Peripherally Inserted Central Catheters Removal Research Articles

Predictors 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.

Iatrogenic acute cardiac tamponade during percutaneous removal of a fractured peripherally inserted central catheter in a premature neonate

Acute cardiac tamponade (ACT) is a life-threatening complication associated with a peripherally inserted central catheter (PICC) in premature neonates. We present a case of ACT in a 4-day-old male infant. On the second admission day, a PICC was inserted. After 2.5 months, chest radiography showed PICC fracture, and its distal portion had migrated into the right pulmonary artery. Percutaneous removal through cardiac catheterization was attempted. However, right ventriculography demonstrated intrapericardial spillage of contrast agents, and iatrogenic ACT was confirmed. Cardiopulmonary resuscitation (CPR) was immediately started with open-chest cardiac massage. Further surgical exploration revealed right atrial appendage perforation. After 25-min CPR, the patient restored spontaneous circulation, and removal of the foreign bodies was performed. The post-operative course was uneventful. PICC fracture is an uncommon complication, but may be life-threatening. Precaution should be taken to avoid ACT during removal of a broken PICC. Once the tamponade is diagnosed, immediate interventions are mandatory.

WS09.1 Should we advocate a structured venous access policy in adults with CF?

Background Peripherally Inserted Central Catheter (PICC) & Totally Implanted Access Device (TIVAD) are widely used to provide venous access for CF patients. Increased concerns have been raised on the long-term risks. Method Increase in observed complications at our center has prompted us to survey problems with PICC & TIVAD from 2006 to 2013 in order to establish a structured venous access policy. Results Despite overall satisfaction with PICC we registered an adverse event rate of 20% (3% insertion complication, 6% insertion site problems, 2% thrombosis and 9% other PICC dysfunction) which resulted in removal of PICC in 1/3 of events. The number of TIVAD insertions declined slightly during this period. Retaining TIVAD after lung transplantation was associated with an increased risk of bloodstream infections (41% of pts with TIVAD, 75% asymptomatic) and 5 patients with TIVAD developed severe mitral valve insufficiency resulting in valve replacement surgery in 3 patients. Four incidents of problematic insertion of ECMO or hemodialysis catheters were registered in the 2 years. Discussion Based on these data and recent literature the following venous access policy was adopted. –screening for hypercoagulability –use of peripherally inserted catheters in both arms –insertion of PICC restricted to non-dominant arm –LMWheparin SC during PICC in pts with previous thrombosis or hypercoagulability –promoting TIVAD in pts with >3 IV / year –insertion TIVAD restricted to non-dominant arm –yearly Doppler-US in pts with PICC or TIVAD –immediate removal of TIVAD after transplantation

A team-based multidisciplinary approach to managing peripherally inserted central catheter complications in high-risk haematological patients: a prospective study.

Use of peripherally inserted central catheters (PICCs) has markedly increased during the last decade. However, there are few studies on use of PICCs in patients with haematological malignancies (HM) receiving intensive chemotherapy. Preliminary data suggest a higher rate of PICC-related complications in these high-risk patients. This prospective observational single-centre study aimed to investigate PICC-related complications after implementation of a multidisciplinary approach to PICC care and compared it with previous literature. A total of 44 PICCs were inserted in 36 patients (27.3%, thrombocytopenia <50 × 10(9)/L at insertion) over 5045 PICC days (median duration, 114.5 days). No major insertion-related complications were observed. Major late complications were obstruction in 13.6% (1.19/1000 PICC days) of patients, catheter-related bloodstream infection in 6.8% (0.59/1000 PICC days), and catheter-related thrombosis in 4.5% (0.39/1000 PICC days). Premature PICC removal occurred in 34% (2.97/1000 PICC days) of patients. The overall rate of potentially major dangerous complications was particularly low (11.36%, 0.99/1000 PICC days) compared with previous studies. This study highlights the utility of a multidisciplinary approach for PICC care in adults with HM receiving intensive chemotherapy. We provide further data to support use of PICCs in such patient populations.

