Focus on peripherally inserted central catheters in critically ill patients

Repositioning of malpositioned peripherally inserted central catheter lines with the use of intracavitary electrocardiogram: A pediatric case series

INTRODUCTION

Peripherally inserted central catheter tip migration is an infrequent event that occurs in neonatal, pediatric, and adult patients. We discuss a novel technique of utilizing intracavitary electrocardiogram to help confirm proper peripherally inserted central catheter tip repositioning, thereby reducing the need for serial radiographs.

CASE PRESENTATION

A case series of four patients will be discussed. The first three patients had peripherally inserted central catheter tips that were initially appropriately positioned but had later peripherally inserted central catheter tip migration. The use of intracavitary electrocardiogram was able to confirm the appropriate repositioning of the peripherally inserted central catheters without the need for serial radiographs. The fourth patient had several central lines in place, which led to difficulty in identifying the peripherally inserted central catheter tip location. The use of intracavitary electrocardiogram confirmed proper positioning of his peripherally inserted central catheter tip when standard radiographs could not provide clarity.

DISCUSSION

Several techniques have been published on methods to reposition a migrated peripherally inserted central catheter tip back to the superior vena cava/right atrial junction. These repositioning techniques often require fluoroscopic guidance or a confirmatory radiograph to assess the appropriate peripherally inserted central catheter tip location. At times, several radiographs may be required before the tip is successfully repositioned. This novel application of intracavitary electrocardiogram can help to minimize radiographs when peripherally inserted central catheter tip repositioning is required.

Peripherally inserted central catheter–related thrombosis rate in modern vascular access era—when insertion technique matters: A systematic review and meta-analysis

Background:

Technical factors at the moment of catheter insertion might have a role in peripherally inserted central catheter–related thrombotic risk. We performed a systematic review and meta-analysis to define the actual rate of peripherally inserted central catheter–related symptomatic deep vein thrombosis in patients in whom catheter insertion was performed according to ultrasound guidance, appropriate catheter size choice, and proper verification of tip location.

Methods:

We searched Medline, Embase, and Cochrane Library. Only prospective observational studies published in peer-reviewed journals after 2010 up to November 2018 reporting peripherally inserted central catheter–related deep vein thrombosis rate were included. All studies were of adult patients who underwent peripherally inserted central catheter insertion. Results were restricted to those studies which included in their methods ultrasound guidance for venipuncture, catheter tip location, and a catheter size selection strategy. Random-effect meta-analyses and arcsine transformation for binomial data were performed to pool deep vein thrombosis weighted frequencies.

Results:

Of the 1441 studies identified, 15 studies involving 5420 patients and 5914 peripherally inserted central catheters fulfilled our inclusion criteria. The weighted frequency of peripherally inserted central catheter–related deep vein thrombosis was 2.4% (95% confidence interval = 1.5–3.3) and remained low in oncologic patients (2.2%, 95% confidence interval = 0.6–3.9). Thrombotic rate was higher in onco-hematologic patients (5.9%, 95% confidence interval = 1.2–10). Considerable heterogeneity (I2 = 74.9) was observed and all studies were considered at high risk of attrition bias.

Conclusions:

A proper technique is crucial at the moment of peripherally inserted central catheter insertion. Peripherally inserted central catheter–related deep vein thrombosis rate appears to be low when evidence-based technical factors are taken into consideration during the insertion procedure.

A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments

The type of central vascular access device providers chosen for providing parenteral supportive treatments has evolved over the past years, going from routinely used centrally inserted catheters to a more recent trend of peripherally-inserted central catheters (PICCs) when expected treatment duration is less than 6 months. This multicenter retrospective study aimed to provide a comprehensive assessment of the safety of PICCs in administering parenteral supportive treatments. All adult inpatients and outpatients who had a PICC inserted for the administration of parenteral supportive treatments (i.e., parenteral nutrition, intravenous fluids, blood products, or antibiotics) between September 2007 and December 2014 in four public Italian hospitals were included. The primary outcome was PICC removal because of an adverse event (AE, defined as occlusion, exit-site infection, or symptomatic thrombosis). Among the 1,250 included patients, 178 PICC-related removals because of AEs (14.2%; 1.62 AEs per 1,000 PICC days) were reported. Rates of PICC removal because of occlusion, exit-site infection, and symptomatic thrombosis were 1.08, 0.32, and 0.23 per 1,000 PICC days, respectively. The median dwell-time between PICC insertion and its removal because of an AE was 67 days (interquartile range 28-180 days). Risk of PICC removal due to AE was higher with open-system PICCs [hazard ratio = 2.75, 95% confidence interval 1.52-4.96]. In this study, we found preliminary evidence that PICCs can be safely used to administer parenteral supportive treatments lasting up to 6 months. PICCs may be a relevant alternative to centrally inserted catheters for medium-term parenteral supportive treatments.

