A randomised, controlled trial comparing the long-term effects of peripherally inserted central catheter placement in chemotherapy patients using B-mode ultrasound with modified Seldinger technique versus blind puncture

Effectiveness and safety of methods to prevent bloodstream and other infections and noninfectious complications associated with peripherally inserted central catheters: A systematic review and meta-analysis

BACKGROUND

Peripherally inserted central catheters (PICCs) have a 29% complication rate. This systematic review assessed 25 interventions to prevent PICC-associated infectious and noninfectious complications in participants of all ages.

METHODS

We searched electronic databases (MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL) and reference lists for randomized (RCTs) and nonrandomized studies published from January 1, 1980-May 8, 2024. We dually selected studies, assessed risk of bias, extracted data, and rated certainty of evidence (COE). We included both single interventions of interest and combinations of at least two (bundle/multimodal). If three or more RCTs existed, we conducted Bayesian random-effects meta-analyses.

RESULTS

Seventy-four studies met our eligibility criteria (60 on individual interventions, 14 on bundle/multimodal), addressing 13 of 25 research questions. The majority were conducted in high-income countries; 36 focused on neonates. Evidence was very uncertain for 11 of the 13 research questions. Evidence with a stronger COE showed that ultrasound-guided catheter insertion reduced phlebitis/thrombophlebitis in adults compared to non-ultrasound-guided insertion (five RCTs; risk ratio [RR] 0.19, 95% credible interval 0.08-0.50); silicone catheters increased phlebitis/thrombophlebitis compared to nonsilicone (one RCT, RR 2.00, 95% confidence interval [95%CI] 1.26-3.17). Bundle interventions decreased local infections (one RCT, RR 0.47, 95%CI 0.31-0.72) and phlebitis/thrombophlebitis in adults (one RCT, RR 0.35, 95%CI 0.22-0.56) compared to routine care.

CONCLUSIONS

Ultrasound-guided catheter insertion and nonsilicone catheters effectively prevented PICC complications. The evidence for other comparisons was too uncertain to draw conclusions, highlighting the urgent need for additional studies on prevention and control interventions.

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.

Evaluating Effectiveness of the Use of an Extremity Stabilization Device for Vascular Access Procedures in Pediatrics

The purpose of this study is to evaluate the effectiveness of SafeBoard, a Food and Drug Administration-approved extremity stabilization device, as an assistive method in performing peripherally inserted central catheter procedures on children 0 to 3 years of age. This is a retrospective chart review ( n  = 59) of vascular access procedures where SafeBoard was utilized ( n  = 32 ) in comparison to those procedures which utilized a traditional approach to placement ( n  = 27). Statistical analysis demonstrated significant effect on length of procedure time, number of personnel needed for procedure, and success of placement when SafeBoard was utilized. Obtaining vascular access in pediatrics can be a challenging endeavor. Most young pediatric patients require procedural sedation and/or assistive personnel as a "holder" for successful vascular access placement to occur. An alternative option for extremity stabilization may provide improved workflow and improved placement success, which in turn may positively affect workflow.

The SIP protocol update: Eight strategies, incorporating Rapid Peripheral Vein Assessment (RaPeVA), to minimize complications associated with peripherally inserted central catheter insertion

Insertion of Peripherally Inserted Central Catheters (PICCs) is potentially associated with the risk of immediate/early adverse events, some of them minimal (repeated punctures) and some relevant (accidental arterial puncture or nerve-related injury). Several strategies adopted during the insertion process may minimize the risk of such events, including late complication risks such as infection, venous thrombosis, or catheter dislodgment and/or malposition. This paper describes an update version of the SIP protocol (Safe Insertion of PICCs), an insertion bundle which includes eight effective strategies that aims to minimize immediate, early, or late insertion-associated complications. These strategies include: preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; appropriate skin antiseptic technique; choice of appropriate vein, adoption of the Zone Insertion Method™; clear identification of the median nerve and brachial artery; ultrasound-guided puncture; ultrasound-guided tip navigation; intra-procedural assessment of tip location; correct securement of the catheter, and appropriate protection of the exit site. This updated version of the SIP protocol includes several novelties based on the most recent evidence-based scientific literature on PICC insertion, such as the clinical relevance of the tunneling technique, the use of ultrasound for intra-procedural tip navigation and tip location, and the new technologies for the protection of the exit site (cyanoacrylate glue) and for the securement of the catheter (subcutaneous anchorage).

Ultrasonography and procedures in intensive care medicine

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

Identifying the impact of the Zone Insertion MethodTM (ZIMTM): A randomized controlled trial

BACKGROUND

In 2011, Dawson proposed the Zone Insertion MethodTM (ZIMTM) to identify the optimal peripherally inserted central catheters (PICCs) insertion site in the upper arm. However, data on the effectiveness and safety of the ZIMTM in guiding PICC placement in Chinese population is limited.

METHODS

In this randomized controlled trial, 120 cancer patients were randomly assigned to the upper portion of the red zone (RZ), the green zone (GZ) and the lower portion of the yellow zone (YZ) groups (at a 1:1:1 ratio). The aim was to compare the degree of patient comfort and the incidence of major PICC complications among the three insertion zones based on the ZIMTM in a Chinese Cancer Center. (Clinical Trials. Gov number, ChiCTR1900024111).

RESULTS

A total of 118 catheters were inserted in 118 patients (2 patients were lost to follow-up). After the 1-month follow-up, patients randomly assigned to the YZ group had a higher degree of comfort with a lower score than those assigned to the other two zone groups: 30.21±3.16 in the YZ group versus 31.65±2.51 in the RZ group and 31.59±2.92 in the GZ group (P=.046). The incidence of thrombosis (10/40, 25%) and occlusion (4/40, 10%) in the RZ, which were significantly higher than those in the other two zone groups (χ2 =7.368, P=.02; χ2 =5.778, P =.03), whereas the risk in the GZ group was similar to that in the YZ group. The incidence of contact dermatitis in the GZ group was significantly higher than that of the other two zone groups (χ2=12.873, P=.001).

