Central vascular catheters versus peripherally inserted central catheters in nurse anesthesia. A perspective within the Greek health system

Poland's first vascular access team 3-year analysis: Insights and learnings

BACKGROUND

During the COVID-19 pandemic, Poland saw a surge in interest in midline catheters (MCs) and Long Peripheral Catheters (LPCs) for intravenous therapy. Before this, MCs were not extensively utilised in the country, and there was no formally established Polish vascular access team. MCs, which have been used for years in many countries, are now becoming increasingly common in Poland. This study aimed to analyse the use of MCs in a 3-year perspective of their introduction in daily clinical practice based on a nurse-led Vascular Access Team (VAT).

METHODS

The records of adult patients who received intravenous therapy with 727 MCs and 293 LPCs from January 2021 to December 2023 at the University Clinical Centre of the Medical University of Warsaw were analysed.

RESULTS

The main indication for cannulation was expected intravenous therapy over 5 days (81.66%, n = 833), of which 71.37% (n = 728) of patients in this group had concomitant difficult intravenous access (DIVA). Over 6 years, centrally inserted central catheters (CICCs) inserted due to DIVA were reduced from n = 108 in 2017 to n = 18 in 2023. The end of intravenous therapy was the reason for the removal of 64.6% of catheters (n = 659), including death and switch to CICCs as well. Complications leading to premature removal accounted for 31.2%, such as: occlusion (14.6%), patient self-removal (7.1%) and thrombosis (3.43%).

CONCLUSIONS

The introduction of MCs as a possible option for peripheral venous access reduces the use of CVCs. Developing MCs programmes should be based on investing in staff competencies, which increases success rates. The nurses and physicians should be trained in infusion care to achieve better results in the use of MCs and LPCs. Increasing the competence of nurses in Poland is necessary for the implementation of full-service and top-level functioning of VAT.

Central venous catheter insertion and maintenance: Evidence-based clinical recommendations

OBJECTIVE

To share with clinicians supporting evidence of the safest and the most effective processes for central venous catheter insertion and maintenance as a strategy to prevent catheter-associated bloodstream infections.

METHODS

A literature search was conducted in the Medline via PubMed, Embase Central and Lilacs databases based on a set of clinical questions aimed at improving safety and effectiveness at key moments in the process of central venous catheter insertion and maintenance. The rapid literature review methodology was used. The studies identified were assessed from the quality point of view, using the Joanna Briggs Institute (JBI) tools for qualitative and quantitative studies and for systematic reviews. Clinical practice guidelines were assessed using the AGREE II tool. The evidence is presented in the form of evidence-based clinical recommendations, which were graded in accordance with the JBI methodology.

RESULTS

Twelve clinical evidence summaries containing evidence related to the safe and effective use of central venous catheters are presented, including the following topics: central venous catheter insertion (CVC), peripherally inserted central catheters (PICC), preoperative assessment, the use of analgesia, field preparation, choice between CVC or PICC, CVC care and maintenance, prevention of complications, and general considerations pertaining to the use of central venous catheters in oncologic patients and in parenteral nutrition.

CONCLUSIONS

Recommendations on the safe and effective use of central venous access catheters in relation to CVC insertion and maintenance processes are presented in the evidence-based summary model. It is necessary to evaluate their implementation in health outcomes in the institutions where they are developed.

Peripherally inserted central catheters inserted with current best practices have low deep vein thrombosis and central line–associated bloodstream infection risk compared with centrally inserted central catheters: A contemporary meta-analysis

Background:

Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines.

Methods:

Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006–2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line–associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle–Ottawa and Cochrane Risk of Bias scales.

Results:

Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line–associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30–0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47–2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients ( p = 0.064). Patient outcomes favored peripherally inserted central catheters.

Conclusion:

When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.

Randomized controlled trials in central vascular access devices: A scoping review

BACKGROUND

Randomized controlled trials evaluate the effectiveness of interventions for central venous access devices, however, high complication rates remain. Scoping reviews map the available evidence and demonstrate evidence deficiencies to focus ongoing research priorities.

METHOD

A scoping review (January 2006-December 2015) of randomized controlled trials evaluating the effectiveness of interventions to improve central venous access device outcomes; including peripherally inserted central catheters, non-tunneled, tunneled and totally implanted venous access catheters. MeSH terms were used to undertake a systematic search with data extracted by two independent researchers, using a standardized data extraction form.

RESULTS

In total, 178 trials were included (78 non-tunneled [44%]; 40 peripherally inserted central catheters [22%]; 20 totally implanted [11%]; 12 tunneled [6%]; 6 non-specified [3%]; and 22 combined device trials [12%]). There were 119 trials (68%) involving adult participants only, with 18 (9%) pediatric and 20 (11%) neonatal trials. Insertion-related themes existed in 38% of trials (67 RCTs), 35 RCTs (20%) related to post-insertion patency, with fewer trials on infection prevention (15 RCTs, 8%), education (14RCTs, 8%), and dressing and securement (12 RCTs, 7%). There were 46 different study outcomes reported, with the most common being infection outcomes (161 outcomes; 37%), with divergent definitions used for catheter-related bloodstream and other infections.

CONCLUSION

More high quality randomized trials across central venous access device management are necessary, especially in dressing and securement and patency. These can be encouraged by having more studies with multidisciplinary team involvement and consumer engagement. Additionally, there were extensive gaps within population sub-groups, particularly in tunneled devices, and in pediatrics and neonates. Finally, outcome definitions need to be unified for results to be meaningful and comparable across studies.