A comparison between two radiological criteria for verifying tip location of central venous catheters

INTRODUCTION

Current guidelines recommend intraprocedural methods-such as Intra-Cavitary ECG (IC-ECG) and echocardiography-for verifying the location of the tip of central venous catheters. Nonetheless, there are clinical conditions which may require to verify tip location by less accurate methods such as Chest X-Ray (CXR). We have compared the feasibility and accuracy of two radiological methods for tip location-the Sweet Spot Criterion (SSC) and the Carina Criterion (CC)-using IC-ECG as reference.

METHODS

In this retrospective multicenter study, we reviewed the radiology databases of three hospitals, examining all CXRs performed on patients after insertion of Peripherally Inserted Central Catheters (PICCs), as long as the tip location had been successfully performed during the procedure by IC-ECG. Tip location was verified using SSC and CC, comparing the two methods in terms of feasibility and accuracy.

RESULTS

We reviewed the CXR of 1116 PICCs successfully inserted by IC-ECG. CC was not feasible in 0.5% (impossible visualization of the carina) and difficult in 1.5%; in 97.7% of cases, the position of the tip was adequate (1-5 cm below the carina), in 0.6% too high (<1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 10.5%; though, according to SSC the tip location was always acceptable (in 94.2% the tip was in the middle of the spot, in 2.5% close to the superior border, and in 2.3% close to the inferior border); no tip was visualized outside of the spot.

CONCLUSION

CC and SSC were similar in terms of feasibility (99.5% vs 99.1%) and accuracy (98.1% vs 100%), though CC was subjectively perceived to be easier and more rapid to perform.

coli suggesting that third-generation cephalosporin may be used as a first-line antibiotic therapy

PURPOSE

To describe the rate of peripherally inserted central catheter (PICC) -associated bloodstream infections, and the pathogens involved.

METHODS

We prospectively analyzed data collected from all adult patients with a PICC insertion in a hematology unit in a tertiary care center between January 1, 2017 and June 30, 2020.

RESULTS

A total of 370 PICCs were inserted in 275 patients with hematological malignancies: 54 (15 %) confirmed cases of central-line associated bloodstream infection (CLABSI) were identified. Enterobacteria were the most frequent bacteria identified, involved in 35 % of CLABSIs. Group 1 enterobacteria bacteremia occurred a much shorter time after insertion (median time to CLABSI 16 days) than group 2 or group 3 enterobacteria (median time to CLABSI 64 days, p-value = 0.049).

CONCLUSION

Among Gram-negative bacilli CLABSI among non-neutropenic patients, E. coli identification was the most frequent and occurred earlier after insertion, suggesting that third-generation cephalosporin may be used as a first-line antibiotic therapy for enterobacteria bacteremia among non-neutropenic patients.

A new pressure-based device for tip navigation and tip location during central venous catheterization: A prospective clinical study on a cohort of 136 adult patients

INTRODUCTION

According to current guidelines, tip location of peripherally inserted central catheters (PICCs) should be verified during insertion, preferably using non-invasive methods such as intracavitary ECG (IC-ECG) or echocardiography. An interesting new option is represented by a new pressure-based device, the CatFinder System (CFS), which might be theoretically useful also for tip navigation.

METHODS

We planned a single-center, prospective, non-randomized trial on adult patients requiring PICC insertion, using simultaneously CFS and IC-ECG, with the purpose of verifying the applicability, feasibility, safety, and accuracy of CFS for intra-procedural tip location. Patients with known ECG abnormalities or cardiac diseases of any type were excluded. The ability of CFS to assess wrong directions of the catheter during insertion (tip navigation) was evaluated by comparison with ultrasound scan.

RESULTS

Out of 136 enrolled adult patients, CFS was found to be applicable in 131 cases (five cases were excluded because of ECG abnormalities) and feasible in 111 cases (in 20 cases, tip location by CFS could not be carried out because of technical issues). There were no complications directly or indirectly related to the CFS maneuvers. Using IC-ECG as a comparison, 87 tips placed by CFS were within 2 cm from the target, 17 were >2 cm from target. In seven cases, CFS was able to detect a wrong direction (to the ipsilateral internal jugular vein), as confirmed by ultrasound.

CONCLUSION

Applicability of CFS in patients with sinus rhythm was 96.3%, feasibility was 84.7%, and safety was 100%. If compared to IC-ECG, accuracy was 83.6% (accepting an error <2 cm) and 96.1% (for an error <3 cm). Unacceptable tip positions (>3 cm) were 3.8% (the tip was too high inside the SVC). This study confirms a possible future role of CFS for intra-procedural tip location and tip navigation, though its use cannot be currently recommended.

Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices

BACKGROUND

The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care.

METHODS

We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis.

RESULTS

A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters.

CONCLUSIONS

Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

The Use of a High Flow PICC Catheter for Stem Cell and Lymphocyte Apheresis: The Initial Experience of a Pediatric Oncology Center in Brazil

BACKGROUND

Autologous hematopoietic stem cell transplant (HSCT), characterized by high intensity chemotherapy followed by the infusion of HSC previously collected from the peripheral blood, is a procedure used in the treatment of several malignancies. In pediatrics, the apheresis procedure represents a challenge, due to the need for insertion of a rigid central venous catheter (CVC) in small children. The CVC is usually used for stem cell collection and then removed. Later, the patient will need a new device for cell infusion.

AIM

We propose the use of one single catheter for both apheresis and infusion.

METHODS

We present five children between 1 and 13 years of age who underwent apheresis using a high flow PICC catheter surgically inserted.

RESULTS

All patients utilized a PICC line double lumen 5Fr (PowerPICC™ 5Fr DL BARD/USA) placed in the brachiocephalic vein tunneled on the chest, inserted under 24 h prior to apheresis to assure the devices were pervious. Three of the patients were diagnosed with solid tumor and one with acute lymphoblastic leukemia (ALL) awaiting Car-T Cell therapy. The four children who underwent autologous HSCT used the same catheter for cell infusion and remained with the catheter following discharge. The child who was submitted for Car-T Cell still awaits infusion and the catheter was removed.

CONCLUSIONS

High flow PICC is a viable alternative for apheresis to maintain an adequate flow of 5 ml/s and can be used as a single catheter throughout the HSCT process, reducing the risks from anesthesia and the catheter insertion procedure.

TYPE OF STUDY

Clinical Research.

Enhancing tube feeding method for neurosurgery: the application of improved PICC technique

BACKGROUND AND PURPOSE

Peripherally inserted central catheter (PICC) used in neurosurgical patients requires changes in patients' head positions. However, such changes can worsen pressure on the brain tissue, lead to sudden acute brain herniation and respiratory arrest, resulting in a higher chance of patient death. This paper addresses the aforementioned problems by introducing a new PICC catheterization method.

METHOD

In a retrospective study, the records of patients with PICC from April 2020 to April 2023 were reviewed, and they were divided into three groups based on the methods employed. The first group as the conventional group, involved changing patients' body positions during catheterization. The second group, as the intracavitary electrocardiographic (IECG) group, utilized intracavitary electrocardiographic monitoring and involved changing patients' body positions during catheterization. The third group as the intracavitary electrocardiographic with improved body positioning (IECG-IBP) group, catheterization was performed with guidance from intracavitary electrocardiographs and without changing the patients' body positions. The ECG changes among patients undergoing different catheter delivery methods were then compared, as well as the rate of catheter tip misplacement.

RESULT

The study encompassed a total of 354 cases. Our findings reveal distinct P wave amplitude percentages among the groups: 0% in the conventional group, 88.46% in the IECG group, and 91.78% in the IECG-IBP group. Furthermore, the following catheter tip misplacement rates were recorded: 11.54% for the conventional group, 5.39% for the IECG group, and 5.47% for the IECG-IBP group. Significantly notable differences were observed in these two key indicators between the conventional group and the IECG-IBP group. Notably, the IECG-IBP group demonstrated a more favorable outcome compared to the IECG group.