CONCLUSIONS

This study found that the lower portion of YZ seems to be another suitable PICC insertion site for a higher degree of comfort and a lower risk of occlusion and thrombosis, which broadens the choice of PICC insertion sites in the upper arm for clinical practice.

Role of varicocele sclerotherapy in the management of benign prostatic hyperplasia and its associated lower urinary tract symptoms (pilot study)

Background

Benign prostatic hyperplasia (BPH) is inescapable with aging and can cause lower urinary tract symptoms, worsening the quality of life. New pathophysiologic mechanisms of BPH development are currently under study to modulate its management. The valvular destruction of the spermatic veins (varicoceles development) incurs a testicular-prostatic hydrostatic pressure gradient, which conveys free undiluted testosterone to the prostate via a testicular-prostatic backdoor passage. Subsequently, prostatic congestion and androgen-dependent prostatic hyperplasia occur resulting in lower urinary symptoms development. The purpose of our study is to detect the effect of testicular venous sclerotherapy on the prostatic enlargement and the related urinary symptoms.

Results

Our single-arm interventional study included 36 patients with an age range of 40–80 years. The patients complained of urinary symptoms and had prostatomegaly with varicoceles by sonography. A median international prostatic symptom score (IPSS) of 19 and a quality of life (QoL) score ranging (3–6) reflected the severity of the urinary symptoms. Venography showed reflux in all cannulated spermatic veins with subsequent sclerotherapy on the left side and bilaterally in 80.6% and 11.1% of the patients, respectively. The technical and clinical success rates reached 91.7% and 83.3%, respectively, with a statistically significant reduction in the IPSS and QoL scores. We observed a statistically insignificant improvement in the sexual satisfaction, prostatic volumes, post-void residual volumes, and PSA levels. Minimal self-limiting complications occurred with an overall rate of 38.9%. Only 16.66% of cases needed further surgery, while the rest had sufficient symptomatic relief post sclerotherapy.

Conclusion

Varicoceles sclerotherapy can be employed to resolve the testicular venous insufficiency and mitigate the severity of the prostatic-related urological symptoms in middle-aged and elderly men, so varicoceles can be considered a confounding variable in the development of the prostatic-related lower urinary tract symptoms.

Status and influencing factors of patients with kinesiophobia after insertion of peripherally inserted central catheter: A cross-sectional study

This study aimed to investigate the current status and influencing factors of kinesiophobia in patients after insertion of peripherally inserted central catheter (PICC). A total of 240 patients with PICC were included. Their postinsertion status and influencing factors were investigated using the general information questionnaire, Tampa Scale of Kinesiophobia (TSK), Medical Coping Modes Questionnaire, Numerical Rating Scale, and Self-rating Anxiety Scale. The mean TSK score was 36.49 ± 4.19 points, and 89 patients (37.08%) had kinesiophobia. Multiple linear regression analysis showed that factors such as education level, age, monthly income level, catheterization history, face, pain level, anxiety, and number of needle insertions influenced postoperative kinesiophobia in patients with PICC (P < .05). The total variation in the TSK score was 71.8%. The incidence of kinesiophobia was relatively high after PICC insertion. The medical staff needs to undertake targeted intervention measures to help minimize kinesiophobia after PICC insertion, allowing patients to perform scientifically correct functional exercises and attain physical recovery.

Application of ultrasound-guided radial artery cannulation in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Numerous studies have demonstrated the benefits and safety of ultrasound guidance in comparison with conventional palpation for radial artery cannulation in adult patients. However, the current evidence for paediatric patients is not fully understood.

OBJECTIVE

The objective of this study was to compare the efficiency and safety of ultrasound guidance with those of traditional palpation for radial artery cannulation in paediatric patients and provide convincing evidence for clinical practice.

METHODS

PubMed, Cochrane Library, ClinicalTrials.gov (Min et al-2019, NCT02795468, Anantasit et al-2017, NCT02668471), China National Knowledge Infrastructure, and Wanfang Data were systematically searched from their inception until December 31, 2019, to identify relevant randomised controlled trials. Data were extracted from the included studies independently by two investigators. The primary outcome of interest was the first-attempt success rate. Review Manager Version 5.3 and trial sequential analysis (beta = 0.9) were applied to analyse the collected data.

RESULTS

A total of eight randomised controlled trials involving 680 paediatric patients were included in this study. The pooled findings showed that ultrasound-guided radial artery cannulation, in comparison with traditional palpation, can significantly improve the first-attempt success rate (relative risk [RR] = 1.65, 95% confidence interval [CI] = 1.36-2.01, P < 0.00001). Trial sequential analysis indicated that this available evidence was conclusive. Moreover, ultrasound guidance was associated with an increased total success rate (RR = 1.38, 95% CI = 1.15-1.66, P = 0.0004), a decreased mean procedural time (standardised mean difference = -0.89, 95% CI = -1.52 to -0.25, P = 0.006), and incidence of haematoma (RR = 0.19, 95% CI = 0.10-0.35, P < 0.00001).

CONCLUSION

Ultrasound-guided radial arterial cannulation in paediatric patients is associated with improved first-attempt success rates, total success rates, and mean procedural time and decreased incidence of haematoma. The current evidence suggests that ultrasound guidance should be the standard of care for radial artery cannulation in clinical practice.

The Incidence, Risk Factors, and Patterns of Peripherally Inserted Central Catheter-Related Venous Thrombosis in Cancer Patients Followed Up by Ultrasound

Purpose

A peripherally inserted central catheter (PICC) is associated with venous thromboembolism (VTE) especially in patients suffering from cancer. We analyzed the incidence, risk factors, and patterns of PICC-related VTE in cancer patients.

Patients and Methods

Patients with cancer who underwent PICC placement were evaluated retrospectively. Routine, prospective ultrasound post-PICC placement was used for asymptomatic and symptomatic patients to identify VTE. Multivariable logistic regression models with odds ratios (ORs) were used to examine VTE risk factors.

