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Editor: A 13-year-old female patient was admitted with bacterial pneumonia and parapneumonic effusion. The patient required a right chest tube and a peripherally inserted central catheter (PICC). Both procedures were performed in the computed tomography (CT) suite to preclude patient transport while under sedation. The chest tube placement was followed by placement of a 5-F double-lumen PICC (Arrow, Reading, PA). As is our routine, before placement of the PICC by the physician, the catheter was cut to 14.5 inches by the nurse based on measurements from the mid-humerus to the shoulder to the suprasternal notch. This was followed by insertion of the J-tipped wire through the PICC until the end of the wire was flush with the end of the PICC. After 1% lidocaine (Abbott Laboratories, North Chicago IL) was applied to anesthetize the skin, ultrasound guidance was used in the puncture of the left basilic vein. A 0.018-inch wire was introduced into the needle and the dilator and sheath were advanced over this wire into the vein. The dilator and wire were removed, and the PICC was advanced to the central venous system. A chest radiograph showed that the PICC was too long. The PICC was therefore removed from the sheath, the wire was pulled back, and the catheter was cut to a new length of 12.5 inches. After reinsertion of the PICC, a chest radiograph showed good position of the PICC (Fig 1). The wire and sheath were removed, the PICC was flushed with heparinized saline solution, and the catheter was sutured in place. Two days later, a chest radiograph was obtained to evaluate the patient’s pneumonia (Fig 2). There appeared to be a guide wire looped in the pulmonary artery. To exclude this being outside the patient, we wanted to repeat chest radiography after the dressing on the patient’s back was removed. Because of the pain involved in removing the dressing, the patient refused, but her parent agreed to a limited CT scan, which confirmed that the wire was in the pulmonary artery (Fig 3). After discussion with the pediatricians, it was determined that no other procedures had been performed on the patient after PICC placement, and therefore the foreign body was somehow related to the PICC. Based on the acute angles that the wire was taking, the assumption was that the foreign body was the outer wrap of the J-tipped wire, which would be floppy enough to make those turns. We believed that the inner part of the J-tipped wire and the 0.018-inch puncture wire were not sufficiently floppy to make such turns. The following morning, the patient was brought to the angiography suite for foreign body retrieval and chest tube removal under sedation. The right common femoral vein was punctured, and, after placement of a 4-F sheath, the right pulmonary artery was catheterized with a Berenstein catheter (Boston Scientific, Watertown, MA) and a Glidewire (Boston Scientific). Exchange was made for a 10-mm Amplatz Goose Neck Snare (Microvena, White Bear Lake, MN), which was used to successfully snare the foreign body and remove it through the sheath. Inspection of the wire showed that it was in fact the outer wrap of the J-tipped wire, and measured 12.5 inches in length. The patient made an uneventful recovery and was discharged 3 days later. PICC placement has proved to be a safe procedure, with a recently reported complication event rate of two per 1,000 catheter-days. The most common complications are catheter dysfunction (eg, thrombosis, catheter related sheath, catheter malposition) and infection (1). Although guide wire fragment retrieval was reported as early as 1971 (2), and PICC fractures have been reported previously (3,4), our search of the literature did not yield any cases of a broken wire fragment resulting in a foreign body during PICC placement. Our goal was to try to ascertain what happened in this instance to be able to prevent future occurrences. The J-tipped guide wire is a 0.018-inch-diameter, 85-cmlong wire comprised of a 0.010-inch stainless-steel core wrapped by an outer spring made of 0.003-inch Tefloncoated stainless steel. The two wires are connected at both ends by a 2-mm ball weld with a weld strength of 15 N (3.5 lbs). The PICC is a 5-F dual-lumen polyurethane catheter with an extension line clamp proximal to each of the two hubs. The J-tipped wire is placed through the larger (18DOI: 10.1097/01.RVI.0000136035.86623.D3 Figure 1. Chest radiograph obtained immediately after PICC placement shows the tip in the lower SVC, the wire in the catheter, and no foreign body. Letters to the Editor
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22PICC management led by technicians: Establishment of a cooperation program with radiologists and evaluation of complications
PICC management led by technicians: Establishment of a cooperation program with radiologists and evaluation of complications
Read more6The dwell time and survival rates of PICC placement after balloon angioplasty in patient with unexpected central venous obstruction.