CONCLUSION

In patients with neurosurgical diseases, especially those with tracheostomy and nuchal stiffness, the IECG-IBP PICC catheter insertion method can effectively reduce the patient's neck resistance, does not increase the patient's headache and dizziness symptoms, and does not reduce the success of one-time catheterization. Rate and does not increase the incidence of jugular venous ectopia.

The difficult PICC insertion is associated with the significant increase of complications in 1 month follow-up

BACKGROUND

PICC is routinely inserted with assistance of ultrasonography and/or ECG navigation (RI- routine insertion). Only in a minority of patients the insertion of a PICC is difficult and fluoroscopic visualization with introduction of special guidewire is necessary for the success of the procedure (DI-difficult insertion). The aim of the study was to evaluate whether DI can be predicted and associated with a risk of complications during follow-up.

METHODS

The study included patients who had a PICC insertion in 2022. The number of patients with RI and DI was recorded and the significance of selected parameters during insertion and the frequency of complications during 1 month follow-up was compared.

RESULTS

About 1404 patients had successful PICC insertion in 2022, RI in 1360 (96.8%) and DI in 44 patients (3.2%). There was no significant effect of age, gender, selected vein, its size, insertion site, and tunneling on the course of PICC insertion. However the number of punctures for needle insertion was higher in DI. The complication rate during 1 month follow-up in DI was 9 (20.4%) versus 101 patients (7.4%) in RI (p = 0.002).

CONCLUSION

PICC insertion was successful in both RI and DI patients. Of the analyzed parameters, the number of needle punctures was associated with DI, and complications during the 1-month follow-up were more frequently noted in the DI group.

End-stage renal disease in a critical patient with superior vena cava syndrome with central vein catheters inserted via the superficial femoral vein: A case study

Superior vena cava syndrome (SVCS) is caused by obstruction to the blood flow through this vein. Indwelling central venous devices, such as cardiac pacemakers and haemodialysis catheters have emerged as the most common benign aetiology of SVCS. SVCS is particularly severe in patients with end-stage renal disease who require continuous renal replacement therapy plus infusion therapy. The presence of SVCS results in a reduction of available venous access for affected patients. Therefore, venous access plays a crucial role in the management of these patients. The importance of dealing with vascular access (VA) in critical patients with these conditions cannot be overstated. This case describes an 81-year-old man with respiratory failure who had end-stage renal disease complicated with SVCS. Using ultrasound-guided puncture, we inserted a peripherally inserted central catheter (PICC) into the superficial femoral vein to meet his infusion requirements in intensive care. After successful placement, the catheter tip position was adjusted using imaging to position the tip relative to the haemodialysis catheter. Whenever patients with severe renal dysfunction are treated, central veins should be preserved. Safe PICC access is possible via the superficial femoral vein to protect the last central VA for rational use. This meets urgent needs for infusion and deserves promotion.

Virtual sedation as a substitute to pharmacological sedation during PICC placement in pediatric patients: A feasibility study

INTRODUCTION

In pediatric patients, PICC insertion is often performed under sedation to reduce pain and anxiety, which is associated with risks such as laryngospasm, apnea, and hypoxia. Furthermore, it requires a pediatric anesthesiologist. The aim of our study was to evaluate the VR as an alternative to pharmacological sedation to reduce those risks and the overall cost.

METHODS

We tested a VR immersive experience for ten children requiring a PICC. To achieve this, we ran a software, specifically designed for the pediatric healthcare setting, on a commercially available VR headset.In order to evaluate this new practice, we recorded the following data:Patient's anxiety before and after the procedure, recorded through a modified numeric rating scale from 0 (no anxiety) to 10 (worst anxiety imaginable).Patient's pain before (e.g., because of preexisting medical conditions) and after the procedure through a Wong-Baker scale.Caregiver's satisfaction.No active or passive restraint was enforced during the whole procedure, patients had to keep their arms still all by themselves.

RESULT

Out of the 10 patients only in a single case, we had to interrupt the attempt with the VR technique and let the anesthesiologist perform a sedation. From the immediate beginning said patient had trouble adapting to the virtual environment and tried to remove the headset.In all other cases, we noticed a drop in the anxiety level of the patient and the pain never increased. Globally, caregivers were pleased with the experience and reported an average satisfaction rate of 9.3 out of 10.

CONCLUSION

Virtual reality seems a valid alternative to traditional sedation in pediatric patients undergoing a PICC placement procedure. Additional studies, with adequate sample size, of patients are necessary to assess the benefit from this new approach, as well as its impact on the overall procedure length.

Placement of peripherally inserted central catheter through upper versus lower limb vein in neonates: A meta-analysis of randomized controlled trials

AIM

Peripherally inserted central catheter (PICC) is an important treatment for the drug and nutrition administration in neonates. We aimed to evaluate the effects and safety of PICC placement through upper versus lower limb vein in neonates, to provide insights into the clinical PICC nursing care.

DESIGN

A meta-analysis.

METHODS

We searched the Cochrane Library, Web of Science, PubMed, Science Direct, China national knowledge infrastructure, Wanfang Data Knowledge Service Platform, China Weipu Database, China Biomedical Literature Database for published randomized controlled trials (RCTs) on the placement of PICC via upper limb and lower limb venipuncture. Two reviewers independently evaluated and cross-checked the quality of the included studies in accordance with the quality standards of the Cochrane Manual. We used RevMan 5.3 software for statistical processing.

RESULTS

A total of 12 RCTs were included in this meta-analysis. Meta-analysis indicated that compared with upper limb veins, PICC insertion through lower limb veins is beneficial to increase the one-time puncture success rate (relative risk [RR]  =  0.73, 95% confidence interval [CI]: 0.68-0.79) and the indwelling time (mean difference [MD] =  -3.60, 95% CI: -5.35 to -1.86), reduce the operation time (MD =  10.37, 95% CI: 7.48-13.26), estimated bleeding volume (MD =  0.55, 95% CI: 0.34-0.75), incidence of catheter ectopia (RR  =  2.46, 95% CI: 1.81-3.35), PICC-associated infection (RR  =  2.82, 95% CI: 1.65-4.83), exosmosis (RR  =  2.45, 95% CI: 1.49-4.04, p < .001) and phlebitis (RR  =  1.40, 95% CI: 1.03-1.90). No significant difference in the Incidence of catheter obstruction between the upper and lower limb veins (RR  =  1.20, 95% CI: 0.73-1.97, p = .48) was found.

PUBLIC CONTRIBUTION

There are certain advantages in neonatal PICC puncture through the lower limb vein. The lower limb vein may be the preferred choice for neonatal PICC puncture.

Nurse-to-patient ratios and readiness for hospital discharge: A moderated mediation model

AIM

To explore whether and to what extent, nurse-patient assessment differences mediate the association between nurse-to-patient ratios and readiness for hospital discharge, and examine whether nurse-patient characteristics moderate the indirect and/or direct effect of mediation model.

DESIGN

A cross-sectional study was carried out from March 2021 to December 2022.

METHODS

A total of 523 pairs of gastrointestinal cancer patients with PICC and their nurses were recruited. All the participants were invited to complete the general information questionnaire and the Readiness for Hospital Discharge Scale. Outcome measure was patient-reported readiness for hospital discharge. This study was reported according to the STROBE checklist.

RESULTS

The patients reported a low level of readiness for hospital discharge. Nurse-patient assessment differences were positively associated with nurse-to-patient ratios but negatively associated with readiness for hospital discharge. Furthermore, nurse-patient assessment differences fully mediated the effect of nurse-to-patient ratios on readiness for hospital discharge, and age and gender of patients only moderated the indirect path of mediation model.

