Clinical management of peripherally inserted central catheters compared to conventional central venous catheters in patients with hematological malignancies: A large multicenter study of the REL GROUP (Rete Ematologica Lombarda - Lombardy Hematologic Network, Italy)

Peripherally inserted central venous catheters decrease central line-associated bloodstream infections and change microbiological epidemiology in adult hematology unit: a propensity score-adjusted analysis

Peripherally inserted central venous catheters (PICCs) have a potential advantage in preventing central line-associated bloodstream infection (CLABSI) compared with the centrally inserted ones (CICCs). However, due to a limited number of studies with insufficient statistical evaluation, the superiority of PICCs is difficult to be generalized in adult hematology unit. We conducted a single-center retrospective study and compared the risk of CLABSI between 472 CICCs and 557 PICCs inserted in adult patients with hematological disorders through conventional multivariate models and a propensity score-adjusted analysis. The overall CLABSI incidence in CICCs and PICCs was 5.11 and 3.29 per 1000 catheter days (P = 0.024). The multivariate Cox regression analysis (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.31-0.75; P = 0.001) and Fine-Gray subdistribution analysis (HR: 0.59; 95% CI: 0.37-0.93; P = 0.023) demonstrated that PICC was independently associated with a reduced risk of CLABSI. Moreover, the stabilized inverse probability of treatment weighting analysis, which further reduced the selection bias between CICCs and PICCs, showed that PICCs significantly prevented CLABSI (HR: 0.58; 95% CI: 0.35-0.94; P = 0.029). Microbiologically, PICCs showed a significant decrease in gram-positive cocci (P = 0.001) and an increase in gram-positive bacilli (P = 0.002) because of a remarkable reduction in Staphylococci and increase in Corynebacterium species responsible for CLABSI. Our study confirmed that PICC was a superior alternative to CICC in preventing CLABSI in the adult hematology unit, while it posed a microbiological shift in local epidemiology.

Retrospective analysis of the safety of peripherally inserted catheters versus implanted port catheters during first-line treatment for patients with diffuse large B-cell lymphoma

Objectives

Both peripherally inserted central catheters (PICCs) and implanted port catheters (PORTs) are commonly used for the delivery of immunochemotherapy. We compared the safety of the two types of devices in a homogeneous and monocentric population of diffuse large B‐cell lymphoma (DLBCL) patients who were treated with first‐line immunochemotherapy by evaluating the numbers of catheter‐related venous thromboses (VTs) and infections that occurred in the six months after implantation according to the type of device.

Methods

Using a propensity score, the adjusted relative risk (ARR) between the type of catheter and the occurrence of catheter‐related complications (infection and/or VT) of interest was retrospectively determined.

Results

479 patients were enrolled (266 PORTs/213 PICCs), and 26 VTs (5.4%) and 30 infections (6.3%) were identified in the period following PICC/PORT implantation. The adjusted relative risk (ARR) of catheter‐related complications (infection and/or VT) according to the type of device was 2.6 (95% CI =1.3–5.9, p = .0075). This risk increase associated with the PICC device was significant for both infections (ARR = 3.2; 95% CI = 1.3–10.9) and thrombosis (ARR = 4; 95% CI = 1.5–11.6).

Conclusion

Our study supports the preferential use of PORTs for the first line of treatment for DLBCL patients.

Conditional catheter-related thrombosis free probability and risk-adapted choices of catheter for lung cancer

Background

Current predictive tools assess catheter‐related thrombosis (CRT) in patients with lung cancer in a static manner at a single time point of catheterization. The subsequent hazard changes over time are unknown. The conditional catheter‐related thrombosis‐free probability (CCFP) can provide dynamic information on continual CRT‐free expectations. This study aimed to assess the CCFP and hazard rates based on risk categories and various venous access devices (VADs).

Methods

This retrospective study reviewed 939 patients with lung cancer with peripherally inserted central venous catheters (PICCs) or central venous catheters (CVCs) identified at the National Clinical Research Center for Cancer between January 1, 2015 and December 31, 2018. The incidence of CRT has also been reported. Patients were stratified into low‐ and high‐risk groups according to multivariate Cox regression analyses. CCFP is defined as the CRT‐free probability given that patients have no CRT for a definite time.