The incidence and risk factors of peripherally inserted central catheter-related infection among cancer patients

BackgroundAs the use of peripherally inserted central catheters (PICCs) increased in chemotherapy, the identification of complications and risk factors became essential to prevent patient harm. But little is known about PICC-related infection and risk factors among patients with cancer. Our study was to identify the prevalence, patterns, and risk factors of catheter-related infections associated with PICCs.MethodsA 3-year prospective cohort study was conducted in a university-affiliated hospital. All patients with cancer who met inclusion criteria were enrolled. The patients were followed up until catheter removal. Tip cultures were routinely performed at the time of catheter removal. The general information was recorded at the time of PICC insertion, weekly care, and removal. Univariable and multivariable logistic regression analyses were applied for identification of risk factors.ResultsIn total, 912 cancer patients with 912 PICCs of 96,307 catheter days were enrolled. Ninety-four developed PICC-related infection; 46 were exit-site infection, 43 were catheter bacterial colonization, and five were PICC-related bloodstream infection. The median time from catheter insertion to infection was 98.26 days. Multivariate analysis showed StatLock fixing (odds ratio [OR] =0.555, 95% confidence interval [CI]: 0.326–0.945) and tip position located in the lower one-third of the superior vena cava (OR =0.340, 95% CI: 0.202–0.571) were associated with lower PICC infection rate. Catheter care delay (OR =2.612, 95% CI: 1.373–4.969) and indwelling mostly in summer (OR =4.784, 95% CI: 2.681–8.538) were associated with higher infection incidence.ConclusionStatLock fixing and tip position located in the lower one-third of the superior vena cava were protective factors against PICC-related infection, while catheter care delay and indwelling mostly in summer were risk factors. Policy and measures targeting these factors may be necessary to reduce the risk of infection.

Neonatal late-onset sepsis following peripherally inserted central catheter removal: association with antibiotic use and adverse line events.

The objective of the study was to evaluate incidence of and risk factors for sepsis following peripherally inserted central catheter (PICC) removal. The retrospective cohort study looked at neonatal intensive care unit patients with PICC placement between February 2003 and June 2010 at a single medical center in the United States. Results showed that 14/216 patients (6.5%) had sepsis within 5 days of PICC removal. PICC removal because of adverse events was significantly associated with sepsis (P = .017). Antibiotic use before PICC removal did not have a significant impact on sepsis. The conclusions of the study are that removal of PICCs because of adverse events is significantly associated with late-onset neonatal sepsis and that antibiotic use at the time of PICC removal is not associated with a decline in sepsis rate.

Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients.

Peripherally inserted central catheters (PICC) are being increasingly used in critical care setting. However, PICCs are associated with a number of complications, particularly upper extremity venous thrombosis (UEVT), leading to post-thrombotic syndrome, pulmonary embolism and increased risk of catheter-related infection. To review the literature surrounding PICCs and highlight the epidemiology, pathophysiology, diagnosis and management of PICC-related thrombosis in critically ill patients. We performed an electronic literature search of the databases PubMed, EMBASE and Google scholar using set search terms, from their commencement date to the end of January 2014. It has been shown that PICCs may double the risk of deep venous thrombosis compared with centrally inserted venous catheters, in critically ill patients. However, the incidence of PICC-related thrombosis in critically ill patients has not been quantified. Ultrasonography is the preferred diagnostic imaging modality. There are no randomized controlled trials (RCTs) on the best treatment of PICC-related thrombosis in the intensive care unit (ICU) setting and in most cohort studies, anticoagulation strategies with or without PICC removal have been used. Decision to insert a PICC should be taken after careful risk stratification. There is lack of high-quality evidence assessing prevention strategies and management of PICC-related thrombosis in the ICU. Well-designed RCTs are required to estimate the prevalence of UEVT in ICU patients with PICCs and evaluate the efficacy and magnitude of clinical benefit and cost-effectiveness of therapeutic strategies.