Results

Of 2353 PICCs placed, 165 patients (7.01%) developed PICC-related VTE with a median thrombosis time of 12 days. After adjustment of multivariable analysis, patients with PICC-related VTE were more likely to have a ratio of PICC diameter:vein diameter >0.35 (adjusted OR, 1.689; 95% CI, 1.023–2.789) and high level of triglycerides (1.561; 1.096–2.223). The prevalence of A (adjusted OR, 1.680; 95% CI, 1.009–2.798), B (1.835; 1.137–2.961), and AB (3.275; 1.840–5.829) blood group was significantly higher than that of the O blood group in VTE patients. Venous recanalization was observed in 44.8% (74/165) patients after anticoagulation therapy, and more often in patients with combined deep VTE than in patients with isolated superficial VTE (OR, 17.942; 95% CI, 5.427–59.316). The recanalization time was 20±5 (range, 10–31) days.

Conclusion

The non-O blood group, larger ratio of PICC diameter:vein diameter, and high level of triglycerides were significantly associated with PICC-related VTE. Almost half of cases of PICC-related deep VTE could be reversed by anticoagulation treatment.

Subcutaneous tunneling technique to improve outcomes for patients undergoing chemotherapy with peripherally inserted central catheters: a randomized controlled trial

OBJECTIVE

To compare the value of the subcutaneous tunneling technique versus the normal technique in improving the outcomes of patients undergoing chemotherapy with peripherally inserted central catheters (PICCs).

METHODS

One hundred thirty patients were randomly divided into an experimental group (subcutaneous tunneling technique) and control group (normal technique) according to the PICC placement technique, and clinical data were compared between the groups.

RESULTS

In total, 129 PICCs were successfully inserted. Compared with the control group, the experimental group had a lower occurrence of complications after placement (especially catheter dislodgement: 3.1% vs. 15.4%, venous thrombosis: 3.1% vs. 15.4%, and wound oozing: 14.1% vs. 27.7%), lower occurrence of unscheduled PICC removal (3.1% vs. 13.8%), greater comfort during placement (14.16 ± 2.21 vs. 15.09 ± 2.49 on a scale ranging from 6 to 30 points, with higher scores indicating lower degrees of comfort), and lower costs of PICC maintenance (median (interquartile range) per-day maintenance cost: 13.90 (10.99-32.83) vs. 15.69 (10.51-57.46) Yuan). The occurrence of complications and amount of bleeding during placement were not significantly different between the two groups.

CONCLUSIONS

The subcutaneous tunneling technique can improve PICC placement by reducing complications and costs of maintenance with better patient comfort during placement.

Risk factors for catheter related thrombosis during outpatient parenteral antimicrobial therapy

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) delivery using peripherally inserted central catheters is associated with a risk of catheter related thrombosis (CRT). Individualised preventative interventions may reduce this occurrence, however patient selection is hampered by a lack of understanding of risk factors. We aimed to identify patient, infection or treatment related risk factors for CRT in the OPAT setting.

METHODS

Retrospective case control study (1:3 matching) within OPAT services at two tertiary hospitals within Australia.

RESULTS

Over a 2 year period, encompassing OPAT delivery to 1803 patients, there were 19 cases of CRT, giving a prevalence of 1.1% and incidence of 0.58/1000 catheter days. Amongst the cases of CRT, there were nine (47%) unplanned readmissions and two (11%) pulmonary emboli. Compared to controls, cases had a higher frequency of malposition of the catheter tip (4/19 (21%) vs 0/57 (0%), p = 0.003) and complicated catheter insertion (3/19 (16%) vs 1/57 (2%), p = 0.046).

CONCLUSIONS

Although CRTs during OPAT are infrequent, they often have clinically significant sequelae. Identification of modifiable vascular access related predictors of CRT should assist with patient risk stratification and guide risk reduction strategies.

Effect of Chahuang ointment on prevention of phlebitis from peripherally inserted central catheter: randomized clinical trial

OBJECTIVE

To assess the effect of Chahuang ointment, a Chinese herbal ointment, on the prevention of phlebitis in patients with peripherally inserted central catheters.

METHOD

This was a multicenter randomized controlled trial, with 171 eligible patients randomly assigned into one of three groups: the Chahuang ointment group, the Mucopolysaccharide Polysulfate cream group, and the control group. The degrees of vein injuries at 72 hours after peripherally inserted central catheter insertion were the primary outcome. Secondary outcomes were the vascular wall thickness, tissue edema and microthrombus evaluated by Color Doppler Flow Imaging, the vascular endothelial growth factor, and endothelin-1 (ET-1) expression in vivo.

RESULTS

Compared with the control group, the Chahuang ointment group showed significantly lower incidence of postoperative phlebitis, tissue edema, and microthrombus at 72 hours after peripherally inserted central catheter insertion (all P<0.01). The VEGF and ET-1 expression were significantly inhibited in the Chahuang ointment group after 3 days of treatment (both P<0.01). There were no statistical differences in the degree of vein injuries, microthrombus, or tissue edema between the Chahuang ointment and mucopolysaccharide polysulfate groups (all P>0.05).

CONCLUSION

Chahuang ointment was shown to provide effective prevention and protection against phlebitis after peripherally inserted central catheter insertion.

The Influence of Venous Characteristics on Peripherally Inserted Central Catheter-Related Symptomatic Venous Thrombosis in Cancer Patients

Background

With increasing use, peripherally inserted central catheters (PICCs) are associated with the risk of venous thrombosis. Few studies have focused on the relationships between venous thrombosis and venous characteristics. This study aimed to identify effects of venous characteristics on symptomatic PICC-related venous thrombosis in cancer patients and explore the relationship between venous characteristics and blood flow velocity.

