Risks associated with peripherally inserted central catheters – Authors' reply

Abstract

David Faraoni correctly states that the ratio between catheter and vein is important when examining risk of peripherally inserted central catheter (PICC)-associated thrombosis. Indeed, contemporary catheter insertion practices now call for ultrasound examination of venous anatomy to ensure (among other factors) adequate vessel size prior to placement.1Moureau N Lamperti M Kelly LJ et al.Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training.Br J Anaesth. 2013; 110: 347-356Crossref PubMed Scopus (121) Google Scholar Unfortunately, few studies reliably reported PICC gauge for our systematic review;2Chopra V Anand S Hickner A et al.Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis.Lancet. 2013; 382: 311-325Summary Full Text Full Text PDF PubMed Scopus (397) Google Scholar and when mentioned, overall results were presented rather than outcomes stratified by catheter. An individual patient-level meta-analysis is thus necessary to study the association between catheter size and thrombosis. We would be interested in doing such a study should these data become available. Tetsuji Fujita asserts that duration of PICC use could have influenced thrombotic risk. By contrast with PICC-related bloodstream infection,3Chittick P Azhar S Movva K Keller P Boura JA Band J Early onset versus late onset peripherally inserted central venous catheter infections: an analysis of risk factors and microbiology.Infect Control Hosp Epidemiol. 2013; 34: 980-983Crossref PubMed Scopus (8) Google Scholar the association between time of PICC use and thrombosis has not been well studied. Factors beyond duration of use—such as number of insertion attempts, catheter adjustments, diameter, and non-central tip-position—might also affect the timing of thrombosis;4Chopra V Anand S Krein SL Chenoweth C Saint S Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence.Am J Med. 2012; 125: 733-741Summary Full Text Full Text PDF PubMed Scopus (151) Google Scholar a prospective study is needed to gain further knowledge. Finally, Alexander Zarbock and Peter Rosenberger point out that PICC-related infections could vary with insertion site and dwell time. We agree. We did a meta-analysis of 23 studies examining the risk of PICC-bloodstream infection compared with tunnelled and non-tunnelled central venous catheters.5Chopra V O'Horo JC Rogers MA Maki DG Safdar N The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis.Infect Control Hosp Epidemiol. 2013; 34: 908-918Crossref PubMed Scopus (221) Google Scholar Our analysis found that PICCs were associated with lower risk of infection only in non-hospitalised, ambulatory patients; no benefit was observed among hospitalised patients. These findings help dispel the myth that PICCs confer an overall protective effect for infection. Rather, patient's context and history appear more relevant when considering the risk of PICC-related bloodstream infection. Randomised controlled trials taking into account insertion site and duration of use might provide important data in selected patients. We declare that we have no conflicts of interest. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysisPICCs are associated with a higher risk of deep vein thrombosis than are CVCs, especially in patients who are critically ill or those with a malignancy. The decision to insert PICCs should be guided by weighing of the risk of thrombosis against the benefit provided by these devices. Full-Text PDF Risks associated with peripherally inserted central cathetersThe risk of thromboembolism associated with peripherally inserted central catheters (PICCs) was recently assessed in a systematic review and meta-analysis (July 27, p 311).1 The investigators conclude that PICCs are associated with a higher risk of deep vein thrombosis than are central venous catheters, especially in critically ill patients or those with malignancy. I completely agree with the authors that the decision to insert PICCs should be guided by the benefit-to-risk balance. However, a major component of this evaluation was not considered in this analysis: the size. Full-Text PDF Risks associated with peripherally inserted central cathetersIn a meta-analysis by Vineet Chopra and colleagues,1 peripherally inserted central catheters (PICCs) were associated with an increased risk of deep venous thrombosis, when compared with other central venous catheters. These findings suggest that PICCs are associated with a higher risk of upper extremity deep venous thrombosis than are central venous catheters, but duration of catheter placement is not taken into account in the estimation of thrombotic risk. Full-Text PDF Risks associated with peripherally inserted central cathetersIn their meta-analysis on the risk of venous thromboembolism associated with peripherally inserted central catheters (PICCs),1 Vineet Chopra and colleagues noted that the insertion site of these venous catheters in different patient populations is associated with an increased risk of deep vein thrombosis. The incidence of PICC-related deep vein thrombosis was particulary high in critically ill patients. Full-Text PDF