Complications associated with peripheral or central routes for central venous cannulation

Peripherally inserted central catheters versus implanted port catheters in patients with breast cancer: a post hoc analysis of the PICCPORT randomised controlled trial

Background

Breast cancer is the most prevalent malignancy affecting women. However, the optimal strategy for patients requiring long-term central venous catheters in breast cancer treatment remains uncertain. Previous investigations involving a mixed cancer population have shown a higher frequency of adverse events among patients receiving peripherally implanted central catheters (PICCs) compared with totally implanted central catheters (PORTs). Our study aimed to compare catheter-related adverse events in breast cancer patients.

Methods

We conducted a post hoc analysis of a previously published multicentre RCT known as PICCPORT. Data pertaining to baseline characteristics, insertion specifics, complication rates, and patient satisfaction were collected for breast cancer patients who required long-term central venous catheters for cancer treatment. The primary endpoint was a composite variable encompassing thrombotic, occlusive, infectious, or mechanical complications, while patient satisfaction served as a secondary endpoint.

Results

Our analysis included 80 patients receiving PORT and 78 patients receiving PICC. There was no statistically significant difference in the incidence of complications between the PICC and PORT groups. Interestingly, PICC insertion was less painful than PORT insertion, although both groups reported low levels of pain.

Conclusions

While acknowledging the limitations of an underpowered post hoc subgroup analysis, our findings suggest that the well-established superiority of PORTs in terms of adverse events among cancer patients might not be as substantial for breast cancer patients in particular. Ultimately, the optimal strategy for selecting long-term access devices in breast cancer patients remains to be determined.

Clinical trial registration

NCT01971021.

[Evaluation of city-hospital management of a patient with a Picc-Line central line: patient tracer method]

We carried out an exploratory study to evaluate the interfaces of a complex care pathway. To do this, we used the "patient tracer" methodology of the French National Authority for Health. The results show that patients are satisfied and that the care pathway is being structured. However, the quality of transmissions and traceability could be improved. There are a number of areas for improvement in order to secure care on a regional scale.

Incidence and risk factors for central venous access device failure in hospitalized adults: A multivariable analysis of 1892 catheters

BACKGROUND

Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion.

OBJECTIVE

To quantify CVAD failure and complications; and identify risk factors.

DESIGNS, SETTINGS, AND PARTICIPANTS

Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations.

RESULTS

In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24-5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68-6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31-6.68), and diabetes (HR 3.25, 95%CI 1.40-7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08-0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14-0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48-33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08-6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk.

Complications and Practice Variation in the Use of Peripherally Inserted Central Venous Catheters in People With Cystic Fibrosis: The Prospective Study of Peripherally Inserted Venous Catheters in People With Cystic Fibrosis Study

BACKGROUND

Peripherally inserted central catheters (PICCs) are used commonly to administer antibiotics to people with cystic fibrosis (CF), but their use can be complicated by venous thrombosis and catheter occlusion.

RESEARCH QUESTION

Which participant-, catheter-, and catheter management-level attributes are associated with increased risk of complications of PICCs among people with CF?

STUDY DESIGN AND METHODS

This was a prospective observational study of adults and children with CF who received PICCs at 10 CF care centers in the United States. The primary end point was defined as occlusion of the catheter resulting in unplanned removal, symptomatic venous thrombosis in the extremity containing the catheter, or both. Three categories of composite secondary outcomes were identified: difficult line placement, local soft tissue or skin reactions, and catheter malfunction. Data specific to the participant, catheter placement, and catheter management were collected in a centralized database. Risk factors for primary and secondary outcomes were analyzed by multivariate logistic regression.

RESULTS

Between June 2018 and July 2021, 157 adults and 103 children older than 6 years with CF had 375 PICCs placed. Patients underwent 4,828 catheter-days of observation. Of the 375 PICCs, 334 (89%) were ≤ 4.5 F, 342 (91%) were single lumen, and 366 (98%) were placed using ultrasound guidance. The primary outcome occurred in 15 PICCs for an event rate of 3.11 per 1,000 catheter-days. No cases of catheter-related bloodstream infection occurred. Other secondary outcomes developed in 147 of 375 catheters (39%). Despite evidence of practice variation, no risk factors for the primary outcome and few risk factors for secondary outcomes were identified.

INTERPRETATION

This study affirmed the safety of contemporary approaches to inserting and using PICCs in people with CF. Given the low rate of complications in this study, observations may reflect a widespread shift to selecting smaller-diameter PICCs and using ultrasound to guide their placement.

Peripherally inserted central catheters versus implantable port catheters for cancer patients: a meta-analysis

Background

The implanted vascular access ports (PORTs) were compared with peripherally inserted central catheters (PICCs) as the administration of chemotherapy regarding different clinical effects and adverse effects. Which is better is debatable. Hence, the current study was conducted to assess the safety and efficacy of these two optimal vascular access strategies.