Use of peripherally inserted central catheters with a dedicated vascular access specialists team versus centrally inserted central catheters in the management of septic shock patients in the ICU

OBJECTIVES

Peripherally inserted central catheters (PICCs) are increasingly recognized as an alternative to centrally inserted central catheters (CICCs) in critical care, yet the data regarding the safety and feasibility of this choice in septic shock management is growing but still lacking. In this study, we aimed to determine the feasibility, safety, and impact on outcomes of using dedicated vascular access specialist (VAS) teams to insert PICCs versus CICCs on patients admitted to the ICU with septic shock.

DESIGN

Retrospective cohort study.

SETTING

Mayo Clinic Rochester Medical ICU and Mayo Clinic Arizona Multidisciplinary ICU from 2013 to 2016.

PATIENTS

All adult patients hospitalized with diagnosis of septic shock excluding patients who declined authorization for review of their medical records, mixed shock states, and readmissions.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Comprehensive data regarding septic shock diagnosis and resuscitation were abstracted from electronic medical records. A total of 562 patients with septic shock were included in the study; 215 patients were resuscitated utilizing a PICC and 347 were resuscitated using a CICC. On univariate analysis, the time to central line insertion and time to vasopressor initiation were found to be reduced in those who received PICC at time of ICU admission versus CICC. Other favorable outcomes were also observed in those who received PICC versus CICC including shorter ICU length of stay and lower unadjusted hospital mortality. A multivariable analysis for hospital mortality showed that after adjusting for important covariates, neither the time to central line insertion nor the time to vasopressor initiation was associated with a lower hospital mortality.

CONCLUSIONS

Across two tertiary referral centers within the same enterprise, use of a dedicated VAS team for insertion of PICCs for initial resuscitation in patients with septic shock was feasible and associated with shorter time to central venous access and initiation of vasopressors; however, adjusted hospital mortality was not different between the two groups.

Effects of Peripherally inserted Central Catheter (PICC) materials and designs on reduction of PICC-related complications: A systematic review and meta-analysis

Studies showed that integrating coating or valve into Peripherally Inserted Central (PICC) can prevent related complications. However, data regarding efficiency were controversial. Therefore, a systematic review was needed to analyse the effect of PICC materials and designs on reduction of PICC-related complications. We searched PubMed, Cochrane library, EMbase, grey literature and referent literature from inception to 5 August 2022. Randomized controlled trials (RCTs) and case-control study were included. Two authors extracted data independently, using a predesigned Excel form, and assessed the quality of included RCTs according to the Cochrane Handbook for Systematic Reviews (V5.1.0), case-control study was assessed by the Newcastle-Ottawa Scale. Data were analysed using Review Manager (v5.3.0). A total of 10 RCTs and one case-control study were included. Meta-analysis results showed that PICC designs reduce the incidence of obstruction, and at the critical value of PICC-associated bloodstream infection, but may have no effects on other complications. Based on the literature reviewed, we can only say PICC new materials did not reflect significant reduction on complications, what's more, the result needs more multicentre, large RCTs to support. We suggested clinicians combine descriptive research and cost-effect analysis to select appropriate PICC materials and designs for patients.

Pain-related changes in crSO2 among premature infants undergoing PICC insertion

OBJECTIVE

To evaluate the effectiveness of cerebral regional oxygen saturation (crSO₂) values, measured using near-infrared spectroscopy (NIRS), in assessing pain associated with the peripherally inserted central catheter (PICC) in premature infants.

METHODS

NIRS was used to measure the crSO₂ levels of 48 premature infants with gestational age (GA) of < 32 weeks or a birth weight of < 1500 g. Premature infant pain profile (PIPP) scores, vital signs, transcutaneous oxygen tension (TcpO₂), transcutaneous carbon dioxide tension (TcpCO₂), and crSO₂ values were monitored. One-way repeated measure analysis of variance was used to compare heart rate (HR), respiratory rate (RR), blood pressure (BP), peripheral oxygen saturation (SpO₂), TcpO₂, TcpCO₂, and crSO₂ values before (Time 1), during (Time 2), and after (Time 3) PICC insertion. The correlation between the PIPP scores at Time 2 and the fluctuations (values detected at Time 2 minus those at Time 1) of SpO_2, TcpO_2, and crSO₂ were also analyzed.

RESULTS

The PIPP score at Time 2 was significantly higher than those at Times 1 and 3. HR, RR, and BP values increased (p < .05), and SpO₂ and crSO₂ levels decreased at Time 2 (p < .05) compared with those at Time 1. Stratified analysis based on GA revealed significant differences in HR, RR, and crSO₂ values between Times 1 and 2 in infants with a GA of ≥ 32 weeks. In infants with a GA < 32 weeks, significant differences were observed in HR, RR, SpO₂, BP, and crSO₂ values between Times 1 and 2. The fluctuation of the crSO₂ level was strongly correlated with the PIPP score at Time 2 (r = -0.829, p < .001). A weak correlation was observed between the PIPP score at Time 2 and TcpO₂ level fluctuation (r = 0.375, p = .009). No correlation was observed between the PIPP score at Time 2 and SpO₂ level fluctuation (r = 0.242, p = .097).

CONCLUSION

The fluctuation of crSO₂ levels strongly correlates with PICC procedural pain. Hence, crSO₂ levels measured using NIRS may be used as an indicator for pain assessment in premature infants.

Cyanoacrylate glue as part of a new bundle to decrease neonatal PICC-related complications

A "bundle" is defined as a combination of evidence-based interventions that, if followed collectively and reliably, improve patient outcomes. The aim of this quasi-experimental study, conducted in a level-III NICU in Belgium, was to assess the impact of central line dressing and maintenance bundle implementation on the rate of catheter-related mechanical complications. We performed a quality improvement (QI) project. Prior to bundle implementation, neonatal PICC lines were secured by Steri-Strip® and occlusive dressing. We implemented a new PICC bundle consisting of the use of glue, sutureless device (Griplock®), and a transparent dressing to secure the catheter to the skin. We compared the rate of infections, mechanical complications, and dislocations before and after bundle implementation (periods 1 and 2, respectively). The use of glue resulted in a significantly decreased rate of central line-associated bloodstream infection (CLABSI) (p < 0.001), dislocations, and mechanical complications (p < 0.0001). During period 2, there was a significant increase for the average number of days the catheter stayed in place (p < 0.05). We did not observe catheter breakage or patient skin irritations attributable to the use of glue (not even in ELBW infants).

CONCLUSION

The implementation of the new bundle to secure neonatal PICCs in our NICU was associated with a significant reduction in CLABSI and dislodgment rates, without glue-related complications. Active surveillance of CVC placement procedure, positioning, and management, as well as analysis of related complications is crucial for improving patient safety. Continuous implementation of up-to-date central line bundles based on best practice recommendations is a key for quality improvement in NICUs.

WHAT IS KNOWN

• Stable vascular access is crucial in the NICU. Neonatal PICC securement issues can have serious consequences and are associated with device failure.

WHAT IS NEW

• Catheter securement with tissue adhesive is safe and effective in reducing failure and complication rates in the neonatal population.

Pain during PICC insertion in preterm infants: the needle is not the only problem

OBJECTIVE

To evaluate whether warm povidone-iodine (PI) application before peripherally inserted central catheter (PICC) placement eased pain related to the procedure in premature infants and reduced the duration of the procedure and the number of attempts.

METHODS

A prospective randomized controlled trial was conducted with infants born before 32 weeks of gestation who required the first placement of the PICC. Skin disinfection was performed with warm PI before the procedure in the warm PI(W-PI) group, whereas PI kept at room temperature was used in the regular PI(R-PI) group. NPASS scores of the infants were evaluated three times: at baseline(T0), during skin preparation(T1), and during needle insertion(T2).

