Peripherally Inserted Central Catheter Tip Location Research Articles

Incidence and risk factors of neonatal peripherally inserted central catheter-related thrombosis: A systematic review and meta-analysis.

Catheter-related thrombosis is a common complication of the peripherally inserted central catheter (PICC) in neonates, leading to unintended tube removal and significantly affecting neonatal health and safety. Despite widespread reporting on the estimated occurrence and factors contributing to neonatal PICC-related thrombosis, these findings have not been synthesized. The purpose of this study was to determine the incidence and risk factors of neonatal PICC-related thrombosis. Systematic literature review and meta-analysis. Two independent researchers systematically explored multiple databases-such as PubMed, Medline, Embase and the Cochrane Library-from their inception until October 2023. Our study aggregates and scrutinizes studies specifically addressing the incidence and risk factors of neonatal PICC-related thrombosis. Employing the RevMan 5.3 software, a meta-analysis was executed to determine the incidence of both thrombosis and odds ratios (OR), accompanied by their respective 95% confidence intervals (CI) for the risk factors. A total of 327 articles were screened, and data from 24 studies were used in synthesis. Neonatal PICC-related thrombosis incidence varied from 0.23% to 17.91%. The pooled incidence was 2% (95% CI: 1%-2%; I2 = 94%; p < .0001). The study identified 12 risk factors, including insertion sites in the lower extremities (OR = 0.22; 95% CI: 0.09-0.56; p = .001), gestational age <28 weeks, abdominal pathology, fresh frozen plasma by day 5 > 50 mL/kg, PICC tip location (proximal placement), two lumens, three lumens, prolonged hospital stay, infection, mothers' use of anticoagulants, patients with cardiac insufficiency and being twin-to-twin transfusion syndrome donor. The analysis indicates an overall pooled incidence of neonatal PICC-related thrombosis of 2%. Twelve factors were identified as risks associated with neonatal PICC-related thrombosis. Understanding the risk factors can provide evidence-based recommendations for improving awareness, control and treatment and better nursing management. This systematic review and meta-analysis illuminates the incidence and risk factors linked to neonatal PICC-related thrombosis, delivering essential insights pivotal for clinical decision-making and enhancing patient care within neonatal health care settings.

Ultrasound vs. standard radiography to determine peripherally-inserted central catheter tip location

Background The use of a peripherally-inserted central catheter (PICC) has increased in preterm neonates to facilitate the administration of total parenteral nutrition. Standard radiography (thoracoabdominal X-ray) is the gold standard for determining the position of the PICC tip. However, radiography is not always accurate, influenced by the position of the extremities and anatomic variations, time-consuming procedural process, involves radiation, and is costly. Ultrasonography (USG) may serve as an easier, safer, less costly, and more real-time alternative in the neonatal intensive care unit (NICU) patients. Objective To assess the accuracy of USG use in determining PICC tip position compared to that of standard radiography. Methods This diagnostic study was conducted in the NICU at Dr. Cipto Mangunkusumo Hospital, Jakarta. The PICCs were placed using standard NICU procedure, then the tip position was evaluated using the USG immediately before standard radiography was performed. A 2x2 table was constructed to compare the diagnostic accuracy of the two modalities. Results A total of 29 neonates were included in our study. Subjects’ mean gestational age and weight were 31.7 weeks and 1,618.9 g respectively. Concordance of PICC tip positioning between standard radiography and USG occurred in 27 neonates (93.1%). USG had 88.89% sensitivity, 95% specificity, and 93.1% diagnostic accuracy. Conclusion USG has excellent diagnostic accuracy for confirmation of the PICC tip position.

Automated precision localization of peripherally inserted central catheter tip through model-agnostic multi-stage networks