Methods

The following electronic databases were searched: PubMed, Embase, and the Cochrane Library updated in May 2023. Studies on the differences in complication rates in patients with cancer using either PICC or PORT for chemotherapy were included. Meta-analysis Revman 5.3 software was used for statistical analysis.

Results

A total of 22 articles were retrieved. The results suggested that PORT has a superior safety profile, with lower incidences of overall adverse effects (OR=2.72, 95% CI=1.56-4.72 P=0.0004), catheter-related thrombosis (OR=2.84, 95% CI=1.97-4.11, P<0.00001), and allergic reactions (OR=6.26, 95% CI=1.86-21.09, P=0.003) than typically expected with PICC. Moreover, PICC was non-inferior to the PORT group with respect to DVT (OR=2.00, 95% CI=0.86-4.65, P=0.11) and infection (OR=1.55, 95% CI=0.75-3.22, P=0.24).

Conclusion

PORT achieved safety benefits compared with chemotherapy through PICC. Therefore, PORT is regarded as safe and effective vascular access for the administration of chemotherapy. When considering economic factors and some key elements, more high-quality research would help verify these clinical benefits.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identififier CRD42023421690.

Self-injecting non-prescribed substances into vascular access devices: a case study of one health system's ongoing journey from clinical concern to practice and policy response

BACKGROUND

Overdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance.

CASE PRESENTATION

We report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient's perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation.

CONCLUSION

SIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.

Assessment of the Hawthorne effect during central venous catheter manipulation

OBJECTIVES

To describe the compliance to the practices of hand hygiene and hub disinfection before manipulation of the central venous catheter in two moments: before and after educational intervention. Adherence to hand hygiene was assessed with two methods: direct observation and video camera.

METHODS

Before and after study conducted with the nursing team in an adult intensive care unit, in São Paulo, Brazil, including 180 observations using video cameras and direct observation. Hand hygiene compliance before catheter manipulation and compliance with the correct technique and the hub disinfection for five seconds were observed.

RESULTS

When video cameras recording was observed, hand hygiene compliance increased from 46% to 66% and the use of the proper technique increased from 23% to 46% (p < 0.05). Regarding hub disinfection compliance, no difference was observed between the periods. Hand hygiene compliance in direct observation increased from 83% to 87% and in indirect observation, from 46% to 66% after the intervention.

CONCLUSION

After the educational intervention, hand hygiene compliance before CVC manipulation and the use of the correct technique improved. When observed indirectly, the adherence to these practices was lower, reinforcing the Hawthorne effect.

Preoperative prediction of the need for arterial and central venous catheterization using machine learning techniques

Some surgical patients require an arterial or central venous catheterization intraoperatively. This decision relied solely on the experience of individual anesthesiologists; however, these decisions are not easy for clinicians who are in an emergency or inexperienced. Therefore, applying recent artificial intelligence techniques to automatically extractable data from electronic medical record (EMR) could create a very clinically useful model in this situation. This study aimed to develop a model that is easy to apply in real clinical settings by implementing a prediction model for the preoperative decision to insert an arterial and central venous catheter and that can be automatically linked to the EMR. We collected and retrospectively analyzed data from 66,522 patients, > 18 years of age, who underwent non-cardiac surgeries from March 2019 to April 2021 at the single tertiary medical center. Data included demographics, pre-operative laboratory tests, surgical information, and catheterization information. When compared with other machine learning methods, the DNN model showed the best predictive performance in terms of the area under receiver operating characteristic curve and area under the precision-recall curve. Operation code information accounted for the largest portion of the prediction. This can be applied to clinical fields using operation code and minimal preoperative clinical information.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit

BACKGROUND

This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite.

METHODS

Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside.

RESULTS

The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001).

CONCLUSIONS

In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU

PURPOSE

Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice.

MATERIALS

A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed.

RESULTS

314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p < 0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p < 0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p = 0.001). 2/3 of respondents (n = 173, 66%) stated more research on ICU vascular access was needed.

CONCLUSION

Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

What is new in catheter use and catheter infection prevention in the ICU

PURPOSE OF REVIEW

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

RECENT FINDINGS

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

SUMMARY

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.

Risk Factors for Central Venous Access Device-Related Thrombosis in Hospitalized Children: A Systematic Review and Meta-Analysis

OBJECTIVE

 To identify the potential associations of patient-, treatment-, and central venous access device (CVAD)-related factors with the CVAD-related thrombosis (CRT) risk in hospitalized children.

METHODS

 A systematic search of PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP database was conducted. RevMan 5.3 and Stata 12.0 statistical software were employed for data analysis.

