Vascular access devices in leukemia: a retrospective review amongst patients treated at the Ottawa Hospital with induction chemotherapy for acute leukemia

Prevalence of PICC-related thrombosis in patients with hematological malignancies: a systematic review

PURPOSE

To estimate the prevalence of peripherally inserted central catheter (PICC)-related venous thrombosis in patients with hematological malignancies.

METHODS

A systematic review of observational studies that evaluated the occurrence of PICC-related venous thrombosis in children, adults, and older people with hematological malignancies was conducted. Searches were carried out on June 12th, 2023 on PubMed, CINAHL, Embase, Web of Science Core Collection, Scopus, and LILACS, and to gray literature on Google Scholar, and ProQuest Dissertations and Theses Global. Eligibility criteria were applied independently by two reviewers, first on the titles and abstracts on the Rayyan platform and then on the full text of eligible studies. Risk of bias was assessed by the JBI checklist. Data were summarized descriptively, and the meta-analysis was carried out using the MetaXL 5.3 software. The review followed JBI guidelines and PRISMA for reporting.

RESULTS

In the 40 studies included, prevalence of PICC-related venous thrombosis was 9% in general, 9% in adults, and 6% in children with hematological malignancies. Most studies only evaluated cases of symptomatic thrombosis (n = 25; 64%).

CONCLUSION

Patients with hematological malignancies using PICC have an estimated prevalence of PICC-related venous thrombosis of 9%, and this rate may be underestimated due to the consideration of mostly symptomatic cases.

Central venous catheters do not increase the hemorrhagic risk in acute promyelocytic leukemia patients during induction therapy

In acute promyelocytic leukemia (APL), hemorrhage, particularly intracranial hemorrhage, is the most common cause of early death. A central venous catheter (CVC) may provide a greater guarantee of safety and comfort to APL patients. However, CVCs have seldom been attempted in APL patients during induction therapy because of concerns about increasing the risk of hemorrhagic complications after this invasive procedure. To evaluate the hemorrhagic risk after CVC placement in APL patients during induction therapy, we retrospectively analyzed 95 newly diagnosed patients with APL from January 2010 to December 2022. Among these patients, 39 patients in the CVC group and 56 patients in the non-CVC group were included. Laboratory and clinical parameters of the two groups were collected and compared. There were no significant differences in median platelet, fibrinogen (Fbg), D-dimer, prothrombin time (PT), white blood count (WBC) and hemoglobin (Hb) between the CVC and non-CVC groups on the first day of the visit (day 0) and the following days (day 4, day 7, day 11, day 14, day 18 and day 21) (p = 0.382, p = 0.805, p = 0.456, p = 0.902, p = 0.901 and p = 0.097, respectively). The consumption of transfused platelets and Fbg was not significantly different between the CVC group and non-CVC group (5.0 vs. 4.5 units, p = 0.34, and 6.8 vs. 6.0, p = 0.36, respectively). The last day of platelet and Fbg transfusion was also not significantly different (21 vs. 19, p = 0.238 and 7.5 vs. 8.5, p = 0.684, respectively). The incidences of total hemorrhagic events and hemorrhagic death were lower in the CVC group than in the non-CVC group (17.9% vs. 37.5%, p = 0.04 and 0% vs. 16.1%, p = 0.01, respectively). The 30-day survival rate was not significantly different (92.3% vs. 82.1%, respectively, p = 0.145) for the CVC group compared with the non-CVC group. Our study suggested that CVCs did not increase the hemorrhagic risk in APL patients during induction therapy and that a CVC should be considered in this type of clinical situation.

Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Symptomatic Deep Vein Thrombosis Associated With Peripherally Inserted Central Catheters of Different Diameters: A Systematic Review and Meta-Analysis

We assessed the relationship between peripherally inserted central catheter (PICC) diameters and symptomatic deep vein thrombosis (DVT) rates. We conducted a systematic search for articles published between 2010 and 2021 reporting DVT incidence by catheter diameter in patients who had a PICC, followed by meta-analyses for DVT risk in each diameter group. Pooled DVT rates were incorporated into an economic model. Of 1627 abstracts screened, 47 studies were included. The primary meta-analysis of 40 studies demonstrated the incidence of DVT was 0.89%, 3.26%, 5.46%, and 10.66% for 3, 4, 5, and 6 French (Fr) PICCs (P  =  .01 between 4 and 5 Fr). Rates of DVT were not significantly different between oncology and nononcology patients (P  =  .065 for 4 Fr and P  =  .99 for 5 Fr). The DVT rate was 5.08% for ICU patients and 4.58% for non-ICU patients (P  =  .65). The economic model demonstrated an annual, incremental cost savings of US$114 053 for every 5% absolute reduction in 6 Fr PICCs use. Using the smallest PICC that meets the patients' clinical needs may help to mitigate risks and confer savings.

