Peripherally Inserted Central Catheter Placements Research Articles

Virtual Reality for the Management of Pain and Anxiety for IR Procedures: A Prospective, Randomized, Pilot Study on Digital Sedation

PurposeTo assess the analgesic and anxiolytic effects of virtual reality (VR) augmentation in patients undergoing peripherally inserted central catheter (PICC) placement or fine-needle aspiration thyroid biopsy. Materials and MethodsThis is a prospective, single-center randomized controlled trial with 107 patients enrolled. Patients were randomly assigned to receive standard of care (SOC) or SOC+VR during PICC or thyroid biopsy procedures. Pain and anxiety were individually measured using the visual analog scale (VAS) before and after the procedure. Vital signs including heart rate and systolic and diastolic blood pressure were recorded. One-way analysis of variance test and Games–Howell post hoc analysis were used to assess effect size and statistical significance between SOC and SOC+VR measures. ResultsThe PICC cohort consisted of 59 patients (33 in SOC+VR and 26 in SOC), with a median age of 53.1 years (interquartile range [IQR], 38.3–62.7 years). The thyroid biopsy cohort consisted of 48 patients (26 in SOC+VR and 22 in SOC), with a median age of 60.1 years (IQR, 49.0–67.2 years). One-way analysis of individuals undergoing thyroid biopsies with adjunctive VR revealed an effect size of −1.74 points (SE ± 0.71; P = .018) on VAS pain scale when compared with SOC. Analysis of individuals undergoing PICC placements revealed an effect size of −1.60 points (SE ± 0.81; P = .053) on VAS anxiety when compared with SOC. ConclusionsVR as a nonpharmacologic adjunct reduced some procedure-related pain and anxiety without increasing the procedural duration.

Analysis of factors related to thrombosis in patients with PICC placements.

This study aimed to investigate the conditions of patients with peripherally inserted central catheter (PICC) placements, analyze the risk factors influencing thrombosis in PICC-placed patients, and formulate more accurate and effective PICC management strategies. A total of 147 patients undergoing PICC placements were selected as the study subjects. Clinical data were collected, and the patients were divided into thrombosis and non-thrombosis groups. Detect levels of bilirubin, white blood cells, venous pressure, heparin concentration, blood flow, citric acid, and platelets. Pearson chi-square test, Spearman correlation analysis, as well as univariate and multivariate logistic regression were employed to analyze independent risk factors. Among the 147 patients with PICC placements, there were 84 males and 63 females. Thrombosis occurred in 116 cases, with an incidence rate of 78.91%. Pearson chi-square test showed a significant correlation between citric acid, blood flow, platelets and frailty (P < .001) with thrombosis formation. Spearman correlation analysis revealed a significant correlation between citric acid (ρ = -0.636, P < .001), blood flow (ρ = 0.584, P < .001), platelet count (ρ = 0.440, P < .001), frailty (ρ = -0.809, P < .001) and thrombosis in PICC placement patients. Univariate logistic regression analysis indicated a significant correlation between thrombosis formation and citric acid (OR = 0.022, 95% CI = 0.006-0.08, P < .001), blood flow (OR = 33.973, 95% CI = 9.538-121.005, P < .001), platelet count (OR = 22.065, 95% CI = 5.021-96.970, P < .001), frailty (OR = 0.003, 95% CI = 0.001-0.025, P < .001). Multivariate logistic regression analysis also showed a significant correlation between thrombosis formation and citric acid (OR = 0.013, 95% CI = 0.002-0.086, P < .001), blood flow (OR = 35.064, 95% CI = 6.385-192.561, P < .001), platelet count (OR = 4.667, 95% CI = 0.902-24.143, P < .001), frailty (OR = 0.006, 95% CI = 0.001-0.051, P < .001). However, gender (OR = 0.544, 95% CI = 0.113-2.612, P = .447), age (OR = 4.178, 95% CI = 0.859-20.317, P = .076), bilirubin (OR = 2.594, 95% CI = 0.586-11.482, P = .209), white blood cells (OR = 0.573, 95% CI = 0.108-3.029, P = .512), venous pressure (OR = 0.559, 95% CI = 0.129-2.429, P = .438), and heparin concentration (OR = 2.660, 95% CI = 0.333-21.264, P = .356) showed no significant correlation with thrombosis formation. Patients with PICC placements have a higher risk of thrombosis, citric acid, blood flow, platelet count and frailty are the main risk factors.