RESULTS

 In terms of patient-related factors, the patient history of thrombosis (odds ratio [OR] = 3.88, 95% confidence interval [CI]: 2.57-5.85), gastrointestinal/liver disease (OR = 1.85, 95% CI: 0.99-3.46), hematologic disease (OR = 1.45, 95% CI: 1.06-1.99), and cancer (OR = 1.58, 95% CI: 1.01-2.48) were correlated with an increased risk of CRT. In terms of treatment-related factors, parenteral nutrition (PN)/total PN (OR = 1.70, 95% CI: 1.21-2.39), hemodialysis (OR = 2.17, 95% CI: 1.34-3.51), extracorporeal membrane oxygenation (OR = 1.51, 95% CI: 1.31-1.71), and cardiac catheterization (OR = 3.92, 95% CI: 1.06-14.44) were associated with an increased CRT risk, while antibiotics (OR = 0.46, 95% CI: 0.32-0.68) was associated with a reduced CRT risk. In terms of the CVAD-related factors, CRT risk was more significantly increased by peripherally inserted central catheter than tunneled lines (OR = 1.81, 95% CI: 1.15-2.85) or totally implantable venous access port (OR = 2.81, 95% CI: 1.41-5.60). And subclavian vein catheterization significantly contributed to a lower CRT risk than femoral vein catheterization (OR = 0.36, 95% CI: 0.14-0.88). Besides, multiple catheter lines (OR = 4.06, 95% CI: 3.01-5.47), multiple catheter lumens (OR = 3.71, 95% CI: 1.99-6.92), central line-associated bloodstream infection (OR = 2.66, 95% CI: 1.15-6.16), and catheter malfunction (OR = 1.65, 95% CI: 1.07-2.54) were associated with an increased CRT risk.

CONCLUSION

 The exact identification of the effect of risk factors can boost the development of risk assessment tools with stratifying risks.

Guide-wire replacement of a mini-midline catheter with a central venous catheter: A retrospective study on 63 cases

BACKGROUND

Achieving a reliable venous access in a particular subset of patients and/or in emergency settings can be challenging and time-consuming. Furthermore, many hospitalized patients do not meet the criteria for central venous catheter positioning, unless an upgrade of the treatment is further needed. The mini-midline catheter has already showed to be reliable and safe as a stand-alone device, since it is easily and rapidly inserted and can indwell up to 1 month.

METHODS

In this further case series, we retrospectively evaluated data from 63 patients where a previously inserted mini-midline catheter was upgraded to a central venous catheter (the devices inserted in the arm replaced by peripherally inserted central catheter and others inserted "off-label" in the internal jugular replaced by single lumen centrally inserted central catheter), being used as introducer for the Seldinger guidewire.

RESULTS

The guidewire replacement was been made even early (after 1 day) or late (more than 10 days), usually following a need for an upgrade in treatment. No early or late complications were reported.

CONCLUSION

According to the preliminary data we collected, this converting procedure seems to be feasible and risk-free, since neither infectious nor thrombotic complications were reported.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Airway Compromise due to Retropharyngeal Emphysema-A Rare Complication of an Extravasated Peripherally Inserted Central Venous Catheter

A 48-year-old woman was scheduled for flexible bronchoscopy, video-assisted thoracoscopic surgery and mediastinal washout. She had developed voice changes, difficulty swallowing, shortness of breath with a fever and increased respiratory rate in intensive care unit 12 days after a double liver and kidney transplantation. Computerised tomography of neck and chest demonstrated extensive retropharyngeal and subcutaneous emphysema, laryngeal distortion and pneumo-mediastinum; however, the causative factors were not immediately obvious. Intraoperatively, an un-anticipated diagnosis of extravasated peripherally inserted central venous cannula (PICC) was made. Total parenteral nutrition had extravasated into the mediastinum and thorax. Subsequent inflammation and infection resulted in air pocket formation. The retropharyngeal air pockets were caused by mediastinal emphysema tracking through the tissue planes to the anterior and posterior larynx. Awareness of the tip position and accompanying clinical and radiological enquiry, must be performed prior to use of PICC lines in critically ill patients.

Atrial fibrillation induced by peripherally inserted central catheters

Peripherally inserted central catheters (PICCs), a form of central venous catheter (CVC) inserted into the cephalic or basilic veins, are most commonly used for administration of long-term antibiotics or for total parenteral nutrition. PICCs are associated with fewer complications than traditional CVCs; however, they have been implicated in accidental malpositioning, leading to both atrial and ventricular arrhythmias. We present a case of atrial fibrillation possibly triggered by migration of the tip of the PICC deep into the right atrium. Retraction of the tip resulted in resolution of the arrhythmia.

Analysis of central venous access injuries from claims to the Swedish Patient Insurance Company 2009-2017

INTRODUCTION

Insertion and use of central venous access devices (CVADs) can be associated with serious adverse events. The incidence is generally low but considering the vast use of CVADs the consequences can, from a patient safety and health economics perspective, be severe. No exact knowledge exists of number of catheters or complications in Sweden, as there is currently no comprehensive registry. The aim was to analyse injuries reported to the Swedish National Patient Insurance Company (Löf) within 7 days after insertion or removal of a CVAD.

