Neonatal Peripherally Inserted Central Catheter Practices and Providers: Results From the Neonatal PICC1 Survey

Role of a radiopaque agent and surveillance radiographs for peripherally inserted central catheters in newborn infants

BACKGROUND

Controversy exists regarding the use of a radiopaque agent to identify peripherally inserted central catheter (PICC) tip positions in newborn infants and of serial radiography to monitor PICC tip migration.

OBJECTIVE

To investigate the roles of (1) the injection of a radiopaque agent to identify PICC tip position and (2) the performance of weekly radiography to monitor PICC migration.

MATERIALS AND METHODS

This retrospective single-centre cohort study included newborn infants who received a PICC between 1 January 2016 and 31 December 2020. A radiopaque agent was injected to identify PICC tip position and radiographs were performed weekly to detect PICC migration.

RESULTS

We identified 676 PICC episodes in 601 infants. A radiopaque agent was used for 590 of these episodes. There was no difference in the proportion of central PICC tip positions based on radiopaque agent use status (490/590, 83% for the radiopaque agent used group versus 73/85, 85.8% for the radiopaque agent not used group, P=0.51). Irrespective of the site of PICC insertion, outward migration was observed for most centrally placed PICCs over their entire in situ duration. Inward migration was identified in 23 out of 643 PICC episodes (3.6%) only on radiographs obtained on or before day 7. Based on serial radiographs, the odds for PICC tips remaining in a central position were lower the longer the PICC remained in situ (adjusted odds ratio-OR 0.93; 95% confidence interval 0.92-0.95). There was no difference in PICC migration between side and limb of insertion.

CONCLUSION

PICC tips can be identified without injection of a radiopaque agent. Serial radiographs identified PICC migration over the in situ duration. This study has implications for reducing exposure to a radiopaque agent and ongoing migration surveillance practices.

An Observational Study on the Use of Peripheral Intravenous Lines vs. Central Lines in a Neonatal Intensive Care Unit

Background and Objectives: There is a debate regarding the preferred intravenous (IV) access for newborns. Our aim was to study practices regarding the choice of vascular access and outcomes. Methods: A seven-month prospective observational study on IV lines used in all newborns admitted to Bnai Zion Medical Center’s neonatal intensive care unit (NICU). Results: Of 120 infants followed, 94 required IV lines. Infants born at ≤32 weeks gestation, or with a head circumference ≤29 cm were more likely to require two or more IV lines or a central line for the administration of parenteral nutrition or medications for longer periods. However, central lines (umbilical or peripherally inserted central catheters (PICC)) were not associated with better nutritional status at discharge based on weight z-scores. Only one complication was noted—a central line-associated bloodstream infection in a PICC. Conclusions: Our data suggest preferring central IV access for preterm infants born at ≤32 weeks or with a head circumference ≤29 cm. We encourage other NICUs to study their own data and draw their practice guidelines for preferred IV access (central vs. peripheral) upon admission to the NICU.

An Information-Based Nursing Quality Evaluation Model of Daily PICC Work in Outpatient Clinics

Our purpose of this study was to analyze the application value of the information-based nursing quality evaluation model in improving the daily work quality of the PICC room in the outpatient department. From January 2020 to December 2020, 465 patients who received PICC treatment were selected as the research objects and divided into the observation group (265 cases, July 2020–December 2020, information-based nursing quality evaluation model after implementation) and the control group (200 cases, January 2020–June 2020, before the implementation of the information-based nursing quality assessment model). Compared with the control group, the children and their families in the observation group had higher PICC health knowledge and compliance scores, longer mean time for catheter placement, lower overall complication rate, and higher overall satisfaction rate after the intervention. The information-based nursing quality evaluation model can improve the daily work quality of the PICC room in the outpatient clinic, improve the clinical efficacy of PICC in patients, and reduce the incidence of complications such as catheter shedding. It is worthy of clinical application.

Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study

BACKGROUND

Within every neonatal clinical setting, vascular access devices are considered essential for administration of fluids, nutrition, and medications. However, use of vascular access devices is not without danger of failure. Catheter securement adhesives are being evaluated among adult populations, but to date, studies in neonatal settings are scant.

PURPOSE

This research describes the prevalence of peripherally inserted central catheter failure related to catheter securement before and after the introduction of tissue adhesive for catheter securement. The identified modifiable risks might be used to evaluate efficacy, to innovate neonatal practice and support future policy developments.