Catheter Dwell Time and CLABSIs in Neonates With PICCs: A Multicenter Cohort Study

To determine whether the daily risk of central line-associated bloodstream infections (CLABSIs) increases over the dwell time of peripherally inserted central catheters (PICCs) in high-risk neonates. Multicenter retrospective cohort including NICU patients with a PICC inserted between January 2005 and June 2010. We calculated incidence rates and used Poisson regression models to assess the risk of developing CLABSI as a function of PICC dwell time. A total of 4797 PICCs placed in 3967 neonates were included; 149 CLABSIs occurred over 89,946 catheter-days (incidence rate 1.66 per 1000 catheter-days). In unadjusted analysis, PICCs with a dwell time of 8 to 13 days, 14 to 22 days, and ≥23 days each had an increased risk of infection compared with PICCs in place for ≤7 days (P < .05). In adjusted analysis, the average predicted daily risk of CLABSIs after PICC insertion increased during the first 2 weeks after PICC insertion and remained elevated for the dwell time of the catheter. There was an increased risk of CLABSIs in neonates with concurrent PICCs (adjusted incidence rate ratio 2.04, 1.12-3.71). The incidence of Gram-negative CLABSIs was greater in PICCs with dwell times >50 days (incidence rate ratio 5.26, 2.40-10.66). The risk of CLABSIs increased during the 2 weeks after PICC insertion and then remained elevated until PICC removal. Clinicians should review PICC necessity daily, optimize catheter maintenance practices, and investigate novel CLABSI prevention strategies in PICCs with prolonged dwell times.

Peripherally Inserted Central Catheter Thrombosis—Reverse Tapered versus Nontapered Catheters: A Randomized Controlled Study

PurposeTo compare the thrombosis rate, ease of insertion, bleeding rate, and complications of a nontapered peripherally inserted central catheter (PICC) versus a reverse tapered PICC. MethodsThis was a prospective randomized, controlled trial conducted in single center. All patients 18–90 years old requiring PICC insertion were considered for the study. All patients were followed until PICC removal. Ultrasound examination of the arm was performed at PICC removal or at 28 days. There were 332 patients randomly assigned—164 to the nontapered PICC group and 168 to the reverse tapered PICC group. ResultsThe overall thrombosis rate was 71.9%. The thrombosis rate was 70.4% in the nontapered PICC group and 73.4% in the reverse tapered PICC group (P = .58). The symptomatic thrombosis rate was 4.3% in the nontapered PICC group and 3.6% in the reverse tapered PICC group (P = .75). The complete thrombosis rate was 15.6% in the nontapered PICC group compared with 20.8% in the reverse tapered PICC group (P = .44). There was a statistically significantly higher thrombosis rate in patients with cancer (71.9% vs 66.7%, P = .002). ConclusionsThis study showed a high incidence of thrombosis of peripheral veins used for PICC insertion. The implication of this thrombosis is significant in light of the morbidity and potential mortality associated with this condition. A difference in thrombosis rate between devices could not be detected in this study.

Management Of PICC-Associated Thrombosis In Patients Receiving Chemotherapy For Hematologic Malignancies