Complications associated with peripherally inserted central catheters and Hickman™ in patients with advanced pulmonary hypertension treated with intravenous prostanoids

BACKGROUND

Epoprostenol requires continuous infusion and may lead to catheter-related complications. Evidence regarding the comparison between peripherally inserted central catheters (PICC) or tunneled central catheters in Pulmonary Hypertension (PH) is scarce. We sought to study the incidence of mechanical and infectious complications associated with PICC and Hickman catheters in patients with PH under epoprostenol treatment.

METHODS

This is a single-center retrospective study of patients with PH who received continuous treatment with intravenous epoprostenol for at least 24 h between January 2010 and July 2020. Mechanical and infectious complications were analyzed according to the catheter type: PICC and Hickman. The incidence of catheter-related complications was calculated per 1000 exposure-days of risk.

RESULTS

175 catheters were implanted in 109 patients, of which 100 (57.1%) were Hickman and 75 (42.9%) were PICC. After a median follow-up of 334 [130-798] days, there were no differences in the rates of local (0.22 vs 0.21; p = 0.904) or blood-stream infections (0.13 vs 0.21; p = 0.405). Mechanical complications were more frequent in the PICC group (0.98 vs 0.23 p=<0.001), including venous thrombosis (0.16 vs 0.00 p = 0.003) and catheter occlusion (0.66 vs 0.04 p=<0.001). These complications were associated with a greater need for hospitalization (1.48 vs 0.50; p=<0.001), without differences in mortality during follow-up (0.33 vs 0.21; p = 0.288).

CONCLUSION

In patients with PH treated with intravenous epoprostenol, both Hickman and PICC catheters were associated with high rate of complications. Although there were no differences in the frequency of infectious-related complications, PICC was associated with a higher frequency of catheter occlusion and deep venous thrombosis.

Comparative analysis of infectious complications with outpatient vs. inpatient care for adults with high-risk myeloid neoplasm receiving intensive induction chemotherapy

We recently reported an early hospital discharge (EHD) care strategy following intensive acute myeloid leukemia (AML)-like chemotherapy is safe. To evaluate its impact on infectious outcomes, we compared all adults treated from 8/1/2014 to 7/31/2018 discharging within 72 h of completing chemotherapy (EHD) with hospitalized patients (controls) across 354 induction and 259 post-remission cycles. While overall outcomes were similar, gram-positive bacteremias were more common in EHD patients than control (p<.001), although they received fewer days of IV antimicrobials (p< .001). Notably, cumulative infection risks in EHD patients were similar after induction and post-remission therapy. In multivariable analysis, only EHD status was independently associated with risk for gram-positive bacteremia (p= .01), whereas the only independent risk factor for fungal infection was fluconazole (vs. posaconazole) use (p< .001). The observation of increased rates of gram-positive bacteremias with EHD identifies improvements in catheter management as one area to further increase the safety of this care approach.

A prospective study of the use of central venous catheters in patients newly diagnosed with acute myeloid leukemia treated with induction chemotherapy

PURPOSE

Central venous catheters (CVCs) are widely used in acute myeloid leukemia (AML) patients. Complications associated with CVCs are frequently encountered and contribute to morbidity and mortality. Prospective studies investigating and comparing complications of different types of CVCs in AML patients and their effects on the quality of life are limited.

METHODS

We conducted a prospective observational study and evaluated the complications associated with the use of CVCs in adult AML patients during induction chemotherapy and evaluated quality of life outcomes as reported by the patients during and after their hospitalization.