Background:Peripherally inserted central catheters (PICCs) have been widely used as one of the representative central venous lines (CVCs) due to their long-term intravascular access with low infectivity. However, PICCs have a fatal drawback of a high frequency of tip mispositions, increasing the risk of puncture, embolism, and complications such as cardiac arrhythmias. To automatically and precisely detect it, various attempts have been made by using the latest deep learning (DL) technologies. However, even with these approaches, it is still practically difficult to determine the tip location because the multiple fragments phenomenon (MFP) occurs in the process of predicting and extracting the PICC line required before predicting the tip. Objective:This study aimed to develop a system generally applied to existing models and to restore the PICC line more exactly by removing the MFs of the model output, thereby precisely localizing the actual tip position for detecting its misposition. Methods:To achieve this, we proposed a multi-stage DL-based framework post-processing the PICC line extraction result of the existing technology. Our method consists of the following three stages: 1. Existing PICC line segmentation network for a baseline, 2. Patch-based PICC line refinement network, 3. PICC line reconnection network. The proposed second and third-stage models address MFs caused by the sparseness of the PICC line and the line disconnection due to confusion with anatomical structures respectively, thereby enhancing tip detection. Results:To verify the objective performance of the proposed MFCN, internal validation and external validation were conducted. For internal validation, learning (130 samples) and verification (150 samples) were performed with 280 data, including PICC among Chest X-ray (CXR) images taken at our institution. External validation was conducted using a public dataset called the Royal Australian and New Zealand College of Radiologists (RANZCR), and training (130 samples) and validation (150 samples) were performed with 280 data of CXR images, including PICC, which has the same number as that for internal validation. The performance was compared by root mean squared error (RMSE) and the ratio of single fragment images (RatioSFI) (i.e., the rate at which model predicts PICC as multiple sub-lines) according to whether or not MFCN is applied to seven conventional models (i.e., FCDN, UNET, AUNET, TUNET, FCDN-HT, UNET-ELL, and UNET-RPN). In internal validation, when MFCN was applied to the existing single model, MFP was improved by an average of 45 %. The RMSE improved over 63% from an average of 27.54 mm (17.16 to 35.80 mm) to 9.77 mm (9.11 to 10.98 mm). In external validation, when MFCN was applied, the MFP incidence rate decreased by an average of 32% and the RMSE decreased by an average of 65%. Therefore, by applying the proposed MFCN, we observed the consistent detection performance improvement of PICC tip location compared to the existing model. Conclusion:In this study, we applied the proposed technique to the existing technique and demonstrated that it provides high tip detection performance, proving its high versatility and superiority. Therefore, we believe, in countries and regions where radiologists are scarce, that the proposed DL approach will be able to effectively detect PICC misposition on behalf of radiologists.

Monitoring the Infusion Rate During Cough: A New Method to Position the PICC and Outcome Evaluation

With the wide application of peripherally inserted central catheter (PICC) in clinic, the associated complications are gaining more attention. Among them, catheter misplacement is the common one and the main cause for unplanned extubation. It is reported that rate of catheter misplacement during catheterization is 12.5%-25%, which makes determination of PICC tip location the focus of operator. Coughing could instantly and indirectly change the pleural cavity pressure and thus alter the inner pressure of superior vena cava, which further changes the dripping speed, so by observing the dripping speed, the PICC tip location can be determined, and thus adjustment can be made to improve the success rate of one-time catheterization. By comparing rate of catheter misplacement between two groups, the present study assessed the method of determining the PICC tip location by observing the dripping speed when coughing. Results shows that the method is effective in reducing the rate of catheter misplacement, with 1 out of 252 cases experienced catheter misplacement in experimental group, which only accounted for 0.4%. This method is not only convenient to use, but also effective in determining catheter misplacement both during and after the catheterization, which is worthy of clinical application. This is a brand new method for determining the PICC tip location, which has never been reported.

Optimal tip position of peripherally inserted central catheter (PICC) using electrocardiogram–a retrospective analysis