To evaluate the dwell time and actual survival rates of peripherally inserted central catheter (PICC) placements after balloon angioplasty in patients with unexpected central venous obstructions. Data were obtained on all PICC insertions performed in a tertiary care hospital from August 2008 to December 2013. Thirty-five PICCs attempted after balloon angioplasty in 25 patients (15 male and 10 female patients; mean age, 63 years). Fisher's exact test was used to test for differences in reasons for catheter removal between the groups of patients with stenosis or obstructions. Survival curves for PICC dwell time of all patients, stenosis group, and obstruction group were generated separately using Kaplan-Meier survival analysis and compared with log-rank tests. There were a total 21 obstructions and 14 stenoses. The overall technical success rate of PICC placement after balloon angioplasty was 94% (33 of 35 procedures). The PICC dwell time was determined for 27 PICCs and ranged from 4 to 165 days (mean, 39.6 days). Among all PICCs, 16 were removed early, resulting in an actual survival rate of 40.7% (11 of 27 PICCs). There were no significant differences in reasons for catheter removal between the stenosis and obstruction groups (p = 0.24). The dwell times for both groups were not significantly different by Kaplan-Meier analysis (p = 0.54). PICC placement after balloon angioplasty is a good treatment option for patients with unexpected central venous lesions, and offers high technical success rates. The actual survival rate was relatively lower (40.7%) than that from previous studies.
Read more14Are Cuffed Peripherally Inserted Central Catheters Superior to Uncuffed Peripherally Inserted Central Catheters? A Retrospective Review in a Tertiary Pediatric Center
Are Cuffed Peripherally Inserted Central Catheters Superior to Uncuffed Peripherally Inserted Central Catheters? A Retrospective Review in a Tertiary Pediatric Center
Read more22Prospective observational study on the complications and tolerability of a peripherally inserted central catheter (PICC) in neuro-oncological patients.
The use of central venous catheters with peripheral insertion (PICC) has increased rapidly in recent years, particularly in cancer patients. The benefits provided may occasionally be affected by relevant complications, such as infections and thrombotic events, especially in neuro-oncological patients. To date, the risk of PICC-related complications in this subset of patients is unknown, as is tolerability. As a primary objective, this study aimed to collect complications related to PICCs in primary neuro-oncological patients. As a secondary objective, the study aimed to evaluate PICC tolerability. Neuro-oncological patients with PICCs that were placed as part of normal clinical practice at IRCCS Neurologico C. Besta were consecutively enrolled in the study. PICC-related complications were recorded immediately (during the procedure), early (within 1week after PICC insertion), and late (1-3-5months after PICC placement). At the same time points, all patients were also evaluated for tolerability through interviews with semi-structured, open-ended questions. Sixty patients were enrolled (41 males and 19 females, with a median age of 56.2years). Excluding loss to follow-up, 33/49 patients developed at least one complication related to the PICC. Immediate complications mainly included hematoma (8), accidental arterial puncture (4), and primary malpositioning (3). Regarding early and late complications, 3 device-related infections, 8 thrombotic events, and 20 mechanical complications were registered. Semi-structured interviews revealed an overall positive experience with the device. The most negative impact was on hygiene habits, with 34 patients becoming caregiver-dependent. Over time, almost all patients became used to the device and perceived greater security during chemotherapy. A strongly negative issue was the difficulty of relying on competently trained healthcare personnel in outpatient setting. The results showed a nonnegligible increased thromboembolic risk in neuro-oncological patients with PICCs, almost double that in historical oncological populations. It is essential to extend the study to a greater number of patients to achieve reliable results and to identify patients at high risk. The device seems to be positively accepted by the majority of patients, without affecting activities of daily living.
Read more49A Nurse Led Peripherally Inserted Central Catheter Line Insertion Service is Effective with Radiological Support
A Nurse Led Peripherally Inserted Central Catheter Line Insertion Service is Effective with Radiological Support
28Predictors of Nonelective Removal of Peripherally Inserted Central Catheters in Infants.
Nonelective removal of peripherally inserted central catheters (PICCs) due to complications continues to be a major concern in neonatal intensive care units (NICUs) around the world. Nonelective removal results in interruption of intravenous therapy, added costs, stress, and negative impacts on infant's health. Identification of predictors of complications that lead to nonelective removal of PICCs would allow for the initiation of preventive strategies to improve the quality of care. To identify predictors of nonelective removal of PICCs in neonates. A prospective cohort study with a sample of 524 PICC lines inserted in 436 neonates admitted to a tertiary-level NICU of a Brazilian hospital. Data were collected on all neonates between August 31, 2010, and August 30, 2012. Neonates were monitored daily from insertion of the catheter until its removal. Bivariate analysis and a logistic regression were conducted in order to identify predictors of nonelective removal. A diagnosis of a transitory metabolic disorder (hypoglycemia; disorders of calcium, magnesium, sodium, or potassium; or dehydration), previous PICC line insertion, insertion of dual-lumen polyurethane PICC, noncentral tip position, and multiple intravenous solutions in a single-lumen silicone PICC were predictors of nonelective removal of PICC lines. The avoidance of repeated PICC insertions, noncentral tip position, and placement of single-lumen silicone PICCs for administration of four or more intravenous solutions is suggested. Interventions should be explored that facilitate PICC insertion success and correct tip placement.