Fluoroscopically guided repositioning of peripherally inserted central catheter in patients failing ultrasound-guided-only placement: a retrospective five-year study.

Ultrasound (US)-guided-only insertion at the bedside is safe and improves the success rates of peripherally inserted central catheter (PICC). However, PICC insertion procedures remain challenging for special cases. To show that fluoroscopically guided tip repositioning, for failed US-guided PICC placement, safely led to satisfactory positioning in difficult cases and, importantly, improved success rates of PICC placements. A retrospective study of 1560 patients who underwent US-guided PICC placement were performed. Patients who failed US-guided PICC placement were transferred to the interventional radiology department for fluoroscopically guided tip repositioning. Baseline characteristics as well as insertion-related factors were collected. All data were analyzed using SPSS software. In total, 37 (2.4%) patients who failed US-guided PICC placement accepted fluoroscopically guided adjustment or re-insertion. Of these 37 patients, 32 were enrolled. We observed no significant differences between right and left arm PICC access (P > 0.05), even though a higher percentage of PICCs were inserted into left arms (56.3%). The basilic vein (65.6%) was the most common insertion site. Only four patients experienced slight angiospasm (3.1%) and venous thrombosis (9.4%). US-guided PICC insertion failures were primarily due to line tip malposition (84.4%). All patients successfully underwent fluoroscopically guided tip repositioning, which resulted in optimal catheter tip positioning. PICC lines were adjusted in most patients (n=28, 87.5%). Malposition was the primary issue causing US-guided PICC insertion failure. Fluoroscopically guided tip repositioning safely and efficaciously led to satisfactory positioning in difficult cases; thus, we recommend this method for patients failing US-guided PICC placement.

Safety and Efficacy of Peripherally Inserted Central Catheter Placement by Surgical Intensivist–Led Vascular Access Team

This study aimed to evaluate the safety and efficacy of bedside peripherally inserted central catheter (PICC) placement under ultrasonography (USG) guidance in the general ward by a surgical intensivist-led vascular access team versus that of PICC placement in the intensive care unit (ICU) or fluoroscopy unit. We conducted this retrospective study of all patients who underwent PICC placement between March 2021 and May 2022. Clinical, periprocedural, and outcome data were compared for PICC placement in the ICU, general ward, and fluoroscopy unit groups, respectively. A total of 354 PICC placements were made in 301 patients. Among them, USG-guided PICC placement was performed in 103 and 147 cases in the ICU and general ward, respectively, while fluoroscopy-guided PICC placement was performed in 104 cases. USG-guided PICC placement more often required post-procedural catheter repositioning than fluoroscopy-guided PICC placement (P<0.001), but there was no significant difference in any adverse events (P=0.796). In addition, USG-guided PICC placement in the general ward was more efficient than fluoroscopy-guided PICC placement (0.73 days vs. 5.73 days, respectively; P<0.001). In the multivariate analysis, previous PICC placement within 6 months was an independent risk factor for a PICC-associated bloodstream infection (odds ratio, 2.835; 95% confidence interval, 1.143-7.034; P=0.025). USG-guided PICC placement in the general ward by a surgical intensivist-led vascular access team has comparable safety and efficiency to that of USG-guided PICC placement in the ICU or fluoroscopy-guided PICC placement.

National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children.