Peripherally Inserted Central Catheter Postinsertion Complications: A Retrospective Study

PICC offers safe intravenous access for medium- to long-term use with inpatients. There is no association between overall complication rates and PICC material type. Oncology status is the strongest predictor of complications.

PICC insertion in the sitting position for a patient with congestive heart failure: A case report

RATIONALE

A peripherally inserted central catheter (PICC) is typically inserted with the patient in the supine position. Here, we placed a PICC in a patient in the sitting position, in order to treat congestive heart failure.

PATIENT CONCERNS

A 65-year-old man was diagnosed with end-stage lung cancer. He had experienced septic shock and was medicated with continuous infusion of noradrenaline through a peripheral vein, in order to maintain sufficient blood pressure. However, indwelling peripheral venous catheters were difficult to place and maintain.

DIAGNOSIS

The patient experienced orthopnea due to congestive heart failure and could not assume any other position.

INTERVENTIONS

An anesthesiologist performed PICC placement while the patient was in the sitting position, using ultrasound guidance.

OUTCOMES

The patient's orthopnea was slightly ameliorated, and he was able to sleep at night.

LESSONS

The technique of inserting a PICC in the sitting position is simple and feasible. This approach may be useful for patients in whom central venous access is needed, but the supine position cannot be achieved.

Predictive risk factors of venous thromboembolism (VTE) associated with peripherally inserted central catheters (PICC) in ambulant solid cancer patients: retrospective single Centre cohort study

Aims

Peripherally inserted central catheters(PICC) lines are becoming increasingly popular in solid cancer patients for the administration of chemotherapy. This study aims looking at the incidence of PICC line related and distant thromboembolism associated with these catheters and exploring risk factors.

Methods

Records were reviewed for 158 patients who underwent PICC line insertion over the two years period in the medical oncology unit, Milton Keynes University Hospital. The Incidence PICC line related Deep Venous Thrombosis (DVT) which is defined as upper extremity DVT at the site of PICC line insertion was documented after checking reports of ultrasound Doppler of all symptomatic patients to confirm the presence of thrombo-embolism and Computed Tomography(CT)scan or Computed Tomography Pulmonary Angiography (CTPA) to confirm the presence Pulmonary Embolism(PE).

Results

23(13%) symptomatic patients with confirmed diagnosis by ultrasound Doppler were found to have PICC line related DVT and similar number of patients developed distant VTE, namely PE and lower limbs DVT. Average time to thrombo-embolism from the insertion of PICC line was 13 days and 51 days in distant VTE. Statistically significant results have been identified in the term of risk factors leading to VTE events during the period of PICC line insertion.

Conclusions

VTE is a common complication in medical oncology patients who underwent insertion PICC line insertion for chemotherapy. Risk of distant VTE is high as well as the PICC line related DVT and the risk of the PICC line related DVT is higher in the first two weeks after PICC insertion. We concluded that high BMI,high PLTs count and Fluropyrimidine containing chemotherapy are all significant risk factors for VTE events recorded while smoking and high BMI are significantly contributing to the high rate of the PICC line related DVT.

Risk factors associated with peripherally inserted central catheter-related venous thrombosis in hospitalized patients of advanced age

Objective

This study was performed to determine the risk factors associated with peripherally inserted central catheter (PICC)-related venous thrombosis in patients of advanced age (>65 years).

Methods

In total, 549 hospitalized patients aged 66 to 104 years who were undergoing PICC placement from January 2008 to December 2014 were enrolled. Symptomatic venous thrombosis was confirmed by B-mode or Doppler ultrasonography in the presence of clinical signs. Logistic regression analysis was performed on the variables of interest to identify the risk factors for thrombosis. Odds ratios (ORs) with the corresponding 95% confidence intervals were generated.

Results

Of the 549 patients with PICC placement, 106 (19.3%) developed PICC-associated venous thrombosis, 84 cases of which were symptomatic. The logistic regression results revealed that PICC-related venous thrombosis was associated with a history of venous thrombosis (OR, 6.745 [3.237–14.056]), number of lumens (OR, 1.934 [1.362–2.572] and OR, 3.762 [1.672–5.932] for dual and triple lumens, respectively), and PICC gauge (OR, 1.821 [1.256–2.537] and OR, 3.864 [1.367–8.251] for 5-Fr and 6-Fr, respectively).

Conclusions

A history of thrombosis, high number of lumens, and large-gauge catheters were strong risk factors for patients aged >65 years undergoing PICC placement.