Read more59Bedside placement of peripherally inserted central catheters: a cost-effectiveness analysis.
To compare two strategies for placement of peripherally inserted central catheters (PICCs). In strategy A, all PICC placements were initially attempted at the patient's bedside by trained intravenous (i.v.) nurses, with failures referred to the interventional radiology (IR) service. In strategy B, all PICCs were placed by interventional radiologists under fluoroscopic and/or venographic guidance. Decision analysis and cost-effectiveness models were constructed with commercially available software. Data used in the model were obtained from a review of the authors' experience with bedside placement of PICCs by an i.v. team and data obtained from the literature. The cost-effectiveness of strategy A relative to strategy B depends on (a) the ability of the i.v. team to access a vein at the patient's bedside, (b) the cost of fluoroscopy or the IR suite, and (c) the intended use of the PICC. If the cost of fluoroscopy or the IR suite exceeds $100, strategy A is more cost-effective for most intended PICC uses. If the cost is less than $75, strategy B is more cost-effective for all intended PICC uses. If the cost is between $75 and $100, the most cost-effective strategy depends on the intended use of the PICC and the need to have the tip placed at the junction of the superior vena cava and right atrium.
Read more2Clinical Study of Peripherally Inserted Central Catheter-Related Thrombosis and Its Influence on the Blood Flow Status of the Inserted Veins in Cancer Patients
To investigate the clinical features of peripherally inserted central catheter (PICC)-related thrombosis (PICCRT) within 2 weeks after PICC placement in cancer patients and its dynamic influence on the blood flow status of veins inserted with catheter, and to provide support for implementing thrombosis prevention and control measures. Between May 2019 and July 2020, patients who had solid tumors and who had PICC were prospectively enrolled at West China Hospital, Sichuan University. Scheduled color Doppler imaging was performed to examine the status of PICCRT formation at 8 points of time, with the first one conducted one day before the insertion of PICC and the other 7 completed within 2 weeks after the insertion of PICC. Then, based on whether patients had PICCRT, the patients were divided into two groups, a non-PICCRT group and a PICCRT group. The PICCRT group was further divided into two subgroups, an asymptomatic PICCRT group and a symptomatic PICCRT group, according to whether the patients had thrombosis-related symptoms and signs. Comparisons were made to study the incidence of PICCRT and the vascular diameter and the blood flow velocity in the veins inserted with catheters at different points of time in the patients of different groups. Among 173 cancer patients in the cohort, 126 (72.8%) developed PICCRT, all of which occurred within 1 week after PICC insertion. There were 95 cases of asymptomatic PICCRT and 31 cases of symptomatic PICCRT. Before and after PICC insertion, the vascular diameter of both the asymptomatic and symptomatic PICCRT groups was significantly smaller than that of the non-PICCRT group and the blood flow velocity was significantly slower than that of the non-PICCRT group, with the difference continuing to increase with the prolongation of catheter indwelling time. Inserting catheters in veins with bigger vascular diameter and faster blood flow velocity may help reduce the incidence of PICCRT. The first week post catheter insertion is the key intervention period for the prevention of PICCRT.
Read moreReduction of the catheter-associated bloodstream infection rate and an opportunity to improve the quality of care in a long-term acute care hospital
Reduction of the catheter-associated bloodstream infection rate and an opportunity to improve the quality of care in a long-term acute care hospital
Read more252Risk of Symptomatic DVT Associated With Peripherally Inserted Central Catheters
Risk of Symptomatic DVT Associated With Peripherally Inserted Central Catheters
13Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications
Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm. To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications. This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients. Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate <45 mL/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs. A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P < .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61). This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety.