METHOD AND SETTING

This was a retrospective observational analysis of routinely collected anonymized intravenous therapy-related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar.

RESULTS

The results showed that the use of an approved medical grade adhesive for catheter securement resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight, and catheter type.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In parallel with currently published international literature, this study's findings support catheter securement with an octyl-based tissue adhesive in use with central venous catheters. When device stabilization is most pertinent, securement with tissue adhesive is a safe and effective method for long-term vascular access among the neonatal population.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Peripherally inserted central cathether migration in neonates: Incidence, timing and risk factors

BACKGROUND

PICC line use is a common practice in neonatal units, but it is associated with various complications. Catheter migration is the most common complication in neonates. Periodic imaging is recommended to monitor the tip position of the PICCs, but the optimal frequency is undetermined. The incidence, timing and risk factors that are associated with PICC migration have not been fully investigated beyond 24 hrs in neonates. The aim of the study was to determine the incidence, timing and risk factors that are associated with peripherally inserted central venous catheter (PICC) migration in neonates.

METHODS

This was a single center, retrospective study of 168 PICCs placed in 141 neonates in the neonatal intensive care unit (NICU) between 2015 and 2016. The incidence of catheter migration was determined radiographically at 12-24 hrs and every third day after insertion until it was removed.

RESULTS

Overall incidence of PICC migration was 28%and most commonly was detected within the first three days after PICC placement (83%). The incidence of PICC migration was higher in males. The PICC migration was associated with difficulty advancing the PICC at the time of insertion and PICC dressing change.

CONCLUSION

Serial evaluation of PICC placement in neonates is required to maintain proper position. Based on our experience in our unit, we recommend periodic imaging at 12-24 hrs and on the third day after PICC placement as most migration occurred within three days after insertion.

How to minimize central line-associated bloodstream infections in a neonatal intensive care unit: a quality improvement intervention based on a retrospective analysis and the adoption of an evidence-based bundle

Central line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in neonatal intensive care units (NICUs). A "bundle" is defined as a combination of evidence-based interventions that provided they are followed collectively and reliably, are proven to improve patient outcomes. The aim of this quasi-experimental study was to assess the impact of new central line insertion, dressing, and maintenance "bundles" on the rate of CLABSI and catheter-related complications. We performed a quality improvement (QI), prospective, before-after study. In the first 9-month period, the old "bundles" and pre-existing materials were used/applied. An intervention period then occurred with changes made to materials used and the implementation of new "bundles" related to various aspects of central lines care. A second 6-month period was then assessed and the CLABSI rates were measured in the NICU pre- and post-intervention period. The QI measures were the rate of CLABSI and catheter-related complications. Data are still being collected after the study to verify sustainability. The implementation of the new "bundles" and the change of certain materials resulted in a significantly decreased rate of CLABSI (8.4 to 1.8 infections per 1000 central venous catheter (CVC) days, p = 0.02,) as well as decreased catheter-related complications (47 to 10, p < 0.007).Conclusions: The analysis of pre-existing "bundles" and the implementation of updated central line "bundles" based on best practice recommendations are crucial for reducing the rate of CLABSI in the NICU. The implementation of the new evidence-based central line "bundles" was associated with a significant reduction in CLABSI rate in our unit soon after implementation. What is Known: • Central line-associated bloodstream infection (CLABSI) is a major cause of morbidity and mortality in the neonatal population. • The implementation of evidence-based "bundles" in the NICU is associated with a reduction in the incidence of CLABSI. What is New: • For the improvement in quality care in the NICU, audits are necessary to assess the existing systems. • The "Plan-Do-Study-Act cycle" is an effective tool to use when tackling challenges in an existing system. Using this tool assisted in the approach to reducing CLABSI in our NICU.

Saturation oxygenation pressure index: a non-invasive bedside measure for severity of respiratory disease in neonates on CPAP

