Long peripheral catheters for deep arm vein venous access: A systematic review of complications

Long peripheral catheters for intravenous infusions of iloprost or alprostadil therapy in rheumatologic outpatients

BACKGROUND

Long peripheral catheters (LPCs) role in Difficult IntraVenous Access (DIVA) patients admitted to the emergency department has already been studied, resulting in a rapid, safe, and cost-effective procedure. Although their use in outpatient settings is established, there is a lack of studies assessing their benefits. In particular, rheumatologic outpatients affected by scleroderma, especially those affected by digital ulcers, are often treated with intravenous infusions of prostaglandin I2 (PGI2) analog (IV-PGI2A).

OBJECTIVE AND METHODS

From 1 October 2021 to 31 March 2024, we conducted a prospective study enrolling DIVA outpatients affected by systemic sclerosis or undifferentiated connective tissue disease who needed IV-PGI2A therapy at L. Sacco Hospital in Milan (Italy). Each treatment cycle consisted of four consecutive days of infusion of iloprost or alprostadil. The primary aim was to assess the efficacy and potential complications associated with LPCs for IV-PGI2A.

RESULTS

Twenty-six patients were enrolled 23 were females (88.5%), and the median age was 72 years (IQR 56-78.7). In total, 97 LPCs were inserted, with a mean number of insertions per patient/year of 2.3. An increase in LPCs insertion during the 30 months of the enrollment period was observed. Eighteen patients required more than one LPC placement, and in 61% of them, the second venipuncture was executed at a different site. No procedural complications were registered (accidental puncture of the brachial artery, accidental median nerve puncture, bleeding) nor late complications (Catheter-Related Thrombosis, Catheter-Related Bloodstream Infections, Accidental Removal).

CONCLUSIONS

Our experience shows that LPCs could be valuable and safe for rheumatologic outpatients. The increased number of insertions and new and total patients enrolled each year defines the satisfaction of patients and health care professionals.

Complications associated to midline- and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection

INTRODUCTION

Long peripheral catheters (LPCs) and midline catheters (MCs) are indiscriminately labelled with different names, leading to misclassifications both in primary and secondary studies. The available studies used different methods to report the incidence of catheter-related complications, affecting the possibility of properly comparing the catheter outcomes. The aim of this review was to explore the complications related to LPCs and MCs after reclassifying according to their length.

METHODS

Systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, conducted on PubMed, Scopus and CINAHL databases. The study protocol was registered in the International Prospective Register of Systematic Reviews. Data regarding LPCs and MCs were compared. Catheter outcomes were classified into major and minor complications, recomputed and reported as cases/1000 catheter-days.

RESULTS

Fourteen studies were included. Over-half of the devices were correctly labelled by the authors, misclassifications affected particularly LPCs improperly labelled MCs. The cumulative incidence of catheter-related bloodstream infections was 0.3 and 0.4/1000 catheter-days, that of symptomatic catheter-related thrombosis was 0.9 and 1.8/1000 catheter-days for MCs and LPCs, respectively. Minor complications and catheter failure were higher for LPCs.

CONCLUSIONS

A misclassification exists in the labelling of MCs and LPCs. A widespread heterogeneity of diagnostic criteria adopted to classify the catheters' outcomes was found, exposing the risk of misestimating the incidence of complications and undermining the possibility of effectively comparing results of the published research. We proposed a list of definitions and relevant variables as a first step toward the development of standardized criteria to be adopted for research purposes.

Increased risk of complications in lower versus upper limb peripheral intravenous cannulation in children with severe neurological impairment

BACKGROUND

Obtaining peripheral intravenous catheter (PIVC) access in children with severe neurological impairment (SNI) is often challenging and commonly associated with complications, including dislodgement, phlebitis and extravasation. In severe cases, extravasation injury may lead to tissue necrosis, ulceration and long-term morbidity. The aim of this study was to determine the relative incidence of PIVC complications secondary to lower limb cannulation, compared to upper limb, in children with SNI.

METHODS

A single centre, retrospective, observational review was conducted. Patients with SNI, admitted at a tertiary paediatric centre over 6 months between July and December 2022, were included.

RESULTS

One-hundred fifty-five PIVC procedures were conducted in 110 children over the study period. Complications were more common in lower limb PIVCs (12/16, 75%) compared to upper limb (58/139, 42%), p = 0.01.

CONCLUSION

Upper limb cannulation is preferred in children with SNI.