RESULTS

Fifty-two infants (26 in the W-PI group,26 in the R-PI group) were enrolled in the study. The perinatal and baseline demographic characteristics did not significantly differ between the two groups. While the median NPASS scores at T0 and T2 were similar between the groups, the median T1 score was significantly higher in the R-PI group(p = .019). While the median NPASS scores at T1 and T2 were similar in the R-PI group, there was a significant difference in the W-PI group, with NPASS scores being significantly lower at T1 compared to T2. The results demonstrate that skin disinfection was just as painful as needle insertion in the R-PI group. The duration of the procedure and the number of needle insertions were significantly lower in the W-PI group.

CONCLUSIONS

Before invasive interventions, such as PICC insertion, we recommend warm PI as a part of non-pharmacological pain management.

Application of peripherally inserted central catheter in immune tolerance induction treatment of children with hemophilia A and accompanying inhibitors in China

OBJECTIVE

To explore the feasibility, safety and cost effectiveness of the use of peripherally inserted central catheter (PICC) in children with hemophilia A and inhibitors who underwent ITI treatment.

METHOD

This retrospective cohort study evaluated the effect of PICC placement and ITI on bleeding rates, costs, and parents' satisfaction before and within 6 months after PICC placement in children with hemophilia A and inhibitors.

RESULTS

A total of 20 children with hemophilia A and high-titer inhibitors were included, with a success rate for PICC placement of 100%, at a cost of ¥6730.50. Parents' satisfaction with PICC was 100%, and the total length of catheter indwelling was 6055 days. In terms of curative effect, the success rate of ITI treatment was 75%, and the annualized bleeding rate was decreased from 10.90 ± 12.16 times before placement to 2.10 ± 3.32 times (p < 0.05). The transportation expense for children and their parents to the clinic decreased from ¥20,920 ± 32,274.57 before catheter placement to ¥2915 ± 2195.99 (p < 0.05). Time of children missed school and their parents missed work decreased from 10.85 ± 22.36 days to 1.90 ± 3.58 (p < 0.05) days and 40.33 ± 46.11 days to 3.83 ± 7.11 days (p < 0.05), respectively.

CONCLUSION

The use of PICC for ITI treatment in children with hemophilia A and accompanying inhibitors in developing countries (e.g. China) can ensure the effect of ITI, reducing expense and improving the quality of life without obvious side effects.

Can the length of a catheter change the time to bubble at the tip performing the "Bubble Test"? A bench study

INTRODUCTION

Intraprocedural tip control techniques are critical during central venous catheter placement. According to international guidelines (INS 2021), intracavitary electrocardiography is the first method of choice to verify it; when this technique is not feasible, it is considered acceptable to use a contrast-enhanced ultrasound-based tip location method, commonly known as "bubble-test" as an effective alternative.

OBJECTIVE

To assess whether the length of the vascular catheter can alter the time between the injection of the contrast media and its appearance at the catheter tip and the injection duration. Differences between operators stratified according to experience were evaluated as secondary endpoints.

METHODS

A bench study was conducted using an extracorporeal circuit. For each catheter length (60, 40, and 20 cm), three injections were obtained by each of the five operators with different levels of experience for a total of 45 measurements. Differences among operators were evaluated using ANOVA, and the impact of catheter length and operator expertise on times was assessed using repeated measurement models.

RESULTS

Hub-to-tip times of 247.33 ms (SD 168.82), 166 ms (SD 95.46), 138 ms (SD 54.48), and injection duration of 1620 ms (SD 748.58), 1614 ms (SD 570.95), 1566 ms (SD 302.83) were observed for 60, 40, 20 cm catheter length, respectively. A significant time variability between operators was observed. Moreover, moving from 60 to 20 cm, hub-to-tip time was significantly longer for 60 cm devices (p = 0.0124), while little differences were observed for injection duration.

CONCLUSIONS

Catheter length can change both the time between the injection of the contrast media and its appearance at the catheter tip and the injection duration. Hub-to-tip times obtained with 20 and 40 cm and overall injection duration did not differ significantly; skilled personnel could substantially reduce both values analyzed in this study.

Risk Factors and Predictive Models for Peripherally Inserted Central Catheter Unplanned Extubation in Patients With Cancer: Prospective, Machine Learning Study

BACKGROUND

Cancer indeed represents a significant public health challenge, and unplanned extubation of peripherally inserted central catheter (PICC-UE) is a critical concern in patient safety. Identifying independent risk factors and implementing high-quality assessment tools for early detection in high-risk populations can play a crucial role in reducing the incidence of PICC-UE among patients with cancer. Precise prevention and treatment strategies are essential to improve patient outcomes and safety in clinical settings.

OBJECTIVE

This study aims to identify the independent risk factors associated with PICC-UE in patients with cancer and to construct a predictive model tailored to this group, offering a theoretical framework for anticipating and preventing PICC-UE in these patients.

METHODS

Prospective data were gathered from January to December 2022, encompassing patients with cancer with PICC at Xiangya Hospital, Central South University. Each patient underwent continuous monitoring until the catheter's removal. The patients were categorized into 2 groups: the UE group (n=3107) and the non-UE group (n=284). Independent risk factors were identified through univariate analysis, the least absolute shrinkage and selection operator (LASSO) algorithm, and multivariate analysis. Subsequently, the 3391 patients were classified into a train set and a test set in a 7:3 ratio. Utilizing the identified predictors, 3 predictive models were constructed using the logistic regression, support vector machine, and random forest algorithms. The ultimate model was selected based on the receiver operating characteristic (ROC) curve and TOPSIS (Technique for Order Preference by Similarity to Ideal Solution) synthesis analysis. To further validate the model, we gathered prospective data from 600 patients with cancer at the Affiliated Hospital of Qinghai University and Hainan Provincial People's Hospital from June to December 2022. We assessed the model's performance using the area under the curve of the ROC to evaluate differentiation, the calibration curve for calibration capability, and decision curve analysis (DCA) to gauge the model's clinical applicability.

RESULTS

Independent risk factors for PICC-UE in patients with cancer were identified, including impaired physical mobility (odds ratio [OR] 2.775, 95% CI 1.951-3.946), diabetes (OR 1.754, 95% CI 1.134-2.712), surgical history (OR 1.734, 95% CI 1.313-2.290), elevated D-dimer concentration (OR 2.376, 95% CI 1.778-3.176), targeted therapy (OR 1.441, 95% CI 1.104-1.881), surgical treatment (OR 1.543, 95% CI 1.152-2.066), and more than 1 catheter puncture (OR 1.715, 95% CI 1.121-2.624). Protective factors were normal BMI (OR 0.449, 95% CI 0.342-0.590), polyurethane catheter material (OR 0.305, 95% CI 0.228-0.408), and valved catheter (OR 0.639, 95% CI 0.480-0.851). The TOPSIS synthesis analysis results showed that in the train set, the composite index (Ci) values were 0.00 for the logistic model, 0.82 for the support vector machine model, and 0.85 for the random forest model. In the test set, the Ci values were 0.00 for the logistic model, 1.00 for the support vector machine model, and 0.81 for the random forest model. The optimal model, constructed based on the support vector machine, was obtained and validated externally. The ROC curve, calibration curve, and DCA curve demonstrated that the model exhibited excellent accuracy, stability, generalizability, and clinical applicability.

CONCLUSIONS

In summary, this study identified 10 independent risk factors for PICC-UE in patients with cancer. The predictive model developed using the support vector machine algorithm demonstrated excellent clinical applicability and was validated externally, providing valuable support for the early prediction of PICC-UE in patients with cancer.

