obtained in all the study subjects, while mild difficulties were recorded in 3/67 infants (4.5%) with the HP1 blood sampling and in 5/67 infants (7%) with the HP2 blood sampling. Pairwise comparison of test results performed on blood samples drawn with HP1 and HP2 techniques showed moderate agreement for CT and α-angle, strong agreement for CFT, LY30 and LY45 and almost perfect agreement for A10, A20 and MCF. In pairwise comparison of VCM analyses performed on blood samples drawn with S technique vs HP1 and HP2 techniques, Kendall's τ correlation coefficient was significant for CT (S vs HP1 and HP1 vs HP2), CFT (S vs HP1 and S vs HP2), α-angle (S vs HP1) and MCF (S vs HP1). This suggests that the measurement error depends on the extent of the measurement. The overall ICC for blood sampling techniques ranged from 0.289 to 0.879 with best agreement observed for CFT (strong) and for A10, A20 and MCF (almost perfect). The LY30 index was the least repeatable measurement (poor agreement). The VCM analysis performed on the blood sample drawn with the HP1 technique showed the best repeatability compared with that performed with the S blood-sampling technique.Conclusion. VCT test results performed with the VCM analyzer on native blood drawn by heel prick in neonates are comparable to those obtained from standard blood samples. This could allow for a widespread, real-time assessment of the overall bedside haemostasis of these small patients.

Complete Blood Count Collected Via Venipuncture Versus Peripherally Inserted Central Catheter in Hematological Patients: A Comparison of 2 Methods

BACKGROUND

The use of peripherally inserted central catheters (PICCs) in cancer care is increasing over traditional central venous catheters. Nurses frequently collect blood by venipuncture when a PICC is inserted, as there is no available evidence to confirm the reliability of blood tests collected through PICCs in adults.

OBJECTIVE

The aim of this study was to assess the reliability of blood samples for complete blood count (CBC) obtained through PICCs as an alternative to venipuncture.

METHODS

A cross-sectional design was used to recruit adult hematological patients. The blood samples were collected within 5 minutes of each other by a specialist nurse. Hemoglobin, hematocrit, and platelet count were evaluated. To determine method comparison, Passing-Bablok regression, test of linearity, Pearson product-moment correlation coefficient, and Bland-Altman plots were used.

RESULTS

Thirty paired blood samples were collected in 29 hematological patients with a mean age of 66.8 years. A statistical difference was found for hemoglobin (P = .001) and hematocrit (P = .001) levels, but no clinical difference. The regression models revealed no systematic differences and no proportional differences with a linear relationship between the methods. Bland-Altman plots highlighted a good agreement between methods.

CONCLUSION

Blood samples for CBC drawn by PICCs are as reliable as those collected via venipuncture. Blood sampling via PICC could be recommended in people with hematological malignancies in needs of frequent blood tests.

IMPLICATIONS FOR PRACTICE

Sampling through a PICC provides reliable laboratory results for CBC, and it could reduce patients' discomfort and increase the safety of professionals reducing the risk of accidental percutaneous needlestick injuries.

Incidence and risk factors of superficial and deep vein thrombosis associated with peripherally inserted central catheters in children

Essentials Pediatric studies on peripherally inserted central catheter (PICC)-related thrombosis are scarce. This study analyzes incidence and risk factors for PICC-related venous thrombosis in children. PICC-related thrombosis is a common, and nearly always, asymptomatic complication. Echo-guided insertion and a catheter to vein ratio < 0.33 may notably decrease this complication.