BackgroundTunneled central venous catheters have traditionally been used for administration of chemotherapy (chemo) for acute leukemia treatment. Peripherally inserted central catheters (PICC) are increasingly being used, but there is an increased risk of PICC-associated thrombosis (PAT). There is limited information on management of PAT in this subgroup of patients (pt). MethodsIn this retrospective cohort study we investigated the primary management of PICC related upper extremity venous thrombosis (TB) in pt with hematologic malignancy undergoing chemo at Mayo Clinic Rochester. Eligible pt were 18 years and older, had documentation of PICC placement at our institution, initiation of chemo within a week of PICC placement, and the TB was objectively documented by compression venous ultrasound (CVU). Superficial venous TB (SVT) was defined as TB of subcutaneous veins (basilic and cephalic) and deep venous TB (DVT) defined as TB of brachial, axillary, subclavian, or innominate superior vena cava and internal jugular veins. We retrospectively stratified initial management (IM) into 1) PICC removal alone (PR), 2) PR and therapeutic anticoagulation (AC), 3) AC alone, and 4) conservative management (CM) consisting of symptomatic care and observation. We also investigated factors influencing IM of PAT. Long term outcomes including incidence of pulmonary embolism (PE), post phlebitic syndrome and recurrence of TB were noted. ResultsBetween 2006 and 2012, 190 pt with AML (n=160), MDS or MDS/MF (n=10), or ALL (n=20) met our study criteria. Overall, 40/190 (21.6%) developed PAT: AML n=38, ALL n=1, MDS/MF n=1.SVT occurred in 16/40 (40%) pt and DVT occurred in 24/40 (60%) pt. IM is shown in Table 1.One pt with SVT received AC for 6 weeks as well as PR. In this pt, IM included AC because of proximity of TB to deep veins. 7 pt had a follow up (f/u) CVU within 3 months demonstrating: TB progression (prog, n=1, IM with PR alone but with prog AC was started); TB stability (stab, n=2, both IM with PR alone) and TB resolution/improvement (R/I, n= 4, 2 IM with PR and 2 IM with CM) In the 5 pt with CM, 2 pt had f/u CVU demonstrating improvement, one pt had charted clinical improvement , and 2 pt had no charted clinical f/u.Of DVT pt on AC (n=14), 5 pt completed at least 2 months of AC. Reasons for early cessation (n=9) of AC included thrombocytopenia (tcp, n=4), hematoma (n=1), hematuria (n=1), subarachnoid hemorrhage (n=1), and unknown (n=1). One pt died 2 days after presence of DVT was noted.Two pt initially treated with PR alone developed a second TB with placement of a new PICC on contralateral arm and AC was subsequently initiated (duration: 3 months (n=1), and 8 days (n=1)). 14 pt with DVT had f/u CVU within 3 months which demonstrated prog (n=2), stab (n= 8), or R/I ( n=4) of TB (Table 2).The 2 pt with TB prog subsequently received longer term AC guided by platelet count. In 5 pt with PICC not initially removed, 3 pt had PR after completion of chemo. (1-4 days), one pt had PR at discharge (27 days from TB), and one pt had PICC in place on discharge.One pt with DVT experienced a PE within one year f/u. This pt had initially completed 3 days of AC which was stopped because of tcp. ConclusionIn this cohort of patients with PAT, the most common IM consisted of PR, which appeared to result in a low recurrence rate among pt with SVT. In pt with DVT, the role of AC remains to be defined given the abbreviated course of AC in most pt. Though, the lack of CVU followup in all pt limits conclusions, there appeared to be a low rate of symptomatic prog. Initiation of AC was largely guided by platelet count and degree of occlusive symptoms. Thrombocytopenia was also the most commonly cited reason for discontinuing AC. Close clinical follow up aided by the use of CVU was integral to ensure that PAT did not lead to further adverse events. Disclosures:No relevant conflicts of interest to declare.

Prospective follow-up of complications related to peripherally inserted central catheters

An increased use of peripherally inserted central catheters (PICC) in French hospitals has been observed in recent years. We report complications having occurred following the placement of PICC in a teaching hospital. Patients and methodsA prospective study was made for 7months, between October 2010 and April 2011, including all patients having undergone PICC placement in interventional radiology. ResultsTwo hundred and sixty-seven PICC were inserted in 222 patients for intravenous antibiotic therapy (68%), parenteral nutrition (13%), or chemotherapy (9%). The median duration of PICC use was 17 days (min–max: 1–140) for the 200 PICC monitored until removal. The most common complication was obstruction (n=41), 16 of which motivated PICC removal (8%). Five cases of vein thrombosis (2.5%) and 20 infectious complications (10%) led to removal. There were 14 accidental removals (7%). The overall infection rate was 2.3 per 1000 catheter-days with 0.86 per 1000 catheter-days for central line-associated bloodstream infection. Thirty-four percent of PICC were removed without any complications without any difference according to use. ConclusionPICC are a simple alternative to standard central venous catheter but the rate of complications is high and could be decreased by a stringent management and training for this type of catheter.