BackgroundCorrect tip location of a peripherally inserted central catheter (PICC) is crucial to ensure optimal drug delivery and avoid creating potential complications. P‐wave amplitude changes in the intravascular electrogram (ivECG) can guide the PICC tip to the optimal location during the catheter placement procedure, but its accuracy is limited. Therefore, the main objective of this study was to evaluate the ratios of different waves in ivECG and body external ECG (exECG) when the correct tip location was confirmed by chest X‐ray (CXR).MethodsIn this retrospective study, we analyzed the ivECG, exECG, and CXR of 146 patients who underwent a PICC placement procedure. The optimal location of the PICC tip was defined in the lower 1/3 of the superior vena cava (SVC) to the junction of the SVC and right atrium, known as the cavo‐atrial junction (CAJ). The catheter tip to carina distance (TCD) was also measured using vertebral body units (VBU). The PICC tip location was categorized as follows: Zone 1, malposition with TCD &lt; 1.2 VBU; Zone 2, suboptimal with 1.2 VBU ≤ TCD &lt; 1.8 VBU; Zone 3, optimal with 1.8 VBU ≤ TCD &lt; 2.8 VBU; Zone 4 deep with TCD &gt; 2.8 VBU. The amplitude ratios between/within the ivECG and the exECG of the corresponding waves were calculated and compared.ResultsThe external/internal ratio of the amplitude of uprising P‐wave (Psp) and declining P‐wave (Ppe) in Zone 3 was significantly higher than in Zone 1 (p &lt; 0.001) and Zone 2 (p = 0.004). The amplitude ratio in the ivECG of uprising P and QR (Pspiv/QRiv), uprising P and RS (Pspiv/RSiv), declining P and QR (Ppeiv/QRiv), and declining P and RS (Ppeiv/RSiv) were significantly lower in Zone 3 compared to Zone 1 (p &lt; 0.001, respectively). There was a moderate correlation between TCD using VBU and ECG height ratios such as Pspiv, Ppeiv, Pspiv/QRiv, and Pspiv/RSiv (p &lt; 0.001, respectively).ConclusionsThe height ratios of ECG waves such as Pspiv, Ppeiv, Pspiv/QRiv, and Pspiv/RSiv can help determine the catheter tip location during the catheter insertion procedure; however, caution is required for accurate positioning of the PICC tip.

Effects of indwelling centrally inserted central catheter on tip location of peripherally inserted central catheter with intracavitary electrocardiogram guidance: A retrospective case-control study.

Intracavity electrocardiogram (IC-ECG) guidance is an effective technology for monitoring the tip locations of centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs). However, for patients with an indwelling CICC, there has been no study on whether the CICC affects PICC tip positioning with IC-ECG guidance. Thirty people with a CICC requiring PICC insertion, matched with age to controls without a CICC. The stability of IC-ECG waveforms, the amplitude of P-waves, and the accuracy of PICC tip location were compared. There was no significant difference in the stability of the IC-ECG waveforms (χ2 = 0.22, p = 0.64). The amplitudes of baseline P-waves and ideal P-waves also showed no significant difference (t1 = 0.06, p1 = 0.96, t2 = 0.80, p2 = 0.43). Neither the accuracy of tip location (χ2 = 1.40, p = 0.50) nor the distance of PICC tip (t = -0.03, p = 0.98) were significantly different. For patients with an indwelling CICC, the position of PICC tip can be accurately determined by the dynamic changes in the P-wave amplitude.

Diagnostic accuracy among trainees to safely confirm peripherally inserted central catheter (PICC) placement using bedside ultrasound.

Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment. A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded. Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34-44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%. With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.

Diagnostic Accuracy Among Trainees to Safely Confirm Peripherally Inserted Central Catheter (PICC) Placement Using Bedside UltrasoundCE

Highlights Abstract Background: Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment. Methodology: A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded. Results: Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34–44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%. Conclusions: With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.

Intracavitary electrocardiogram guidance for placement of peripherally inserted central catheters in premature infants.

This study evaluated the accuracy of intracavitary electrocardiogram (IC-ECG) guidance for placement of peripherally inserted central catheters (PICCs) in premature infants, relative to chest X-ray.Premature infants (n = 173) underwent placement of a PICC monitored by ECG, and a stable heart rhythm was shown. Changes in the P wave of the ECG reflected the position of the catheter tip, and a characterized P wave indicated the correct position. The P wave results were compared with a chest X-ray.P wave changes were observed in 157 (90.75%) of the premature infants on the ECG. Among them, the catheter tips of 148 (85.55%) and nine (5.20%) patients were in the correct and non-correct position, respectively, which was confirmed by chest X-ray. No characteristic P wave changes were observed in 16 (9.32%) patients on ECG, in which the catheter tips of eight (4.62%) patients each were in the correct and non-correct position, according to the chest X-ray. The accuracy of IC-ECG guidance for placement of the PICC was 90.17%. The PICC tip location results of the IC-ECGs were statistically similar to that of the chest X-rays.IC-ECG guidance is accurate for placement of PICC in premature infants, and provides an economical assessment without radiation.

