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Zhang F, Ye G, Chen P, Gui Z. Comparative Predictive Modeling for PICC Line Complications in Oncology: A Retrospective Study. Br J Hosp Med (Lond) 2024; 85:1-15. [PMID: 39347656 DOI: 10.12968/hmed.2024.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Aims/Background Peripherally inserted central catheter (PICC) are increasingly used in cancer treatment, offering significant therapeutic benefits while also posing risks for complications such as infection, thrombosis, and catheter migration. Effective prediction and management of these complications are crucial to optimizing patient outcomes and reducing healthcare costs. Methods This retrospective study analyzed PICC line insertion in 266 cancer patients implemented from January 2019 to December 2023 at a regional healthcare facility in China. Using least absolute shrinkage and selection operator (LASSO) logistic regression, we identified key factors influencing PICC line complications and developed a tailored nomogram for individual risk assessment. The efficacy of the model was compared with support vector machine (SVM), random forest, and gradient boosting machine (GBM) using receiver operating characteristic (ROC) and decision curve analysis (DCA) metrics. Results Factors such as body mass index (BMI), diabetic status, and age were found to be significant predictors of PICC line complications. The LASSO model demonstrated superior predictive capability (area under the curve, AUC = 0.79) over SVM (AUC = 0.40), random forest (AUC = 0.70), and GBM (AUC = 0.64). A tailored nomogram was developed for clinical use, enabling personalized risk evaluation. Conclusion The study underscores the utility of LASSO logistic regression in the personalized risk evaluation of PICC line complications, recommending its integration into clinical practice. The tailored nomogram provides a practical tool for clinicians to enhance care customization for patients requiring PICC lines, thereby improving treatment outcomes and patient safety.
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Affiliation(s)
- Feifei Zhang
- Gynaecology Department, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Guanjun Ye
- Peripherally Inserted Central Catheter Department, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Ping Chen
- Gastrointestinal Surgery Department, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Zongying Gui
- Radiochemotherapy Department, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
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Maezawa T, Sakuraya M, Yoshida K. The safety of peripherally inserted central venous catheters in critically ill patients: A retrospective observational study. J Vasc Access 2024; 25:1479-1485. [PMID: 37070255 DOI: 10.1177/11297298231169059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
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.
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Affiliation(s)
- Toshinori Maezawa
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
| | - Kenichi Yoshida
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
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Rosenthal VD, Yin R, Rodrigues C, Myatra SN, Divatia JV, Biswas SK, Shrivastava AM, Kharbanda M, Nag B, Mehta Y, Sarma S, Todi SK, Bhattacharyya M, Bhakta A, Gan CS, Low MSY, Bt Madzlan Kushairi M, Chuah SL, Wang QY, Chawla R, Jain AC, Kansal S, Bali RK, Arjun R, Davaadagva N, Bat-Erdene I, Begzjav T, Mohd Basri MN, Tai CW, Lee PC, Tang SF, Sandhu K, Badyal B, Arora A, Sengupta D, Tao L, Jin Z. Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections over 18 years in 281 ICUs of 9 Asian countries. J Vasc Access 2024; 25:1508-1518. [PMID: 37151085 DOI: 10.1177/11297298231169542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia. METHODS From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR). RESULTS A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk. CONCLUSIONS The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.
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Affiliation(s)
- Victor Daniel Rosenthal
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- International Nosocomial Infection Control Consortium (INICC) Foundation, Miami, FL, USA
| | - Ruijie Yin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Camilla Rodrigues
- Department of Microbiology, Pd Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha Nacional Institute, Mumbai, India
| | - Jigeeshu Vasishth Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha Nacional Institute, Mumbai, India
| | - Sanjay K Biswas
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha Nacional Institute, Mumbai, India
| | - Anjana Mahesh Shrivastava
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha Nacional Institute, Mumbai, India
| | | | - Bikas Nag
- Department of Critical Care, Desun Hospital, Kolkata, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesiology, Medanta The Medicity, Haryana, India
| | - Smita Sarma
- Department of Critical Care and Anesthesiology, Medanta The Medicity, Haryana, India
| | - Subhash Kumar Todi
- Department of Critical Care, Advanced Medicare Research Institute AMRI Hospitals, Kolkata, India
| | - Mahuya Bhattacharyya
- Department of Critical Care, Advanced Medicare Research Institute AMRI Hospitals, Kolkata, India
| | - Arpita Bhakta
- Department of Pediatric Intensive Care, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chin Seng Gan
- Department of Pediatric Intensive Care, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Michelle Siu Yee Low
- Department of Pediatric Intensive Care, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | | | - Soo Lin Chuah
- Department of Pediatric Intensive Care, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Qi Yuee Wang
- Department of Pediatric Intensive Care, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rajesh Chawla
- Department of Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Sudha Kansal
- Department of Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | - Roseleen Kaur Bali
- Department of Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | - Rajalakshmi Arjun
- Department of Critical Care, Kerala Institute of Medical Sciences Health, Trivandrum, India
| | | | | | | | - Mat Nor Mohd Basri
- Department of Anesthesia and Critical Care, International Islamic University Malaysia, Kuantan Pahang, Malaysia
| | - Chian-Wern Tai
- Department of Anesthesia and Critical Care, International Islamic University Malaysia, Kuantan Pahang, Malaysia
| | - Pei-Chuen Lee
- Department of Anesthesia and Critical Care, International Islamic University Malaysia, Kuantan Pahang, Malaysia
| | - Swee-Fong Tang
- Department of Critical Care, Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Kavita Sandhu
- Department of Critical Care, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Binesh Badyal
- Department of Critical Care, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Ankush Arora
- Department of Critical Care, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Deep Sengupta
- Department of Critical Care, Max Super Speciality Hospital Saket Delhi, New Delhi, India
| | - Lili Tao
- Department of Pneumonology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhilin Jin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Sakai H, Hirosue M, Iwata M, Terasawa T. 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. J Vasc Access 2024; 25:1601-1609. [PMID: 37341211 DOI: 10.1177/11297298231173160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
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.