METHODS

A retrospective analysis of all injuries filed in the period 2009-2017 was performed, evaluating patient data, type of catheter, insertion technique and type of injury. If the injury was deemed avoidable by Löf, degree of disability and mortality was registered.

RESULTS

A total of 87 claims of injuries were found of which 36 (41%) were assessed as avoidable. The most common injuries were: bleeding (18%), early infection (17%), pneumothorax (17%) and early thrombosis (15%). No patients died of their injuries, but 17 of 36 suffered permanent disability of varying degrees. Ultrasound-guided insertion was used in 19% of the cases.

CONCLUSION

In Sweden, few injuries related to CVAD use are reported to Löf. About 40% of filed claims were categorized as having an avoidable injury and therefore eligible for compensation. About half of the compensated patients suffered a permanent disability. The results indicate underreporting of CVC-related injuries in Sweden during the studied time-period.

Incidence of and risk factors for totally implantable vascular access device complications in patients with gastric cancer: A retrospective analysis

Totally implantable vascular access devices (TIVADs) are often used to administer chemotherapy by prolonged intravenous infusion. The objective of the present study was to investigate the incidence of long-term complications and identify risk factors associated with TIVAD placement in patients with gastric cancer. A total of 121 patients with gastric cancer who had undergone 150 TIVAD placement procedures for chemotherapy or supportive care were enrolled in the present retrospective cohort study. A number of risk factors were analyzed, including age, sex, hypertension, diabetes mellitus, history of thrombosis, body mass index, disease stage, and site and purpose of TIVAD. In total, 40 TIVADs (26.7%) developed long-term complications, of which 27 (18.0%) were infections, seven (4.7%) were catheter-related deep vein thrombosis (CR-DVT), and six (4.0%) were obstructions. Chemotherapy was associated with an increased rate of infectious adverse events (odds ratio 2.925; 95% CI, 1.104-7.750; P=0.031) according to the multivariate analysis. CR-DVT occurred more frequently in upper arm ports than in chest wall ports; however, this difference was not statistically significant (7.5 vs. 0.0%; P=0.084) according to the univariable analysis. All CR-DVTs developed in the upper arm sites. Chemotherapy and the upper arm site were associated with long-term complications in patients with TIVAD. However, further studies are needed to confirm the findings of the present study and to determine the reasons for the high incidence of long-term complications in these patients.

In-line filtration reduced phlebitis associated with peripheral venous cannulation: Focus on cost-effectiveness and patients' perspectives

BACKGROUND

In a previous trial, in-line filtration significantly prevented postoperative phlebitis associated with short peripheral venous cannulation. This study aims to describe the cost-effectiveness of in-line filtration in reducing phlebitis and examine patients' perception of in-hospital vascular access management with and without in-line filtration.

METHODS

We analysed costs associated with in-line filtration: these data were prospectively recorded during the previous trial. Furthermore, we performed a follow-up for all the 268 patients enrolled in this trial. Among these, 213 patients responded and completed 6 months after hospital discharge questionnaires evaluating the perception of and satisfaction with the management of their vascular access.

RESULTS

In-line filtration group required 95.60€ more than the no-filtration group (a mean of € 0.71/patient). In terms of satisfaction with the perioperative management of their short peripheral venous cannulation, 110 (82%) and 103 (76.9%) patients, respectively, for in-line filtration and control group, completed this survey. Within in-line filtration group, 97.3% of patients were satisfied/strongly satisfied; if compared with previous experiences on short peripheral venous cannulation, 11% of them recognised in-line filtration as a relevant causative factor in determining their satisfaction. Among patients within the control group, 93.2% were satisfied/strongly satisfied, although up to 30% of them had experienced postoperative phlebitis. At the qualitative interview, they recognised no difference than previous experiences on short peripheral venous cannulation, and mentioned postoperative phlebitis as a common event that 'normally occurs' during a hospital stay.

CONCLUSION

In-line filtration is cost-effective in preventing postoperative phlebitis, and it seems to contribute to increasing patient satisfaction and reducing short peripheral venous cannulation-related discomfort.

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.

Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial

BACKGROUND

Centrally inserted totally implanted vascular access ports (PORTs) and peripherally inserted central catheters (PICCs) are widely used for the administration of chemotherapy. Our aim was to study the incidence of catheter-related deep venous thrombosis in patients with cancer receiving chemotherapy through either a PICC or a PORT.

METHODS

Adults with non-haematological cancer (mainly breast and colorectal) from two Swedish oncology centres were included and followed for up to 1 yr. Patients were randomly assigned to receive a single-lumen PICC or PORT. The primary end point was the occurrence of a clinically significant catheter-related deep venous thrombosis, and the secondary end point was a composite of adverse events related to the catheter: insertion complication, thrombosis, occlusion, infection, and mechanical problems.