Peripherally Inserted Central Catheter Complications in Neonates With Upper Versus Lower Extremity Insertion Sites

To compare peripherally inserted central catheter (PICC) complication rates in upper versus lower extremity insertion sites in neonates. Neonates who had PICCs inserted while hospitalized in an urban, 84-bed, level III neonatal intensive care unit in the southwestern United States between 2004 and 2009 were included in the study. A total of 559 neonates with 626 PICCs were reviewed. Neonates who were transferred out of the hospital with an indwelling PICC or had incomplete PICC data were excluded (n = 29). Comparative descriptive. Retrospective review of PICC records. Demographic data, neonate survival to PICC removal, PICCs inserted by non-PICC team members, and complications were compiled. Complications included presumed sepsis, occlusion, leaking, infiltration/edema, inadvertent removal, phlebitis, pleural effusion, tip malposition, and catheter breakage. The complications were analyzed between extremities using chi-square or independent-samples t test where appropriate. Type and rate of complication requiring PICC removal and the extremity used for insertion. A total of 374 PICCs (59.7%) were inserted in upper extremities and 252 (40.3%) in lower extremities. The upper and lower extremity groups were comparable in all variables except neonate survival to PICC removal, which was greater in neonates with lower extremity PICCs (95.2% in upper extremities vs 98.8% in lower extremities; P = .01). No significant difference (P = .08) was found in the overall complication rate (27% in upper extremity PICCs vs 21% in lower extremity PICCs). Presumed sepsis was the most common complication requiring PICC removal in both extremity groups. At the time of removal, upper extremity PICCs were more likely to have a noncentral tip than lower extremity PICCs (15% vs 4%, respectively). In PICCs removed because of complications, noncentral tips were found to be statistically significant in upper extremity PICCs (P < .0001). No significant difference was found in complications that necessitated PICC removal between upper versus lower extremity PICC insertion sites. Catheter tip location may have a significant impact on complications and deserves further investigation. The choice of a PICC insertion site in neonates should be based on the quality of appropriate, available veins and the preference and skill of the inserter. Every effort should be made to achieve and maintain a centrally located PICC tip.

Peripherally Inserted Central Catheter (PICC) Complications During Pregnancy

Peripherally inserted central catheters (PICCs) are routinely used in women with hyperemesis gravidarum. However, little is known about the consequences of PICC insertion in these patients. Our aim was to analyze PICC-related complication rates among pregnant women. Pregnant women with PICC insertion between January 2000 and June 2006 were studied retrospectively. Infusate type, comorbid conditions, and PICC duration were characterized. Major complications, defined as need for surgical intervention, bacteremia requiring intravenous antibiotics, or thromboembolic events, were identified. Minor complications, including phlebitis, PICC malfunction, early PICC removal, infection requiring oral antibiotics, or hospitalization for PICC evaluation, were also studied. Eighty-four catheters in 66 women were eligible for study, totaling 2544 PICC days. Catheters remained in place for 1-177 days; median duration was 21.0 days. PICCs were used for intravenous fluid (IVF, 59.4%), parenteral nutrition (PN, 34.5%), and antibiotics (6%). The overall complication rate was 18.5 per 1000 PICC days (55.9% of PICCs); 22.6% were major, with bacteremia being most frequent (20.2%). A diagnosis of diabetes was the only factor that significantly predicted complications (hazard ratio, 2.71; 95% confidence interval, 1.13-6.13). PICC duration and type of infusate (PN vs IVF alone) were not associated with complications. PICC insertion in pregnant women is associated with a high complication rate, which appears to be independent of the type of infusate and occurs in the majority of women. PICCs should be used judiciously and only when clearly necessary during pregnancy. Further studies are needed to determine how to reduce PICC-related complications in this population.

Peripherally Inserted Central Catheters (PICCs) Can Be Successfully Utilized in Haematological Patients: Efficacy of an Educational Program.