RESULTS

Fifty newly diagnosed patients with AML (median age, 59 years) who received intensive induction chemotherapy were enrolled in the study. Twenty-nine patients (58%) had a peripherally inserted central catheters (PICCs) placed and 21 (42%) patients received a Hickmann tunneled central catheter (TCC). Three percent of cases developed catheter-related thrombosis in PICCs and no thrombosis in TCCs. Catheter-related bloodstream infection was diagnosed in 8% of patients. CVC occlusion occurred in 44 patients (88%). The total number of occlusion events was 128; 97% of patients with PICCs and 76% of patients with TCCs (p = 0.003). All patients reported that the use of CVC simplified their course of treatment. Most patients reported similar restrictions in activity associated with TCCs and PICCs.

CONCLUSION

The present study demonstrates that thrombosis and catheter-related bloodstream infections remain important complications of CVCs in AML patients. Occlusion rates were higher with the use of PICCs and the use of CVCs impacted the quality of life.

Complications and Costs of Peripherally Inserted Central Venous Catheters Compared With Implantable Port Catheters for Cancer Patients: A Meta-analysis

BACKGROUND

Peripherally inserted central catheters (PICCs) and implantable port catheters (IPCs) are 2 most common central venous access for cancer patients receiving chemotherapy. However, no specific evidence exists to guide practitioners on safety and less cost.

OBJECTIVE

To compare the differences of complications and costs of PICC and IPC in the treatment of cancer patients with chemotherapy and to provide a basis for better clinical decision making.

METHODS

All the cohort studies were searched in the Cochrane Library, JBI, PubMed, Elsevier, Web of Science, CINAHL, CBM, and CNKI from inception to July 2018. Two reviewers screened and selected trials, evaluated quality, and extracted data. Meta-analysis and description of the outcomes were performed by using the RevMan 5.3 software.

RESULTS

A total of 761 articles were retrieved, with 15 articles meeting eligibility criteria. Outcome analysis showed no difference in 1-puncture success rate. Peripherally inserted central catheter use was associated with higher complication rates than IPC, including occlusion, infection, malposition, catheter-related thrombosis, extravasation, phlebitis, and accidental removal rate. The life span of IPC was longer than that of PICC, and the costs of IPC were lower.

CONCLUSIONS

Implantable port catheter has advantages over PICC in reducing cancer patients' complications and less cost in terms of long-term cancer chemotherapy.

IMPLICATIONS FOR PRACTICE

In terms of safety, the results provide evidence for practitioners to choose which type of central venous catheters is better for cancer chemotherapy patients. In terms of costs, practitioners need to make decisions about which type of central venous catheters has less cost.

Hindrances of peripherally inserted central catheter care of leukemia patients: a qualitative study

OBJECTIVE

A peripherally inserted central catheter (PICC) needs regular care. However, clinical observations found that some discharged leukemia patients in mainland China had not complied with the requirement of regular care. Our study aims to explore the facilitators and hindrances of regular cares of PICC in leukemia patients with the Colaizzi phenomenon analysis.

METHODS

This qualitative report used the descriptive phenomenological method to collect information and was conducted in accordance with the COREQ checklist. By purposive sampling, 11 leukemia patients with PICC were selected and interviewed in the Department of Hematology of a first-class hospital in Wuhan (central China). The interviews were conducted from March 2016 to May 2017.

RESULTS

Two facilitators for PICC care were extracted through interviews, including fear of nosocomial infection and convenience for treatment. Eleven hindrances were summarized, including high costs, unavailability of local services, worries about affecting family members, a lack of health awareness, inconvenient transportations, fluke minds, physical discomfort, fears of leukemia and chemotherapy, short chemotherapy intervals, damage to appearance, and no insurance coverage of costs.

CONCLUSION

Leukemia patients' compliance with PICC care was hindered by several factors. The improvement of PICC care may need joint efforts of patients, nursing professionals, hospitals' managerial staff, and governments.