SUMMARY

Background Upper-extremity venous thrombosis is associated with the use of peripherally inserted central catheters (PICCs). Few pediatric studies have focused on this issue. Objectives To determine the incidence and risk factors for PICC-related superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) in children. Patients/methods An observational follow-up cohort study was conducted at a single hospital between June 2012 and June 2015. All patients receiving a PICC were enrolled and followed up, with weekly Doppler ultrasound examination of the catheterized limb until PICC removal. Patient, procedural and follow-up data were analyzed. Results In the study period, 265 PICCs were inserted (median age of patients 6.5 years, interquartile range [IQR] 2.4-13 years; median weight 20 kg, IQR 11-38 kg; 54% males; 67.9% chronically ill), and patients were followed up for a total of 9743 days. The median indwelling time was 21 days (IQR 12-37 days). During follow-up, 88 (33.2% of insertions) PICC-related thromboses (incidence rate [IR] 9.03 per 1000 catheter-days) were diagnosed, 66 (24.9%) as isolated SVT, seven (2.6%) as isolated DVT, and 15 (5.7%) as SVT with associated DVT (IR 6.78, 0.71 and 1.54 per 1000 catheter-days, respectively). Only 9.9% of patients with SVT and 18.2% of those with DVT were symptomatic. The main risk factors for PICC-related SVT and DVT were a catheter/vein ratio of > 0.33 and thrombosis of the catheterized superficial vein, respectively. Conclusions PICC-related thrombosis is a common and nearly always asymptomatic complication in children, the SVT rate being approximately three times higher than the DVT rate. Optimal vein and catheter selection, yielding the lowest possible catheter/vein ratio, may decrease the rate of PICC-related thrombosis.

A Comparison of Antibiotic Serum Concentrations Drawn Simultaneously from Peripherally Inserted Central Catheters and Peripheral Veins in Children with Respiratory Infection

The purpose of the study was to evaluate serum concentration of antibiotics drawn from a peripherally inserted central catheter (PICC) compared with a peripheral venipuncture. This prospective comparative study included patients with ages 1month to 21years admitted with a respiratory infection requiring IV vancomycin or IV tobramycin via a newly placed PICC. The difference between the antibiotic levels from the venipuncture and PICC samples was statistically significant for both the peak and trough levels. However, the difference in values was not enough to impact antibiotic dosing and therefore was not clinically significant.

[The PICC line, a new approach for venous access]

Peripheral Inserted Central Catheter (PICC) line is a peripherally inserted central catheter. This implantable medical device is placed into a peripheral vein of the arm in order to obtain an intravenous central access. This device can find its use in various applications like intravenous delivery of parenteral nutrition, anticancer agents and antibiotics, as well as for blood sampling. PICC line is not widely used in medical practice because it remains largely unknown. The aim of this review is thus to introduce PICC line to the medical and scientific community. First, we will approach its insertion and maintenance of the dressing. We will then detail the benefits and drawbacks associated with its use, and finally discuss its position with regards to the other central venous access available.

Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations

Venous access required both for blood sampling and for the delivery of medicines and nutrition is an integral element in the care of sick infants and children. Peripherally inserted central catheters (PICCs) have been shown to be a valuable alternative to traditional central venous devices in adults and neonates. However, the evidence may not extrapolate directly to older paediatric patients. In this study, we therefore review the indications, methods of insertion and complications of PICC lines for children beyond the neonatal age to provide clinical recommendations based on a search of the current literature. Although the literature is heterogeneous with few randomised studies, PICCs emerge as a safe and valuable option for intermediate- to long-term central venous access in children both in and out of hospital. Insertion can often be performed in light or no sedation, with little risk of perioperative complications. Assisted visualisation, preferably with ultrasound, yields high rates of insertion success. With good catheter care, rates of mechanical, infectious and thrombotic complications are low and compare favourably with those of traditional central venous catheters. Even in the case of occlusion or infection, fibrinolytics and antibiotic locks often allow the catheter to be retained.

The Effects of Focused Nursing Education on 3F Groshong™ PICC Occlusion Rates: The Experience of One Tertiary Pediatric Care Facility