Methods

The data of patients who underwent placement of PICC were retrospectively studied between January 2015 and September 2017. Symptomatic PICC-related venous thrombosis was confirmed by ultrasound. Univariable, multivariable logistic regression analyses were performed to identify the risk factors associated with PICC-related venous thrombosis. In October 2017, 169 patients with PICCs were enrolled prospectively, and the relationships between blood flow velocity and venous characteristics were recorded and analyzed.

Results

A total of 2933 cancer patients were enrolled in this study; of these patients, 68 experienced symptomatic venous thrombosis. In the bivariate analysis, body mass index (BMI), history of venous thrombosis, triglycerides, tumor category, vessel diameter, vessel depth and arm circumference were associated with thrombosis. The multivariable analyses showed that arm circumference, vascular diameter, triglyceride level and tumor category were independent risk factors for thrombosis. Blood flow velocity was positively correlated with vessel depth and arm circumference but not with vessel diameter.

Conclusion

Different venous characteristics can lead to different blood flow rates, which can affect the incidence of thrombosis. A vein depth of greater than 1.07cm or less than 0.57cm was associated with a higher incidence of PICC-related venous thrombosis, and the greater the arm circumference and vessel diameter, the greater the risk of venous thrombosis.

Association between ABO blood group and venous thrombosis related to the peripherally inserted central catheters in cancer patients

OBJECTIVE

To evaluate the potential relation between the ABO blood group and the risk of venous thrombosis in cancer patients with peripherally inserted central catheters (PICCs).

METHODS

The patients who underwent PICC catheterization in Beijing Cancer Hospital from January 2018 to October 2019 were retrospectively analyzed. The general information, disease diagnosis, catheterization situation, and complications were recorded for each patient. Further, the blood group status was identified using the hospital information systems. Logistic and Cox proportional hazard regression analyses were performed to identify the risk factors for symptomatic PICC-related thrombosis.

RESULTS

Among the 2315 patients, 131 had symptomatic thrombosis after PICC catheterization. The incidence of symptomatic thrombosis was lower in patients with blood type O when compared with that in patients with blood types other than O. The history of venous thrombosis, tumor category, arm circumference, and insertion attempts are risk factors associated with the PICC-related venous thromboembolism (VTE). After multivariable adjustment, insertion attempts and the non-O blood type were observed to remain associated with thrombosis.

CONCLUSION

The risk of PICC-related thrombosis in patients with non-O blood type is significantly higher than that in patients with blood type O.

Venous Thromboembolism After Peripherally Inserted Central Catheters Placement in Children With Acute Leukemia: A Single-center Retrospective Cohort Study

OBJECTIVE

To explore the incidence rate and characteristics of symptomatic venous thromboembolism (VTE) after peripherally inserted central catheters (PICC) placement in children with acute leukemia (AL).

METHODS

The authors performed a retrospective study aiming at children admitted to Pediatric Blood Diseases Center with a new diagnosis of AL and received a PICC insertion, collected the clinical materials of all venous thrombosis cases, and analyzed the incidence rate and characteristics in various types of AL.

RESULTS

From September 2007 to December 2018, a total of 2423 patients got PICCs at least once, of whom 29 patients experienced thrombosis events and the overall incidence rate of symptomatic VTE after PICC insertion was 1.2%. Deep venous thrombosis accounted for the majority with 75.9%. Seven cases of cerebral venous sinus thrombosis were documented and they all developed in patients with acute lymphoblastic leukemia (ALL). No pulmonary embolism was detected. Patients with acute myeloid leukemia (AML) had an identical risk of thrombosis to patients with acute lymphoblastic leukemia (ALL) (1.7% vs. 1.09%, P>0.05). All thrombi in patients with AML were located on the upper extremity, whereas in the ALL group about half of the thromboembolism developed in other locations. There were no statistical differences between patients in different clinical trials of the ALL group (0.7% vs. 1.6%, P>0.05).

CONCLUSIONS

The incidence rates of symptomatic VTE after PICC placement in children with AL in our center were relatively low and acceptable. For patients with AML, PICC placement plays the most important role in venous thrombosis. However, in patients with ALL, the potential risk factors were more complex.

A longitudinal observational retrospective study on risk factors and predictive model of PICC associated thrombosis in cancer patients

To analyze the incidence of PICC associated venous thrombosis. To predict the risk factors of thrombosis. To validate the best predictive model in predicting PICC associated thrombosis. Consecutive oncology cases in 341 who initially naive intended to be inserted central catheter for chemotherapy, were recruited to our dedicated intravenous lab. All patients used the same gauge catheter, Primary endpoint was thrombosis formation, the secondary endpoint was infusion termination without thrombosis. Two patients were excluded. 339 patients were divided into thrombosis group in 59 (17.4%) and non-thrombosis Group in 280 (82.6%), retrospectively. Tumor, Sex, Age, Weight, Height, BMI, BSA, PS, WBC, BPC, PT, D-dimer, APTT, FIB, Smoking history, Location, Catheter length, Ratio and Number as independent variables were analyzed by Fisher's scoring, then Logistic risk regression, ROC analysis and nomogram was introduced. Total incidence was 17.4%. Venous mural thrombosis in 2 (3.4%), "fibrin sleeves" in 55 (93.2%), mixed thrombus in 2 (3.4%), symptomatic thrombosis in 2 (3.4%), asymptomatic thrombosis in 57 (96.6%), respectively. Height (χ² = 4.48, P = 0.03), D-dimer (χ² = 37.81, P < 0.001), Location (χ² = 7.56, P = 0.006), Number (χ² = 43.64, P < 0.001), Ratio (χ² = 4.38, P = 0.04), and PS (χ² = 58.78, P < 0.001), were statistical differences between the two groups analyzed by Fisher's scoring. Logistic risk regression revealed that Height (β = -0.05, HR = 0.95, 95%CI: 0.911-0.997, P = 0.038), PS (β = 1.07, HR = 2.91, 95%CI: 1.98-4.27, P < 0.001), D-dimer (β0.11, HR = 1.12, 95%CI: 1.045-1.200, P < 0.001), Number (β = 0.87, HR = 2.38, 95% CI: 1.619-3.512, P < 0.001) was independently associated with PICC associated thrombosis. The best prediction model, D-dimer + Number as a novel co-variable was validated in diagnosing PICC associated thrombosis before PICC. Our research revealed that variables PS, Number, D-dimer and Height were risk factors for PICC associated thrombosis, which were slightly associated with PICC related thrombosis, in which, PS was the relatively strongest independent risk factor of PICC related thrombosis.

