Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial

Long peripheral catheters for intravenous infusions of iloprost or alprostadil therapy in rheumatologic outpatients

BACKGROUND

Long peripheral catheters (LPCs) role in Difficult IntraVenous Access (DIVA) patients admitted to the emergency department has already been studied, resulting in a rapid, safe, and cost-effective procedure. Although their use in outpatient settings is established, there is a lack of studies assessing their benefits. In particular, rheumatologic outpatients affected by scleroderma, especially those affected by digital ulcers, are often treated with intravenous infusions of prostaglandin I2 (PGI2) analog (IV-PGI2A).

OBJECTIVE AND METHODS

From 1 October 2021 to 31 March 2024, we conducted a prospective study enrolling DIVA outpatients affected by systemic sclerosis or undifferentiated connective tissue disease who needed IV-PGI2A therapy at L. Sacco Hospital in Milan (Italy). Each treatment cycle consisted of four consecutive days of infusion of iloprost or alprostadil. The primary aim was to assess the efficacy and potential complications associated with LPCs for IV-PGI2A.

RESULTS

Twenty-six patients were enrolled 23 were females (88.5%), and the median age was 72 years (IQR 56-78.7). In total, 97 LPCs were inserted, with a mean number of insertions per patient/year of 2.3. An increase in LPCs insertion during the 30 months of the enrollment period was observed. Eighteen patients required more than one LPC placement, and in 61% of them, the second venipuncture was executed at a different site. No procedural complications were registered (accidental puncture of the brachial artery, accidental median nerve puncture, bleeding) nor late complications (Catheter-Related Thrombosis, Catheter-Related Bloodstream Infections, Accidental Removal).

CONCLUSIONS

Our experience shows that LPCs could be valuable and safe for rheumatologic outpatients. The increased number of insertions and new and total patients enrolled each year defines the satisfaction of patients and health care professionals.

Complications associated to midline- and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection

INTRODUCTION

Long peripheral catheters (LPCs) and midline catheters (MCs) are indiscriminately labelled with different names, leading to misclassifications both in primary and secondary studies. The available studies used different methods to report the incidence of catheter-related complications, affecting the possibility of properly comparing the catheter outcomes. The aim of this review was to explore the complications related to LPCs and MCs after reclassifying according to their length.

METHODS

Systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, conducted on PubMed, Scopus and CINAHL databases. The study protocol was registered in the International Prospective Register of Systematic Reviews. Data regarding LPCs and MCs were compared. Catheter outcomes were classified into major and minor complications, recomputed and reported as cases/1000 catheter-days.

RESULTS

Fourteen studies were included. Over-half of the devices were correctly labelled by the authors, misclassifications affected particularly LPCs improperly labelled MCs. The cumulative incidence of catheter-related bloodstream infections was 0.3 and 0.4/1000 catheter-days, that of symptomatic catheter-related thrombosis was 0.9 and 1.8/1000 catheter-days for MCs and LPCs, respectively. Minor complications and catheter failure were higher for LPCs.

CONCLUSIONS

A misclassification exists in the labelling of MCs and LPCs. A widespread heterogeneity of diagnostic criteria adopted to classify the catheters' outcomes was found, exposing the risk of misestimating the incidence of complications and undermining the possibility of effectively comparing results of the published research. We proposed a list of definitions and relevant variables as a first step toward the development of standardized criteria to be adopted for research purposes.

Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study

BACKGROUND

Midline catheters are peripheral intravenous (IV) catheters in which the tip of the catheter does not reach the central circulation. In children, the use of midline catheters could lead to decreased complications from central venous catheters. To validate the safety of midline catheter use in children, we aimed to describe the complications and dwell time of pediatric midline catheters. The primary outcome was the incidence of catheter-related venous thromboembolism (VTE).

METHODS

We conducted an observational, prospective study including consecutive patients at a tertiary multidisciplinary pediatric hospital. One hundred pediatric midline catheters were followed for thrombotic, infectious, and mechanical complications. After catheter removal, Doppler ultrasonography was performed to detect asymptomatic VTE.