RESULTS

The trial recruited 399 participants (PICC, n=201; PORT, n=198) between March 2013 and February 2017. The PICCs were associated with 16 (8%) deep venous thromboses compared with two (1%) in the PORT group (HR=10.2; 95% confidence interval, 2.3-44.6; P=0.002). The overall incidence of composite adverse events was higher for patients with a PICC compared with those with a PORT (HR=2.7; 95% confidence interval, 1.6-4.6; P<0.001).

CONCLUSIONS

PICCs are associated with higher risk for catheter-related deep venous thrombosis and other adverse events when compared with PORTs. This increased risk should be considered when choosing a vascular access device for chemotherapy, especially in patients with solid malignancy.

CLINICAL TRIAL REGISTRATION

NCT01971021.

Optimizing vascular-access device decision-making in the era of midline catheters

This narrative review addresses vascular access device choice from peripheral intravenous catheters through central venous catheters, including the evolving use of midline catheters. The review incorporates best practices, published algorithms, and complications extending beyond CLABSI and phlebitis to assist clinicians in navigating complex vascular access decisions.

Comparing Incidence of Thrombosis in PICC and Midlines and Evaluating the Role of Anticoagulation, Site of Insertion, and Risk Factors

New practice models are in demand for prevention and reduction in rates of catheter thrombosis that can be devastating to the health care system and patients Risk factors for catheter thrombosis were analyzed retrospectively for their impact Site of insertion and overall use of anticoagulation at the time of catheter placement did not show any significant impact on incidence of thrombosis Several variables (i.e., triple lumen, critically ill) were used to create a clinical prediction score model

Economic evaluation of the treatment of Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) from the national payer perspective: introduction of a new treatment to the patient journey. A simulation of three European countries

Background: The aim of this study was to develop a spending predictor model to evaluate the direct costs associated with the management of ABSSSIs from the National health-care provider's perspective of Italy, Romania, and Spain. Methodology: A decision-analytic model was developed to evaluate the diagnostic and clinical pathways of hospitalized ABSSSI patients based on scientific guidelines and real-world data. A Standard of Care (SoC) scenario was compared with a dalbavancin scenario in which the patients could be discharged early. The epidemiological and cost parameters were extrapolated from national administrative databases (i.e., hospital information system). A probabilistic sensitivity analysis (PSA) and one-way sensitivity analysis (OWA) were performed. Results: Overall, the model estimated an average annual number of patients with ABSSSIs of approximately 50,000 in Italy, Spain, and Romania. On average, the introduction of dalbavancin reduced the length of stay by 3.3 days per ABSSSI patient. From an economic perspective, dalbavancin did not incur any additional cost from the National Healthcare perspective, and the results were consistent among the countries. The PSA and OWA demonstrated the robustness of these results. Conclusion: This model represents a useful tool for policymakers by providing information regarding the economic and organizational consequences of an early discharge approach in ABSSSI management.

Peripherally inserted central catheter-associated bloodstream infection: Risk factors and the role of antibiotic-impregnated catheters for prevention

BACKGROUND

Antimicrobial-impregnated (AIP) peripherally inserted central catheters (PICCs) may lower risk of central line-associated bloodstream infection (CLABSI) compared with nonantimicrobial-impregnated (NAIP) catheters. We sought to assess risk factors for CLABSI with a focus on the effect of AIP PICCs.

METHODS

CLABSI rate was determined among patients who received PICCs from July 2009 through June 2012 using a retrospective study design. A nested case-control study matched for operators (interventional radiology [IR], infectious diseases [IDs], and the nurse venous access team [VAT]) was conducted to assess risks for PICC CLABSI.

RESULTS

Eighty-nine PICC CLABSIs (1.66%) occurred among 5,372 PICC placements a mean of 32 days after placement. Higher infection risk (1.75) was observed for IR-placed PICCs compared with ID-placed PICCs (P = .02). In addition, higher infection risk (4.22) was observed for IR-placed PICCS compared with VAT-placed PICCs (P = .0008). IR-placed NAIP catheters, as indicated by multivariate analysis, revealed a 5.45-fold greater CLABSI risk compared with AIP catheters (P < .0005). Other risk factors included chemotherapy, placement of a tunneled catheter, leukemia, and AIDS.

CONCLUSIONS

PICC CLABSIs were highest among patients receiving NAIP catheters in this large study. Highest risk occurred with placement of a tunneled catheter, AIDS, leukemia, and if the indication for PICC was chemotherapy. Our study suggests that the AIP PICC should be considered in all patients receiving PICCs.

Antithrombogenic peripherally inserted central catheters: overview of efficacy and safety

INTRODUCTION

Thrombotic complications associated with peripherally inserted central catheters (PICCs) are common, as most synthetic materials when placed in the presence of serum often result in platelet activation, fibrin deposition, thrombotic occlusion, and potentially embolization. A current innovation focus has been the development of antithrombogenic catheter materials, including hydrophilic and hydrophobic surfaces. These are being incorporated into PICCs in an attempt to prevent the normal thrombotic cascade leading to patient harm.