Results

A total of 507 patients with PICCs and 432 patients with CVCs were included in this study. The 3‐month CCFP increased from 74.2% at catheter insertion to 93.6% at 3 months. The hazards of CRT in the first month were highest (16.4%) and slightly thereafter. The high‐risk group initially had a higher (21.4%) but significantly decreased CRT hazard after 2 months (8.3%), whereas the low‐risk group maintained a comparable lower risk hazard of less than 5% after 1 month. In the overall cohort, patients with CVCs had lower CRT probability than those with PICCs (HR, 1.76; 95% CI: 1.28–2.41; p < 0.01). Further analysis demonstrated that compared with PICCs, CVCs provided a CRT‐free benefit in low‐risk patients (p = 0.02) but not in high‐risk patients (p = 0.06).

Conclusions

CCFP increased, and the hazards of CRT decreased over time in a risk‐dependent manner in patients with lung cancer. These valuable dynamic data may help optimize risk‐adjusted choices of VADs and risk‐adjusted prophylactic anticoagulation strategies for patients.

Risk Factors for Complications Associated with Peripherally Inserted Central Catheters During Induction Chemotherapy for Acute Myeloid Leukemia

Objective Peripherally inserted central catheters (PICCs) are widely used in patients with hematologic malignancies. However, the risks of PICC-related complications during chemotherapy for acute myeloid leukemia (AML) are not fully understood. Methods We conducted a retrospective review of 128 adult patients with AML who received induction therapy by way of PICC insertion between 2012 and 2019. Results The median duration of PICC insertion was 30 days. The incidence rate of catheter-related bloodstream infection (CRBSI) was 2.4% at 30 days, and women were more likely to suffer from CRBSI than men. Local reactions at the insertion site were observed in 56 patients; however, these events did not predict CRBSI. The incidence rates of catheter-related thrombosis (CRT) were 1.6% at 30 days. Obesity put patients at an increased risk for CRT. Unexpected PICC removal occurred in 59 patients, and women were at a higher risk of catheter removal than men. Conclusion Low PICC-related complication rates, possibly associated with high rates of catheter removal, were observed during intensive chemotherapy for AML. Women and obese patients require careful monitoring of their PICC. Procedures to achieve appropriate PICC removal without increasing the complication rate need to be considered.

Catheter-related bloodstream infection associated with multiple insertions of the peripherally inserted central catheter in patients with hematological disorders

Patients with hematological disorders are treated with multiple cycles of chemotherapy. As a result, they often require multiple insertions of the peripherally inserted central catheter (PICC) for prolonged periods of time. Although PICCs have been widely used worldwide in various patients, the safety and feasibility of the multiple insertions of the PICC in this population have not been fully verified. We performed a retrospective analysis to clarify the relationship between complications and multiple PICC insertions in patients with hematological disorders who were treated with either chemotherapy or immunotherapy. A total of 651 PICCs were inserted in 261 patients with a median age of 66 years. Acute myeloid leukemia (AML) and non-Hodgkin's lymphoma were the most common diseases in our patient cohort. The total catheter days (CDs) was 29,485 days, with a median catheter duration of 30 days. The rate of catheter-related bloodstream infection (CRBSI) in our patient cohort at high rate of re-insertion was 2.0/1000 CDs. Although multiple PICC insertions were not a risk factor of CRBSI, our findings suggest that a prolonged catheter dwell time may be associated with CRBSI. AML was an important risk factor of CRBSI. While the PICC dwell time depends on the treatment cycle, our findings indicate that it should be limited to approximately 30 days and catheters may be removed and re-inserted as needed.

[The use of venous catheter : Which ones to choose, how to prevent their complications?]

Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.

Development and Validation of a New Clinical Prediction Model of Catheter-Related Thrombosis Based on Vascular Ultrasound Diagnosis in Cancer Patients

Background: Central venous catheters are convenient for drug delivery and improved comfort for cancer patients, but they also cause serious complications. The most common complication is catheter-related thrombosis (CRT). Objectives: This study aimed to evaluate the incidence and risk factors for CRT in cancer patients and develop an effective prediction model for CRT in cancer patients. Methods: The development of our prediction model was based on a retrospective cohort (n = 3,131) from the National Cancer Center. Our prediction model was confirmed in a prospective cohort from the National Cancer Center (n = 685) and a retrospective cohort from the Hunan Cancer Hospital (n = 61). The predictive accuracy and discriminative ability were determined by receiver operating characteristic (ROC) curves and calibration plots. Results: Multivariate analysis demonstrated that sex, cancer type, catheter type, position of the catheter tip, chemotherapy status, and antiplatelet/anticoagulation status at baseline were independent risk factors for CRT. The area under the ROC curve of our prediction model was 0.741 (CI: 0.715-0.766) in the primary cohort and 0.754 (CI: 0.704-0.803) and 0.658 (CI: 0.470-0.845) in validation cohorts 1 and 2, respectively. The model also showed good calibration and clinical impact in the primary and validation cohorts. Conclusions: Our model is a novel prediction tool for CRT risk that accurately assigns cancer patients into high- and low-risk groups. Our model will be valuable for clinicians when making decisions regarding thromboprophylaxis.