RESULTS

The mean age was 6.0 years (standard deviation [SD], 4.7), and median catheter dwell time was 6 (4-8) days. Most midline catheters were inserted in arm veins, most commonly in the basilic vein (56%). Catheter-related VTE was diagnosed in 30 (30%; 95% confidence interval [CI], 21%-40%) cases, corresponding to an incidence rate of 39 (95% CI, 26-55) cases per 1000 catheter days. Eight of 14 saphenous vein catheters were complicated by VTE compared to 22 of 86 arm vein catheters, suggesting an imbalance in favor of arm vein insertion site. Two patients needed anticoagulation therapy due to catheter-related VTE. Thirty (30%) catheters were removed unintentionally or due to complications, 22 of these needed additional IV access to complete the intended therapy. No catheter-related bloodstream infection (95% CI, 0%-4%) occurred. Mechanical complications occurred in 33 (33%; 95% CI, 24%-43%) midline catheters.

CONCLUSIONS

In children, thrombotic and mechanical complications of midline catheters are common, but only few VTEs are severe enough to warrant anticoagulation therapy. Systemic infectious complications are rare. Seventy-eight percent of patients did not need additional venous access to complete short-term IV therapy. Considering the rate of clinically relevant complications and the catheter dwell time, pediatric midline catheters could be an alternative to central venous access for short-term (5-10 days) IV therapy.

Midline Catheter Use in the Neonatal Intensive Care Unit

Neonates admitted to the neonatal intensive care unit (NICU) are a unique population who most often begin life acutely or critically ill. Venous access is required by most acutely/critically ill neonates, especially those born preterm. Access is required for implementing management strategies such as stabilization, medications, fluids, nutrition, and transfusion of blood products. However, achieving and maintaining venous access in these neonates can be difficult, especially in preterm infants due to a myriad of contributing factors. Peripheral intravenous (PIV) catheters and peripherally inserted central catheters (PICC) are 2 common vascular access approaches used in the NICU and have traditionally been the most studied in the neonatal literature. Both options offer advantages and disadvantages. An alternative to PIVs and PICCs is the midline peripheral catheter (MPC), which in the literature may also be referred to as extended dwell peripheral intravenous catheters. Depending on the intended use, the MPC offers a venous access approach between a PIV and PICC. Usage of MPCs in the NICU is slowly increasing with the limited published evidence suggesting they are viable option when considering the need for vascular access. The purpose of this article is to present the advantages and disadvantages of MPCs as an alternative approach for venous access in neonates when appropriate.

Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) frequently fail during treatment causing therapy interruption, pain, recatheterization, and additional health care costs. Midline catheters (MCs) may improve functional dwell time and reduce failure compared with traditional PIVCs.

Objective

To compare device failure of MCs with PIVCs.

Design, Setting, and Participants

This was a pragmatic, randomized clinical superiority trial with an embedded internal pilot study conducted from July 2020 to May 2022. The study took place in a quaternary pediatric hospital in Brisbane, Queensland, Australia. Inclusion criteria were patients aged 1 to 18 years requiring peripherally compatible intravenous therapy for 4 days or longer.

Interventions

Patients were randomly assigned 1:1 to receive a PIVC or MC, stratified by age (≤5 years, >5 years). One catheter was studied per patient.

Main Outcomes and Measures

The primary outcome was all-cause device failure, defined as premature cessation of device function. Secondary outcomes included number of insertion attempts, insertion failure, pain (on insertion), procedural time, patient/parent satisfaction (with insertion), device dwell time, device complications during dwell time, additional vascular access devices required to complete treatment, clinician satisfaction (at removal), and health care costs.

Results

Of the 128 patients randomly assigned to study groups, 127 patients (median [IQR] age, 7 [2-13] years; 71 male [56%]) had a device inserted, with 65 (51.2%) in the PIVC group and 62 (48.8%) in the MC group. All patients were included in the intention-to-treat analysis. Device failure was lower in patients in the MC group (10 [16.1%]) compared with those in the PIVC group (30 [46.2%]; odds ratio [OR], 0.22; 95% CI, 0.10-0.52; P <.001). MCs were associated with fewer insertion attempts (mean difference [MD], -0.3; 95% CI, -0.5 to 0; P = .04), increased dwell time (MD, 66.9 hours; 95% CI, 36.2-97.5 hours; P <.001), and fewer patients required additional vascular access devices to complete treatment in the MC group (4 [6.5%]) and PIVC group (19 [29.2%]; OR, 0.17; 95% CI, 0.05-0.52; P = .002). Compared with PIVCs, use of MCs was associated with greater patient (9.0 vs 7.1 of 10; P = .002) and parent (9.1 vs 8.2 of 10; P = .02) satisfaction and lower health care costs (AUS -$151.67 [US -$101.13] per person; 95% credible interval, AUS -$171.45 to -$131.90 [US -$114.20 to -$87.95]).