The treatment of respiratory distress in neonates ranges from non-invasive continuous positive airway pressure (CPAP) to advanced invasive mechanical ventilation. Monitoring on CPAP is often done by calculating oxygenation after blood gas analysis which is an invasive procedure. Saturation oxygen pressure index (SOPI) is a simple, non-invasive, bedside tool to monitor the severity of respiratory illness in neonates on CPAP. This study was aimed at validation of SOP index against AaDO2 and determine the cut-off values of SOPI for A-aDO2 of 70, 85 and100. This was a prospective observational study on 126 neonates with respiratory distress and treated with CPAP. The correlation between SOPI and A-aDO2 was validated using Bootstrap method. There was a significant positive correlation between SOPI and A-aDO2 with the Spearman correlation coefficient (rho) being 0.815 (p = 0). The mean coefficient of correlation after Bootstrap was 0.827 (p value < 0.0001). SOPI values of 1.52, 1.57 and 1.6 predicted A-aDO2 value of 70, 85 and 100 with a sensitivity of above 80% and specificity above 90%, respectively.Conclusion: SOPI has a significant positive correlation of 82.7% against A-aDO2 and can be a valuable tool to assess respiratory distress in neonates without arterial blood gas. What is Known: • Saturation oxygen pressure index (SOPI) is a non-invasive monitoring tool for neonates on N-CPAP. • SOPI has a good correlation with AaDO2. What is New: • Correlation of SOPI with AaDO2 is now validated. • Values between 1.52 and 1.88 indicate clinically useful range of AaDO2 for escalation of respiratory support from CPAP.

Nursing Interventions to Reduce Peripherally Inserted Central Catheter Occlusion for Cancer Patients: A Systematic Review of Literature

BACKGROUND

Cancer patients are considered the most at risk of the consequences of catheter occlusion. Therefore, nursing interventions that can effectively reduce the occlusion of peripherally inserted central catheter (PICC) lines must be identified to ensure a smooth treatment.

OBJECTIVE

This study aimed to evaluate nursing interventions to minimize PICC line occlusion and make recommended measures for preventing or decreasing occlusion and abnormal extubation.

METHODS

Studies about PICC occlusion that were published up to January 2017 were searched and screened in PubMed, Web of Science, Science Direct (Elsevier), EMBASE, Cochrane Library, and Chinese databases CNKI and Wanfang. Two independent reviewers screened the literature in accordance with the inclusion and exclusion criteria, assessed the quality of the included studies, and extracted the data. Further meta-analysis was performed using RevMan 5.3.

RESULTS

Thirteen trials were included. Meta-analysis revealed that education for nurses (relative risk, 0.31; 95% confidence interval, 0.19-0.51; P < .00001) was significantly associated with PICC occlusion, whereas PICC type (relative risk, 0.60; 95% confidence interval, 0.32-1.15; P = .12) was not significantly associated with PICC occlusion. The solution to washing pipes and the PICC insertion techniques were descriptively analyzed to reach statistical significance.

CONCLUSION

This study determined the correlation of PICC occlusion with the nurses' knowledge and skills, PICC types, flushing liquid and methods, and insertion techniques.

IMPLICATIONS FOR PRACTICE

The findings of this study can serve as a guide for clinical work and for developing targeted measures to reduce occlusion.

Maximal sterile barrier precautions independently contribute to decreased central line-associated bloodstream infection in very low birth weight infants: A prospective multicenter observational study

BACKGROUND

The use of peripherally inserted central catheters (PICCs) in neonates differs among various institutions and countries because there are no random controlled trials or large observational studies regarding maximal sterile barrier (MSB) precautions in neonatal intensive care units. Our objective was to investigate the association of MSB implementation with central line-associated bloodstream infection (CLABSI) in very low birth weight infants.

METHODS

This was a prospective multicenter observational study in Japan of infants with birth weight less than 1501 grams and in whom a PICC was placed for the first time between October 2014 and March 2017. Risk factors for CLABSI, both related and unrelated to MSB, were assessed by the mixed-effects Cox proportional hazards model, with the neonatal center variable as the random effect.

RESULTS

In total, 33,713 catheter-days among 2383 infants were included. We observed 70 cases of CLABSI. MSB precautions were implemented in 13.9% of insertions and were associated with a lower CLABSI risk (adjusted hazard ratio, 0.20; 95% confidence interval, 0.05-0.84).

CONCLUSIONS

We found that MSB implementation during PICC insertion in infants with birth weight less than 1501 grams independently contributed to a decrease in CLABSI risk.

Outcomes associated with peripherally inserted central catheters in hospitalised children: a retrospective 7-year single-centre experience

OBJECTIVES

The use of peripherally inserted central catheters (PICCs) are an integral part of caring for hospitalised children. We sought to estimate the incidence of and identify the risk factors for complications associated with PICCs in an advanced registered nurse practitioners (ARNP)-driven programme.

DESIGN

Retrospective cohort study.

SETTING

Single-centre, large quaternary children's hospital.