Quality of life in patients with PICC diagnosed with mesothelioma: Results of a multicenter epidemiological survey (LifePICC)

BACKGROUND

Pleural mesothelioma (PM) is a rare and aggressive cancer. PICC devices are widely used in cancer patients. The aim of the study is to evaluate the quality of life of patients with PICC diagnosed with PM treated at the Hospital of Casale Monferrato and Alessandria (Italy), an area with a high incidence of asbestos-related diseases.

STUDY DESIGN AND METHODS

Longitudinal prospective observational study with data collection at PICC insertion (T0), after 3 months (T1), 6 months (T2), and 9 months (T3). Participants were aged >18 years, diagnosed with PM, eligible for PICC insertion. Questionnaires used: EORTC QLQ-C30, EORTC QLQ-LC13, and HADS rating scale.

RESULTS

Twenty-eight patients were enrolled. The mean age was 68.93 years (SD 9.13), mostly male (57.1%). The most frequent cancer stage at diagnosis was III (39.3%), then I (32.1%), and IV (21.4%). 85.7% were treated with chemotherapy, 14.3% also with immunotherapy. 96.4% of patients reported no complications during PICC implantation. The perception of health status and quality of life, measured on a scale of 1-7, was in line with an average score of 5 during the evaluation period. The total anxiety and depression score remained normal for most patients (0-7).

CONCLUSIONS

The PICC management involved a multidisciplinary team with different skills: study findings revealed the key role that dedicated nurses play in PICC placement and ensuring patient problems are promptly addressed. From our study results, PICC placement does not seem to negatively impact the patient's quality of life.

The use of hypnotic communication in PICC placement: randomized controlled trial study

Every time a patient undergoes a medical procedure, unpredicted personal stress occurs. According to the available literature, the hypnotic communication technique has been used to reduce stress and pain during several major invasive procedures. The primary goal of this study was to compare the effectiveness of hypnotic communication combined with buffered Lidocaine, versus buffered Lidocaine alone, on patients' negative emotions while undergoing Peripherally Inserted Central Venous Catheter (PICC) placement. Secondary aims were evaluating patients' pain, satisfaction, and procedure timing and costs. A randomized controlled trial was conducted in an Italian Hospital involving patients who needed a PICC, with any disease or condition, aged over 18, cognitively oriented, able to hear, and willing to give consent. Emotional assessment was performed using the Emotion Thermometer Tool. Sixty-seven subjects were enrolled: 17 refused to participate, and 25 were randomly assigned to each group. The results showed a statistically significant higher decline in the total Emotion Thermometer Tool score for the experimental group using hypnotic communication. A significant mean reduction in anger and depression was also observed, while both groups reported low levels of perceived pain. Hypnotic communication appears to be a successful method for reducing emotional stress during PICC placement. However, further research is needed to determine the relationship between hypnotic communication, emotional distress, and pain perception in patients undergoing central vascular catheter insertion.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections in ICUs of 8 Latin American countries

BACKGROUND

Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors in Latin-America.

METHODS

From January 1, 2014 to February 10, 2022, we conducted a multinational multicenter prospective cohort study in 58 ICUs of 34 hospitals in 21 cities in 8 Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama). We applied multiple-logistic regression. Outcomes are shown as adjusted-odds ratios (aOR).

RESULTS

About 29,385 patients were hospitalized during 92,956 days, acquired 400 CLABSIs, and pooled CLABSI rate was 4.30 CLABSIs per 1,000 CL-days. We analyzed following 10 variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization (DU) ratio, CL-type, tracheostomy use, hospitalization type, intensive care unit (ICU) type, and facility ownership, Following variables were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 3% daily (aOR=1.03;95%CI=1.02-1.04; P < .0001); number of CL-days before CLABSI acquisition, rising risk 4% per CL-day (aOR=1.04;95%CI=1.03-1.05; P < .0001); publicly-owned facility (aOR=2.33;95%CI=1.79-3.02; P < .0001). ICU with highest risk was medical-surgical (aOR=2.61;95%CI=1.41-4.81; P < .0001). CL with the highest risk were femoral (aOR=2.71;95%CI=1.61-4.55; P < .0001), and internal-jugular (aOR=2.62;95%CI=1.82-3.79; P < .0001). PICC (aOR=1.25;95%CI=0.63-2.51; P = .52) was not associated with CLABSI risk.

CONCLUSIONS

Based on these findings it is suggested to focus on reducing LOS, CL-days, using PICC instead of femoral or internal-jugular; and implementing evidence-based CLABSI prevention recommendations.

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.

A retrospective study of subcutaneous anchor securement systems in oncology patients

INTRODUCTION

Maintaining optimal central venous catheter tip position requires reliable catheter securement. A vital decision about the choice of engineered securement device is often made by what is conveniently available in the insertion kit or default clinical routine. The importance of continuous securement for oncology patients prompted the need for an evaluation of securement options currently available. This study aimed to assess the effectiveness of two engineered securement devices to assist the oncology patient in reaching the end of their catheter need.

METHODS

A retrospective study was conducted to assess patients' ability to finish their therapy with one peripherally inserted central catheter. Implant and explant data for adult oncology patients was evaluated spanning 2007-2021. All patients received a PICC with either an adhesive securement device or a subcutaneous anchor securement system.

RESULTS

Partial or complete dislodgement causing the unplanned removal of the PICC occurred at 12% for ASD and 0.4% for SASS (p < 0.0001). The probability of reaching the end of need with one PICC, regardless of the reason for premature removal, at 2 years for patients with an adhesive securement device was 68% (n = 944). For patients with a subcutaneous anchored securement device, it was over 95% (n = 8313). The difference in the probability of reaching the end of the need with one PICC between the two securement devices was calculated at (p < 0.0001).

CONCLUSION

With over 9200 patients and more than a million catheter days, the results of this retrospective study demonstrate the SASS's superiority in assisting the patient to reach the end of need with a single PICC.

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.

ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients

Central venous access devices are routinely used in clinical practice for administration of fluids and medications, for drawing blood samples and for hemodynamic monitoring. The adoption of ultrasound guided venipuncture has significantly reduced procedure-related complications, as documented by the recommendations of most recent guidelines. Ultrasound has also an important role also in other aspects of central venous catheterization, such as in the pre-procedural evaluation of the venous patrimony and in the detection of early and late non-infective complications. Recently, bedside ultrasound has been regarded as a promising tool also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in adult patients, and to suggest a structured standardized protocol for clinical practice.

Right heart thrombus in transit and peripherally inserted central catheters

Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.

Association of umbilical venous catheters vs peripherally inserted central catheters with death or severe intraventricular hemorrhage among preterm infants < 30 weeks: A randomized clinical trial

BACKGROUND

Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs) are routinely inserted in preterm infants for total parenteral nutrition and medications. We aimed to examine whether the rates of severe intraventricular hemorrhage (IVH) or death vary among preterm infants receiving UVCs compared to PICCs.

METHODS

This randomized controlled trial included preterm infants <  30 weeks gestation assigned after birth to either UVC placement group or PICC group.

RESULTS

A total of 233 preterm infants (117 infants in UVC group, 116 infants in PICC group) were randomized and collected data was available for intention-to-treat analysis. There were no differences in baseline population characteristics. Severe IVH occurred in 16 infants (13.6%) in the UVC group and 11(9.5%) in the PICC group (risk difference [RD], 4.1% [5% CI, -4 to 12.3]; P = 0.42). The incidence of death before 28 days of life did not differ significantly between groups (10 [8.5% ] in UVC vs 6 [5.1%] in PICC; RD, 3.4% [95% CI, -3.0 to 9.84]; P = 0.44). Seventeen percent (20/117) of the UVC group died or developed severe IVH compared with 12% (14/116) of the PICC group (risk difference, 5% [95% CI, -4.01 -14.06]; P = 0.36). The incidence of necrotizing enterocolitis (NEC) was significantly higher in the UVC group infants than in the PICC group infants (7.7% vs. 1.7%); p = 0.03.