Peripherally inserted central catheters in critically ill patients - complications and its prevention: A review

Peripherally inserted central catheter (PICC) is extensively used in critical care settings, because it plays a vital role in providing safe central venous entry. However, PICC is associated with several complications, which should be detected to shorten the duration of patients' improvement, reduce health care cost, and lessen the incidence of various PICC-related complications. Therefore, this study aimed to outline current literature on PICC procedures, potential complications, and measures for prevention. Understanding evidence-based guidelines regarding insertion technique, early detection of complications, and care bundle of PICC is significant in complication prevention. Implementation of education, training, and appropriate multidisciplinary approaches on PICC care among nurses and caregivers is the key to preventing complications. Thus, the strict care of indwelling PICC lines, the targeted and reasonable PICC-associated complication prevention, and nursing care have a major clinical significance in reducing the occurrence of potential PICC complications.

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.

Tuberculous peritonitis diagnosed using laparoscopy with assistance of a central venous catheter

Laparoscopy with peritoneal biopsy is a tool for rapid and accurate diagnosis of tuberculous peritonitis (TBP). However, laparoscopic procedures are not risk-free; complications include injuries to the gastrointestinal tract and major blood vessels. The purpose of the present study was to introduce a novel method for safe and straightforward laparoscopic diagnosis of TBP. A case series of 12 patients with TBP diagnosed between October 2012 and November 2013 at our hospital is presented. The patients underwent a novel method of laparoscopy involving the use of a central venous catheter (CVC). The diagnosis was confirmed by biopsy and histology. The efficacy of the method for TBP diagnosis was evaluated by the time taken for the procedure and the rate of successful completion. The safety of the method was evaluated by recording all intra- and post-operative adverse events encountered. The mean age of the patients was 41 years and 33% were male. The mean operation time was 50.6 min and the median duration of hospital stay was 7 days. In all cases, diagnostic laparoscopy was successfully performed. Targeted biopsies were taken from all of the patients and revealed caseous granulomatous inflammation. All patients tolerated the procedure without significant bleeding or digestive tract perforation. In conclusion, the present case series demonstrated a novel method of diagnostic laparoscopy with CVC that is a feasible and straightforward procedure for TBP diagnosis.

Complications related to the insertion and maintenance of peripheral venous access central venous catheter

OBJECTIVE

To evaluate the rates and nature of the complications related to the Central Peripheral Access Catheter (CVCAP or PICC) from its insertion to its withdrawal.

METHODS

Prospective observational study. All patients older than 14 years of age with a PICC inserted in the polyvalent intensive care unit (ICU) during the period between May 1, 2015 and April 30, 2016 were included. Data collected included: demographic data, insertion details, reason for insertion and removal, maintenance unit, total dwell time, incidence of complications and related factors and infection rate.

RESULTS

144 PICCs were inserted, of which 94 corresponded to the ICU group (65.28%) and 50 (34.72%) to the non-ICU group. The most important complication was the suspicion of infection: 17.36% (rate of 15.2 per 1000 days of PICC). The total number of confirmed infections was 6.25% (5.5 per 1000 days of PICC), 1.39% (1.2 per 1000 days) being in the ICU group and 4.86% (4.2 per 1000 days) in the non-ICU group. There were 5 bacteraemias, all in the non-ICU group (3 per 1000 days). The most frequent germ was Staphylococcus epidermidis (6 cases). Phlebitis had an incidence of 9.03% (7.9 per 1000 days of PICC).

CONCLUSIONS

PICC, effective device for central venous access due to the minimal incidence of risks in implantation and to its advantages with regard to the classic central venous catheters, is a further nursing technique.

Knowledge, attitude, and practice toward the daily management of PICC in critically ill cancer patients discharged from intensive care units

Background

Peripherally inserted central catheters (PICCs) are widely used in critically ill cancer patients. We aimed to investigate the status of knowledge, attitude, and practice (KAP) toward the daily management of PICCs in critically ill cancer patients discharged from intensive care units.

Methods

Totally, 152 critically ill cancer patients discharged from two intensive care units in China were surveyed using a self-administered KAP questionnaire. Patients' demographics and PICC-related KAP scores were collected and analyzed using independent-samples t-test and multivariate stepwise linear regression analysis.

Results

All 152 patients completed the survey. The mean KAP scores were 32.61±3.80 points, 28.11±3.18 points, and 44.31±3.98 points, respectively. KAP scores were found to have significant positive correlations with each other (P<0.05). The major factors influencing the total KAP score were the PICC indwelling time and the patient's educational degree, age, and place of residence (P<0.05).

Conclusion

We noted that KAP status toward the daily management of PICC in critically ill cancer patients discharged from intensive care units is not optimistic and needs to be further improved. Attention should be paid to the health education patterns of KAP, and individualized instruction should be pursued.

The incidence of symptomatic upper limb venous thrombosis associated with midline catheter: Prospective observation

Aim:

The evaluation of the incidence of symptomatic upper limb venous thrombosis (ULVT) associated with midline catheters in patients admitted to the hospital.