Surgical retrieval of PICC-related right atrial thrombus in a child with acute lymphoblastic leukemia: a case report

BACKGROUND

Peripherally inserted central catheters (PICCs) are widely used in cancer patients for administering chemotherapy drugs, antibiotics, and nutrients. PICC-related thrombi are not uncommon and may result in pulmonary embolism and the formation of thrombi in the right atrium. The latter are associated with an increased risk of subsequent morbidity or mortality because of their potential for embolization in the pulmonary vasculature.

CASE PRESENTATION

A 16-year-old male with acute lymphoblastic leukemia (ALL) was admitted to our hospital after an echocardiographic examination revealed a ring-like structure in the right atrium that was still present after 6 months' anticoagulation treatment with aspirin. The boy had had a PICC inserted 2 years previously for chemotherapy; the PICC was intact and successfully removed 18 months after insertion when chemotherapy is finished. Subsequent computer tomography and radiography differentiated right atrial ring-shaped mass with a diameter of approximately 15 mm. Cardiac surgery was performed to remove the mass which was found to be a calcified thrombus.

CONCLUSION

Although this is a rare occurrence, recognition of the possibility of a calcified thrombus may minimize the misdiagnosis of PICC-related thrombus and allow surgical retrieval if the thrombus is sufficiently large.

Effects of passive music therapy on anxiety and vital signs in lung cancer patients undergoing peripherally inserted central catheter placement procedure

Purpose:

To evaluate the effects of passive music therapy on anxiety and vital signs among lung cancer patients at their first peripherally inserted central catheter placement procedure in China.

Methods:

A randomized controlled clinical trial was conducted in the cancer center of a hospital in Chengdu from May to December 2017. A total of 304 lung cancer patients who met the inclusion and exclusion criteria were recruited and randomly assigned to experimental ( n = 152) and control ( n = 152) group, respectively. The control group only received standard care, while the experimental group received standard care and passive music therapy during peripherally inserted central catheter placement (30–45 min) and after catheterization, until discharged from the hospital (twice a day, 30 min once). Measures include anxiety and vital signs (blood pressure, heart rate, and respiratory rate).

Results:

Repetitive measurement and analysis of variance showed that the patients in experimental group had a statistically significant decrease in anxiety, diastolic blood pressure, and heart rate over time compared to the control group, but no significant difference was identified in systolic blood pressure and respiratory rate.

Conclusion:

Passive music therapy can efficiently relieve the anxiety of lung cancer patients during peripherally inserted central catheter placement. It also can lower the patient’s diastolic blood pressure and slow down the heart rate. So, music therapy benefits patients with peripherally inserted central catheter.

The right methodology for long-term vascular access research: Three burning questions

Over the last 20 years, there has been a great proliferation of studies of different aspects of the long-term vascular access field. Despite the availability of such studies, methodological pitfalls surrounding long-term vascular access research are rarely mentioned. Methodological issues inherent to retrospective analyses make them very poor tools for providing generalizable results, as they often become estimates of local experiences rather than reflections of up-to-date practices. Second, despite being an often-ignored element when designing studies on catheter-related complications, a proper follow-up time definition and its length are crucial to limiting the impact of attrition bias on research results. Finally, meta-analyses constitute a powerful tool in modern evidence-based era, but several pitfalls can affect overall results. When designing a systematic review and meta-analytic process, study selection should always reflect the relevance of clinical questions and the capability to contextualize results in the modern and evidence-based vascular access era.

Effect of tunneled and nontunneled peripherally inserted central catheter placement: A randomized controlled trial

PURPOSE

To compare the effect of tunneled and nontunneled peripherally inserted central catheter placement under B-mode ultrasound.

METHODS

A single center, randomized, controlled, nonblinded, prospective trial was conducted in Guangzhou, China, between July 2018 and May 2019. A total of 174 participants were randomized to the experimental group (tunneled peripherally inserted central catheter) or the control group (nontunneled peripherally inserted central catheter) and were followed until extubation. Basic characteristics, peripherally inserted central catheter characteristics, the incidence of complications, and the costs of peripherally inserted central catheter placement and maintenance were collected. Data were analyzed by intention-to-treat.

RESULTS

A total of 168 of the participants had successful peripherally inserted central catheter placements (85/87, 97.7% in the experimental group and 83/87, 95.4% in the control group, P = 0.682). Compared to the control group, the experimental group had a lower incidence of complications during the placement (18.4% vs 32.2%, P = 0.036), a lower incidence of wound oozing (27.6% vs 57.5%, P < 0.001), a lower incidence of medical adhesive-related skin injury (9.2% vs 25.3%, P = 0.005), a lower incidence of venous thrombosis (1.1% vs 9.2%, P = 0.034), a lower incidence of catheter dislodgement (1.1% vs 9.2%, P = 0.034), and lower costs of peripherally inserted central catheter maintenance at 1, 2, and 3 months (P < 0.05).

CONCLUSION

Tunneled peripherally inserted central catheter may be recommended for good effectiveness.

Influence of guide wire removal on tip location in peripherally inserted central catheters (PICCs): a retrospective cross-sectional study

OBJECTIVES

The aim of this study was to identify the prevalence of peripherally inserted central catheter (PICC) malposition and the influence of guide wire removal on tip location in PICCs and determine whether related factors, including age, sex, side of insertion and brand of catheter, influence the PICC tip location.

SETTING

Single-centre research institute in China recruiting patients from the hospital.