AREAS COVERED

This review focuses on the laboratory efficacy and clinical effectiveness of antithrombogenic PICCs to prevent PICC-associated thrombosis, as well as their efficiency and safety. This synthesis was informed by a systematic identification of published and unpublished laboratory and clinical studies evaluating these technologies.

EXPERT COMMENTARY

A range of PICCs have been developed with antithrombogenic claims, using varying technologies. However, to date, there is no peer-reviewed laboratory research describing the individual PICCs' effectiveness. Despite promising early clinical trials, adequately powered trials to establish efficacy, effectiveness, efficiency, and safety of all of the individual products have not yet been undertaken.

Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals

OBJECTIVES

To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward.

DESIGN

Retrospective cohort study.

SETTING

Fifty-two hospital Michigan quality collaborative.

PATIENTS

Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria.

CONCLUSIONS

Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.

Impact and Safety Associated with Accidental Dislodgement of Vascular Access Devices: A Survey of Professions, Settings, and Devices

Background: Dislodgement rates with intravenous catheters are reported at 1.8%–24% events per year resulting in failed access, interrupted treatment, and greater resource consumption with catheter replacement. The purpose of this study was to quantitatively evaluate the perceptions of frequency, impact, contributing factors, and safety issues from accidental dislodgement affecting intravenous (IV) devices as reported by healthcare clinicians.

Methodology: A cross-sectional descriptive survey was conducted via a voluntary online web-based survey of clinicians. Subjects were divided as those actively working in a clinical healthcare setting and those no longer active. Analysis of data was performed quantifying responses of clinicians on question of dislodgement.

Results: Survey results indicate clinicians routinely observe a significant percentage of accidental dislodgement, with 68% of the 1561 respondents reporting often, daily, or multiple times daily occurrence and 96.5% identifying peripheral intravenous catheters as most common device experiencing accidental dislodgement. Respondents prioritized 10 contributing factors, with confused patient (80%), patient physically removes catheter (74%), and IV catheter tape or securement loose (65%) as the top 3 causes. Over 95% of respondents consider IV dislodgement a safety risk to patients.

Conclusions: This study reports perceptions and impact of accidental dislodgement with IV devices. Inconsistencies exist with use, application, and management of catheter securement and dressings for IV catheters. Risk of additional complications and complete device failure are increased when dislodgement occurs. Given possible complications, along with necessitating replacement of the IV device in many cases, IV catheter dislodgement was considered a safety risk to patients by nearly all respondents.

Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis

BACKGROUND

Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other.

METHODS

An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies.

RESULTS

Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity.

CONCLUSION

TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.

Risk of Venous Thromboembolism Following Peripherally Inserted Central Catheter Exchange: An Analysis of 23,000 Hospitalized Patients

BACKGROUND

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.

METHODS

We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.

RESULTS

Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).

CONCLUSION

Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.

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.

The Valsalva manoeuvre versus tourniquet for venipuncture

BACKGROUND

During ultrasound-guided cannulation, venous filling is required for venipuncture. Tourniquet with an elastic tube at the axilla is the most common method to induce venous stasis for cannulation of the deep veins of the arm. Although effective, this method might be associated with short- and long-term complications. Valsalva manoeuvre has been used to produce venous filling in other extrathoracic veins. The aim of this observational study is to demonstrate the effect of Valsalva manoeuvre in respect of the elastic tourniquet on venous distention during echography-guided cannulation of the deep veins of the arm.

METHOD

Sixty-nine patients scheduled for cannulation of basilic or brachial vein were prospectively observed. Vein diameters were recorded at rest and after 10 s of Valsalva or tourniquet placement.

RESULTS

The mean difference between basilic vein diameters during tourniquet and Valsalva manoeuvre was 0.006 mm (95% confidence interval = -inf, 0.09) with a standard deviation of 0.5 mm (95% confidence interval = 0.5, 0.7; p > 0.01). The mean difference between brachial vein diameters during tourniquet and Valsalva manoeuvre was 0.04 mm (95% confidence interval = -0.23, 0.15) with a standard deviation of 0.8 mm (95% confidence interval = 0.7, 0.9; p > 0.01).

DISCUSSION

This increase in cross-sectional basilic and brachial vein diameters was not different to that obtained with the elastic tube tourniquet.

Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study

BACKGROUND

The guidelines for peripherally inserted central catheters (PICCs) recommend avoiding insertion if the anticipated duration of use is =5 days. However, short-term PICC use is common in hospitals. We sought to identify patient, provider, and device characteristics and the clinical outcomes associated with short-term PICCs.

METHODS

Between January 2014 and June 2016, trained abstractors at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites collected data from medical records of adults that received PICCs during hospitalization. Patients were prospectively followed until PICC removal, death, or 70 days after insertion. Multivariable logistic regression models were fit to identify factors associated with short-term PICCs, defined as dwell time of =5 days. Complications associated with short-term use, including major (eg, venous thromboembolism [VTE] or central lineassociated bloodstream infection [CLABSI]) or minor (eg, catheter occlusion, tip migration) events were assessed.