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Affiliation(s)
- Hirotaka Sakai
- Department of Emergency Medicine and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Miyuki Hirosue
- Department of Emergency Medicine and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Mitsunaga Iwata
- Department of Emergency Medicine and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency Medicine and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Hastings A, Barton A. Rapid haemostasis to achieve dressing longevity: evaluation trial results using StatSeal catheter exit site protection. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:S8-S14. [PMID: 39023031 DOI: 10.12968/bjon.2024.0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Peripherally inserted central catheters (PICCs) are vital in delivering intravenous therapy. Despite their advantages, PICCs can lead to complications such as catheter exit site bleeding, which can cause patient distress and increase infection risk. This study evaluated the efficacy of StatSeal, a topical haemostatic device, in managing PICC exit site bleeding. StatSeal uses a hydrophilic polymer and potassium ferrate to form a seal, reducing access site bleeding and minimising dressing changes. For this study, Patients were recruited at Frimley Health NHS Foundation Trust; the trial involved 177 patients with StatSeal, and shows that 99% did not require additional dressing changes within the standard 7-day period. The findings demonstrate StatSeal's effectiveness in improving patient outcomes by reducing exit site bleeding and associated complications, enhancing the efficiency of vascular access maintenance and potentially lowering associated healthcare costs. The trial emphasises the importance of innovative solutions such as StatSeal to advance PICC care and improve patient experience.
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Affiliation(s)
- Angela Hastings
- Clinical Nurse Specialist, Vascular access and IV therapy, Frimley Health NHS Foundation Trust, Frimley, angela
| | - Andrew Barton
- Nurse Consultant, IV Therapy and Vascular Access, Frimley Health NHS Foundation Trust, Frimley, and Chair, National Infusion and Vascular Access Society
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Karabey T, Karagözoğlu Ş. The effect of new device on pain and comfort levels in individuals undergoing peripheral intravenous cannula insertion. J Vasc Access 2024; 25:432-438. [PMID: 35903016 DOI: 10.1177/11297298221113685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM AND OBJECTIVES The purpose of this study is to see how ShotBlocker® affects the pain and comfort level associated with short peripheral intravenous cannula (PIV) insertion. METHODS The study was conducted on a single sample group using a pre-post design. Individuals in the sample group who underwent a brief PIV insertion procedure served as both the study's control and intervention groups. In the sample group, the same nurse inserted a peripheral intravenous catheter into the cephalic veins of the right and left forearms using a standard insertion and ShotBlocker®. The pain and comfort levels were assessed using the VAS and Comfort Scale. RESULTS When the distribution of the average pain and comfort scores of the individuals treated with the peripheral intravenous catheter was examined, it was found that the average pain score of the peripheral intravenous catheter insertion using ShotBlocker® was statistically significantly lower than the peripheral intravenous catheter insertion using the standard method, and the comfort score averages were statistically higher. When the correlation between the pain and comfort score averages of individuals undergoing peripheral intravenous catheter insertions was investigated, a statistically significant and strong negative relationship (p = 0.001) was discovered. CONCLUSIONS As a result, the use of ShotBlocker® during the short PIV insertion procedure is an effective method to reduce the pain caused by the peripheral intravenous catheter. It was determined that the comfort level of the individuals increased as the pain due to peripheral intravenous catheter insertion decreased.
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Affiliation(s)
- Tuba Karabey
- Nursing Department, Faculty of Health Sciences, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - Şerife Karagözoğlu
- Nursing Department, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey
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Locatello LG, Saitta T, Maggiore G, Signorini P, Pinelli F, Adembri C. A 5-year experience with midline catheters in the management of major head and neck surgery patients. J Vasc Access 2023; 24:1412-1420. [PMID: 35441553 DOI: 10.1177/11297298221091141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development. METHODS Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications. RESULTS A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications. CONCLUSIONS MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.
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Affiliation(s)
| | - Thomas Saitta
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Patrizia Signorini
- Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Fulvio Pinelli
- Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Chiara Adembri
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesiology, Careggi University Hospital, Florence, Italy
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Hussain RN, Mandal AKJ, Li N, Kafsi JE, Sioftanos A, Missouris CG. Right heart thrombus in transit and peripherally inserted central catheters. Thromb J 2023; 21:68. [PMID: 37349797 DOI: 10.1186/s12959-023-00513-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023] Open
Abstract
Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.
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Affiliation(s)
- Rezwan N Hussain
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit K J Mandal
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.
| | - Nick Li
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- The Queen's College, University of Oxford, Oxford, UK
| | - Jihène El Kafsi
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | | | - Constantinos G Missouris
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Nicosia, Cyprus
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