Peripherally Inserted Central Catheters in Children

A prospective journey of the peripherally inserted central catheter service, at a tertiary paediatric centre in Western Australia

BACKGROUND

To document the evolution of the Peripherally Inserted Central Catheter service at Princess Margaret Hospital, now Perth Children's Hospital.

METHODS

Between January 2012 and June 2013 patients referred to Anaesthesia for a Peripherally Inserted Central Catheter were prospectively followed up. A repeat audit was conducted between January 2015 and June 2016, following the introduction of a number of measures aimed at improving the service.

RESULTS

Audit 1: A total of 200 Peripherally Inserted Central Catheter insertions were attempted in 138 patients. Successful placement occurred in 86% of cases (172/200). The median age of patients was 7.71 years (range 0-20). The percentage of Peripherally Inserted Central Catheters remaining in situ for the predicted duration was 49/172 (28.5%). Complications were documented in 78/172 (45.4%) of cases. Audit 2: A total of 310 Peripherally Inserted Central Catheter placements were attempted in 244 patients. Successful insertion rate was 95.5% (296/ 310). The median age of patients was 5.3 years (range 0.0-18.72). The percentage remaining in situ for the predicted duration was 145/296 (49%). Complications were documented in 67/296 (22.6%) of cases.

CONCLUSION

The evolution of the Peripherally Inserted Central Catheter service at our free standing Tertiary Paediatric Hospital is well documented following these 2 audits. The introduction of a dedicated Anaesthesia led Peripherally Inserted Central Catheter service at our centre has resulted in improved insertion success rates and a reduction in complications.

Sutured Securement of Peripherally Inserted Central Catheters Yields Fewer Complications in Pediatric Patients

BACKGROUND

Pediatric peripherally inserted central catheters (PICCs) can be secured with tape, sutures, or sutureless securement devices. Despite widespread catheter use, no standardized method of securement has been proven superior.

METHODS

A prospective randomized trial of catheter securement with either tape or suture was undertaken in pediatric patients hospitalized at a tertiary children's hospital. Patient demographics, catheter dwell time, and all catheter complications were collected. All patients were followed for the entire dwell time of the catheter, including those discharged with lines still in place.

RESULTS

Sixty-six patients completed the study, with 34 children in the suture group and 32 children in the tape group. Patients' ages ranged from 9 months to 19 years. Overall complication rate in our sutured group was 5.8%, and 32.4% in the tape group.

CONCLUSIONS

In this study of children of varying ages, sutured PICCs were associated with significantly fewer complications than those catheters secured with tape (p=.005). The 3 most common complications included migration, occlusion, and leaking catheters.

Management of peripherally inserted central catheters (PICC) in pediatric heart failure patients receiving continuous inotropic support

The study aim was to evaluate present practice of maintaining PICC line patency in pediatric heart failure patients receiving continuous inotropes by comparing one cohort receiving low dose continuous heparin with one receiving no heparin. A case control retrospective chart review compared the two cohorts on duration of patency (measured in days) and need for thrombolytic agents. Median duration of patency for the heparin group was 24 days versus 16 days for the no heparin group (p=0.07). Use of thrombolytic agents was 28% in the heparin group compared to 50% in the no heparin group (p=0.08). Although not statistically significant, findings were clinically significant and supportive of current practice.

Retrospective Analysis of a Pediatric Vascular Access Program and Clinical Outcomes

Background: The specialty of pediatric vascular access has grown rapidly during the past 5 years across the United States. The majority of children's hospitals have nurse-led vascular access teams that are providing comprehensive services, including the placement of peripherally inserted central catheters. A children's hospital in the southeastern United States conducted an Internal Review Board approved, retrospective analysis of 669 patients who had a peripherally inserted central catheter placed.

Objective: The objective was to have a better understanding of the program and clinical outcomes as well as identify areas for improvement.

Methods: A data collection tool was developed to review the medical records of patients receiving a peripherally inserted central catheter from January 2009 through June 2011. Variables of interest included patient age, admitting diagnosis, intended therapy, procedure location, sedation type and usage, procedure success, insertion attempts, vessel selected, catheter size and type, catheter tip location, reason for discontinuation, and infection. The data was collected and analyzed by a nurse researcher from the University of South Florida.

Results: Using the Modified Seldinger Technique and ultrasound, the team inserted a full line of polyurethane catheters, including computed tomography-injectable catheters, with an insertion success rate of 94%. We identified a significant reduction in our hospital's infection rate—from 9.12 per 1,000 catheter line days to 2.0 per 1,000 catheter line days—during the first year and a half of the program. The use of sedation and anesthesia was significantly reduced, with 49% of patients receiving an oral anxiolytic dose of midazolam and the integration of certified child life specialists into the procedure.

Conclusions: Pediatric vascular access is a rapidly growing specialty in nursing. Nurse-led vascular access teams have become commonplace in children's hospitals throughout the United States. Although the specialty has grown rapidly during the past 5 years, there is a need for data sharing to contribute to the knowledge base of pediatric vascular access.

Guide-wire fragment embolisation in paediatric peripherally inserted central catheters

OBJECTIVE

To report guide-wire fragment embolisation of paediatric peripherally inserted central catheter (PICC) devices and explore the safety profile of four commonly used devices.

DESIGN, SETTING AND PARTICIPANTS

Clinical incidents involving paediatric PICC devices in Queensland public hospitals were reviewed. A PICC user-experience survey was conducted at five public hospitals with 32 clinicians. A device design evaluation was undertaken, and magnetic resonance imaging (MRI) safety was tested by a simulation study.

MAIN OUTCOME MEASURES

Embolisation events; technical mistakes, multiple attempts and breakages during insertion; willingness to use the device; failure modes and risk priority rating; movement and/or temperature change on exposure to MRI.

RESULTS

Six clinical incidents of silent guide-wire embolisation, and four near misses were identified; all were associated with one type of device. The survey found that this device had a reported broken-wire embolisation rate of 0.9/100 insertions with no events in other devices; two of the four devices had a higher all-cause embolisation rate (3.3/100 insertions v 0.4/100 insertions) and lower clinician acceptance (68%-71% v 91%-100%). All devices had 6-17 identified failure modes; the two devices that allowed removal of a guide wire through a septum had the highest overall risk rating. Guide-wire exposure to MRI was rated a potential safety risk due to movement.

CONCLUSIONS

There is marked variation in the safety profile of 3 Fr PICC devices in clinical use, and safety performance can be linked to design factors. Pre-MRI screening of all children who have previously had a PICC device inserted is recommended. We advocate a decision-making model for evaluation of device safety.

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.

Assessing Pediatric Patients for Vascular Access and Sedation

Central venous catheters have been established as a reliable source of vascular access since the 1970s. Peripherally inserted central catheters became a popular central catheter in the early 1990s for adults and children. The management of vascular access in children is an essential part of inpatient and outpatient care. Assessing and inserting the appropriate catheter for the pediatric patient is just a part of the component for central catheter care. Care providers also need to assess these children for sedation or distraction for the procedure. This article discusses factors for catheter choice and points for assessing children for sedation or distraction for vascular access insertion.