Although a growing body of evidence suggests that early transition to oral antimicrobial therapy is equally efficacious to prolonged intravenous antibiotics for treatment of acute pediatric osteomyelitis, little is known about the pediatric trends in peripherally inserted central catheter (PICC) placements. Using a national database, we examined incidence rates of pediatric hospitalizations for acute osteomyelitis in the United States from 2007 through 2016, as well as the trends in PICC placement, length of stay (LOS), and cost associated with these hospitalizations. This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 through 2016. Patients ≤18 years of age with acute osteomyelitis were identified by using appropriate diagnostic codes. Outcomes measured included PICC placement rate, LOS, and inflation-adjusted hospitalization costs. Weighted analysis was reported, and a hierarchical regression model was used to analyze predictors. The annual incidence of acute osteomyelitis increased from 1.0 to 1.8 per 100 000 children from 2007 to 08 to 2015 to 16 (P < .0001), whereas PICC placement rates decreased from 58.8% to 5.9% (P < .0001). Overall, changes in LOS and inflation-adjusted hospital costs were not statistically significant. PICC placements and sepsis were important predictors of increased LOS and hospital costs. Although PICC placement rates for acute osteomyelitis significantly decreased in the face of increased incidence of acute osteomyelitis in children, LOS and hospital costs for all hospitalizations remained stable. However, patients receiving PICC placements had longer LOS. Further studies are needed to explore the long-term outcomes of reduced PICC use.

Clinical Impact of Chronic Venous Changes Induced by Central Lines in Children: A Cohort with Abnormal Venograms

PurposeTo explore the hypothesis that central venous stenosis/obstructions (CVS/O) in children are influenced by prior central venous access devices (CVADs) and are associated with future risk for thromboses. Material and MethodsA convenience sample of 100 patients with abnormal venography (stenosis, collaterals, occlusions) documented during peripherally inserted central catheter (PICC) placements were identified from consecutive PICC placements (January 2008 to November 2012). The patients (41 males, 59 females, median age 2.7 years, median weight 11 kg) were categorized based on venographic presence (Group A, n = 53) or absence (Group B, n = 47) of visible connection to the superior vena cava. Each patient’s CVAD history, before and after venography, was analyzed (until October 2016). ResultsBefore venogram, Group B patients were associated with a higher number of previous CVADs, larger diameter devices, greater incidence of malposition, and more use of polyurethane catheters than Group A patients (P < .001). An ipsilateral PICC was successfully placed in 98% of Group A, compared to 32% of Group B (P < .001). After venogram, significantly more Doppler ultrasounds (DUS) were performed and thromboses diagnosed in Group B (57% and 36%) compared to Group A (21% and 8%) (P < .003; P = .001), respectively. ConclusionsPrevious catheter characteristics influenced the severity of venographic changes of CVS/O (Group B). Group B was associated with more subsequent symptomatic thromboses. This information may assist parents and referring physicians to anticipate potential adverse sequelae from CVS/O on the child’s venous health.

Cost-Effectiveness of a Guided Peripherally Inserted Central Catheter Placement System: A Single-Center Cohort Study

PurposeTo assess the cost-effectiveness of peripherally inserted central catheter (PICC) placements using an ultrasound and electrocardiogram-guided system versus external measurements and confirmatory chest X-rays (CXRs). Materials and MethodsSixty-eight guided PICC placements were performed in 63 outpatients (mean age, 43 ± 13 years; 50% male) and compared to 68 propensity score-matched PICC placements (mean age, 44 ± 13 years; 56% male) performed using external measurements by the same operators. Post-placement CXRs were used to confirm final catheter tip positioning. Cohorts were compared in terms of repositioning rates, desired tip positioning rates (in the lower third of the superior vena cava or at the cavoatrial junction), and estimated cost per PICC positioned as desired using manufacturer quotes, Medicare reimbursement rates, and hourly wages for staff time. Agreement between tip positioning according to the guided system versus CXR was also assessed. ResultsGuided PICC placements required less repositioning (1.5% vs 10.3%, P = .03) and resulted in more catheters positioned as desired (86.8% vs 67.6%, P = .01) than the external measurement approach. The cost per PICC positioned as desired was lower for guided placements ($318.54 vs $381.44), suggesting that the guided system was cost-effective in this clinical setting. Guided system-CXR agreement for tip position was poor (κ=0.25, P = .002) due to tips being slightly farther from the cavoatrial junction on CXR than indicated by the guided system. ConclusionsThe guided PICC placement system was cost-effective in outpatients treated by a single division of interventional radiology at an academic institution.