Methods:

The frequency of symptomatic ULVT diagnosed in a group of patients with midline catheters confirmed by sonographic examination in hospitalised patients at Faculty Hospital over the period of 1 year.

Results:

Four hundred thirty-nine midline catheters were inserted in 430 patients (250 women and 180 men) during year 2015. Nine patients had two midline catheters. The average age of the patient was 68 years (range: 19–96 years). The median time of midline catheter introduction into a vein was 10 days (range: 1–112 days). Symptomatic thrombosis was diagnosed in 20 patients (4.5%), 3.3/1000 catheter days. It was associated with gender (male) and midline insertion in the cephalic vein.

Conclusion:

The risk of upper limb symptomatic thrombosis associated with midline catheters during a stay in the hospital should be taken into consideration when indicating optimal venous access.

Use of peripherally inserted central venous catheters (PICCs) in children receiving autologous or allogeneic stem-cell transplantation

Introduction:

The aim of our study was to present our experience with the use of peripherally inserted central catheters (PICCs) in pediatric patients receiving autologous or allogenic blood stem-cell transplantation. The insertion of the device in older children does not require general anesthesia and does not require a surgical procedure.

Methods:

From January 2014 to January 2017, 13 PICCs were inserted as a central venous device in 11 pediatric patients submitted to 14 autologous or allogeneic stem-cell transplantation, at the Bone Marrow Transplant Unit of the Children’s Hospital of Brescia. The mean age of patients at the time of the procedure was 11.3 years (range 3-18 years). PICCs remained in place for an overall period of 4104 days. All PICCs were positioned by the same specifically trained physician and utilized by nurses of our stem-cell transplant unit.

Results:

No insertion-related complications were observed. Late complications were catheter ruptures and line occlusions (1.2 per 1000 PICC days). No rupture or occlusion required removal of the device. No catheter-related venous thrombosis, catheter-related bloodstream infection (CRBSI), accidental removal or permanent lumen occlusion were observed. Indications for catheter removal were completion of therapy (8 patients) and death (2 patients). Three PICCs are currently being used for blood sampling in follow-up patients after transplantation.

Conclusions:

Our data suggest that PICCs are a safe and effective alternative to conventional central venous catheters even in pediatric patients with high risk of infectious and hemorrhagic complications such as patients receiving stem-cell transplantation.

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions. Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased. Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007-June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied. Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; -5.72; 95% CI: -9.45, -1.82) and arterial lines (p = 0.02; -7.8; 95% CI: -13.90, -1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:-1.38, 5.24). Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for.

The microbiological characteristics and risk factors for PICC-related bloodstream infections in intensive care unit

The study was aimed to investigate the pathogens distribution and risk factors for PICC-related bloodstream infection in intensive care unit (ICU) patients. 402 patients placed with PICC in ICU were recruited in the study. The microbiological characteristics of PICC-related infection were investigated by Vitek 2 Compact automated microbial system. Antibiotics sensitivity was performed with disk diffusion and minimum inhibitory concentration (MIC) methods. Multivariate logistic and cox analyses were performed to identify the risk factors for PICC-related infection in ICU patients. 38 PICC-related infection cases were observed, and its morbidity was 9.45%. The morbidity was significantly higher in power PICC cases than that in common PICC cases. Gram-positive bacteria might be responsible for the major infection cases, followed by gram-negative bacteria, and fungi. Drug sensitivity analyses indicated that gram-negative bacteria showed low resistance to carbapenems antibiotics, and Cefperazone/sulbactam. The gram-positive bacterial exhibited sensitive to Teicoplanin and Vancomycin. The isolated fungi showed low resistance to the commonly used antifungal antibiotics. Multivariate analyses demonstrated that power PICC, high Charison scores, diabetes mellitus, double lumens triple lumens were risk factors for PICC-related infections among ICU patients. Power PICC, high Charison scores, diabetes mellitus, multi-lumens are risk factors for PICC-related bloodstream infection in ICU patients.

Central venous Access device SeCurement And Dressing Effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial

Background

Peripherally inserted central catheters (PICCs) are commonly used for delivering intravenous therapy. PICC failure is unacceptably high (up to 40%) due to mechanical, infectious and thrombotic complications. Poor securement potentiates all complication types. This randomised controlled trial (RCT) aimed to examine the feasibility of a large RCT of four dressing and securement methods to prevent PICC failure.