Comparison of complication rates and incidences associated with different peripherally inserted central catheters (PICC) in patients with hematological malignancies: a retrospective cohort study

Patients with hematological malignancies (HM) or undergoing hematopoietic cell transplantation (HCT) require reliable vascular access. Peripherally inserted central catheters (PICC) meet this need, however, studies suggest these patients have higher rates of PICC-associated complications. This retrospective cohort study evaluates the influence of PICC type on the rates and incidences of complications. Four hundred and eighty-five dual lumen PICCs were inserted into 469 complex patients with HM or undergoing HCT: 161 Groshong^®, 60 PowerPICC^® Solo, 165 BioFlo^®, and 99 Arrow^®. The rates and incidences of complications differed significantly across the PICC types. The overall rate of complication ranged from 7.40 to 26.4/1000 catheter days (CDs). The rate of deep vein thrombosis (0.31-1.48/1000 CDs) and occlusion differed across the PICC types, while the rate of central line-associated bloodstream infection (0.53-0.74/1000 CDs) did not. Following multivariate adjustment, PICC type was associated with complication rate. This highlights that PICC type should be considered in clinical decisions.

Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies

Central venous catheters are essential for the treatment of patients with haematological malignancies and the recipients of stem-cell transplant. This patient population is, however, at high risk for catheter-related bloodstream infections that can result in substantial morbidity, mortality, and health-care-associated costs. Efficient prevention, early diagnosis, and effective treatment are essential to providing the best care to these patients. Although confirming the catheter as a source of infection remains challenging, the Infectious Diseases Society of America definition of catheter-related bloodstream infection remains the most precise definition to use in these patients. Gram-positive bacteria, particularly coagulase-negative Staphylococcus spp, remain the leading cause of catheter-related bloodstream infection, although an increase in Gram-negative bacteria as the causative agent has been noted. Although removal of the line and appropriate intravenous antibiotics remain the mainstay of treatment in most cases, novel technologies, including exchange with antibiotic-coated catheters and treatment with lock solutions, are particularly relevant in this patient population. In this Review we present the types of central venous catheters used in this patient population and analyse the different definitions of catheter-related infections, with an overview of their prevention and management.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

The incidence and risk factors of peripherally inserted central catheter-related infection among cancer patients

BACKGROUND

As the use of peripherally inserted central catheters (PICCs) increased in chemotherapy, the identification of complications and risk factors became essential to prevent patient harm. But little is known about PICC-related infection and risk factors among patients with cancer. Our study was to identify the prevalence, patterns, and risk factors of catheter-related infections associated with PICCs.

METHODS

A 3-year prospective cohort study was conducted in a university-affiliated hospital. All patients with cancer who met inclusion criteria were enrolled. The patients were followed up until catheter removal. Tip cultures were routinely performed at the time of catheter removal. The general information was recorded at the time of PICC insertion, weekly care, and removal. Univariable and multivariable logistic regression analyses were applied for identification of risk factors.

RESULTS

In total, 912 cancer patients with 912 PICCs of 96,307 catheter days were enrolled. Ninety-four developed PICC-related infection; 46 were exit-site infection, 43 were catheter bacterial colonization, and five were PICC-related bloodstream infection. The median time from catheter insertion to infection was 98.26 days. Multivariate analysis showed StatLock fixing (odds ratio [OR] =0.555, 95% confidence interval [CI]: 0.326-0.945) and tip position located in the lower one-third of the superior vena cava (OR =0.340, 95% CI: 0.202-0.571) were associated with lower PICC infection rate. Catheter care delay (OR =2.612, 95% CI: 1.373-4.969) and indwelling mostly in summer (OR =4.784, 95% CI: 2.681-8.538) were associated with higher infection incidence.

CONCLUSION

StatLock fixing and tip position located in the lower one-third of the superior vena cava were protective factors against PICC-related infection, while catheter care delay and indwelling mostly in summer were risk factors. Policy and measures targeting these factors may be necessary to reduce the risk of infection.

A team-based multidisciplinary approach to managing peripherally inserted central catheter complications in high-risk haematological patients: a prospective study

PURPOSE

Use of peripherally inserted central catheters (PICCs) has markedly increased during the last decade. However, there are few studies on use of PICCs in patients with haematological malignancies (HM) receiving intensive chemotherapy. Preliminary data suggest a higher rate of PICC-related complications in these high-risk patients. This prospective observational single-centre study aimed to investigate PICC-related complications after implementation of a multidisciplinary approach to PICC care and compared it with previous literature.