PMD112 - Interventional Radiology to Bedside Peripherally Inserted Central Catheter Placement: A U.S. Hospital Cost Analysis

Estimate the health economic impact associated with nurse-based (RN) increased use of Sherlock 3CG® Tip Confirmation System (TCS) for intensive care unit (ICU) and non-ICU bedside peripherally inserted central catheter (PICC) placements compared to current physician-based interventional radiology (IR) department PICC placement (e.g., confirmatory chest x-ray) and physician-based centrally inserted central catheters (CICC) insertion procedures. A model was developed to estimate health economic outcomes over a three-year time horizon. For the current mix, it was assumed that all non-ICU patients received IR PICC placement and the majority of ICU patients received CICC placement. The future mix assumed that all eligible patients receiving IR PICC placement (~93%) switched to Sherlock 3CG® TCS. Tray, kit, and operational costs were assessed. Differences in staff time were also estimated. Inputs were derived from published literature where available. Sensitivity analyses, such as varying unit costs and utilization inputs were conducted to test a range of assumptions. Increased use of Sherlock 3CG® TCS was predicted to result in procedural cost savings when compared with current conventional PICC placements in the IR. In the base case, for an estimated population size of 1,325 annual patients, the cumulative three-year cost-savings were predicted to be $734,328. In addition, increased use of bedside PICC placement with Sherlock 3CG® TCS was predicted to reduce resource use (e.g., physician or IR staff time) when compared with conventional PICC placement in the IR. Finally, Sherlock 3CG® TCS was predicted to be cost-saving in the majority of sensitivity analyses. These analyses suggest that increased use of RN-based Sherlock 3CG® TCS may reduce the clinical, resource, and economic limitations associated with physician-based IR PICC placement methods. These analyses were not based upon head-to-head clinical comparisons and therefore additional data would help to further elucidate these findings.

Safety of fentanyl for peripherally inserted central catheter in non-intubated infants in the neonatal intensive care unit.

To evaluate the safety of fentanyl in non-intubated infants undergoing peripherally inserted central catheter (PICC) placement. A retrospective chart review of PICC placements over a 3 years' period. We compared the 12h periods before and after fentanyl for clinically significant cardiorespiratory events (spells). Of the 998 neonates screened, 258 were eligible. The mean standard deviation gestational age was 34.1 (4.3) weeks and the median (inter-quartile range) postnatal age was 4 (7, 11) days. The mean (standard deviation) fentanyl dose was 0.6 (0.2) µg/kg. Respiratory depression occurred only in two infants (prevalence rate = 0.78%, 95% CI (0, 1.85)). No cases of hypotension or chest wall rigidity occurred. There was no evidence of an increase in the number of infants with spells or in the number of spells per infant (p = 0.34 and p = 0.06, respectively). Fentanyl appears to be associated with only a small risk of respiratory depression in non-intubated infants.

Abstract No. 630 Cost and positioning of ultrasound and electrocardiogram-guided PICCs

To compare the accuracies and costs of peripherally inserted central catheter (PICC) placement using anatomical landmarks and an ultrasound and electrocardiogram (US/ECG)-guided system in inpatient and outpatient settings. 468 PICC placements at a single institution were reviewed: 250 inpatient placements with anatomical landmarks (Group A), 150 outpatient placements with anatomical landmarks (Group B), and 68 outpatient placements with an US/ECG-guided system (Group C). Costs were estimated using 2012 Medicare reimbursement rates. Chi-squared tests with phi coefficients were used to compare rates of ideal positioning and repositioning. Ideal position was defined as in or between the lower third of the superior vena cava and upper right atrium. Analyses of variance were used to identify independent variables associated with higher costs. No significant differences were found between groups in terms of age or gender (p>0.05). Ideal catheter tip position rates for groups A-C were 53.3%, 64.7%, and 87.1%, respectively (ϕ = 0.24, p30.3% or price reduction of $25.29 (inpatient)/$41.82 (outpatient) would necessary for the ECG-guided system to be cost effective. However, repositioning also required an additional 50 minutes staff time per case and delayed treatment ≥24 hours in 5.1% of the entire cohort. US/ECG-guided PICC systems can significantly reduce tip malposition rates. They may be cost-effective if indirect costs are considered in patient groups with high repositioning rates.