PARTICIPANTS

A total of 837 adult patients with inserted PICCs were recruited from October 2016 to May 2017.

INTERVENTIONS

This was a cross-sectional study aiming to identify the prevalence of PICC malposition and the influence of guide wire removal on tip location in PICCs. A linear regression model and a variance of factorial design analysis were performed. The PICC tip location was documented on a postinsertion chest X-ray. Multivariable analyses were performed based on the following related factors: age, sex, side of insertion and brand of catheter.

RESULTS

The tip location moved a mean of 17.4 mm among the 837 included patients. The prevalence of PICC malposition was 83.6% (700/837), while 16.4% (137/837) of PICCs remained in correct location. The mean movement caused by guide wire removal without an adjusted tail end was (-1.95±26.90) mm. The difference between tail end adjustment movement and actual tip position movement in each PICC was (33.0±17.1) mm in type C, which was significantly higher than the findings for type A (12.8±13.3) mm and type B (12.9±12.7) mm.

CONCLUSIONS

PICC malposition is a frequent event. Different catheter brands were associated with different ranges of movement in tip location after guide wire removal. The age and sex of the patients and the insertion side did not influence the extent of movement.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine

PREPROCEDURE

1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation.

TECHNIQUES

General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques.

POSTPROCEDURE

21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise.

TRAINING

23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.

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.

The diagnostic value of intracavitary electrocardiogram for verifying tip position of peripherally inserted central catheters in cancer patients: A retrospective multicenter study

Purpose:

To evaluate the feasibility and accuracy of intracavitary electrocardiogram for verifying tip position of peripherally inserted central catheters in cancer patients during follow-up period.

Methods:

From March 2015 to October 2015, 126 patients involved in eight hospitals who underwent peripherally inserted central catheter placement received intracavitary electrocardiogram and chest X-ray to verify position of the catheter tip during follow-up period. Their intracavitary electrocardiogram was compared with surface electrocardiogram to judge catheter tip landing zone in one of three different anatomical zones. The amplitude of intracavitary electrocardiogram P wave and the ratio of intracavitary electrocardiogram P wave/surface electrocardiogram P wave were measured and showed correlation with catheter tip position confirmed by chest X-ray. Based on chest X-ray principle, all the cases were assigned into three intracavitary electrocardiogram groups to explore the optimal cut-off values for intracavitary electrocardiogram P wave and intracavitary electrocardiogram P wave/surface electrocardiogram P wave by analyzing the receiver operating characteristic.

Results:

No technique-related complications or adverse events occurred in this study. The matching rate between intracavitary electrocardiogram and chest X-ray method was 93.7%. The optimal cut-off values for intracavitary electrocardiogram P wave were set from 3.15 to 3.75 mV, and intracavitary electrocardiogram P wave/surface electrocardiogram P wave from 1.65 to 3.25.

Conclusions:

It is demonstrated in this retrospective multicenter study that the intracavitary electrocardiogram method for verifying tip position of peripherally inserted central catheter during follow-up period is feasible and accurate in all adult patients with cancer.

Handgrip exercise reduces peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers: A randomized controlled trial

BACKGROUND

Peripherally-inserted central catheter-related venous thrombosis has serious complications including the loss of vascular access, recurrent venous thrombosis, and post-thrombotic syndrome. Current guidelines recommend non-pharmacological strategies to prevent peripherally-inserted central catheter-related venous thrombosis. There is little evidence for the effectiveness of handgrip exercise on the prevention of peripherally-inserted central catheter-related venous thrombosis.

OBJECTIVES

To examine the effectiveness of handgrip exercise using an elastic ball to prevent peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers.

DESIGN

A randomized controlled trial.

SETTINGS

One teaching hospital in Nanjing, China.

PARTICIPANTS

In total, 120 subjects with solid cancers were eligible; each had a new peripherally-inserted central catheter. They were recruited and randomly assigned into two exercise groups and one control group.

METHODS

Subjects from exercise groups 1 and 2 performed a 3-week, 25-repetition handgrip exercise, 3 and 6 times daily, respectively. The control group subjects performed a gentle limb exercise with no frequency and intensity requirements. Ultrasound was used to detect venous thrombosis development and examine axillary vein blood flow over the three points.

RESULTS

There were 32 cases of peripherally-inserted central catheter-related venous thrombosis detected. Two venous thrombosis cases in the control group were symptomatic, but all venous thrombosis cases in the exercise groups were asymptomatic. All venous thromboses were partial. There were significant differences in the incidence of venous thrombosis among the three groups (χ² = 12.813, p = 0.002; χ² = 9.340, p = 0.009; χ² = 11.480, p = 0.003; and χ² = 10.534, p = 0.005, respectively) at days 2, 3 and 21. The incidence of venous thrombosis in the two exercise groups was lower than that in the control group over the 3 time points (all, p < 0.05). The between-group effects and interaction effect in vein maximum velocity and time-mean flow velocity showed significant differences (F = 4.180, p = 0.025; F = 4.010, p = 0.045; and F = 2.928, p = 0.025) at days 2, 3, and 21, respectively. The axillary vein blood flow parameters in the control group were lower than those in the two exercise groups at day 21 (all, p < 0.05). However, no significant differences occurred in the incidence of venous thrombosis and axillary vein blood flow parameters between the two exercise groups.

CONCLUSION

Handgrip exercise using an elastic ball daily for three weeks could decrease the incidence of peripherally-inserted central catheter-related venous thrombosis. The method is simple, with no negative consequence reported. Further studies are required to confirm this conclusion and to explore the optimal frequency of handgrip exercise.

A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.

Peripherally Inserted Central Catheters in Pediatric Oncology Patients: A 15-Year Population-based Review From Maritimes, Canada

The present population-based study evaluates the management and complications of peripherally inserted central catheters (PICC) in all pediatric oncology patients diagnosed in Maritimes, Canada from 2000 to 2014. A total of 107 PICCs were placed in 87 (10.1%) pediatric oncology patients. A high percentage (33% and 44%, respectively) of the first and second PICC lines was associated with complications. Thrombosis, occlusion, and infection were the most frequent complications. Age above 10 years and left body side of insertion were significantly associated with PICC complications. Given the frequent use of PICCs and the high incidence (>33%) of complications, there is a need to mitigate PICC line complications.