METHODS

A total of 44 PICCs were inserted in 36 patients (27.3%, thrombocytopenia <50 × 10(9)/L at insertion) over 5045 PICC days (median duration, 114.5 days).

RESULTS

No major insertion-related complications were observed. Major late complications were obstruction in 13.6% (1.19/1000 PICC days) of patients, catheter-related bloodstream infection in 6.8% (0.59/1000 PICC days), and catheter-related thrombosis in 4.5% (0.39/1000 PICC days). Premature PICC removal occurred in 34% (2.97/1000 PICC days) of patients. The overall rate of potentially major dangerous complications was particularly low (11.36%, 0.99/1000 PICC days) compared with previous studies.

CONCLUSIONS

This study highlights the utility of a multidisciplinary approach for PICC care in adults with HM receiving intensive chemotherapy. We provide further data to support use of PICCs in such patient populations.

The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis

BACKGROUND

Peripherally inserted central catheters (PICCs) are associated with central line-associated bloodstream infection (CLABSI). The magnitude of this risk relative to central venous catheters (CVCs) is unknown.

OBJECTIVE

To compare risk of CLABSI between PICCs and CVCs.

METHODS

MEDLINE, CinAHL, Scopus, EmBASE, and Cochrane CENTRAL were searched. Full-text studies comparing the risk of CLABSI between PICCs and CVCs were included. Studies involving adults 18 years of age or older who underwent insertion of a PICC or a CVC and reported CLABSI were included in our analysis. Studies were evaluated using the Downs and Black scale for risk of bias. Random effects meta-analyses were used to generate summary estimates of CLABSI risk in patients with PICCs versus CVCs.

RESULTS

Of 1,185 studies identified, 23 studies involving 57,250 patients met eligibility criteria. Twenty of 23 eligible studies reported the total number of CLABSI episodes in patients with PICCs and CVCs. Pooled meta-analyses of these studies revealed that PICCs were associated with a lower risk of CLABSI than were CVCs (relative risk [RR], 0.62; 95% confidence interval [CI], 0.40-0.94). Statistical heterogeneity prompted subgroup analysis, which demonstrated that CLABSI reduction was greatest in outpatients (RR [95% CI], 0.22 [0.18-0.27]) compared with hospitalized patients who received PICCs (RR [95% CI], 0.73 [0.54-0.98]). Thirteen of the included 23 studies reported CLABSI per catheter-day. Within these studies, PICC-related CLABSI occurred as frequently as CLABSI from CVCs (incidence rate ratio [95% CI], 0.91 [0.46-1.79]).

LIMITATIONS

Only 1 randomized trial met inclusion criteria. CLABSI definition and infection prevention strategies were variably reported. Few studies reported infections by catheter-days.

CONCLUSIONS

Although PICCs are associated with a lower risk of CLABSI than CVCs in outpatients, hospitalized patients may be just as likely to experience CLABSI with PICCs as with CVCs. Consideration of risks and benefits before PICC use in inpatient settings is warranted.

Comparison of complication rates of Hickman(®) catheters versus peripherally inserted central catheters in patients with acute myeloid leukemia undergoing induction chemotherapy

Central venous access devices (CVADs) are used for intravenous therapy in patients with hematological malignancies. There are limited data comparing catheter outcomes in patients with acute myeloid leukemia (AML) undergoing induction chemotherapy. A retrospective review comparing the incidence of early and late CVAD-associated complications and their effect on CVAD removal was performed in patients with AML undergoing induction chemotherapy between 2007 and 2011. Overall, 64 Hickman(®) catheters and 84 peripherally inserted central catheters (PICCs) were inserted. There was a trend toward increasing use of PICCs. The rate of CVAD occlusion was higher in PICCs compared to Hickman catheters (48.2% vs. 3.2%), for a rate of 20.43 vs. 1.25 per 1000 CVAD-days (p = 0.0001). There was no significant difference in the rates of CVAD-associated thrombosis, premature removal, blood stream infection (BSI) and CVAD-related BSI. Importantly, there was no significant difference in the rate of CVAD removal between Hickman catheters and PICCs for the duration that the CVADs were in place. The choice of type of CVAD inserted into patients with newly diagnosed AML will depend on ease of catheter placement, cost, perception of frequency and severity of complications, and clinician preference.