AbstractAbstract 3161 Purpose:Patients with haematological disorders frequently require the insertion of medium or long-term central venous catheters (CVCs) for stem-cell transplantation, the administration of chemotherapy, or transfusions. Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy and blood progenitor cell transplantation. Methods:Evidence-based interventions were implemented in our department from November 2009 to July 2012, and include: 1.An high level nurse education program for correct practices and prevention of catheter-associated complications. was developed for PICC nursing team; 2) The use of ultrasound guide for the insertion of the tip of PICCs, thanks to a special operator training; 3) Bedside placement and confirmed PICC tip placement by chest radiography after removal of the guidewire and before the securing of the catheter; 4) Maintenance of maximum sterile barrier precautions during PICC insertion and aftercare; 5) chlorhexidine preparation, replace 10% povidone iodine for skin antisepsis; 6) adoption of PICC patient nurse archive, including the information of weekly PICC line review at our department for each patient. Aim:Here, we carried out a clinical prospective investigation to determine the efficacy of these interventions in reducing the rate of PICC-related complications (thrombotic events, exit site infection and other complications requiring early removal of PICCs); the studied population included hematology patients receiving intensive chemotherapy compared to allogeneic/autologous stem cell transplant recipients. Results:Three hundred sixty-four (364) PICCs were in place in 299 patients for a total of 41.111 PICC days ( range, 1–482 days; mean 112,94 days); 292 were inserted in patients receiving conventional chemotherapies, and 72 in patients undergoing allogeneic or autologous hematopoietic stem cell transplantation (SCT). Sixty-six (60) PICCs were inserted during severe thrombocytopenia (platelets < 50 × 10(9)/L), seventy (70) during severe neutropenia (neutrophils < 0.5 × 10(9)/L) and thirty-eight (38) during antithrombotic prophylaxis. Predominantly, patients had Lymphoma (50%). The rate of major complication was very low: 15 thrombotic complications PICC-related (4%; 0.36 per 1,000 CVC days), and 3 CRBSI (0,8%; 0.07 per 1,000 CVC days) during neutropenia. Mechanical complications occurred in 52 catheters, and were accidental dislodgement (30), catheter break (3), catheter inadequate (19); other reasons for catheter removal were completion of therapy (137), lumen occlusion (19) and death (58). Interesting, taking in account the underlying disease, lymphoma and leukemia patients have, respectively, an increased risk of developing a CRBSI and a thrombotic PICCs-complication when submitted to hematopoietic stem cell transplantation (SCT) (see table 1). However, compared with allogeneic/autologous stem cell transplant group, the intensive chemotherapy group was associated with a marginally lower incidence of CRBSI complication rate (0.6 % vs 1.0 %, 0.10 vs 0.60 per 1,000 CVC days) [odds ratio (OR) 2,042]; no relevant differences in terms of thrombotic complications between the two cohorts (4.11 % vs 4.17%), 0.29 vs 0.39 per 1,000 CVC days) [odds ratio (OR) 1.014]. Conclusions:Our findings suggest, therefore, PICC devices are a viable and safe option for management of the haematology patients receiving intensive chemotherapy and even in patients particularly prone to infective and thrombotic complications such as patients receiving blood stem cell transplantation.Table 1Outcomes according to underlying disease and relative adhibitionDiagnosisChemotherapyASCTStatisticsOdds Ratio% Definite CRBSI% Thrombosis% Definite CRBSI% ThrombosisDefinite CRBSI (%)Definite CRBSI per 1000 PICC daysTrombosis (%)Trombosis per 1000 PICC daysRange (days)Means (days)OR CRBSIOR ThrombosisLymphoma (n. 182)0.694.162.632.631.100.103.850.344–336146.33.860.62Acute Leukemia (n 120))0.954.76013.330.830.075.830.4699–432213.803.07Others (n. 62)02.32000.0001.610.196-28779.200Overall0.684.111.394.170.820.074.120.360–482112.942.0421.014CRBSI catheter-related bloodstream infection. PICC peripherally inserted CVC. ASCT allogeneic/autologous stem cell transplant Disclosures:No relevant conflicts of interest to declare.

Catheter-related Mycobacterium abscessus bacteremia manifested with skin nodules, pneumonia, and mediastinal lymphadenopathy

Although previously rare, catheter-related bloodstream infection caused by rapidly growing mycobacteria is now increasingly encountered, especially among cancer patients who have catheters implanted for chemotherapy treatments. A 73-year-old female patient with acute myeloid leukemia (AML) had Mycobacterium abscessus bacteremia with manifestations of multiple skin nodules, pneumonia, and mediastinal lymphadenopathy 4 months after the implantation of a peripherally inserted central catheter (PICC) for the delivery of chemotherapy. The catheter-related M. abscessus bacteremia was confirmed by positive blood cultures of specimens drawn from a PICC line and a peripheral vein. She defervesced with the administration of meropenem, amikacin, levofloxacin, clarithromycin, and by the removal of PICC. Her fever subsided for 3 months with the disappearance of skin and lung lesions; however, she died of AML relapse. Bacteremia and skin infection caused by M. abscessus can be detected by culture and pathological examinations and should be considered in leukemia patients with a PICC. With appropriate laboratory diagnosis, M. abscessus bacteremia with disseminated infections can improve with catheter removal and combination antimicrobial therapy.