Conclusions and Relevance

Findings suggest that MC insertion for patients requiring peripherally compatible intravenous therapy for 4 days or longer should be prioritized to reduce the resource intensive, expensive, and burdensome sequelae of device failure.

Trial Registration

Australia New Zealand Clinical Trials Registry, ACTRN12620000724976.

Long peripheral catheters in children: A scoping review

BACKGROUND AND OBJECTIVES

Long peripheral catheters (LPCs) are emerging vascular access devices used for short-medium term vascular access needs. Literature in adults suggests LPCs have longer dwell-times than peripheral intravenous catheters (PIVs) and lower rates of serious complications than peripherally inserted central catheters (PICCs). The role of LPCs in children is less established. The objective of this scoping review is to describe and synthesize the existing literature on the effectiveness and safety of LPCs in children.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Searches were done in MEDLINE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, Scopus, CINAHL (Ebsco), and Google Scholar most recently on February 22, 2022. Studies were included if published in English on or after 2000 and included patients <18 years of age.

RESULTS

Twenty-one studies were included. The body of literature is variable in quality, measurements, and reported outcomes. Median dwell-time ranged from 5 to 14 days. The rate of completion of therapy ranged from 20% to 86%. Dislodgement, occlusion, and infiltration were the most common complications reported (0%-31%). Venous thromboembolism rates ranged from 0% to 13%. The rate of catheter-related bloodstream infection was 0% in 9 of 10 studies. Less than 50% of studies reported comparative outcomes.

CONCLUSION

LPCs show promising outcomes in select populations, with longer dwell-time than PIVs and possibly lower rates of serious complications than PICCs. However, more research is needed to clarify the optimal use of LPCs in pediatrics.

Techniques and Technologies to Improve Peripheral Intravenous Catheter Outcomes in Pediatric Patients: Systematic Review and Meta-Analysis

OBJECTIVE

Insertion and function of pediatric peripheral intravenous catheters (PIVCs) present challenges. We systematically reviewed techniques and technologies to improve PIVC outcomes (first-time insertion success, overall insertion success, time to insertion, dwell time, failure, and complications).

DATA SOURCES

Cochrane Central Register of Controlled Trials (CONTROL), Cumulative Index to Nursing and Allied Health (CINAHL), US National Library of Medicine, and Embase.

STUDY SELECTION

English-language pediatric trials published post 2010 reporting PIVC outcomes.

DATA EXTRACTION

Following Cochrane standards, two authors screened, extracted, and critiqued study quality (Grading of Recommendations Assessment, Development and Evaluation approach) data, random effects analysis, results expressed as risk ratios (RR), mean differences (MD) and 95% CIs.

RESULTS

Twenty-one studies (3237 children; 3098 PIVCs) were included. First-time insertion success significantly increased with ultrasound guidance (compared with landmark insertion; RR, 1.60; 95% CI, 1.02-2.50). Use of ultrasound guidance (compared with landmark insertion) did not improve overall PIVC insertion success (RR, 1.10; 95% CI, 0.94-1.28). There was no evidence of an effect of near-infrared (compared with landmark) on first-time insertion success (RR, 1.21; 95% CI, 0.91-1.59) or number of attempts (MD, -0.65; 95% CI, -1.59 to 0.29); however, it significantly reduced PIVC insertion time (MD, -132.47; 95% CI, -166.68 to -98.26) and increased first-time insertion success in subgroup analysis of patients with difficult intravenous access (RR, 2.72; 95% CI, 1.02-7.24).

LIMITATIONS

Few studies per intervention, small sample sizes, and inconsistent outcome measures precluded definitive conclusions.

CONCLUSIONS

Ultrasound and near-infrared appear to improve pediatric PIVC insertion. High-quality studies examining the full extent of techniques and technologies are needed. Registration: CRD42020175314.