Safety of peripherally inserted central catheters during pregnancy: a retrospective study

PURPOSE

We investigated the incidence of complications associated with peripherally inserted central line catheters, inserted using a standardized technique, during pregnancy and the postpartum period.

MATERIALS AND METHODS

A retrospective case series was performed that included all pregnant and postpartum women who received peripherally inserted central catheters (PICCs) at a single institution between 2006 and 2014. Patient demographics and data on infectious, mechanical and thrombotic complications were collected. Some patients required more than one line insertion during the same pregnancy. In these instances, only the first line placement for each subject was included in the analysis of complications.

RESULTS

One hundred and forty-six catheters were inserted in 112 pregnant and postpartum patients. The total incidence of complications was 17% (19/112). Specific complications included infection (n = 4, 3.6%), mechanical (n = 5, 4.4%), deep venous thrombosis (n = 2, 1.8%) and other (n = 8, 7.1%). Demographics of the complication and no complication groups were similar.

CONCLUSIONS

In contrast with previous studies, we report a complication rate associated with peripheral line use in pregnant and postpartum women that appears similar to that in non-pregnant populations.

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.

Superior success rate of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement in patients with cancer: A randomized open-label controlled multicenter study

Background

Intracavitary electrocardiogram (IC ECG) guidance emerges as a new technique for peripherally inserted central catheters (PICCs) placement and demonstrates many potential advantages in recent observational studies.

Aims

To determine whether IC ECG-guided PICCs provide more accurate positioning of catheter tips compared to conventional anatomical landmarks in patients with cancer undergoing chemotherapy.

Methods

In this multicenter, open-label, randomized controlled study (ClinicalTrials.gov number, NCT02409589), a total of 1,007 adult patients were assigned to receive either IC ECG guidance (n = 500) or anatomical landmark guidance (n = 507) for PICC positioning. The confirmative catheter tip positioning x-ray data were centrally interpreted by independent radiologists. All reported analyses in the overall population were performed on an intention-to-treat basis. Analyses of pre-specified subgroups and a selected large subpopulation were conducted to explore consistency and accuracy.

Results

In the IC ECG-guided group, the first-attempt success rate was 89.2% (95% confidence interval [CI], 86.5% to 91.9%), which was significantly higher than 77.4% (95% CI, 73.7% to 81.0%) in the anatomical landmark group (P < 0.0001). This trend of superiority of IC ECG guidance was consistently noted in almost all prespecified patient subgroups and two selected large subpopulations, even when using optimal target rates for measurement. In contrast, the superiority nearly disappeared when PICCs were used via the left instead of right arms (interaction P-value = 0.021). No catheter-related adverse events were reported during the PICC intra-procedures in either group.

Conclusions

Our findings indicated that the IC ECG-guided method had a more favorable positioning accuracy versus traditional anatomical landmarks for PICC placement in adult patients with cancer undergoing chemotherapy. Furthermore, there were no significant safety concerns reported for catheterization using the two techniques.

Comparison of three types of central venous catheters in patients with malignant tumor receiving chemotherapy

BACKGROUND

Central venous catheters (CVCs) have been an effective access for chemotherapy instead of peripherally intravenous catheters. There were limited studies on the choices and effects of different types of CVCs for chemotherapy. The aim of this study was to compare the complications, cost, and patients' quality of life and satisfaction of three commonly used CVCs for chemotherapy, such as implanted venous port, peripherally inserted central catheters (PICCs), and external non-tunneled central venous catheters (NTCs).

METHODS

A double-center prospective cohort study was carried out from March 2014 to December 2016. Catheterization situation, complications, catheter maintenance, cost, and patients' quality of life and satisfaction were recorded, investigated, and analyzed. Forty-five ports, 60 PICCs and 40 NTCs were included. All the CVCs were followed up to catheter removal.

RESULTS

There was no statistical difference in catheterization success rates between port and PICC. NTC had less success rate by one puncture compared with port. Ports had fewer complications compared with PICCs and NTCs. The complication rates of ports, PICCs and NTCs were 2.2%, 40%, and 27.5%, respectively. If the chemotherapy process was <12 months, NTCs cost least, and the cost of port was much higher than PICC and NTC. When the duration time was longer than 12 months, the cost of port had no difference with the cost of PICC. Quality of life and patients' satisfaction of port group were significantly higher than the other two groups.

CONCLUSION

Although port catheterization costs more and needs professional medical staff and strict operational conditions, ports have fewer complications and higher quality of life and patients' satisfaction than PICCs and NTCs. Therefore, not following consideration of the economic factor, we recommend port as a safe and an effective chemotherapy access for cancer patients, especially for whom needing long chemotherapy process.

Application of peripherally inserted central catheter in acute myeloid leukaemia patients undergoing induction chemotherapy

Increasingly, peripherally inserted central catheters (PICC) are applied in patients with haematological malignancies. The feasibility and safety of PICC for induction chemotherapy in acute myeloid leukaemia (AML) remain unclear. Medical records of 89 newly diagnosed adult de novo AML patients, who achieved complete remission, were retrospectively reviewed (PICC group, n = 43; intravenous [IV] line group, n = 46). Patients' clinical characteristics and the number of blind punctures for blood sampling were compared between these two groups, and risk factors associated with bacteraemia were identified by univariate analysis. Patients in the PICC group experienced significantly fewer blind punctures than those in the IV line group (3.3 ± 3.6 vs. 14.4 ± 6.0; p = .000); 20.9% of PICC patients had bacteraemia, compared with 23.9% in the IV line group (p = .803). Most patients (76.7%) removed their PICC because treatment was completed. PICC increased the quality of life in AML patients undergoing chemotherapy induction by reducing the number of blind blood punctures required. Bacteraemia in PICC patients was comparable to that in IV line patients. PICC is, therefore, a feasible and safe central venous device for use in AML patients.