Methods

This single-centre pilot RCT included 124 admitted medical/surgical/cancer patients aged ≥ 16 years with a PICC. Interventions were: (i) standard polyurethane dressing and sutureless securement device (SPU + SSD, control); (ii) polyurethane with absorbent lattice pad dressing (PAL + Tape); (iii) combination securement-dressing (CSD); and (iv) tissue adhesive (TA + SPU). All groups except TA + SPU had a chlorhexidine-gluconate (CHG) impregnated disc. Feasibility outcomes were recruitment and safety/acceptability of the interventions. The primary outcome was PICC failure, a composite of PICC removal for local infection, catheter-associated bloodstream infection, dislodgement, occlusion, and/or catheter fracture. Secondary outcomes included individual complications, dressing failure and dwell time, PICC dwell time, skin complications/phlebitis indicators, product costs, and patient and staff satisfaction. Qualitative feedback was also collected.

Results

PICC failure incidence was: PAL + CHG + Tape (1/5; 20%; 17.4/1000 days), SPU + SSD + CHG (control) (4/39; 10%; 9.0/1000 days), TA + SPU (3/35; 9%; 9.6/1000 days), and CSD + CHG (3/42; 7%; 9.4/1000 days). Recruitment to PAL + CHG + Tape was ceased after five participants due to concerns of PICC dislodgement when removing the dressing. CSD + CHG, TA + SPU (TA applied only at PICC insertion time), and control treatments were acceptable to patients and health professionals.

Conclusion

A large RCT of CSD + CHG and TA + SPU (but not PAL + CHG + Tape) versus standard care is feasible.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12616000027415. Registered on 15 January 2016.

The risk of venous thromboembolism associated with peripherally inserted central catheters in ambulant cancer patients

Background

Deep vein thrombosis (DVT) is a common complication of peripherally inserted central catheters (PICCs). PICCs are increasingly utilised in the management of cancer patients, a group which carries both additional risks for vascular thromboembolism as well as for complex morbidity. We analysed a cohort of cancer patients subjected to PICC insertion in a single cancer centre for the incidence of all-type vascular thromboembolism (VTE) and investigated relative risk factors.

Methods

In this clinical audit, the records of patients referred for PICC insertion in our centre in the period between 1/1/2011 and 1/4/2014 were retrospectively reviewed. The primary outcomes investigated were a) PICC-related deep vein thrombosis (PRDVT) and b) distant VTE (lower limb DVT and pulmonary embolism). 4Fr single lumen PICCs were placed in all patients. The Kaplan Meier method was used to study time from PICC insertion to PRDVT/VTE. Survival curves were compared using the log rank method. Logistic and Cox regression analyses were used to assess local, distant and combined endpoints.

Results

Four hundred ninety patients were included in the analysis of which 27 (5.5%) developed a PRDVT. Statistically significant risk factors for developing PRDVT in multivariate analysis included more than one attempt for insertion (OR 2.61, 95%CI: 1.12–6.05) and the use of fluoropyrimidine containing chemotherapy (OR 4.27, 95%CI 1.3–14.07). Twenty-six patients developed a distant VTE. Male gender was the only significant risk factor for distant VTE. When all-type VTE were considered together fluoropyrimidine containing chemotherapy (OR 4.54, 95% CI 1.63–12.61), male gender (OR 2.03, 95% CI 1.04–3.93) and white cell count (OR 1.12, 95% CI 1.00–1.26) were statistically significant as risk factors in this analysis.

Conclusions

This is a large study of VTE following PICC insertion in cancer patients which also looks at the rate of distant VTE. The observed PRDVT incidence is comparable with available literature. Fluoropyrimidine containing chemotherapy and more than one attempt for PICC insertion were independent predictors of PICC-associated VTE whilst the former remained an independent predictor of all-type VTE. Anticoagulation did not prevent thrombotic events in this cohort.

Central venous pressure monitoring via peripherally or centrally inserted central catheters: a systematic review and meta-analysis

INTRODUCTION

The central venous pressure (CVP) is the most commonly used static marker of preload for guiding fluid therapy in critically ill patients, though its usefulness remains controversial. Centrally inserted central catheters (CICCs) are the gold-standard devices for CVP monitoring but peripherally inserted central catheters (PICCs) may represent a valid alternative. We undertook a systematic review and meta-analysis with the aim to investigate whether the difference between PICC- and CICC-measured CVP is not significant.

METHODS

We searched for clinical studies published in PubMed and EMBASE databases from inception until December 21st 2016. We included studies providing data on paired and simultaneous CVP measurement from PICCs and CICCs. We conducted two analyses on the values of CVP, the first one according to the total number of CVP assessments, the second one considering the number of patients recruited.

RESULTS

Four studies matched the inclusion criteria, but only three of them provided data for the meta-analyses. Both analyses showed non-significant differences between PICC-measured and CICC-measured CVP: 1489 paired simultaneous CVP assessments (MD 0.16, 95%CI -0.14, 0.45, p = 0.30) on a total of 57 patients (MD 0.22, 95%CI -1.46, 1.91, p = 0.80). Both analyses showed no heterogeneity (I2 = 0%).