CONCLUSIONS

The incidence of severe IVH or death did not differ significantly among preterm m infants <  30 weeks gestation subjected to UVC or PICC placement. Early inotropic support was a significant risk factor for the development of severe IVH. UVC maybe an additional risk factor for the development of NEC, but further research is required to validate this finding.

The safety of peripherally inserted central venous catheters in critically ill patients: A retrospective observational study

BACKGROUND

Centrally inserted central venous catheters (CICCs) are commonly placed in critically ill patients who require a central venous catheter (CVC). Recently, peripherally inserted central venous catheters (PICCs) have been widely used on general wards. However, the safety of PICCs in critically ill patients remains unclear.

METHOD

We conducted a retrospective observational study at a mixed intensive care unit (ICU). Adult patients (⩾18 years) who were emergently admitted to the ICU and underwent CVC insertion between April 2019 and March 2021 were enrolled. We compared the safety of PICCs and CICCs. The primary outcome was the overall rate of catheter-related complications, including bloodstream infections, thrombosis, insertional trauma, catheter malfunction, and accidental removal. We used a stabilized inverse probability weighting (sIPW) model to estimate the effects of PICC use.

RESULTS

A total of 239 CVCs (PICCs, 53; CICCs, 186) were inserted into 229 patients. Although the severity of illness did not differ significantly between the groups, the length of hospital stay and mean indwelling catheter duration were significantly longer in the PICC group. There was no significant intergroup difference in the overall rate of catheter-related complications (PICC: 9.4% vs CICC: 3.8%; odds ratio [OR]: 2.65; 95% confidence interval [CI]: 0.63-10.2, p = 0.145), and there were 7.7 and 9.0 complications per 1000 catheter days in the PICC and CICC groups, respectively (hazard ratio [HR]: 0.61; 95% CI: 0.14-2.65, p = 0.513). After adjustment using the sIPW model, PICC use was not found to be associated with a reduction in catheter-related complications (adjusted OR: 3.10; 95% CI: 0.90-10.7; adjusted HR: 0.53; 95% CI: 0.14-1.97).

CONCLUSION

We found no significant differences in catheter-related complications between patients treated using CICCs and those treated using PICCs after emergency ICU admission. Our findings imply that PICCs may be an alternative to CICCs in critically ill patients.

Impact of peripherally inserted central venous catheter-associated phlebitis in neonate guided by intracavitary electrocardiogram: A systematic review and meta-analysis of randomised controlled trials

Because the application of intracavitary electrocardiogram (IC-ECG)-guided peripherally inserted central catheter (PICC) in the treatment of neonates is controversial in terms of phlebitis reduction compared with traditional X-ray positioning technique, a systematical evaluation is needed on the impact of IC-ECG on this common complication following PICC. Literature retrieval was conducted on large databases including PubMed, Google Scholar, Cochrane library, and CNKI. Randomised controlled trials (RTCs) of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in the treatment of neonates up to July 7, 2022, were collected. Then indicators of included studies were compared and analysed by two researchers. Meta-analysis was performed on the STATA 17.0 software. After excluding invalid trials, 11 out of 316 randomised controlled trials were included for further analysis. Meta-analysis results showed that compared with the control group, IC-ECG-guided PICC could decrease the incidence of phlebitis (I²  = 0.00%, P = 0.76, OR = 0.33, 95% CI 0.19-0.56) and that no significant difference was observed between preterm neonates and term neonates (P = 0.74). Meanwhile, total complications were decreased in neonates (I²  = 0.00%, P = 0.00 OR = 0.23, 95% CI 0.16-0.33). IC-ECG-guided PICC could also improve the accuracy of optimal tip location (I²  = 0.00%, P = 0.53, OR = 5.37, 95% CI 3.80-7.59). IC-ECG-guided PICC could achieve reduced phlebitis incidence and total complications in the treatment of neonates, as well as increased accuracy of optimal tip location, no matter if those neonates were preterm or not. This study was registered in inplasy.com with No. INPLASY202280012 (DOI: 10.37766/inplasy2022.8.0012).

Safety of Cryopreserved Stem Cell Infusion through a Peripherally Inserted Central Venous Catheter

The management of patients undergoing stem cell transplantation requires a multipurpose central venous catheter (CVC) to facilitate drug administration, parenteral nutrition, transfusion of blood products, and collection of blood samples. Peripherally inserted central venous catheters (PICCs) appear to meet these requirements but are rarely used for stem cell infusion. We aimed to retrospectively assess the safety and feasibility of stem cell infusion through PICC and to evaluate its impact on transplantation kinetics. We retrospectively analyzed the outcomes of peripheral blood stem cell (PBSC) transplantation in patients receiving cryopreserved autologous or allogeneic PBSC by PICCs and compared the results with patients receiving transplants through a conventionally inserted central venous catheter (CICC). Despite statistically significant differences in CD34⁺ dose, infusion rate, and total length of administration, the clinical outcomes of transplantation, exemplified by platelet and neutrophil engraftment, along with the length of hospitalization, were not affected by the prolonged infusion time and lower infusion velocity in the PICC group. Our study showed that the clinical outcomes of PBSC transplantation did not differ between the PICC and CICC groups, suggesting that both types of catheters can be implemented in a PBSC transplantation setting.

Impact of distance of the catheter tip from cavo-atrial junction on bubble test (delay) time: A prospective study

INTRODUCTION

Correct tip positioning is a critical aspect in central vascular access devices insertion. The verification of positioning at the cavo-atrial junction is usually performed by intracavitary electrocardiography. Recently, echocardiographic techniques were proposed, including the direct visualization of the catheter or the visualization of a saline/air bolus (i.e. "bubble test"). As for the latter, a push-to-bubbles delay time below 2 s was proposed to indicate a correct positioning of the catheter tip. The aim of this study was to measure the variations of the push-to-bubbles time at increasing distance from the cavo-atrial junction, to verify if a cut-off of 1-2 s correspond to a well-positioned catheter.

METHODS

We performed a prospective study including patients with clinical indication of positioning a peripherally inserted central catheter. The catheter tip was positioned at the cavo-atrial junction (P0) via intracavitary electrocardiography, and the push-to-bubbles delay time was measured. The catheter was then retracted 5 cm (P1) and 10 cm (P2), and the test was repeated at this positioning. Push-to-bubbles time measurements were performed off-line by analyzing an audio/video recording which included the echography screen and the voice signal of the operator.

RESULTS

Forty-nine patients were included. The average push-to-bubble time when the catheter tip was in the reference position was 0.41 ± 0.21 s. Retraction of the PICC catheter of 5 and 10 cm determined a significant increase of the push-to-bubbles time: mean time difference was +0.34 (95% IC 0.25-0.43, p < 0.001) s between P0 and P1 (5 cm distance), and +0.77 (95% IC 0.62-0.92, p < 0.001) s between P0 and P2 (10 cm distance). When the catheter was at the reference position (i.e. cavo-atrial junction) only 2.1% of bubbles delay times were above 1 s.

CONCLUSION

The push-to-bubbles time is very low when the catheter tip is at the cavo-atrial junction. This delay increases progressively with increasing distance from the target. Push-to-bubbles delay time above 1 s might indicate a catheter not close to the cavo-atrial junction.

Clinical factors associated with peripherally inserted central catheters (PICC) related bloodstream infections: a single centre retrospective cohort

BACKGROUND

Despite their spread in daily practice, few data is available on clinical factors associated with peripherally inserted central catheter (PICC)-related bloodstream infections (PR-BSI). We aimed to assess the PR-BSI incidence, microbiology, and factors associated with PR-BSI with a focus on clinical symptoms.