Peripherally Inserted Central Catheter lines for Intensive Care Unit and onco-hematologic patients: A systematic review and meta-analysis

BACKGROUND

It is unclear whether Peripherally Inserted Central Catheter (PICC) lines are associated with lower complication rates as compared to conventional Central Venous Catheters (CVCs), especially in high risk patients.

OBJECTIVE

To compare Central Line Associated Bloodstream Infection (CLABSI) and catheter-related thrombosis rates in Intensive Care Unit (ICU) and onco-hematologic patients with PICC lines and CVCs.

METHODS

We systematically reviewed the PubMed, Cochrane and Google Scholar databases to identify relevant studies. Study quality was evaluated using appropriate assessment tools and the pooled odds ratio (OR) and confidence interval (CI) were calculated. Sensitivity analyses were performed based on meta-analysis method, type of study and prophylaxis implementation.

RESULTS

Thirteen studies were included in our meta-analysis. PICC lines were associated with a significantly higher rate of thrombosis in ICU [OR (95%CI): 2.58(1.80,3.70); P_z<0.00001] and onco-hematologic [OR (95%CI): 2.91(2.11,4.02); P_z<0.00001] patients. CLABSI rates with PICC lines were not significantly different in ICU patients [OR (95%CI): 1.65(0.91,2.99); P_z= 0.1], but significantly lower CLABSI rates were observed in onco-hematologic patients [OR (95%CI): 0.38(0.16,0.91); P_z=0.03]. Sensitivity analyses verified the robustness of our results.

CONCLUSIONS

PICC lines are associated with higher rates of thrombotic events. However, they might be suitable for onco-hematologic patients due to lower CLABSI rates.

Comparison of outcomes of central venous catheters in patients with solid and hematologic neoplasms: an Italian real-world analysis

INTRODUCTION

Although many reports have analyzed the outcomes of central venous catheters (CVCs) in oncologic and oncohematologic patients, current guidelines do not routinely recommend a specific type of CVC over the other.

METHODS

We retrospectively evaluated the outcomes of 178 patients with CVCs referred to an Italian specialized cancer center between January 2016 and December 2018. The analysis compares midterm peripherally inserted central venous catheters (PICCs) with long-term centrally inserted catheters, including totally implanted ports and tunneled catheters with central insertion (tCVCs).

RESULTS

A total of 130 PICCs (73%) and 48 tCVCs (27%) were analyzed. The overall complication rate was significantly increased in the PICC cohort compared to the tCVC cohort (43.1% vs 25%, respectively; p = 0.037), leading to complication-related device removal in 30.8% of PICCs vs 12.5% of tCVCs (p = 0.013). No significant differences in terms of catheter-related thromboses (p = 0.676) or catheter-related infections (p = 0.140) were detected. Nonthrombotic obstructions were significantly higher in the PICC group compared to the tCVC cohort (p = 0.006). Overall complication-free survival was significantly longer for tCVCs compared to PICCs (hazard ratio [HR], 0.262; 95% confidence interval [CI], 0.128-0.536; p < 0.0001), as well as obstruction-free survival (HR, 0.082; 95% CI, 0.018-0.372; p < 0.0001). In multivariable analysis, the type of CVC was independently correlated with the occurrence of any complication (HR, 0.273; 95% CI, 0.135-0.553; p < 0.0001).

CONCLUSIONS

This Italian real-world experience suggests that PICCs are associated with a higher risk of overall complications compared with tCVCs. Catheter choice in oncologic patients should be guided by treatment type and duration, risk-benefit assessment, patient preferences, and compliance.

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.

Peripherally inserted central venous catheter placed and maintained by a dedicated nursing team for the administration of antimicrobial therapy vs. another type of catheter: a retrospective case-control study

INTRODUCTION

Data concerning the use of peripherally inserted central catheters (PICC) for the administration of intravenous (IV) antimicrobials in the acute care setting is scarce.