CONCLUSIONS

Available evidence supports that CVP monitoring with PICCs is accurate and reproduces similar values to those obtained from CICCs. The possibility to monitor CVP should not be used among clinical criteria for preferring a CICC over a PICC line.

Peripherally InSerted CEntral catheter dressing and securement in patients with cancer: the PISCES trial. Protocol for a 2x2 factorial, superiority randomised controlled trial

INTRODUCTION

Around 30% of peripherally inserted central catheters (PICCs) fail from vascular, infectious or mechanical complications. Patients with cancer are at highest risk, and this increases morbidity, mortality and costs. Effective PICC dressing and securement may prevent PICC failure; however, no large randomised controlled trial (RCT) has compared alternative approaches. We designed this RCT to assess the clinical and cost-effectiveness of dressing and securements to prevent PICC failure.

METHODS AND ANALYSIS

Pragmatic, multicentre, 2×2 factorial, superiority RCT of (1) dressings (chlorhexidine gluconate disc (CHG) vs no disc) and (2) securements (integrated securement dressing (ISD) vs securement device (SED)). A qualitative evaluation using a knowledge translation framework is included. Recruitment of 1240 patients will occur over 3 years with allocation concealment until randomisation by a centralised service. For the dressing hypothesis, we hypothesise CHG discs will reduce catheter-associated bloodstream infection (CABSI) compared with no CHG disc. For the securement hypothesis, we hypothesise that ISD will reduce composite PICC failure (infection (CABSI/local infection), occlusion, dislodgement or thrombosis), compared with SED.

SECONDARY OUTCOMES

types of PICC failure; safety; costs; dressing/securement failure; dwell time; microbial colonisation; reversible PICC complications and consumer acceptability. Relative incidence rates of CABSI and PICC failure/100 devices and/1000 PICC days (with 95% CIs) will summarise treatment impact. Kaplan-Meier survival curves (and log rank Mantel-Haenszel test) will compare outcomes over time. Secondary end points will be compared between groups using parametric/non-parametric techniques; p values <0.05 will be considered to be statistically significant.

ETHICS AND DISSEMINATION

Ethical approval from Queensland Health (HREC/15/QRCH/241) and Griffith University (Ref. No. 2016/063). Results will be published.

TRIAL REGISTRATION

Trial registration number is: ACTRN12616000315415.

[The incidence and risk factors of catheter-related-thrombosis during induction chemotherapy in acute lymphocytic leukemia children]

目的

分析初诊急性淋巴细胞白血病（ALL）诱导化疗期外周静脉穿刺中心静脉置管（PICC）患儿导管相关性血栓（CRT）的危险因素。

方法

收集2014年3月1日至2014年12月31日首都医科大学附属北京儿童医院血液肿瘤中心白血病病房行PICC置管的116例初诊ALL患儿临床资料。

结果

①PICC置管后第15天33例（28.4%）患儿发生CRT（CRT组），83例患儿未发生CRT（非CRT组）。②两组在性别、年龄分布、ALL危险度、免疫表型以及置管时两组血常规、凝血功能、是否合并感染、置管静脉方面差异无统计学意义，CRT组右侧置管比例高于非CRT组[75.8%（25/33）对55.4%（46/83），P=0.043]。③CRT组患者均无临床症状，置管第15天D-二聚体高于非CRT组[0.18（0.05~2.45）mg/L对0.11（0.01~5.34）mg/L，P=0.001]。④观察期中出现3例导管相关性并发症，均为导管相关性感染，其中2例并发CRT。⑤置管第33天CRT组26例患者复查B超，19例（73.1%）血栓缩小，6例（23.1%）无明显变化，1例（3.8%）增大。

结论

CRT是初诊ALL患儿诱导化疗期PICC置管的常见导管相关并发症，但症状出现较少，大部分血栓可自行缩小，右侧置管为CRT发生的危险因素；检测D-二聚体水平以及定期进行导管部位B超检查有助于及时发现CRT。

Management of parenteral nutrition in critically ill patients

Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Improving outcomes of short peripheral vascular access in oncology and chemotherapy administration

A short peripheral intravenous catheter or cannula (PIVC) is frequently used to deliver chemotherapy in oncology practice. Although safe and easy to insert, PIVCs do fail, leading to personal discomfort for patients and adding substantially to treatment costs. As the procedure of peripheral catheterization is invasive, there is a need for greater consistency in the choice, insertion and management of short PIVCs, particularly in the oncology setting where there is a growing trend for patients to receive many different courses of IV treatment over a number of years, sometimes with only short remissions. This article reviews best practice with respect to PIVCs in cancer patients and considers the necessity for bundling these actions. Two care bundles, addressing both insertion and ongoing care and maintenance, are proposed. These have the potential to improve outcomes with the use of short PIVCs for vascular access in oncology practice.