Influence of guide wire removal on tip location in peripherally inserted central catheters (PICCs): a retrospective cross-sectional study

ObjectivesThe aim of this study was to identify the prevalence of peripherally inserted central catheter (PICC) malposition and the influence of guide wire removal on tip location in PICCs and...

A randomized controlled study of bedside electrocardiograph-guided tip location technique & the traditional chest radiography tip location technique for peripherally inserted central venous catheter in cancer patients.

Background & objectives:The peripherally inserted central catheter (PICC) has the advantages of higher safety, lower infection rate and longer retention time than peripherally inserted catheter. This study was aimed to evaluate the accuracy and safety of bedside electrocardiograph (ECG)-guided tip location technique in PICC in cancer patients, and compared with traditional chest radiography tip location technique.Methods:Patients were randomly assigned into two groups: The ECG test group patients underwent PICC insertion with ECG-guided tip location, while the control group patients had PICC insertion by the conventional method. The precision of tip location was verified by chest radiography in both groups. The groups were compared with regard to the accuracy of tip placement, anxiety levels before and after the procedure; medical cost and incidence of complications at one week, three months and six months after PICC insertion.Results:Accurate tip location was achieved in 99.30 per cent in the ECG test group vs 92.30 per cent in the control group (P <0.001). At 24 h after the procedure, the anxiety level was significantly lower in the ECG test group. The presence of thrombogenesis was significantly lower in the ECG test group at both three months and six months after the procedure (P=0.04 and P=0.03, respectively).Interpretation & conclusions:The ECG-guided PICC tip location technique was accurate and caused fewer procedure-related complications and less anxiety in patients compared to chest radiography tip location technique. Radiographic confirmation of PICC tip position may not be needed when ECG guidance is used and thus it can help avoid radiation exposure.

Dual-wavelength reflectance spectroscopy of the superior vena cava: A method for placing central venous catheters at the cavoatrial junction.

There are a limited number of methods to guide and confirm the placement of a peripherally inserted central catheter (PICC) at the cavoatrial junction. The aim of this study was to design, test and validate a dual-wavelength, diode laser-based, single optical fiber instrument that would accurately confirm PICC tip location at the cavoatrial junction of an animal heart, in vivo. This was accomplished by inserting the optical fiber into a PICC and ratiometrically comparing simultaneous visible and near-infrared reflection intensities of venous and atrial tissues found near the cavoatrial junction. The system was successful in placing the PICC line tip within 5 mm of the cavoatrial junction.

A Deep-Learning System for Fully-Automated Peripherally Inserted Central Catheter (PICC) Tip Detection.

A peripherally inserted central catheter (PICC) is a thin catheter that is inserted via arm veins and threaded near the heart, providing intravenous access. The final catheter tip position is always confirmed on a chest radiograph (CXR) immediately after insertion since malpositioned PICCs can cause potentially life-threatening complications. Although radiologists interpret PICC tip location with high accuracy, delays in interpretation can be significant. In this study, we proposed a fully-automated, deep-learning system with a cascading segmentation AI system containing two fully convolutional neural networks for detecting a PICC line and its tip location. A preprocessing module performed image quality and dimension normalization, and a post-processing module found the PICC tip accurately by pruning false positives. Our best model, trained on 400 training cases and selectively tuned on 50 validation cases, obtained absolute distances from ground truth with a mean of 3.10mm, a standard deviation of 2.03mm, and a root mean squares error (RMSE) of 3.71mm on 150 held-out test cases. This system could help speed confirmation of PICC position and further be generalized to include other types of vascular access and therapeutic support devices.

Time and resources of peripherally inserted central catheter insertion procedures: a comparison between blind insertion/chest X-ray and a real time tip navigation and confirmation system.