Zwitterionic polymers-armored amyloid-like protein surface combats thrombosis and biofouling

Proteins, cells and bacteria adhering to the surface of medical devices can lead to thrombosis and infection, resulting in significant clinical mortality. Here, we report a zwitterionic polymers-armored amyloid-like protein surface engineering strategy we called as "armored-tank" strategy for dual functionalization of medical devices. The "armored-tank" strategy is realized by decoration of partially conformational transformed LZM (PCTL) assembly through oxidant-mediated process, followed by armoring with super-hydrophilic poly-2-methacryloyloxyethyl phosphorylcholine (pMPC). The outer armor of the "armored-tank" shows potent and durable zone defense against fibrinogen, platelet and bacteria adhesion, leading to long-term antithrombogenic properties over 14 days in vivo without anticoagulation. Additionally, the "fired" PCTL from "armored-tank" actively and effectively kills both Gram-positive and Gram-negative bacterial over 30 days as a supplement to the lacking bactericidal functions of passive outer armor. Overall, this "armored-tank" surface engineering strategy serves as a promising solution for preventing biofouling and thrombotic occlusion of medical devices.

Impact of terminal tip location of midline catheters on catheter-related complications and indwelling duration in elderly patients

AIM

To investigate the relationship between the position of the midline catheter tip and the frequency and type of complications associated with its placement.

DESIGN

A cohort study was performed on patients between May 2018 and December 2021 who underwent midline catheter placement at our institution. Patients were divided into two groups, superficial implementation and deep implementation, based on the midline catheter tip location relative to the clavicle.

METHODS

Clinical data and outcome parameters, including the numbers and types of midline catheter-related complications, day of occurrence and catheter indwell duration, were recorded.

RESULTS

Catheter-related complications occurred in 14 individuals. Compared with the superficial implementation group, the incidence of complications in the deep catheterization group was significantly reduced, with a delayed first occurrence time, and a prolonged catheter indwelling time. The results suggested that locating the midline catheter tip in the distal segment of the axillary vein may reduce catheter-related complication incidence and prolong the indwelling duration.

Development and Implementation of an Ultrasound-Guided Peripheral Intravenous Catheter Education Program for Critical Care Nurses

BACKGROUND

Ultrasound-guided (US-guided) peripheral intravenous (PIV) insertion is a skill used by specially trained nurses for patients with difficult vascular access. It can result in potential complications such as occlusive thrombus, phlebitis, infiltration, and pain. Complications can be prevented or minimized with clinical training to achieve competency. Current research shows that the most effective approach to US-guided PIV training consists of a comprehensive structured educational program that includes didactic, hands-on training and skills application.

OBJECTIVES

This study aimed to develop and implement a US-guided PIV education program for critical care nurses.

METHODS

Structured education was developed using a step-wise method. Critical care nurse practitioners in the intensive care unit (ICU) developed training materials including hands-on training, ultrasound reference material, and supervised skills application. Afterward, US-guided PIV-trained critical care nurses were enabled to train other nurses in the ICU.

RESULTS

The total number of US-guided PIV-trained registered nurses in the ICU increased from 5.8% to 26% of staff, but represents only 20% of those trained at current staffing levels. The percentage of US-guided PIV-trained nightshift/weekend staff increased from 3.9% to 24%, but represents 14% at current staffing levels. One hundred five US-guided PIVs showed a 97% success rate of US-guided PIV placement during an 11-month timeframe, similar to success rates published in the literature that ranged from 86% to 100%. There was 1.9% complication rate for occlusive thrombus, which is below published rates ranging up to 10%.

DISCUSSION

Critical care nurse practitioners in the ICU collaborated with vascular nursing and hospital clinical education to successfully develop and implement a US-guided PIV training program to meet patient needs within a growing community facility. The results of the training program yielded similar success and complication rates as those reported in the literature. Ongoing training is essential for program sustainability.

CONCLUSIONS

Critical care nurse practitioners training registered nurses in US-guided PIV placement is an effective approach to training. Critical care nurses trained in US-guided PIV insertion can safely and effectively train other critical care nurses in US-guided PIV insertion.