Safety and Efficacy of An Educational Program in Reducing Complications of Peripherally Inserted Central Catheters (PICCs) in Haematological Patients,

Abstract 4219 Purpose.Patients with haematological disorders frequently require the insertion of medium or long-term central venous catheters (CVCs) for stem-cell transplantation, the administration of chemotherapy, or transfusion of blood products. Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy. Methods:Evidence-based interventions were implemented in our department in December 2010, and include:1.An high level nurse education program for correct practices and prevention of catheter-associated complications. was developed for PICC nursing team;2) The use of ultrasound guide for the insertion of the tip of PICCs, thanks to a special operator training; 3) Bedside placement and confirmed PICC tip placement by chest radiography after removal of the guidewire and before the securing of the catheter; 4) Maintenance of maximum sterile barrier precautions during PICC insertion and aftercare; 5) chlorhexidine preparation, replace 10% povidone iodine for skin antisepsis; 6) adoption of PICC patient nurse archive, including the information of weekly PICC line review at our department for each patient. Here, we carried out a clinical investigation to determine the efficacy of these interventions in reducing the rate of PICC-related complications (thrombotic events, exit site infection and other complications requiring early removal of PICCs) and to compare PICCs-specific complications (CR-BSI) with a cohort population defined as each consecutive CVC non tunneled inserted over a 6-month period (May–November 2009), and before these evidence-based interventions. Results:Ninety-five PICCs were in place for a total of 7,295 PICC days ( range, 1–331 days; mean, 76,7 days), and fifty-one CVCs were inserted before these interventions (range, 3–577 days; mean, 176,2 days). Sixty-six PICCs were inserted during severe thrombocytopenia (platelets < 50 × 10(9)/L), and 70 during severe neutropenia (neutrophils < 0.5 × 10(9)/L). The majority of the patients were affected by leukaemia, and PICCs were inserted to ensure adequate access throughout chemotherapy. There were 2 thrombotic complications PICC-related (0,27 per 1,000 CVC days), and only one CRBSI (0,14 per 1,000 CVC days) during neutropenia. Other mechanical complications occurred in 11 catheters, and were accidental dislodgement (4), catheter break (3), catheter inadequate (4). Compared with CVCs group, the PICCs group was associated with a lower incidence of CRBSI complication rate (1,05% vs 41,17%, 0,14 vs 3,67 per 1,000 CVC days) [odds ratio (OR) 0,051; relative odds reduction (ROR) 0,98]. Conclusions:Our results indicate that a training and competence assessment program is effective in reducing the main complications PICCs-related in haematological setting.Tab 1Catheter outcomes, by devicen=95 PICCsn=51 CVCsNumberPercentage (%)NumberPercentage (%)Male4850.5%3058,8%Female4749,40%2141,2%Mediane AgeRange 17–82 years49.1Range 23–78 years50,5Type of catheter:Silicon rubber66.3%CVC ST (short term)3568,63%Polyurethane33.1%CVC LT (Long term)1631,37%Polyurethane power injectable8690.5%Definite CRBSI% infectionPer 1000 CVC daysrange (days)Means (days)ORPICCs (n.95)1,050,141–33176,790.0151CVCs (n.51)41,173,673–577176,2CRBSI catheter-related bloodstream infection. PICC peripherally inserted CVC. CVC central venous catheter. Disclosures:No relevant conflicts of interest to declare.