BackgroundThe Sherlock 3CG™ Tip Confirmation System (TCS) provides real-time peripherally inserted central catheter (PICC) tip insertion information using passive magnetic navigation and patient cardiac electrical activity. It is an alternative tip confirmation method to fluoroscopy or chest X-ray for PICC tip insertion confirmation in adults. The purpose of this study was to evaluate time and cost of the Sherlock 3CG TCS and blind insertion with chest X-ray tip confirmation (BI/CXR) for PICC insertions.MethodsA cross-sectional, observational Time and Motion study was conducted. Data were collected at four hospitals in the US. Two hospitals used Sherlock 3CG TCS and two hospitals used BI/CXR to place/confirm successful PICC tip location. Researchers observed PICC insertions, collecting data from the beginning (ie, PICC kit opening) to catheter tip confirmation (ie, released for intravenous [IV] therapy). An economic model was developed to project outcomes for a larger population.ResultsA total of 120 subjects were enrolled, with 60 subjects enrolled in each arm and 30 enrolled at each of the four US hospitals. The mean time from initiation of the PICC procedure to the time to release for IV therapy was 33.93 minutes in the Sherlock 3CG arm and 176.32 minutes in the BI/CXR arm (p < 0.001). No malpositions were observed for PICC insertions using the Sherlock 3CG TCS, while 20% of subjects in the BI/CXR arm had a malposition. BI/CXR subjects had significantly more total malpositions (mean 0.23 vs. 0, p < 0.001). For a hypothetical population of 1,000 annual patients, adoption of Sherlock 3CG TCS was predicted to be cost saving compared with BI/CXR in all three analysis years.ConclusionThe results from this study demonstrate that Sherlock 3CG TCS, when compared with BI/CXR, is a superior alternative with regard to time to release subject to therapy, malposition rates, and minimization of X-ray exposure.

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 Venous Catheter Complications in Children Receiving Outpatient Parenteral Antibiotic Therapy (OPAT).

OBJECTIVE To identify the frequency of and risk factors associated with complications necessitating removal of the peripherally inserted central catheters (PICCs) in patients receiving outpatient parenteral antibiotic therapy (OPAT) and to determine the appropriateness of OPAT in children with OPAT-related complications. METHODS A retrospective cohort of children who had a PICC inserted at the Johns Hopkins Children's Center between January 1, 2003, and December 31, 2013, and were discharged from the hospital on OPAT was assembled. RESULTS A total of 1,465 PICCs were used to provide antibiotic therapy for 955 children after hospital discharge. Among these, 117 PICCs (8%) required removal due to a complication (4.6 of 1,000 catheter days). Children discharged to a long-term care facility were at increased risk of adverse PICC events (incidence risk ratio [IRR], 3.32; 95% confidence interval [CI], 1.79-6.17). For children receiving OPAT, age of the child (adjusted IRR [aIRR], 0.95; 95% CI, 0.92-0.98), noncentral PICC tip location (aIRR, 2.82; 95% CI, 1.66-4.82), and public insurance (aIRR, 1.63; 95% CI, 1.10-2.40) were associated with adverse PICC events. In addition, 34 patients (32%) with adverse events may not have required intravenous antibiotics at the time of hospital discharge. CONCLUSIONS Of children discharged with PICCs on OPAT during the study period, 8% developed a complication necessitating PICC removal. Children discharged to a long-term care facility had an increased rate of complication compared with children who were discharged home. With improved education regarding appropriate duration of antibiotic therapy and situations in which early conversion to enteral therapy should be considered, PICC-related complications may have been avoided in 32% of children. Infect.

Sherlock 3CG(®) Tip Confirmation System for Placement of Peripherally Inserted Central Catheters: A NICE Medical Technology Guidance.

In current clinical practice, peripherally inserted central catheters (PICCs) are typically inserted using external anatomical measurements and a confirmatory chest X-ray, or using fluoroscopy. The Sherlock 3CG® Tip Confirmation System (TCS) allows magnetic tracking of the PICC tip during insertion and confirmation of the final location using ECG, meaning that most patients will not require a chest X-ray or fluoroscopy. The Sherlock 3CG® TCS was evaluated in 2014 by the UK National Institute for Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme. The company (C.R. Bard Ltd) identified four abstracts, one paper pending publication and questionnaire data from NHS users of the Sherlock 3CG® TCS. None of the evidence included a comparator arm. Placement accuracy of PICCs using the Sherlock 3CG® TCS where a chest X-ray was also used ranged from 79.5 to 100 %. The company reported that 9 out of 16 NHS centres that used the Sherlock 3CG® TCS were no longer using chest X-rays to routinely confirm PICC tip location. The evidence did not report the need for catheter repositioning, re-insertion, staff time savings, treatment delays, length of stay, quality of life outcomes or complications. The company’s model found that the Sherlock 3CG® TCS was cost saving by GBP25.67 per patient compared to blind bedside PICC insertion. The External Assessment Centre (EAC) adapted the company’s model to test alternative assumptions for nurse time, theatre cost, malposition rate and reinsertion method, and found that the Sherlock 3CG® TCS was cost incurring by GBP9.37 per patient compared to blind bedside PICC insertion. The use of the Sherlock 3CG® TCS in the UK NHS compared to blind PICC insertion using a confirmatory chest X-ray appears to hover around being cost neutral. Staff time and accuracy were key drivers in the model: evidence for these is sparse and the reality will vary in different situations. If evidence became available for outcomes after the initial insertion, such as replacement, complications and adverse events, the cost implications may change. The direction of this potential change is not known. NICE published guidance MTG24 in March 2015 recommending that the case for adoption of Sherlock 3CG® TCS was supported by the evidence.