9-190 - Ensuring Appropriate Peripherally Inserted Central Catheter (PICC) Utilization

BACKGROUND: Reducing central line utilization is an important intervention to reduce infections. We identified that PICCs accounted for 45% of total central line days, were present in 40% of CLABSIs, and 30% of PICC placements were ordered for “difficult intravenous access” rather than a clinically significant indication. PICCs are more invasive than other line options, exposing patients to additional risks including Central Line Associated Blood Stream Infections (CLABSIs).

Peripherally inserted central catheters optimize nutrient intake in moderately preterm infants.

While very preterm (<32 wk gestation) infants are routinely provided intensive nutritional support via central line, clinical practice varies for nutrient delivery in infants born moderately preterm (32-34 wk gestation). We sought to define the impact of nutritional support via peripherally inserted central catheter (PICC) on nutrient delivery in the first 2 wk of life and growth by discharge. Data were extracted from the records of 187 infants born between 32 and 34 6/7 wk gestation and admitted to the University of Iowa Children's Hospital between April 2012 and December 2013. Records of all feedings, weights, and PICC placements were collected. The growth outcomes at discharge for infants who received nutrition via PICC were compared to those who did not. In the first week of life, newborns who received nutrition via PICC line received 17.6 more kilocalories (confidence interval (CI): 12.5-22.7, P < 0.001) and 1.2 more grams protein per kilogram body weight per day (CI: 0.9-1.4, P < 0.001) compared to control infants. By discharge, the PICC group had gained 302 g more body weight (P < 0.001). This study demonstrates superior nutrient intake and growth in the first 2 wk of life for infants who received nutrition via PICC line.

PO-02 - Retrospective audit of the Peripherally Inserted Central Catheter (PICC) associated thrombosis in patients with haematological malignancies at Cork University Hospital

Peripherally inserted central catheters (PICC) have been increasingly used for administration of chemotherapy, antibiotics and blood products in patients with haematological malignancies. Although generally regarded safe, infections and thrombotic events have occurred with PICC use, necessitating study to guide future clinical prophylaxis and management. 1) Determine the incidence of PICC associated thrombosis in patients with haematological malignancies 2) To identify clinically significant risk factors contributing to these complications. This was a cohort study, conducted in Cork University Hospital, between January 2010 and June 2015. After ethical approval Picture Archiving and Communication System (PACS) in radiology was used. All adult patients with PICC inserted under haematology were identified. A total of 90 patients with haematological malignancies who had PICC line placement were included. Patients' charts were reviewed in the medical record department. Data was collected using proforma sheets. This included patients demographs, type of malignancy, size of the PICC line, and total days of insertion. Haematological laboratory parameters were also recorded. The main outcome measures were PICC associated thrombosis and/or infection Of 131 PICC placements in a total of 90 patients. Out of these total PICC episodes 28.2% developed complications (n=37) and lead to removal. Thrombosis was found in 14.5% (n=19), 13.7% developed infection (n=18) and remaining were without complications. Of those with thrombosis (n=19), 7 patients had a diagnosis of Multiple Myeloma and 6 had Acute Myeloid Leukaemia. Whereas those with PICC associated infection (n=18), 5 had Non-Hodgkin's lymphoma and 5 had Acute Lymphoid Leukaemia. Diagnosis was significantly associated with complication (p=0.019). The mean age of patients who has PICC associated thrombosis was 51.6 years (±8.1 years). PICC removal as a result of complications was associated with increasing PICC lumen size; 30% of 5-French PICCs necessitated removal whereas 79.2% of 6-French PICCs necessitated removal (p=0.01). In addition, increased PICC lumen size was associated with clinically evident thrombophlebitis; 30% of 5-French PICCs displayed thrombophlebitis vs. 77%of 6-French PICCs displayed thrombophlebitis (p=0.017). Decreased in PICC lumen size was shown to influence the risk of complications; of 5 French catheters, 20% had thrombosis and 15% had infection, vs. 6 French catheters (13% and 13% respectively). Men were found to experience complications earlier with 80% of men having complications 1-50 days post PICC insertion and 12% 51-100 days post insertion. The risk of complications of PICC line insertion is relatively high in patients with haematological malignancies. Our institute thrombosis rate is similar to other studies. Haematological diagnosis was significantly associated with complication risk. Increased PICC lumen size was associated with higher removal rates as a result of complications and clinical signs of thrombophlebitis.