RESULTS

Of the 15,397 PICCs placed, 3902 (25.3%) had a dwell time of =5 days. Most (95.5%) short-term PICCs were removed during hospitalization. Compared to PICCs placed for >5 days, variables associated with short-term PICCs included difficult venous access (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.40-1.69), multilumen devices (OR, 1.53; 95% CI, 1.39-1.69), and teaching hospitals (OR, 1.25; 95% CI, 1.04-1.52). Among those with short-term PICCs, 374 (9.6%) experienced a complication, including 99 (2.5%) experiencing VTE and 17 (0.4%) experiencing CLABSI events. The most common minor complications were catheter occlusion (4%) and tip migration (2.2%).

CONCLUSION

Short-term use of PICCs is common and associated with patient, provider, and device factors. As PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary.

Timing of Spirometry May Impact Hospital Length of Stay for Cystic Fibrosis Pulmonary Exacerbation

PURPOSE

The optimal timing of spirometry during hospitalization for acute pulmonary exacerbation (PEx) in patients with cystic fibrosis (CF) is unclear. We retrospectively evaluated whether measuring spirometry earlier during hospitalization was associated with a shorter length of stay (LOS).

METHODS

In this retrospective study, we analyzed data from the electronic medical record of CF patients 6 years of age and older admitted to a single center for acute PEx requiring IV antibiotic therapy between 2009 and 2016. After excluding patient encounters with missing data on covariates, random-effects linear regression was used to predict LOS as a function of days to first pulmonary function testing (PFT), which was spirometry for our study.

RESULTS

One thousand thirty-five hospitalizations of 242 patients met inclusion criteria, with 801 including complete data on covariates. Mean LOS was 10 ± 7 days, with mean time to first PFT of 4 ± 3 days after admission. In multivariable analysis, each additional day to first PFT was associated with 0.97 days longer LOS (95% CI 0.29, 1.64; p = 0.005).

CONCLUSIONS

As CF researchers and clinicians work to improve management of PEx, the timing of spirometry during hospitalization remains an important question. Obtaining objective lung function data earlier during the course of therapy may provide information which can lead to reduced hospital LOS for PEx.

Improving PICC use and outcomes in hospitalised patients: an interrupted time series study using MAGIC criteria

Background

Although important in clinical care, reports of inappropriate peripherally inserted central catheter (PICC) use are growing.

Objective

To test whether implementation of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) can improve PICC use and patient outcomes.

Design

Quasi-experimental, interrupted time series design at one study site with nine contemporaneous external controls.

Setting

Ten hospitals participating in a state-wide quality collaborative from 1 August 2014 to 31 July 2016.

Patients

963 hospitalised patients who received a PICC at the study site vs 6613 patients at nine control sites.

Intervention

A multimodal intervention (tool, training, electronic changes, education) derived from MAGIC.

Measurements

Appropriateness of PICC use and rates of PICC-associated complications. Segmented Poisson regression was used for analyses.

Results

Absolute rates of inappropriate PICC use decreased substantially at the study site versus controls (91.3% to 65.3% (−26.0%) vs 72.2% to 69.6% (−2.6%); P<0.001). After adjusting for underlying trends and patient characteristics, however, a marginally significant 13.8% decrease in inappropriate PICC use occurred at the study site (incidence rate ratio 0.86 (95% CI 0.74 to 0.99; P=0.048)); no change was observed at control sites. While the incidence of all PICC complications decreased to a greater extent at the study site, the absolute difference between controls and intervention was small (33.9% to 26.7% (−7.2%) vs 22.4% to 20.8% (−1.6%); P=0.036).

Limitations

Non-randomised design limits inference; the most effective component of the multimodal intervention is unknown; effects following implementation were modest.

Conclusions

In a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.

Reporting and methodologic evaluation of meta-analyses published in the anesthesia literature according to AMSTAR and PRISMA checklists: a preliminary study

BACKGROUND

There have been few recent reports on the methodological quality of meta-analysis, despite the enormous number of studies using meta-analytic techniques in the field of anesthesia. The purpose of this study was to evaluate the quality of meta-analyses and systematic reviews according to the Assessment of Multiple Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the anesthesia literature.

METHODS

A search was conducted to identify all meta-analyses ever been published in the British Journal of Anaesthesia (BJA), Anaesthesia, and Korean Journal of Anesthesiology (KJA) between Jan. 01, 2004 and Nov. 31, 2016. We aimed to apply the AMSTAR and PRISMA checklists to all published meta-analyses.