“Extended subcutaneous route” technique: a quick subcutaneous tunnelling technique for PICC insertion

Purpose

To describe a quick tunnelling technique for peripherally inserted central catheter (PICC) insertion called the “extended subcutaneous route” technique.

Methods

The “extended subcutaneous route” technique is described step by step.

Results

In 18 consecutive PICCs, inserted with extended route technique in ASST Monza, no complications during insertion were registered. In 969 catheter days observed, we identified only one accidental dislodgement. No other mid-term complications were observed.

Conclusions

Extended subcutaneous route technique allows the creation of a subcutaneous tunnel <5 cm, without skin incision and additional manipulation. Extended subcutaneous route technique may be feasible and useful, particularly for patients with high risk of bleeding or infection.

Defining the Specialty of Vascular Access through Consensus: Shaping the Future of Vascular Access

The Association for Vascular Access (AVA) is an organization of health care professionals founded in 1985 to support and promote the specialty of vascular access. The mission of AVA is to distinguish the vascular access specialty and define standards of vascular access through an evidence-based approach designed to enhance health care. There is little guidance for multidisciplinary procedures/practice, and this is the case for vascular access. There are also inconsistencies and conflicts in terminology. Additionally, there is no consensus of vascular access as a specialty. It is the focus of AVA to promote consistency in vascular access practice. This document embraces a common title for a clinician with knowledge and skills in the area of vascular access. This establishes a new paradigm that will strengthen the advancement of the vascular access specialty.

Variation in prevalence and patterns of peripherally inserted central catheter use in adults hospitalized with pneumonia

BACKGROUND

Although peripherally inserted central catheters (PICCs) are often used in adults hospitalized with pneumonia, patterns related to PICC use in this context are unknown.

METHODS

Premier's inpatient database was used to identify patients hospitalized with pneumonia between July 1, 2007 and November 30, 2011. PICC placement was identified via billing codes. Generalized estimating equations were used to identify factors associated with PICC placement. Hospital risk-standardized rates of PICC insertion were estimated using hierarchical generalized linear models.

RESULTS

There were 545,250 patients (median age: 71 years; range: 57-82 years) included. A total of 41,849 (7.7%) patients received a PICC during hospitalization (median receipt: hospital day 4). PICC recipients were younger (median age: 69 years), had higher levels of comorbidity (Gagne score median: 4 vs 2) and were more often diagnosed with healthcare-associated pneumonia (43.1% vs 29.9%) than those who did not receive PICCs. The 3 patient variables most associated with PICC receipt included weight loss (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.97-2.10), sepsis on admission (OR: 1.80, 95%CI: 1.75-1.85), and intensive care unit status on hospital day 1 or 2 (OR: 1.70, 95%CI: 1.64-1.75). Compared to internal medicine, admission by geriatricians and critical care physicians was associated with PICC placement (OR: 1.81, 95% CI: 1.62-2.03 and OR: 1.14, 95% CI: 1.05-1.24, respectively). Risk-standardized rates of PICC utilization varied from 0.3% to 41.7%. Nearly 70% of the variability in PICC use could not be explained by available data.

CONCLUSIONS

In adults hospitalized with pneumonia, PICC use appears directed towards those with severe illness and varies substantially between hospitals. Journal of Hospital Medicine 2016;11:568-575. © 2016 Society of Hospital Medicine.

Distal Superficial Femoral Vein Cannulation for Peripherally Inserted Central Catheter Placement in Infants with Cardiac Disease

OBJECTIVE

To describe a novel real-time ultrasound (US)-guided distal superficial femoral vein (DSFV) cannulation technique for insertion of peripherally inserted central catheters (PICC) in critically ill infants with congenital heart disease.

DESIGN

Descriptive retrospective cohort study SETTING: Pediatric cardiac intensive care unit in a pediatric tertiary hospital PATIENTS: First 28 critically ill infants that received DSFV PICCs via this new technique.

RESULTS

Thirty-seven US-guided DSFV PICCs were attempted on 31 infants from September 2012 to November 2014; 34 PICCs were placed in 28 patients (success rate 92%). Twenty-six of 28 patients underwent cardiac surgery. Median (IQR) age at time of PICC placement 39 days (13, 151); weight 3.4 kg (3.2, 5.3). 25/34 PICCs were placed in patients with STAT 4 or 5 category. Median PICC duration 16 days (11, 29); maximum duration 123 days. Ten infants (36%) had DSFV PICCs placed as the primary central venous access in perioperative period. Ten of 28 patients underwent cardiac catheterization while DSFV PICC was in place, four of which were performed through ipsilateral common femoral vein. Two patients had femoral arterial lines placed in the ipsilateral femoral artery while DSFV PICC was in place. There were no reported inadvertent arterial punctures. The PICC-associated infection rate was 4.6 per 1000 line days. Four of 34 DSFV PICCs (11.8%) were associated with deep venous thrombosis.