OBJECTIVE: The primary aim of this project is to reduce the incidence of 3 Fr. Groshong™ PICC occlusions through focused nursing education. BACKGROUND: The use of Peripherally Inserted Central Catheters (PICC) has become an essential tool in the care of pediatric patients. The small lumen and long length of PICCs requires specialized skill and knowledge in proper care, maintenance and flushing in order to prevent catheter occlusion and other complications. Occluded catheters compromise patient care and increase costs. Reducing the incidence of catheter occlusion, will have a significant impact on the quality of patient care; patient, family and nursing satisfaction, patient outcomes, and costs. METHODS: A pre-test/post-test design using a convenience sample of all the core staff nurses working on the medical/surgical unit at a Southern California Children's Hospital was utilized. Objective measures included a written assessment of nursing knowledge, direct observations of nurses' flushing technique, and retrospective chart review to determine the rate of total catheter occlusion. RESULTS: Mean written test scores improved from 0.78 to 0.93 (p=0.00) Mean observation scores improved from 0.88 to 0.95, (p=0.004). The pre-test occlusion rate was 21.11/1000 catheter days. The post test occlusion rate was 15.49/1000 catheter days (p=0.057). CONCLUSION: Focused nursing education contributed to reducing 3F Groshong™ PICC occlusions and the associated costs due to PICC occlusions.

Peripherally inserted central catheters

Peripherally inserted central catheters are increasingly used in the pediatric and adolescent population for long-term central access. This article reviews the indications, insertion techniques, and complications of peripherally inserted central catheter lines.

Outcome of peripherally inserted central venous catheters in surgical and medical neonates

BACKGROUND/PURPOSE

Peripherally inserted central venous catheters (PICCs) are commonly used for neonatal vascular access. The aim of this study was to look at PICC line complication rates and possible predictors of PICC infection in a neonatal intensive care unit.

METHOD

This was a prospective study of 226 neonates who had PICCs on our neonatal intensive care unit between January 2006 and June 2009. Complete data was available on 218 neonates who had 294 PICC lines. Criteria for catheter-related sepsis was positive blood cultures (peripheral/central) and/or a positive catheter tip culture after removal in the presence of a clinical suspicion of line sepsis.

RESULTS

Of 218 neonates, 132 (169 lines) were medical, and 86 (125 lines) were surgical. Our PICC line infection rate was 17 infections per 1000 catheter-days. Surgical neonates had infection rates of 24.8% compared with 18.3% of medical neonates (P < .18). The odds ratio for a PICC infection was 3.1 (95% confidence interval, 1.64-5.87) if the catheter was in situ for 9 days or more, P < .01. Coagulase-negative staphylococcus was isolated from 55 (89%) of 62 blood cultures.

CONCLUSIONS

Our PICC infection rate was 17 per 1000 catheter-days. The length of catheter stay was the only predictor of PICC infection.

Neonatal PICC: one unit's six-year experience with limiting catheter complications

Safe dressing techniques for neonatal peripherally inserted central catheters (PICCs) remain controversial in the literature. This article describes one unit's experience with the placement and management of 491 PICCs during a six-year period with more than 5,600 catheter days. The dressing technique described in this article differs from that seen in the literature with the addition of a protective base layer. Catheter complication rates are low, and catheter dressing changes are minimized with this dressing technique.

Comparison of hematologic and biochemical results on blood obtained by jugular venipuncture as compared with intravenous catheter in adult horses

BACKGROUND

During hospitalization, horses typically undergo frequent blood sampling for diagnostic testing and monitoring. The need for numerous samples in hospitalized horses makes acquisition from an intravenous catheter (IVC) both convenient and less stressful to the patient.

HYPOTHESIS

We hypothesized that there would be no significant difference in the plasma chemistry and CBC variables from blood samples obtained from a jugular catheter as compared with direct jugular venipuncture.

ANIMALS

Fifty adult hospitalized horses; 25 receiving constant rate crystalloid therapy, and 25 receiving low volume IV medication.

METHODS

This study was conducted using a prospective, blinded, cross-over design. Samples were obtained sequentially by direct venipuncture of the jugular vein and aspiration from an IVC in the contralateral vein after an appropriate presample of blood was obtained and discarded. Samples were submitted for blinded analysis including CBC, plasma chemistry analysis, stall side plasma glucose concentration, PCV, and total protein concentration. Data obtained were analyzed using a Student's t-test with compensation for unequal variances between the 2 groups. Analyses were Bonferroni corrected for a 5% 2-tailed hypothesis test.