Accurate nonfluoroscopic guidance and tip location of peripherally inserted central catheters using a conductance guidewire system.

Bedside placement of peripherally inserted central catheters (PICCs) may result in navigation to undesirable locations, such as the contralateral innominate or jugular vein, instead of the superior vena cava or right atrium. Although some guidance and tip location tools exist, they have inherent limitations because of reliance on physiological measures (eg, chest landmarks, electrocardiogram, etc), instead of anatomical assessment (ie, geometric changes in the vasculature). In this study, an accurate, anatomically based, non-X-ray guidance tool placed on a novel 0.035" conductance guidewire (CGW) is validated for PICC navigation and tip location. The CGW system uses electrical conductance recordings to assess changes in vessel cross-sectional area to guide navigation of the PICC tip. Conductance rises and oscillates when going in the correct direction to the superior vena cava/right atrium, but drops when going in the incorrect direction away from the heart. Bench and invivo studies in six swine were used to confirm the accuracy and repeatability of the PICC placement at various anatomical locations. The PICC tip location was confirmed by direct visualization vs the desired location. CGW PICC guidance was highly accurate and repeatable with virtually no difference between actual and desired catheter tip location. The difference between the CGW PICC location vs the desired target was-0.07± 0.07 cm (6.6% error) on the bench and 0.04± 0.10 cm (5% error) invivo. No complications or adverse events occurred during CGW usage. The CGW provides an anatomically based, reproducible, and clinically significant method for PICC navigation and tip location that can improve accuracy, decrease the wait time prior to therapy delivery, decrease cost,and minimize the need for X-ray. These findings warrant clinical evaluation of this navigation tool for PICC line placement.

Placement of Peripherally Inserted Central Catheters without Fluoroscopy in Children: Initial Catheter Tip Position

To determine how often placement of peripherally inserted central catheters (PICCs) without imaging guidance results in an initially correct central venous catheter tip location. This study was approved by the hospital's institutional review board, which waived the requirement for informed consent. In a children's hospital, 843 PICCs were placed in 698 patients (age range, 0 days to 26 years; mean, 6.9 years) during a 14-month study period. All PICCs were placed by a specialized team of PICC nurses and interventional radiology technologists in an angiography suite with the supervision of pediatric interventional radiologists. All catheters were threaded blindly to a previously estimated length by either a PICC nurse or a pediatric interventional radiologist, according to National Association of Vascular Access Networks guidelines, and the initial PICC tip location was then determined by means of spot fluoroscopy. PICC tips were regarded as central if they resided anywhere within the superior vena cava (SVC). All catheters were then manipulated with intermittent fluoroscopic guidance to achieve a final central position in the distal third of the SVC. A chi2 test was used to compare initial and final PICC tip locations according to patient age, catheter size, accessed vein, and need for radiologist assistance. A t test was used to compare procedure time with and without radiologist assistance. Analysis included 843 consecutively placed pediatric PICCs, of which 723 (85.8%) had a noncentral initial PICC tip position and required additional manipulation. After catheter repositioning performed with intermittent fluoroscopic guidance, a final central PICC tip location was achieved in 760 PICCs (90.2%). Pediatric PICC placement without fluoroscopic guidance required catheter manipulation of initial PICC tip position in 723 cases (85.8%). PICC placement with fluoroscopic guidance is highly successful, and the authors believe it is best performed in an angiography suite.

Extracolonic Manifestations of Chronic Ulcerative Colitis

The 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.All 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.One 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.The 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.