METHODS

We performed a single-center retrospective case-control study (1:1). Case subjects were defined as patients who received IV antimicrobial treatment through a PICC line placed and maintained by specifically trained nurses (PICC group). Control subjects were defined as patients who received antimicrobial therapy by a peripheral or a central venous catheter (CVC) (control group). Control subjects were matched by type of antimicrobial, causative microorganism of the infection that was being treated and duration of treatment. An event leading to undesired catheter removal (ELUCR) was defined as any circumstance which lead to the removal of the indwelling catheter other than the completion of the scheduled course of antimicrobial therapy.

RESULTS

The study included 50 patients in each group. The total follow-up time was 1376 catheter-days for the PICC group and 1362 catheter-days for the control group. We observed a significantly lower incidence of ELUCR in the PICC group (0.2 versus 7.7 events per 100 catheter-days; P<0.001). When the incidence of ELUCR was analyzed according to the duration of indwelling catheterisation for each type of catheter (divided into one-week intervals), differences between both groups were also significant (P-values≤0.001 for the first three weeks of treatment). During the second week of IV treatment, only one patient in the PICC group (2.1%) developed an ELUCR compared to 19 (38.8%) in the control group (P<0.001).

CONCLUSIONS

A PICC placed and maintained by a dedicated nursing team is an excellent alternative to peripheral venous catheters or CVCs for administrating antimicrobial therapy for both short and long periods of treatment.

Prevalence of idle peripherally inserted central catheters in adult patients: A multicenter cross-sectional study

Background:

Increasing studies concern about idle vascular access devices, but still scant data on idle peripherally inserted central catheters. We aimed to assess the prevalence and risks of idle peripherally inserted central catheters in adult patients.

Methods:

A multicenter cross-sectional observational study was performed between April 2018 and July 2018. Patient demographics and peripherally inserted central catheters–related information were abstracted using a site questionnaire by directly inquiring and medical records reviewing right after their peripherally inserted central catheters were removed.

Results:

Three hundred and fifty-eight patients with peripherally inserted central catheter episodes who met the inclusion criteria were studied. Of the 58,000 total catheter-days recorded, 5311 (9.2%) were considered as idle based on our study criteria. Two hundred and fifty-five (71.2%) patients had at least 1 idle catheter-day with a mean duration of 14.84 (19.31) idle days. The incidence of catheter-related complications in patients with idle peripherally inserted central catheters was lower than that in patients without idle peripherally inserted central catheters, though the difference did not reach statistical significance (odds ratio = 0.635, 95% confidence interval = 0.367–1.099, p = 0.103).

Conclusion:

In conclusion, idle peripherally inserted central catheters were common in adult patients, but the low risks of catheter-related complications may justify maintaining a peripherally inserted central catheter for further observation when necessary.

Oxygen Extraction Ratio (OER) as a Measurement of Hemodialysis (HD) Induced Tissue Hypoxia: A Pilot Study

HD tissue hypoxia associates with organ dysfunctions. OER, the ratio between SaO₂ and central-venous-oxygen-saturation, could estimate oxygen requirements during sessions, but no data are available. We evaluated OER behavior in 20 HD patients with permanent central venous catheter (CVC) as vascular access. Pre-HD OER (33.6 ± 1.4%; M ± SE) was higher than normal (range 20–30%). HD sessions increased OER to 39.2 ± 1.5% (M ± SE; p < 0.05) by 30′ and to 47.4 ± 1.5% (M ± SE; p < 0.001) by end of treatment (delta 40%). During HD sessions of the long and short interdialytic intervals, OER values overlapped, suggesting no influence of patient’s hydration status shifts. OER increased (p < 0.05) after 30′ of isolated HD (zero ultrafiltration), but not during isolated ultrafiltration (zero dialysate flow), suggesting a role for blood-membrane-dialysate interaction, independent of volume reduction. In ten patients, individual variability of pre-HD OER was low and repeatable (maximum calculated difference over time 6.6%), and negatively correlated with HD-induced OER increments (r = 0.860; p < 0.005), suggesting a decline in the adaptive response along with resting OER increments. In 30 prevalent patients, adjusted multivariate analysis showed that pre-HD OER (HR = 0.88, CI 0.79–0.99, p = 0.028) and percent HD-induced OER (HR = 1.04, CI 1.01–1.08, p = 0.015) were both associated with mortality, with threshold values respectively <32% and >40%. In HD patients with CVC as vascular access, OER is a cheap, easily measurable and repeatable parameter useful to assess intradialytic hypoxia, and a potential biomarker of HD related stress and morbidity, helpful to recognize patients at increased risk of mortality.