RESULTS

There were no statistically significant or clinically relevant differences associated with sampling method (venipuncture versus catheter) regardless of fluid administration status in any of the 24 analytes measured.

CONCLUSIONS AND CLINICAL IMPORTANCE

Blood samples obtained by IVC have clinically equivalent values to those taken by direct venipuncture in commonly performed analyses. Additional investigation is warranted to establish if this technique is associated with increased complications such as phlebitis or bacteremia.

Use of a peripherally inserted central catheter as a conduit for central venous access across thrombosed great veins

This report describes a technique of inserting an implantable venous access port (portacath) through a thrombosed and occluded vein employing a pre-existing peripherally inserted central catheter (PICC) as the route of access. The PICC was used as a conduit for venous access in a way that has not been described previously in the literature. This procedure was performed in a young patient with cystic fibrosis in an effort to prevent the use of his virgin contralateral veins, which might be used in the future.

Impact of the Positive Pressure Valve on Vascular Access Device Occlusions and Bloodstream Infections

Background/Purpose: The use of needleless positive pressure connector valves (PPVs) on venous access devices (VADs) has been shown to have possible benefits in decreasing VAD occlusion rates. Catheter-related bloodstream infection (CRBSI) rates, however, have been variable. With this potential for improving patient outcomes, decreasing costs, and facilitating nursing care and catheter management, the use of PPV devices becomes both advantageous and desirable.

Methodology: This was a randomized, prospective, parallel clinical study of 160 medical and surgical step-down unit patients requiring parenteral therapies. Patients were equally randomized to two study groups to assess the impact on occlusion and CRBSI rates, using a PPV versus a standard cap without PPV. VADs included both peripherally inserted catheters (PICCs) and midlines.

Results: Seven VAD occlusions occurred; six in the experimental group, one in the control group (p = 0.43). Also, two CRBSIs occurred in the experimental group, with none in the control group (p = 0.497). All incidents occurred in doublelumen PICCs. The lack of statistical difference between the two groups for occlusions and CRBSIs indicates that the use of PPVs had no impact in preventing such outcomes. However, it was observed that the number of double-lumen PICCs and their dwelling time in the experimental group was significantly higher (p = 0.003).

Conclusion: There was no difference in the rate of catheter occlusions or CRBSIs when using PPVs or standard caps. We consider that the study outcomes may be due to the study's small sample size, and we speculate that longer dwell time of double lumen catheters may have contributed to these outcomes. These observations deserve further investigation. However, the use of PPVs may still be advantageous from a nursing process perspective.

Peripheral insertion of double-lumen central venous catheter using the Seldinger technique in newborns

OBJECTIVE

To report the experience of peripheral insertion of double-lumen central catheters (PIDLCC) in preterm and term newborn infants and to analyze the technical characteristics of the procedure and any observed complications.

STUDY DESIGN

Retrospective review of 61 newborns that had a PIDLCC between 2003 and 2006. The study comprised clinical data analysis, anthropometrics, indications, duration, complications and reasons for withdrawal of the catheters.

RESULT

Weight of the patients was <1 kg in 10%, and >2 kg in 75%. Catheters tip placement was as aimed, mostly superior cava vein (SCV), in 65.5%, and subclavian vein in remaining 34.5% and average duration of catheterization was 13.5+/-9.6 and 8.9+/-5.8 days, respectively. Blood sampling through both lumens was possible especially when the tip was at SCV. Reasons for catheter withdrawal were end of indication (45.9%), phlebitis/edema (21.3%), suspected infection (3.2%), accidental withdrawal (3.2%) and rupture of proximal end (3.2%). In three (4.9%) patients, withdrawal was due to serious complications (two cases of pleural leakage of infusion fluid and one breakage of the metallic guide). About 16.3% of the patients died with the catheter still in situ. Infection findings were positive tip culture (14.7%) and catheter-related sepsis (3.2%).

CONCLUSION

Insertion of PIDLCC is possible in neonates. The incidence of complications, mostly mechanical, requires careful evaluation of indications, and strict adherence to the procedure of insertion and manipulation.