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15Comparison of microbial colonization rates between central venous catheters and peripherally inserted central catheters
BackgroundCentral venous catheters (CVCs) and peripherally inserted central catheters (PICCs), have been widely used as intravascular devices in critically ill patients. However, they might evoke complications, such as catheter colonization that has been considered as predisposing factor for central line-associated bloodstream infections (CLABSIs). Although numerous studies have compared the risk of bloodstream infections between PICCs and CVCs, comparative studies on their colonization rates are limited.ObjectivesThe episodes of catheter colonization in critically ill patients with CVCs or PICCs were retrospectively analysed during a two-year period in a Greek tertiary care hospital and colonization rates, microbial profiles and antimicrobial susceptibility patterns were compared.MethodsClinical and laboratory data of consecutive hospitalized critically-ill patients who underwent PICC and CVC placement between May 2017–May 2019 were analysed. All catheters were examined by the semiquantitative culture technique for bacterial pathogens, either as a routine process after catheter removal or after suspicion of infection. Species identification and antimicrobial resistance patterns were determined by the Vitek2 automated system.ResultsDuring the survey period a total of 122/1187 (10.28%) catheter colonization cases were identified among CVCs and 19/639 (2.97%) cases among PICCs (p = 0.001). The colonization rate was 12.48/1000 catheter-days for the CVC group and 1.71/1000 catheter-days for the PICC group (p < 0.001). The colonization rate per 1000 catheter-days due to multidrug-resistant organisms (MDROs) was 3.85 in all study cases, 7.26 (71/122) in the CVC group and 0.63 (7/19) in the PICC group (p < 0.001). Within the CVC group, the most common microorganism isolated was MDR Acinetobacter baumannii (n = 38, 31.1%) followed by MDR Klebsiella pneumoniae (n = 20, 16.4%). In the PICC group, the predominant microorganism isolated was Candida spp. (n = 5, 23.8%) followed by MDR K. pneumoniae and MDR A. baumannii in equal numbers (n = 3, 14.2%).ConclusionPICC lines were associated with significantly lower colonization rates comparing to the CVC ones. In addition, patterns of microbial colonization revealed a trend over the predominance of MDR gram-negatives in CVCs suggesting that PICCs might be a safer alternative for prolonged inpatient intravascular access. Prevention programs directed by local microbial ecology may diminish catheter colonization rates and CLABSIs.
Read more10Peripherally inserted central catheters and the incidence of candidal sepsis in VLBW and ELBW infants: is sepsis increased?
Peripherally inserted central catheters (PICCs) have been widely used in neonatal clinics. However, the complications such as infection after PICC treatment are also confronting neonatologists especially in developing countries. This study was undertaken to investigate whether PICCs is a safe treatment for very low birth weight (VLBW) infants and extremely low birth weight (ELBW) infants. Fifty-nine VLBW and ELBW infants receiving PICCs and 89 VLBW and ELBW infants receiving peripheral intravenous catheters (PIVCs) were included in this study. The incidence of sepsis and mortality were compared retrospectively between the two groups. There was no difference in the total sepsis incidence and mortality between the PICCs and PIVCs groups (P=0.11 and P=0.61 respectively). However, the candidal sepsis incidence was higher in the PICCs group than in the PIVCs group [6/59 (10.2%) vs 2/89 (2.2%); P=0.044 (Exat Sig. 1-sided), OR=4.93, 95% CI 0.96-25.3]. Placement and indwelling of PICCs are a potential risk factor for candidal sepsis among VLBW and ELBW infants.
Read more1A New Equation to Estimate Peripherally Inserted Central Catheter Length
Background and Objectives: Peripherally inserted central catheter (PICC) placement plays an important role in clinical practice. This study aimed to provide an equation for the proper estimation of catheter length in cases of PICC placement without imaging guidance in relation to patient height, weight, sex, and age. Materials and Methods: For 1137 PICC placement cases in both arm veins of 954 patients at a single center, the elbow crease to the cavoatrial junction length (ECL) was calculated as follows: ECL = (PICC length) + (distance from the elbow crease to the puncture site). We analyzed the relationship between ECL and patient characteristics and suggested a new equation for ECL based on height, weight, sex, and age. Results: The average ECL was 48.0 ± 2.4 cm in the right side and 51.0 ± 3.0 cm in the left side. ECL in the right arm was significantly correlated with patient height, sex, and age, whereas the ECL in the left arm was additionally significantly correlated with patient weight. The ECL (cm) prediction model was as follows: right ECL = 26.32 + 1.33 × (female = 1, male = 2) − 0.02 × age (years) + 0.13 × height (cm); left ECL = 22.09 + 1.28 × (female = 1, male = 2) + 0.02 × age (years) + 0.14 × height (cm) + 0.042 × weight (kg). Conclusions: The appropriate PICC length was predicted based on the patient’s height, weight, sex, and age. The equations in our study can help predict the optimal catheter length and can be automatically calculated using computerized patient information for bedside procedures in PICC.
Read more30Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia
Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia
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