Safety, efficacy, and patient-perceived satisfaction of peripherally inserted central catheters in terminally ill cancer patients: a prospective multicenter observational study

PURPOSE

The purpose of this study was to investigate the safety, efficacy, and subjective satisfaction of peripherally inserted central catheters (PICCs) in terminally ill cancer patients.

METHODS

All PICCs were inserted by an interventional radiologist with radiological guidance. We monitored the occurrence of PICC-related complication and evaluated the patient-perceived satisfaction for PICC using semi-structured questionnaire.

RESULTS

A total of 36 terminally ill cancer patients underwent PICC. Three patients had 2 PICC insertions; hence, finally 39 episodes during 829 PICC days were analyzed. All procedures were completed without any procedure-related complication. The median catheter life span was 19.0 days (95 % CI, 14.1-23.9). Thirty-four cases maintained the PICC until the intended time, while the other 5 cases (12.8 %; 6.1/1000 PICC days) were premature PICC removals. Totally 10 complications (25.6 %; 12.3/1000 PICC days) were reported including premature removals (n = 5), trivial bleedings (n = 3), and thrombophlebitis (n = 2). Patients reported that the procedure was not distressing (42 %), a little distressing (36 %), or distressing (21 %). Of 30 patients who had preserved cognitive function at fifth day, most patients (n = 25, 83 %) reported more comfort although the other 5 patients reported no change (n = 3) or less comfort (n = 2).

CONCLUSIONS

PICCs were safely inserted and showed favorable maintenance rate with acceptable complications. Additionally, most of the patients felt that parenteral access became much comfortable after PICC insertion. When considering the characteristics of terminally ill cancer patients, poor general condition and a limited period of survival, PICC could be a safe and effective method for intravenous access.

Complications of Peripherally Inserted Central Venous Catheters: A Retrospective Cohort Study

BACKGROUND AND AIM

The use of venous catheters is a widespread practice, especially in oncological and oncohematological units. The objective of this study was to evaluate the complications associated with peripherally inserted central catheters (PICCs) in a cohort of patients.

MATERIALS AND METHODS

In this retrospective cohort study, we included all patient carrying PICCs (n = 603) inserted at our institute between October 2010 and December 2013. The main variables collected were medical diagnosis, catheter care, location, duration of catheterization, reasons for catheter removal, complications, and nursing care. Complications were classified as infection, thrombosis, phlebitis, migration, edema, and/or ecchymosis.

RESULTS

All patients were treated according to the same "nursing care" protocol. The incidence rate of complications was two cases per 1000 days of catheter duration. The most relevant complications were infection and thrombosis, both with an incidence of 0.17 cases per 1000 days of the total catheterization period. The total average duration of catheterization was 170 days [SD 6.06]. Additionally to "end of treatment" (48.42%) and "exitus", (22.53%) the most frequent cause of removal was migration (displacement towards the exterior) of the catheter (5.80%).

CONCLUSIONS

PICCs are safe devices that allow the administration of long-term treatment and preserve the integrity of the venous system of the patient. Proper care of the catheter is very important to improve the quality life of patients with oncologic and hematologic conditions. Therefore, correct training of professionals and patients as well as following the latest scientific recommendations are particularly relevant.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) initiative: A summary and review of peripherally inserted central catheter and venous catheter appropriate use

Peripherally inserted central catheters (PICCs) are being selected for venous access more frequently today than ever before. Often the choice of a PICC, when compared with other vascular access devices (VADs), is attractive because of perceived safety, availability, and ease of insertion. However, complications associated with PICCs exist, and there is a paucity of evidence to guide clinician choice for PICC selection and valid use. An international panel with expertise in the arena of venous access and populations associated with these devices was convened to clarify approaches for the optimal use of PICCs and VADs. Here we present for the busy hospital-based practitioner the methodology, key outcomes, and recommendations of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) panelists for the appropriate use of VADs.

Totally implantable venous access port systems and associated complications: A single-institution retrospective analysis of 2,996 breast cancer patients

Totally implantable venous access port systems (TIVAPS) are widely used in breast cancer patients. However, complications are frequent and may necessitate device replacement or removal, resulting in additional patient stress and treatment delays. The aim of this study was to investigate possible risk factors for complications. A total of 2,996 consecutive female breast cancer patients, with a median age of 50.2 years (range, 21.2-85.5 years) were enrolled in this observational, single-centre study between December, 2008 and April, 2014. TIVAPS implantation was principally performed using local anaesthesia and the blind puncture or Seldinger technique through internal jugular or subclavian vein access. A retrospective chart review was conducted to obtain information associated with TIVAPS and patient data. Insertion performed by blind puncture and Seldinger technique had a success ratio of 96.34 and 99.80%, respectively (χ²=29.905, P<0.001). However, the success ratio of the puncture technique group was 99.76% when the TIVAPS was implanted in the right internal jugular vein. The most common complications were late complications, with an overall incidence rate of 5.41% (162/2,996) during the entire device duration. The most common late complications included fibrin formation (1.84%, 55/2,996), port-related bacteraemia (1.44%, 43/2,996) and deep vein thrombosis (0.63%, 19/2,996). No patient died during the study. Our results demonstrated that insertion of TIVAPS by blind puncture or the Seldinger technique through internal jugular or subclavian vein access is convenient, and insertion by the Seldinger technique through the right internal jugular vein is the preferred method. Therefore, TIVAPS is safe for continuous infusional chemotherapy regimens for breast cancer patients.

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.

Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors

BACKGROUND

Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome.

METHODS

This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated.

RESULTS

Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01-3.76]) and PICC gauge (HR 2.21 [95%CI 1.04-4.70] and HR 3.56 [95%CI 1.31-9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis.

CONCLUSIONS

Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.