METHODS

We conducted a retrospective cohort study in a French university hospital. We screened all PICC insertions performed from April 1st, 2018, to April 1st, 2019, and included PICC insertions in adult patients. We assessed the PR-BSI incidence, the factors associated with PR-BSI using a Cox model, and negative and positive predictive values (NPVs and PPVs) of each clinical sign for PR-BSI.

RESULTS

Of the 901 PICCs inserted in 783 patients (38,320 catheters days), 214 PICCs (24%) presented with a complication. The most prevalent complication was PR-BSI (1.9 per 1000 catheter days; 8.1% of inserted PICCs ). Enterobacterales (N = 27, 37%) and coagulase negative Staphylococci (N = 24, 33%), were the main microorganisms responsible for PR-BSI. Factors independently associated with occurrence of PR-BSI were fever (hazard ratio 13.21, 95% confidence interval 6.00-29.11, p < 0.001) and chills (HR 3.66, 95%CI 1.92-6.99, p < 0.001). All clinical signs and a duration of PICC maintenance ≥ 28 days, had a low PPVs (≤ 67.1%) but high NPVs (≥ 92.5%) for PR-BSI.

CONCLUSIONS

Monitoring of clinical signs, especially fever and chills, with caution and limitation of device maintenance duration, could improve PICC management.

Caliber of the deep veins of the arm in infants and neonates: The VEEIN study (Vascular Echography Evaluation in Infants and Neonates)

PURPOSE

Ultrasound-guided peripherally inserted central catheters (PICCs) are increasingly used in children, though their insertion may be limited by the small caliber of the deep veins of the arm. Previous studies have suggested to use age or weight as a guide to the feasibility of PICC insertion. We have planned an observational study with the purpose of identifying the actual feasibility of PICC insertion based on the ultrasound evaluation of the deep veins of the arm in groups of children of different weight range.

METHODS

We have studied 252 children weighing between 2.5 and 20 kg, divided in five different groups (group 1: 2.5-4 kg; group 2: 4.1-7 kg; group 3: 7.1-10 kg; group 4: 10.1-15 kg; group 5: 15.1-20 kg): the caliber of brachial vein, basilic vein, and cephalic vein at mid-upper arm + the caliber of the axillary vein at the axilla were measured by ultrasound scan.

RESULTS

Veins of caliber >3 mm (appropriate for insertion of a 3 Fr non-tunneled PICC) were found at mid-upper arm in no child of group 1 or 2, in 13% of group 3, in 28% of group 4, and in 54% of group 5. An axillary vein >3 mm (appropriate for insertion of a 3 Fr tunneled PICC) were found in 5.8% of group 1, 30.6% of group 2, 67% of group 3, 82% of group 4, and 94% of group 5.

CONCLUSIONS

The age and the weight of the child have a small role in predicting the caliber of the veins of the arm. Veins should be measured case by case through a proper and systematic ultrasound evaluation; however, the clinician can expect that insertion of a 3 Fr PICC may be feasible in one third of children weighing between 4 and 7 kg, and in most children weighing more than 7 kg, especially if adopting the tunneling technique.

Comparing Complication Rates of Midline Catheter vs Peripherally Inserted Central Catheter. A Systematic Review and Meta-analysis

Background

Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach.

Results

Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15-0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48-3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes.

Conclusions

Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

Study on the timing of first dressing change with alginate dressing application in PICC placement among tumor patients

Objective

To explore how the timing of the initial dressing change influences bacterial growth when alginate dressings were used after peripherally inserted central catheter (PICC) line insertion in tumor patients.

Methods

In total, 186 tumor patients who had an alginate dressing after PICC insertion were randomly divided into a control group, observation group one (OG1), and observation group two (OG2). The control group had their first dressing change 48 h after PICC insertion, while OG1 was after 72 h and OG2 was after 96 h after. Samples were taken at the dressing change from the insertion site and surrounding skin. The results of the bacterial culture were compared to investigate how the timing of the first dressing change affected catheter infection.

Results

Of the 186 patients, 29 had a positive bacterial culture. Of these, 10 were in the control group, 9 were in OG1, and 10 were in OG2. IBM SPSS Statistics 21.0 was adopted to analyze the correlation between the timing of the first dressing change and insertion site infection. No statistical significance between the timing of the first dressing change and insertion site infections was found (P > 0.05).

Conclusions

The condition of each tumor patient should be comprehensively evaluated after PICC placement to determine when the first dressing change should occur, but it can likely be extended to 96 h after insertion to promote wound healing, reduce clinical workload, and lower patient economic burden.

Effect of femoral PICC line insertion in neonates with digestive tract disease

OBJECTIVE

To investigate the clinical effects of various catheterization pathways to guide vein selection in neonates.

METHODS

In this retrospective study, a total of 40 newborns admitted to the Neonatal Surgery Department of Nanjing Children's Hospital who were hospitalized for gastrointestinal diseases and required intravenous nutrition from March 2020 to December 2020 were included. The patients were divided into a control group (basilic vein and superficial temporal vein) and an observation group (femoral vein of the lower extremity) according to the puncture site of the vein. Blood loss, incidences of phlebitis, incidences of catheter dislocation, frequency of dressing replacement, catheter-related blood infection rate, the satisfaction of family members and bacteriological test results of the catheter tip (1-2 cm) after catheter removal were compared between the two groups.

RESULTS

The incidence of phlebitis and catheter dislocation was lower while the satisfaction rate of family members was higher in the observation group as compared with those in the control group (all P<0.05).

CONCLUSIONS

PICC insertion through the femoral vein can effectively reduce catheter-related complications, shorten the days of hospitalization and improve the comfort of children and the satisfaction of their families.

The effects of music therapy on peripherally inserted central catheter in hospitalized children with leukemia

To explore the effect of music therapy on children with leukemia who have peripherally inserted central catheters (PICC).

In this study, we divided 107 patients undergoing PICC into music group (47 cases) and control group (60 cases). The music group received music therapy during PICC, while the control group was given no complementary treatment. The total length of catheterization, the use of sedatives and the changes of pain level and emotion level before and after PICC placement were compared between two groups.

Compared with the control group, the total PICC placement time of the music group was significantly shorter (35(30-40) vs. 60(60-60); Z = -8.307; p < 0.001), and the use of sedative medications was also significantly reduced (4.35% (n = 2) vs. 91.84% (n = 45); p < 0.001). Moreover, the pain of catheterization was significantly alleviated. The median difference of pain scores of the music group was significantly less (2(1-3) vs. 5(5-5); p < 0.001). The mood of patients was also improved. The median difference of emotional scores of the music group was significantly more (5(4.75-6) vs. 3(3-3); p < 0.001) than the control group.

Music therapy is effective to use in PICC. It can shorten the treatment time, reduce the use of sedative medications, and improve the children's emotion and pain response significantly, which is worth clinical application.

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

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

ECG method for positioning the tip of peripherally inserted central catheters in patients with atrial fibrillation

OBJECTIVE

To observe the changes of F waves on electrocardiograms (ECGs) in patients with persistent atrial fibrillation during the insertion of a peripherally inserted central catheter (PICC), and to analyze the application effect of the ECG method (through F wave changes) for guiding PICC tip positioning.

METHODS

Seventy-two patients who met the inclusion criteria and needed a PICC catheter were selected as the research subjects. We observed waveforms in the ECGs when the tip of the catheter reached a predetermined position. The chest X-ray results were used as the gold standard to calculate the sensitivity and specificity, and judge the safety and accuracy of ECG-guided PICC tip positioning in patients with atrial fibrillation.

RESULTS

Of the 72 patients, there was no significant difference between the ECG method and chest X-ray results (χ² = 0.2, p > 0.05). Sixty-one patients had F wave changes on ECG and 10 had no obvious changes (X-ray results confirmed that five patients had a tip position that was too shallow, two had ectopic tip positions, and three were located in the correct place). The sensitivity of the method was 95.7% and the specificity was 80%.