Electrocardiogram-Guided Peripherally Inserted Central Catheter Tip Confirmation Using a Standard Electrocardiogram Machine and a Wide-Mouth Electrocardiogram Clip Compared with Traditional Chest Radiograph

ObjectiveThe purpose of this institutional review board-approved, single-blinded, randomized controlled trial was to evaluate the effectiveness of bedside peripherally inserted central catheter (PICC) tip placement using a nonproprietary electocardiogram (EKG) machine and wide-mouth EKG clip connected to the right arm lead and PICC guide wire. The hospital site in this study was an 800-bed community, nonacademic, Magnet hospital in the southeastern United States. MethodsAll patients who provided consent and were eligible for bedside PICC insertion were randomly assigned to either standard PICC insertion or standard PICC insertion plus EKG guidance. Placement was identified by observing for P wave changes, which indicated PICC tip location in relationship to the sinoatrial node in the superior vena cava. After the PICC lines were placed, 2 radiologists blinded to treatment assignment independently reviewed confirmatory chest radiographs. De-identified data were collected and analyzed. ResultsOne hundred eighty-seven patients participated in this study. Of all patients, 94.6% had a baseline rhythm with a discernable P wave. The time to insert the PICC while using EKG guidance increased by a mean difference of 9 minutes (P = .001). The time to notification of the floor nurse that the PICC was read by a radiologist and ready to use for infusions was not significant between groups. In the control group, 91.8% of PICC lines were placed to completion at the bedside vs 90.2% in the experimental group (P = .710). PICCs placed with EKG guidance were successfully placed with the first attempt or 1 pass (89%; n = 91) vs PICCs placed without EKG guidance (75%; n = 63; P = .01). Of the control group, 40% (n = 34) and of the experimental group, 48% (n = 49) had PICC lines placed within 1.5 cm of the sinoatrial junction. Of the control group, 53% (n = 45) and of the experimental group, 65% (n = 66) had PICC lines placed within 1.5 cm of the sinoatrial junction to 3.0 cm above the sinoatrial junction (P = .10). Of the control group, 64.8% (n = 55) and of the experimental group, 82.2% (n = 84) had PICC lines placed within 1.5 cm of the sinoatrial junction to 6.0 cm above the sinoatrial junction (P = .3). Of the control group, 7.1% (n = 6) and of the experimental group, 2.9% (n = 3) had PICC lines placed 6.1 cm or more above the sinoatrial junction. Of the control group, 18.8% (n = 16) and of the experimental group, 8.8% (n = 9) had PICC lines placed too deep in the superior vena cava and below 1.6 cm (P < .05). PICCs inserted with or without EKG guidance statistically had the same amount of chest radiograph images performed (P = .083). Three groups reviewed the chest radiographs to determine the PICC tip location and they agreed to the location 82% of the time and a significant positive correlation between all 3 groups existed. The PICC Team subjectively identified 22 patients as obese. No statistical significance was realized among patients not identified as obese vs those identified as obese. ConclusionsThe data revealed that the control and experimental groups were equally distributed for baseline demographic characteristics such as sex and age. Importantly, it was determined that 94% of participants had a discernable P wave and were candidates for the use of EKG guidance. The time to insert a PICC line at bedside with the use of EKG guidance increased the procedure time by a mean of 9 minutes; however, the ultimate influence on patient care resulted in a savings of 67 minutes after factoring in an average of 76 minutes for radiograph confirmation. Complications and the need to reposition PICC lines were not found to be significant or vastly different or improved with or without the use of EKG guidance. PICC lines placed with the use of EKG guidance were significantly unlikely to be repositioned. Lastly, it was found that obesity did not play any particular role. Based on these findings, the facility determined that EKG guidance is effective and its use was implemented for all bedside PICC placements in which a P wave was discernable.