Deep venous thromboses in patients with hematological malignancies after peripherally inserted central venous catheters

The incidence of deep venous thromboses (DVTs) associated with peripherally inserted central catheters (PICCs) in patients with hematological malignancies is not well described. We sought to determine the incidence, characteristics, and outcomes of PICC-related DVTs in this patient population. Retrospective, single center cohort analysis of patients with hematological malignancies with upper extremity PICCs and symptomatic upper extremity DVTs were identified by electronic medical record databases search. Between April 2001 and February 2006, 899 PICCs were placed in 498 patients, and ultrasound documented DVTs were observed in 39 (7.8%) a median of 26 days after PICC placement. Twenty-three (59%) had a new diagnosis of hematological malignancy at the time of PICC placement. DVT management included PICC removal (71%), thrombectomy/thrombolysis (13%), and 3-month anticoagulation. No pulmonary emboli or hemorrhages were observed. A change to centrally inserted tunneled internal jugular (IJ) catheters was instituted February 2006, and the incidence of DVTs was 0.4% among 843 tunneled IJ catheters placed in a subsequent cohort of 667 patients with hematological malignancies. Patients with hematological malignancies have a high incidence of PICC-associated DVTs. Internal jugular vein tunneled PICCs are associated with a very low incidence of DVTs in this patient population.

Analysis of Complication Rates and Reasons for Nonelective Removal of PICCs in Neonatal Intensive Care Unit Preterm Infants

The aim of this study was to analyze the complication rates of peripherally inserted central catheters (PICCs) in neonatal intensive care units (NICUs) and to study the risk factors associated with the nonelective removal of PICCs. One hundred four premature infants were enrolled. Ninety-one PICCs were removed electively. The complications rate was 31.73%, most of which was phlebitis. All patients were further divided into 2 groups: elective removal (ER) and nonelective removal (non-ER). This study reinforces that phlebitis is an important complication, and mechanical complications are the most common reason for the removal of catheters.

Survey of the Long-term Use of Peripherally Inserted Central Venous Catheters in Children With Cancer

Peripherally inserted central catheters (PICCs) have been used for many years in developed countries, but few studies have been focused on children with cancer in developing countries. In this study, we assessed the feasibility of PICCs and determined the rate of PICC-related complications in children with cancer. We prospectively followed all children with cancer over 3 years of age who received chemotherapy and PICC placement in our cancer center between June 2003 and May 2007. The date of last follow-up was January 31, 2008. A total of 119 PICCs were inserted into 116 patients during the 48-month period. PICCs were placed in 113 of 119 attempts, yielding an insertion rate of 95.0%. The 113 PICCs were in place for a total 26,721 catheter days (median time, 246 d; range, 8 to 455 d). The 113 PICCs had 53 overall complications, for a rate of 1.98/1000 catheter days. Twenty-one (18.6%) PICCs were removed because of complication with a rate of 0.79/1000 catheter days. The most common reason for PICC removal was breakage/leakage. An infection requiring PICC removal occurred in 4 patients. This study demonstrated relatively low complication rate and long duration for PICCs in children with cancer over 3 years of age in our hospital.

2005 Herbst Award Recipient Profile

Parenteral nutrition is administered through a central venous catheter(CVC). Peripherally inserted central catheters (PICC) are appropriate for home parenteral nutrition (HPN). The objective of this study was to examine a group of HPN patients with a PICC in place for more than six months, and the complications associated with PICC removal. Medical records from one home infusion pharmacy were retrospectively reviewed for PICC characteristics and complications leading to removal. Nineteen adult HPN patients had 26 PICC placements. Total PICC days were 22,262 with a mean of 856 (265-2500) days. Seven PICCs were in place for 3 to greater than 5 years. The overall complication rate was 0.58/1000 CVC days. Catheter related bloodstream infection (CRBSI) was the main cause of PICC removal. There was no evidence of symptomatic thrombosis. Patients experienced no infusion related complications. The PICCs were 88% polyurethane, 65% double lumen, and 54% were 5 Fr. No patient received alcohol or antibiotic lock therapy, and 8 patients had successful alteplase administered at least one time. All patients needed caregiver assistance for site care and dressing changes, but were independent in HPN infusion and flushing. This group of patients demonstrated that PICCs are a viable option HPN administration. The PICC overall complication rate was very low, and the most frequent complication leading to removal was CRBSI. The infection rate of 0.36/1000 CVC days is considered very low in an HPN population. This is the only HPN infusion study to date reporting 7 PICCs lasting 3 or more years, with 2 lasting greater than 5 years without complications resulting in removal. Patients received their prescribed therapy reliably and without interruption with this device. Larger studies are needed to confirm the efficacy of maintaining a PICC for very long-term HPN administration.