PARTICIPANTS

Hospitalised children who had PICC inserted from 1 January 2010 to 31 December 2016.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

A total of 2558 PICCs were placed during the study period. Mean age at PICC insertion was 8.7 years, mean dwell time was 17.7 days. The majority of PICCs (97.8%) were placed by ARNP. Most were placed in a single attempt (79.6%). Mean PICC residual external length outside was 2.1±2.7 cm. The rate of central line-associated bloodstream infection (CLABSI), thrombosis and significant bleeding were 1.9%, 1% and 0.2%, respectively. The CLABSI rate in infants and early childhood was higher than those aged ≥5 years (2.8%, 3.1%, respectively vs 1.3%). In a multivariate analysis after adjustment of confounding effects of race and gender, infants (OR= 2.24, CI=1.14 to 4.39, p=0.02) and early childhood cohort (OR=2.37, CI=1.12 to 5.01, p=0.02) were associated with significantly higher odds of developing CLABSI compared with ≥5 years old. In the early childhood cohort, PICCs with longer residual external catheter length (OR=1.30, 95% CI=1.07 to 1.57, p=0.008) and those placed in the operating room (OR=5.49, 95% CI=1.03 to 29.19, p=0.04), were associated with significantly greater risk of developing CLABSI.

CONCLUSIONS

The majority of PICCs were successfully placed by ARNPs on the first attempt and had a low incidence of complications. Infants required more attempts for successful PICC placement than older children. The presence of residual external catheter length and placement in the operating room were independent predictors of CLABSI in younger children.

Feasibility and Outcomes Associated With the Use of 2.6-Fr Double-Lumen PICCs in Neonates

BACKGROUND

Low birth-weight infants' survival continues to improve and there is increased need to provide secure vascular access. This study examines safety of larger peripherally inserted central catheters (PICCs) that offer greater utility.

PURPOSE

To determine feasibility of 2.6-French (Fr) double-lumen PICCs in newborns and compare noninfectious complications such as thrombus formation, catheter breakage, infiltration, and accidental dislodgment and central line-associated bloodstream infection (CLABSI) rate with that of newborn infants treated with 1.9-Fr single- and double-lumen PICCs.

METHODS

Infants requiring PICCs were admitted in our 69-bed level IV neonatal intensive care unit from September 2006 to May 2015. Two distinct groups were compared: the 1.9-Fr-(single-lumen [n = 105] and double-lumen [n = 27])-and 2.6-Fr double-lumen PICCs (n = 111). Data obtained included birth weight and weight at insertion, gestational age at birth and corrected gestation age at insertion, indication, catheter days, indication for removal, and complications: noninfectious and infectious. Univariate and multivariate statistical analysis evaluated data.

RESULTS

There were no differences regarding gestational age at birth and insertion and indications for placement of 2.6-Fr double-lumen (n =111) and 1.9-Fr both single- and double-lumen (n = 132) PICCs. The same was noted between the groups' complications. Noninfectious complications were more common in PICCs with peripheral tip location in all groups.

IMPLICATIONS FOR PRACTICE

Consider use of 2.6-Fr PICCs in a neonatal intensive care unit when the utility of blood administration and sampling is required.

IMPLICATIONS FOR RESEARCH

Examine line migration and CLABSI associated with sampling and blood administration.

PERIPHERAL VENIPUNCTURE: COMPREHENSION AND EVALUATION OF NURSING PRACTICES

ABSTRACT Objective: to understand the nursing practices related to peripheral venipuncture and to analyze the incidence of complications in patients with venous catheters. Method: mixed design, involving: case study, sectional study, cohort study and focus group. The sample consisted of nurses and patients from a medical clinic in Portugal. Thematic analysis and descriptive statistics were performed. Results: stressors capable of influencing nursing practices were identified, including: the decisions of the medical team, the age and characteristics of the venous network of the patient, the availability of other catheters in the institution, the low level of knowledge of nurses regarding the care of patients in the insertion, maintenance and removal of the peripherally inserted central venous catheter. The following complications and their respective incidences were documented in patients with peripheral venous catheters: phlebitis (22.2%), obstruction (27.7%), fluid exiting through insertion site (36.1%), infiltration (38.8%) and accidental catheter removal (47.2%). Catheter obstruction with an incidence of 22.2% was only observed in those who used the peripherally inserted central venous catheter. The following benefits were observed with the use of the peripherally inserted central venous catheter: safe administration of drugs; pain reduction, number of venous punctures and complications. Conclusions: the peripherally inserted central venous catheter is presented as a valid and viable alternative that can improve the quality of nursing care and the safety and well-being of patients.