Mussel-Inspired and Bioclickable Peptide Engineered Surface to Combat Thrombosis and Infection

Thrombosis and infections are the two major complications associated with extracorporeal circuits and indwelling medical devices, leading to significant mortality in clinic. To address this issue, here, we report a biomimetic surface engineering strategy by the integration of mussel-inspired adhesive peptide, with bio-orthogonal click chemistry, to tailor the surface functionalities of tubing and catheters. Inspired by mussel adhesive foot protein, a bioclickable peptide mimic (DOPA)4-azide-based structure is designed and grafted on an aminated tubing robustly based on catechol-amine chemistry. Then, the dibenzylcyclooctyne (DBCO) modified nitric oxide generating species of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) chelated copper ions and the DBCO-modified antimicrobial peptide (DBCO-AMP) are clicked onto the grafted surfaces via bio-orthogonal reaction. The combination of the robustly grafted AMP and Cu-DOTA endows the modified tubing with durable antimicrobial properties and ability in long-term catalytically generating NO from endogenous s-nitrosothiols to resist adhesion/activation of platelets, thus preventing the formation of thrombosis. Overall, this biomimetic surface engineering technology provides a promising solution for multicomponent surface functionalization and the surface bioengineering of biomedical devices with enhanced clinical performance.

Nitric oxide-generating compound and bio-clickable peptide mimic for synergistically tailoring surface anti-thrombogenic and anti-microbial dual-functions

Application of extracorporeal circuits and indwelling medical devices has saved many lives. However, it is accompanied with two major complications: thrombosis and infection. To address this issue, we apply therapeutic nitric oxide gas (NO) and antibacterial peptide for synergistically tailoring such devices for surface anti-thrombogenic and antifouling dual functions. Such functional surface is realized by stepwise conjugation of NO-generating compound of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) chelated copper ions (Cu-DOTA) and dibenzylcyclooctyne- (DBCO-) modified antimicrobial peptide based on carbodiimide and click chemistry respectively. The integration of peptide and Cu-DOTA grants the modified surface the ability to not only efficiently inhibit bacterial growth, but also catalytically generate NO from endogenous s-nitrosothiols (RSNO) to reduce adhesion and activation of platelets, preventing the formation of thrombus. We envision that the stepwise synergistic modification strategy by using anticoagulant NO and antibacterial peptide would facilitate the surface multifunctional engineering of extracorporeal circuits and indwelling medical devices, with reduced clinical complications associated with thrombosis and infection.

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We report a bionic surface strategy for blood-contacting devices by integrating anti-thrombogenic and anti-microbial dual functions. Here, we engineer an endothelium-mimicking surface by combination of the nitric oxide (NO)-generating property and anti-microbial functions of a healthy endothelium, in which the generated gas signal molecule NO and the anti-microbial peptide (AMP) jointly provide synergistic effects against thrombogenicity and biofouling.

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An endothelium-bionic surface strategy is proposed for tailoring surface multi-functionalities.

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Carbodiimide and click chemistries were used for realizing synergistic tethering of NO-generating species and bio-clickable antimicrobial peptide.

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The integration of NO and antimicrobial peptide imparts the tubing surface with anti-thrombogenic and anti-fouling dual functions. The integration of NO releasing and AMP tethering endows the tubing surface with significant anti-thrombogenic and anti-fouling properties. We envision that this bio-inspired surface engineering strategy will provide a promising solution to address the clinical issues.

The Development of a Long Peripheral Catheter Program at a Large Pediatric Academic Center: A Pilot Study

OBJECTIVES

The purpose of this study was to evaluate the feasibility of a new long peripheral catheter (LPC) program at a large academic center in an effort to reduce the use of peripherally inserted central catheters (PICCs) and their related complications.

METHODS

The pilot participants were hospitalized children, age >2 years, with a need for noncentral intravenous access for 2 to 29 days, or laboratory blood draw >5 times per day. Patients expected to discharge with intravenous access were excluded. Included in the pilot program development were a literature review, 1-year baseline data analysis, and program design and implementation. A multidisciplinary committee developed and implemented the program from December 2018 to September 2019. LPCs were placed from August to September 2019.

RESULTS

Regarding the baseline data, between July 2018 and June 2019, 584 PICCs were placed in 461 patients. Of these, 139 PICCs (24%) did not meet requirements necessitating central access and, potentially, could have been avoided if an LPC alternative were available at the time. For the LPC pilot program, 20 LPCs were placed in 19 patients. The median age was 11 (interquartile range of 7-15). The insertion success rate was 83%. There were no serious complications, such as venous thrombosis or catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% (n = 2), and the rate of dislodgement was 25% (n = 5). The catheter failure rate was 74 per 1000 catheter-days. The mean line duration was 6 days.

CONCLUSIONS

There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Long Peripheral Catheters: A Retrospective Review of Major Complications

The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, we found LPCs were often placed for the indications of difficult access and long-term antibiotics. Rates of deep vein thrombosis (1.7%) and catheter-related infection (0.6%) were low. LPCs may represent a novel and safe option for short-term venous access.