Peripherally Inserted Central Catheter (PICC) placement in newborns, Italian training program for nurses: preliminary results

In the Italian Neonatal intensive care Units the positioning of Peripherally Inserted Central Catheters (PICC) is strictly a medical competence, neonatal nurses are the ones fully entrusted of the PICCsmanagement. In 2014 a group of neonatologists and nurses established at the Civil Hospital in Brescia a PICC group; the aim was to review and update the internal procedures but, also to ponder the idea of training nurses to place PICCs. Many were the reasons for this last consideration; to improve the quality and safety of neonatal critical care, to standardize the procedures to reduce errors and complications but also to make neonatal nurses fully aware of their role in PICCs correct management. A course was organized in two phases (lessons and practice) with the aim to provide participants with the knowledge and skills to safely position and manage PICCs. A careful work of review of national and international scientific literature regarding PICCs was carried out, the NICU procedures were updated prior the course onset [1-5]. All the specific topics regarding PICCs were tackled during the first part of the course(theoretical). The second part (practical) was divided in three parts:A) “executor” nurses were supposed to successfully position 4 PICCs under medical supervision, B) “tutor” nurses were asked to correctly position 10 PICCs, C) maintenance of the acquired skills. Data collection forms have been designed to keep records on PICCs placements, management and potential adverse events. Of the 54 nurses working in NICU, 32 (59%) participated actively at the project. At present 20 nurses have started the practical training:6 have completed the A) phase.53 PICCs have been successfully placed by nurses. The medium number of PICC placement for nurse has been 2,65. The training course for nurses has shown a good safety profile, a high success rate, and no post-procedural complications; a questionnaire has been proposed to all the NICU staff to acknowledge their opinions and impact. These preliminary data are promising, but we need to complete the whole program before being able to encourage other centers to follow our steps.

Retrospective Analysis of Peripherally Inserted Central Catheter-related Vein Thrombosis in Lung Cancer Patients

背景与目的经外周置入中心静脉导管（peripherally inserted central catheter, PICC）相关静脉血栓会给患者带来极大危害和经济负担，是不容忽视的PICC相关并发症。本研究旨在探讨肺癌患者置入PICC发生静脉血栓的相关因素，以降低PICC相关静脉血栓的发生率，延长导管使用时间。方法将2010年1月-2013年9月间住院化疗安置PICC的1, 538例肺癌患者纳为研究对象，对发生PICC相关静脉血栓的患者进行回顾性分析，分析患者年龄、性别、置管静脉、置管肢体、血小板计数、凝血酶原时间（prothrombin time, PT）、纤维蛋白原（fibrinogen, FIB）值与发生静脉血栓有无相关性。结果在1, 538例置管患者中，发生静脉血栓38例，发生率为2.47%。患者的年龄、置管肢体、血小板计数、PT对PICC相关性静脉血栓的发生的影响差异无统计学意义（P > 0.05），性别（OR=2.194, P=0.024）、置管静脉（OR=1.955, P=0.006）、FIB值（OR=2.055, P=0.028）对PICC相关性静脉血栓的发生的影响差异有统计学意义；女性患者发生率高于男性患者，头静脉置管的发生率高于肘正中静脉、贵要静脉置管，FIB > 4 g/L的患者发生率高于FIB≤4 g/L的患者。结论患者性别、置管静脉、FIB值与PICC相关静脉血栓的发生密切相关。在PICC护理工作中，应详细评估患者的情况，进行个体化护理，从而有效降低PICC相关静脉血栓发生率，延长导管使用时间。

Évaluation des cathéters centraux à insertion périphérique en population pédiatrique

A peripherally inserted central catheter (PICC) is a central venous access mostly used in France in the adult population, whereas it is only rarely used in the pediatric population. The main objective of this study was to analyze a cohort of children treated with PICCs inserted under radiological guidance. We conducted a single-center study in the Radiology department of Nice University Hospital and the Lenval Foundation Children's Hospital. During a 43-month period between November 2008 and June 2012, a total of 67 catheter placement attempts were performed in 57 pediatric patients aged from 7 months to 18 years. We achieved 95.5% technical success with a median procedure duration of 17min. Only 6% of the PICC placements required light intravenous sedation; all the others were performed using a combination of local anesthesia, EMLA cream, and equimolar mixture of oxygen and nitrous oxide (EMONO). Subjective scale analysis of pain during catheter insertion showed a median score of 2.1. Catheter life ranged from 1 to 210 days (median, 38.3 days) with the treatment fully completed in 75% of the cases. The overall complication rate was 18.7% (4.9 per 1000 catheter-days), largely dominated by mechanical complications (9.4%) such as accidental removal (6.2%) or catheter obstruction (3.1%). Infectious complications occurred in 7.8% of the patients. The duration of catheterization and the use of tape to secure the catheter significantly affected the occurrence of complications. Peripheral insertion of central catheters was highly feasible in infants and children. It is a simple, safe, and effective alternative to intravenous central devices in the pediatric population. The occurrence of complications, typically mechanical, must be reduced and prevented by strict management of this type of central line by the nursing team.