CONCLUSION

As the ECG baselines of patients with persistent atrial fibrillation were difficult to judge and the F wave was irregular, we found that the F wave was significantly higher than before catheter insertion and fell back while withdrawing the catheter, so the catheter should be fed until the F wave significantly increased as the correct position of the catheter tip.

Construction of a rabbit model with vinorelbine administration via peripherally inserted central catheter and dynamic monitoring of changes in phlebitis and thrombosis

Peripherally inserted central catheters (PICCs) are used for the administration of chemotherapy drugs, including vinorelbine. The present study aimed to construct a rabbit model with vinorelbine administration via PICC, and to dynamically monitor the formation of phlebitis and thrombosis. PICC was inserted into 48 rabbits following specific clinical procedures. The rabbits were randomly divided (n=6 per group) into the following eight groups: i) Control (PICC in place for 1 day); ii) 2nd day of PICC placement (received the first cycle of vinorelbine administration); iii) 3rd day of PICC placement; iv) 7th day of PICC placement; v) 14th day of PICC placement; vi) 21st day of PICC placement; vii) 23rd day of PICC placement (received the second cycle of vinorelbine administration); and viii) 24th day of PICC placement. Hematoxylin and eosin staining was performed on catheter, ear vein and anterior vena specimens. Prothrombin time was measured using an automatic coagulation analyzer, followed by routine blood tests. Serum levels of inflammation- and thrombosis-related factors, including C-reactive protein, D-dimer, interleukin-2, interleukin-6, P-selectin and E-selectin, were measured using ELISAs. X-ray examination confirmed that the rabbit model with vinorelbine administration via PICC was successfully constructed. On the 1st and 23rd day of PICC placement, thrombosis was observed in the catheter. Furthermore, on the 1st day of PICC placement, thrombosis was clearly observed in the ear vein and anterior vena samples. After vinorelbine administration, phlebitis occurred in the ear vein and anterior vena cava samples. With increasing time after vinorelbine administration via PICC, thrombosis and phlebitis were notably ameliorated. Moreover, on the day of vinorelbine administration, prothrombin time was significantly decreased and the serum levels of inflammation- and thrombosis-related factors were significantly increased compared with previous days. Collectively, the present study observed the formation and specific evolution of phlebitis and venous thrombosis after vinorelbine administration, providing a reference for the early prediction, timely prevention and treatment of PICC-related chemotherapy complications.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Comparing the accuracy and complications of peripherally inserted central catheter (PICC) placement using fluoroscopic and the blind pushing technique

INTRODUCTION

Peripherally inserted central catheters (PICCs) offer a convenient long-term intravenous access option. Different methods exist for insertion including the use of continuous fluoroscopy for guidance, or bedside insertion techniques. The blind pushing technique is a bedside approach which involves advancing a PICC through the access sheath without imaging guidance, before taking a mobile chest radiograph to confirm tip position. Obtaining optimal position is a critical aim of PICC placement as malpositioned lines have been associated with higher complications including death. We aimed to assess the accuracy of PICC placement by comparing the tip position and complications for lines placed under fluoroscopic guidance to those placed without fluoroscopic guidance.

METHODS

The Radiology Information System was used to identify 100 continuous PICC insertions in each group (fluoroscopic and blind pushing) between 1 January and 12 May 2019. Patients were excluded if there was a known history of central venous occlusion/stenosis.

RESULTS

In the fluoroscopic-guided group, 0% of the lines were malpositioned compared with 60% of the lines placed using the blind pushing technique, P < 0.001. Fluoroscopic-guided PICC insertions were in place for a total of 2446 days and demonstrated 6 complications (2.45 complications per 1000 catheter days). This compared with blind pushing technique PICC insertions which were in place for a total of 1521 days and demonstrated 18 complications (11.83 complications per 1000 catheter days), P = 0.004.

CONCLUSION

The use of fluoroscopy for PICC placement leads to significant improvements in tip accuracy than for PICCs placed using the blind pushing technique. While the use of these imaging resources incurs cost and time, these factors should be balanced in order to offer patients the safest and most accurate method of line insertion.

Bridging the gap: introduction of an antimicrobial peripherally inserted central catheter (PICC) in response to high PICC central line-associated bloodstream infection incidence

OBJECTIVE

To reduce the incidence of central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters (PICC) through the introduction of an antimicrobial (AM) catheter as recommended in evidence-based guidelines and standards.

DESIGN

Quality improvement project comparing incidence of infections pre-implementation and postimplementation of the new catheter.

SETTING

A 582-bed community teaching hospital in Northwest Indiana.

METHODS

Pre-implementation analysis of surveillance data indicated that 50% of CLABSIs occurred inpatients with PICCs in situ. A gap analysis was performed to review institutional practices against evidence-based recommendations. The use of an AM catheter was supported in each of the documents consulted. After introduction of the new device, performance was measured in a prospective manner using standardized Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance protocols for CLABSI and internal data sources for other measures.

RESULTS

After 30 months of data collection, the PICC CLABSI incidence reduced from a baseline rate of 1.83/1000 PICC days to 0.162/1000 PICC days (91.15% reduction, P=0.0002).

CONCLUSION

Combined with continued compliance with basic prevention strategies (ie use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial/antithrombogenic (AM/AT) PICC was associated with a significant reduction in CLABSI.

Entrapped peripherally inserted central catheter due to fibrin sheath in a neonate with noninvasive extraction and review of literature

Peripherally inserted central catheter line entrapment is a rare complication in the neonatal intensive care unit and only a small number of cases have been reported. While studies have suggested recommendations for removal, there is still a need for surgical intervention in some cases. This is a case of a premature infant with long term peripherally inserted central catheter line placement with fibrin sheath formation that required multiple attempts before successful noninvasive removal and a review of the cases with difficult peripherally inserted central catheter removal in newborns.

Comparison of midline catheters and peripherally inserted central catheters to reduce the need for general anesthesia in children with respiratory disease: A feasibility randomized controlled trial

BACKGROUND

The optimal intravenous device for antibiotic administration for children with respiratory disease is uncertain. We assessed the feasibility of a randomized controlled trial comparing midline catheters with peripherally inserted central catheters.

METHODS

Prospective, two-arm, feasibility randomized controlled trial in an Australian tertiary, pediatric hospital. Random assignment of 110 children (<18 years) to receive (i) midline catheter and (ii) peripherally inserted central catheters. Primary outcome was feasibility (eligibility, recruitment, retention, protocol adherence, and acceptability), and the primary clinical outcome was general anesthesia requirement for intravenous catheter insertion.

SECONDARY OUTCOMES

insertion time, treatment delays, infusion efficiency, device failure, complications, and cost.

RESULTS

There was 80% recruitment, 100% retention, no missing data, and high patient/staff acceptability. Mean patient experience assessed on a 0-10 numeric rating scale was 8.0 peripherally inserted central catheters and 9.0 (midline catheters), respectively. Participant eligibility was not achieved (49% of screened patients) and moderate protocol-adherence across groups (89% peripherally inserted central catheters vs. 76% midline catheter). Insertion of midline catheter for pulmonary optimization reduced the requirement for general anesthesia compared to peripherally inserted central catheters (10% vs. 69%; odds ratio = 0.01, 95% confidence interval: 0.00-0.09). Midline catheters failed more frequently (18.1 vs. 5.5 peripherally inserted central catheters per 1000 catheter-days); however, this reduced over trial duration. Midline catheter insertion compared to peripherally inserted central catheters saved AUD$1451 per pulmonary optimization episode.

CONCLUSIONS

An efficacy trial is feasible with expanded eligibility criteria and intensive staff training when introducing a new device. Midline catheter for peripherally compatible infusions is acceptable to patients and staff, might negate the need for general anesthesia and results in significant cost savings.