RESULTS

We identified 121 meta-analyses in the anesthesia literature from January 2004 through the end of November 2016 (BJA; 75, Anaesthesia; 43, KJA; 3). The number of studies published and percentage of 'Yes' responses for meta-analysis articles published after the year 2010 was significantly increased compared to that of studies published before the year 2009 (P = 0.014 for Anaesthesia). In the anesthesia literature as a whole, participation of statisticians as authors statistically improved average scores of PRISMA items (P = 0.004) especially in the BJA (P = 0.003).

CONCLUSIONS

Even though there is little variability in the reporting and methodology of meta-analysis in the anesthesia literature, significant quality improvement in the reporting was observed in the Anaesthesia by applying the PRISMA checklist. Participation of a statistician as an author improved the reporting quality of the meta-analysis.

AngioVac extraction of intra-atrial hepatoma masquerading as PICC-associated thrombus

Thrombus associated with peripherally inserted central catheterization is not uncommon. Treatment is typically conservative; however, more aggressive therapies can be considered in patients with tenuous medical condition. The authors present a patient with metastatic hepatocellular carcinoma masquerading as peripherally inserted central catheter-associated intra-atrial thrombus, subsequently removed via vacuum-assisted mechanical thrombectomy.

Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis

BACKGROUND

Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction.

METHODS

MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016; conference proceedings were searched to identify additional studies. Study selection and data extraction were performed independently by 2 authors.

RESULTS

Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I², 71.6%; T2 = 1.07) was resolved by publication type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003).

CONCLUSIONS

Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.

Effects of Ionizing Radiation on Physical Properties of Peripherally Inserted Central Catheter

Peripherally inserted central catheter (PICC) has been widely used to treat cancer patients. It is unknown whether or not it can be applied safely during radiotherapy. The study aimed to investigate the direct effects of gamma radiation on physical properties of PICC. A total of 60 catheters were included in this study. Thirty PICCs were exposed to a radiation field, and another 30 PICCs received radiation in a 3-cm homogeneity water equivalent phantom and then were irradiated. Each group was divided into three subgroups: 10 PICCs were given conventional fractionation, 2 Gy per fraction, 5 fractions per week; 10 PICCs were continuously given hypofractionation, 10 Gy per fraction, for 6 weeks; and 10 PICCs were given mock radiation as controls. The physical properties of these catheters were analyzed after radiation. None of the PICCs leaked under 300-kPa airflow pressure lasting 15 seconds. Fracture force values and liquid velocity values of all PICCs were within the normal range. The liquid velocity values of the control groups were higher than the two groups that received radiation (P < 0.05), and there was no difference between the two irradiation groups (P > 0.05). There were no statistical differences among the conventional fractionation group, hypofractionation group, and control group when compared to the fracture force values in two parts (P > 0.05). The physical property of PICC is quite stable with a clinically relevant dose of gamma radiation. It is likely that PICC can be used safely in patients receiving radiotherapy, although further in vivo and clinical studies are required.

Assessment of thrombosis in right internal jugular vein after percutaneous superior vena cava catheter insertion during cardiovascular surgery with cardiopulmonary bypass

OBJECTIVE

We evaluated the incidence of percutaneous superior vena cava catheter-related thrombosis and identified risk factors for developing the condition in patients undergoing cardiovascular surgery with cardiopulmonary bypass.

METHODS

A total of 121 patients were evaluated. A percutaneous superior vena cava catheter was inserted into the right internal jugular vein during cardiovascular surgery with cardiopulmonary bypass. The right internal jugular vein was evaluated using ultrasonography, including cross-sectional area and velocity just before insertion of the percutaneous superior vena cava catheter (preoperative) and 24 hours and 48 hours after its insertion. If an echogenic mass was detected in the right internal jugular vein, the size was measured.

RESULTS

The incidence of thrombosis in the right internal jugular vein was 56.2%. Change in the right internal jugular vein cross-sectional area and velocity had no clinical implications. Multiple logistic regression analysis identified age (odds ratio, 1.061; 95% confidence interval, 1.022-1.101; P = .002), superior vena cava catheter indwelling duration (odds ratio, 1.015; 95% confidence interval, 1.008-1.023; P < .001), and amount of transfusion platelet concentrate (odds ratio, 1.155; 95% confidence interval, 1.030-1.295; P = .013) as risk factors for percutaneous superior vena cava catheter-related thrombosis in the right internal jugular vein.

CONCLUSIONS

The incidence of percutaneous superior vena cava catheter-related thrombosis was higher than conventional central venous catheter-related thrombosis. Risk factors were age, superior vena cava catheter indwelling duration, and amount of transfusion platelet concentrate.

[Application of ultrasonography in central venous catheterization; access sites and procedure techniques]

Central venous catheterization is commonly performed in clinical practice. Traditional procedural technique is based on anatomical landmarks, but is associated with a high risk of failure and complications. To decrease their incidence European and American societies recommend application of ultrasonography. Preliminary ultrasonographic examination allows for assessment of local anatomical relations as well as vessel morphology (diameter, patency), while real-time ultrasonography increases chances of successful needle insertion. This paper presents the most common venous access sites and procedure techniques.