Randomized controlled trial of vascular access in newborns in the neonatal intensive care unit

OBJECTIVE

To compare the effectiveness of two methods of vascular access in newborns.

DESIGN

Randomized controlled trial.

SETTING

Neonatal intensive care unit in Regional Hospital of Valdivia, Chile.

PARTICIPANTS

Seventy-four high-risk newborns.

INTERVENTIONS

Peripherally inserted central catheter and peripheral intravenous catheter.

MAIN OUTCOME MEASURES

Length of neonatal intensive care unit stay and incidence of sepsis and phlebitis. RESULTS/DATA ANALYSIS: There were no statistically significant differences in the length of the neonatal intensive care unit stay and in the incidence of sepsis between groups. There was a significant higher incidence of phlebitis in the peripheral intravenous catheter group.

CONCLUSIONS

Although there was not a significant effect of the kind of catheter on length of neonatal intensive care unit stay, the peripherally inserted central catheter is recommended because of the decreased risk of phlebitis and the decreased number of venipuncture attempts and catheters needed to complete intravenous therapy.

Guide to capillary heelstick blood sampling in infants

Capillary blood sampling is an essential method of blood collection performed by nurses of all skill levels to obtain samples for routine laboratory tests in neonates. Accuracy of results depends on proper heelstick and sample collection technique. Recent advances including development of devices designed specifically for heelstick capillary blood sampling and research into expanded safe heel capillary sampling sites are discussed. A step-by-step guide to capillary blood sampling is outlined along with evidence-based practice incorporating neonatal-appropriate disinfection and nonpharmacological analgesia that contribute to improved infant safety and comfort during and after the procedure.

The impact of needleless connector device design on central venous catheter occlusion in children: a prospective, controlled trial

BACKGROUND

Intraluminal occlusion is common in children with central venous catheters (CVCs). Although multiple factors predispose CVCs to occlusion, reflux of blood is frequently implicated. We hypothesized that use of either a single-valve or positive-pressure-valve needleless connector device would reduce CVC occlusion rates in comparison to a standard device. We further hypothesized that saline would be as effective as heparinized saline flush in preventing occlusion and infection.

METHODS

CVC lumens were prospectively capped with 1 of 3 needleless connector devices in a 4-group design. Group 1 lumens were capped with a standard device, group 2 with a single-valve device, group 3 with a positive-pressure-valve device flushed with heparinized saline, and group 4 with a positive-pressure-valve device flushed with saline. Data were obtained regarding occlusion and infection rates and user satisfaction.

RESULTS

Three hundred sixty children with 599 CVC lumens completed the study. Complete occlusion occurred in 19/150 (12.7%) lumens in group 1 in comparison to 2/150 (1.3%) in group 2, 5/149 (3.4%) in group 3, and 6/150 (4%) in group 4 (p < .05). There was a trend toward a 2-fold greater infection rate in group 4. User satisfaction was higher in groups 2, 3, and 4 than group 1 (p < .05).

CONCLUSIONS

CVCs capped with a single-valve or positive-pressure-valve needleless connector device have lower complete catheter occlusion rates than those capped with a standard device. Heparinized saline flush affords no advantages over saline in reducing occlusion rate; however, there was a trend toward lower infection rate with the use of heparinized saline.

Peripherally Inserted Central Catheters in Children

There is little published information describing standards of practice in the placement, use, and maintenance of peripherally inserted central catheter (PICC) devices in children. A Web-based survey tool was designed to query these issues, and 72 intravenous therapy nurses from 72 hospitals provided complete responses to the survey. The respondents were predominantly (81%) from healthcare organizations inserting 40 or fewer PICC devices per month. These hospitals were equally divided in using 0.9% sodium chloride (USP) (saline) or heparinized saline flush to maintain patency, whereas 76% used catheters for blood sampling. Flushing and blood sampling practices were not related to catheter occlusion rates. From their survey, the authors conclude that the standards of practice for 3-Fr PICC devices, the most commonly used for children, are quite variable and in need of standardization for this specific population.