CONCLUSIONS

DSFV is a novel venous access site for PICC placement with high success rate and sufficient longevity and flexibility for critically ill infants with cardiac disease. More experience and larger studies are needed to confirm its potential advantages.

Clinical evaluation of the use of an intracardiac electrocardiogram to guide the tip positioning of peripherally inserted central catheters

The use of peripherally inserted central catheters (PICCs) provides important central venous accesses for clinical treatments, tests and monitoring. Compared with the traditional methods, intracardiac electrocardiogram (ECG)-guided method has the potential to guide more accurate tip positioning of PICCs. This study aimed to clinically evaluate the effectiveness of an intracardiac ECG to guide the tip positioning by monitoring characteristic P-wave changes. In this study, eligible patients enrolled September 2011 to May 2012 according to the inclusion and exclusion criteria received the catheterization monitored by intracardiac ECG. Then chest radiography was performed to check the catheter position. The results revealed that, with 117 eligible patients, all bar one patient who died (n = 116) completed the study, including 60 males and 56 females aged 51.2 ± 15.1 years. Most (n = 113, > 97%) had characteristic P-wave changes. The intracardiac ECG-guided positioning procedure achieved correct placement for 112 patients (96.56%), demonstrating 99.12% sensitivity and 100% specificity. In conclusion, the intracardiac ECG can be a promising technique to guide tip positioning of PICCs. However, since the sample size in this study is limited, more experience and further study during clinical practice are needed to demonstrate achievement of optimal catheterization outcomes.

Focused Simulation Training: Emergency Department Nurses’ Confidence and Comfort Level in Performing Ultrasound-Guided Vascular Access

Study objectives

The objective of this study is to assess Emergency Department (ED) nurses’ confidence, comfort level, and competency in performing ultrasound-guided vascular access after a focused ultrasound simulation training session.

Methods

A cross-sectional study at an academic medical center. A simulation-based ultrasound training module was used to train ED nurses in ultrasound-guided intravenous (IV) access. The training module consisted of didactics followed by hands-on practice on human models and Blue Phantom ultrasound training block model. All subjects completed a questionnaire after completing the training module.

Results

A total of 40 nurses were enrolled. All subjects successfully demonstrated competency during the training session by identifying upper extremity sonographic vascular anatomy on a human model and performing real-time ultrasound-guided IV access on Blue Phantom ultrasound training block model. On a scale of 1-10, the average confidence level in performing the ultrasound-guided vascular access was 6.9 [95% confidence interval (95% CI) 6.3-7.46], with 98% (95% CI, 92-102%) reporting no difficulty in recognizing upper limb vascular anatomy on ultrasound. Ninety-two percent (95% CI, 84-100%) agreed that focused training in ultrasound-guided IV access was adequate to learn the procedure.

Conclusions

After a focused simulation training session, ED nurses had a high level of comfort using ultrasound for vascular access. Despite having a moderate degree of confidence, ED nurses were accurate in identifying vascular anatomy and performing ultrasound-guided vascular access.

Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management

Vascular interventional radiology procedures are relatively safe compared with analogous surgical procedures, with overall major complication rates of less than 1%. However, major vascular injuries resulting from these procedures may lead to significant morbidity and mortality. This review will discuss the etiology, clinical presentation, diagnosis, and management of vascular complications related to percutaneous vascular interventions. Early recognition of these complications and familiarity with treatment options are essential skills for the interventional radiologist.

Use of Double-Lumen Peripherally Inserted Central Catheters for Safer Perioperative Management of Esophageal Cancer Patients

Purpose

As a step to large-scale clinical trials, we conducted a small-scale exploratory study to clarify whether the secondary lumen of the double-lumen (DL) peripherally inserted central catheters (PICCs) could perform as well as the secondary lumen of the DL centrally inserted central catheters (CICCs), with an acceptable complication rate in the perioperative surgery period.

Methods

Forty thoracic esophageal cancer patients requiring central venous catheterization during the perioperative period were assigned to the DL-PICC (4.5-French, 60-cm) group or the DL-CICC (16-gauge, 30-cm) group, with 1:1 randomization. The primary endpoint was the completion rate of continuous catecholamine infusion via the secondary lumen during the observation period.

Results

Thirty-two cases (14 cases in the PICC group and 18 cases in the CICC group) were analyzed. Continuous catecholamine infusion via the secondary lumen was completed in all 32 cases. No major complications related to PICC/CICC placement/maintenance were noted in the groups during the median observation period of 6 days.

Conclusions

The secondary lumen of the DL-PICCs performed as well as the secondary lumen of the DL-CICCs with acceptable safety during the relatively short perioperative period of these thoracic esophageal cancer patients (UMIN Clinical Trial Registry UMIN000008131).