Management of peripherally inserted central catheter associated deep vein thrombosis in children

No protocol exists for prophylaxis or therapeutic management of peripherally inserted central catheter (PICC) related deep venous thrombosis (DVT) in children. Currently, very few patients are provided prophylaxis for DVT. In this study, we analyzed our current practice of PICC placement to identify the frequency of DVT, analyze risk factors and determine current treatment patterns in order to determine the need for protocols. The dataset was retrospectively collected from January 1, 2000 to December 31, 2011. Patients with an upper extremity PICC were assessed for subsequent DVT formation. Variables included: demographics, co-morbidities, method of DVT diagnosis, treatment course, and recurrence. There were 1,289 PICC placements, with 24 (1.9 %) per line events of DVT in 23 patients, of which 3 had recent surgery, 2 had sepsis, 1 had a family history of clots, and 2 had a malignancy. All but one was symptomatic. Diagnosis was made in 92 % by ultrasound, the remaining with CT. No patients had prophylaxis. Of the seven patients who underwent hypercoagulable work-up, three were positive. 15 patients were treated with enoxaparin, 5 patients were treated with heparin, 2 treated with tissue plasminogen activator and 2 were observed. 84 % were treated with long-term enoxaparin for a mean of 3.3 months with 54 % proven clot resolution and 1 patient had recurrence of UE DVT. The risk of DVT with PICC placement is small in children and prophylaxis can probably be reserved for those with previous DVT or known hypercoagulable state.

Peripherally inserted central catheter service: improving practice with ultrasound

Intravenous therapy can be complex, often requiring central venous access. The Bristol Haematology and Oncology Centre (BHOC) has a well-established nurse-led peripherally inserted central catheter (PICC) service. Over the past three years at the BHOC, the use of ultrasound-guided placement has been explored and developed as a way forward for the already well-established PICC placement service. Once competency is established, the use of ultrasound significantly increases the success rate of PICC insertions, allowing access to the basilic and brachial veins, reducing the incidence of thrombosis. This article examines how the use of ultrasound was introduced, consequently improving the success rate of PICC placements.

Peripherally Inserted Central Catheter Placement in Patients with Unsuspected Central Venous Obstruction

To evaluate the feasibility and clinical usefulness of peripherally inserted central catheter (PICC) placement in patients with unsuspected central venous obstruction. Of 3,272 PICC procedures performed from January 1999 to July 2006, 57 patients had central venous stenosis or obstruction during placement of the PICC. Sixty PICC placements were performed in 57 patients (30 male and 27 female patients; mean age, 59 years). The PICC placements in 57 patients were evaluated with regard to the location and severity of venous disease, underlying causes of venous stenosis or obstruction, catheter placement technique, technical success rate, catheter dwelling time, and complication rate. There were 48 complete obstructions and 12 stenoses. Ipsilateral lesion passage was attempted in 31 patients and was successful in 26 (84%) and unsuccessful in five (16%). Over-the-wire PICC placement was performed in 16 patients, and PICC placement after angioplasty was performed in 10. Contralateral PICC placement without a trial of traversing the lesion was done in 26 patients. The PICC dwell time ranged from 2 to 150 days (median, 25.5 days). Complications occurred in four of the 57 patients (7%) and included tube tip migration (n = 1), catheter occlusion (n = 1), and catheter infection (n = 2). PICCs can be safely placed across central venous lesions in patients with asymptomatic central venous stenosis or obstruction. Contralateral placement is favorable in cases of ipsilateral passage failure.