Peripherally Inserted Central Venous Catheters Insertion Research Articles

Experience of a vascular ultrasound-guided program: from the ICU to the hospital

Abstract Background The use of peripherally inserted central venous catheters (PICCs) has increased worldwide in the last decade. However, PICCs are associated to catheter-related thrombosis (CRT) and central line-associated bloodstream infections (CLABSIs). We describe the characteristics of patients requiring a PICC, estimate the incidence rate, and identify potential risk factors of PICC-related complications. Methods All adult patients requiring a PICC at our institution (Fundación Santa Fe de Bogotá, Bogota, Colombia) from September 2022 to May 2024 were included in the analysis. The database from active PICC monitoring collected demographic and PICC-related information. The incidence rate of CLABSI and CRT, and crude odds ratios (cORs) were estimated. Results Overall, 1936 individuals were included in the study. The median age was 67 years (IQR: 50–78 years), and 51.5% were females. The median duration of PICC lines was 10 days (IQR: 4–17). Seventy-nine patients had catheter-related complications, mostly in the Intensive Care Unit (ICU). The CLABSI and CRT institutional incidence rates per 1000 catheter-days were 2.03 (2.96 in the ICU) and 0.58 (0.61 in the ICU), respectively. Prolonged catheter use (≥ 6 days), PICC insertion in the intensive care unit, and postoperative care after cardiac surgery were identified as potential risk factors for CLABSI, while a catheter insertion into the brachial vein was associated with CRT. Conclusion Daily PICC assessment, particularly in patients with prolonged catheter use, PICC insertion into the brachial vein, or in postoperative care after cardiac surgery may significantly reduce CLABSI and CRT cases. Implementing Vascular Access Teams, venous catheter care bundles, and institutional insertion protocols optimize clinical outcomes.

Thrombosis and infections associated with PICC in onco-hematological patients, what is their relevance?

Peripherally inserted central venous catheters (PICC) in the onco-hematological patients may be associated with thrombosis or infections that may have short- to medium-term repercussions. Single-centre retrospective analysis of a prospectively collected cohort. Primary objective was to establish the PICC-thrombosis and infections incidence. Secondary objectives were to analyze profile of patients suffering from these complications and variables associated with an increased likelihood of developing these events. 549 patients were recruited. 58.5% (n = 321) were oncology patients and 41.5% (n = 228) hematology patients. The incidence of PICC-associated thrombosis was 3.5% (n = 19). Thrombosis was associated with progression of the underlying malignant pathology in 10.6% (n = 2) of cases. No association was found between clinical variables analysed and development of thrombosis. Incidence of PICC-associated infections was 7.65% (n = 42). In the 30days prior to PICC infection, 57.1% (n = 24) had a febrile syndrome of another focus, 73.8% (n = 11) had been hospitalized, 49.5% (n = 25) had a neutrophil count of 0-500 cells/mm3 and 47.6% (n = 20) had an episode of neutropenic fever. Variables significantly associated with the development of infection were hematological patients, high-flow PICC, 3-lm PICC or PICC insertion because of administration of vesicant therapy. Incidence of PICC-associated thrombosis is low and apparently less prognostically aggressive than other forms of thrombosis associated with cancer, without identify predictive factors. Infection was more prevalent and the identification of risk factors in our series could facilitate its prevention.

Validation of Michigan risk score and D-dimer to predict peripherally inserted central catheter-related thrombosis: A study of 206,132 catheter days

The Michigan Risk Score (MRS) was the only predicted score for peripherally inserted central venous catheters (PICC) associated upper extremity venous thrombosis (UEVT). Age-adjusted D-dimer increased the efficiency for UEVT. There were no external validations in an independent cohort. A retrospective study of adult patients with PICC insertion was performed. The primary objective was to evaluate the performance of the MRS and age-adjusted D-dimer in estimating risk of PICC-related symptomatic UEVT. The sensitivity, specificity and areas under the receiver operating characteristics (ROC) of MRS and age-adjusted D-dimer were calculated. Two thousand one hundred sixty-three patients were included for a total of 206,132 catheter days. Fifty-six (2.6%) developed PICC-UEVT. The incidences of PICC-UEVT were 4.9% for class I, 7.5% for class II, 2.2% for class III, 0% for class IV of MRS (p = 0.011). The incidences of PICC-UEVT were 4.5% for D-dimer above the age-adjusted threshold and 1.5% for below the threshold (p = 0.001). The areas under ROC of MRS and age-adjusted D-dimer were 0.405 (95% confidence interval (CI) 0.303-0.508) and 0.639 (95% CI 0.547-0.731). The sensitivity and specificity of MRS were 0.82 (95% CI, 0.69-0.91), 0.09 (95% CI, 0.08-0.11), respectively. The sensitivity and specificity of age-adjusted D-dimer were 0.64 (95% CI, 0.46-0.79) and 0.64 (95% CI, 0.61-0.66), respectively. MRS and age-adjusted D-dimer have low accuracy to predict PICC-UEVT. Further studies are needed.

Peripherally Inserted Central Venous Catheters Provide Safe and Easy Central Venous Access in Patients with Head and Neck Cancer

Abstract Purpose The use of peripherally inserted central venous catheters (PICCs) has increased recently; several reports have revealed that they can be easily and safely used in patients with various diseases. However, there are few reports on the use of PICCs in patients with head and neck cancer. This study was aimed at evaluating the safety and feasibility of use of PICCs in patients with head and neck cancer. Materials and Methods We retrospectively analyzed the date of 118 PICC insertions in 85 patients with head and neck cancer from January 2014 to December 2017. The PICCs have been placed under ultrasound guidance in all cases. Results The PICC puncture success rate was 95.2%. Catheter-related bloodstream infection occurred in four cases. The most common complication necessitating PICC removal was suspected catheter-related bloodstream infection (24 cases). All cases with confirmed and suspected catheter-related bloodstream infection improved with administration of antimicrobial agents. Phlebitis occurred in five cases, in all of whom the PICC placement had been made via an antecubital vein; the condition improved without treatment in all five cases. Deep vein thrombosis occurred in two cases, both of which improved with oral anticoagulant therapy. Conclusion This study demonstrated that the complications associated with ultrasound-guided PICC insertion are manageable, and improve with conservative treatment in the majority of cases. Therefore, use of PICCs may be considered for easy and safe central venous access in patients with head and neck cancer, because the insertion success rate was acceptable.

89. A Collaborative & Novel Antimicrobial Stewardship Initiative– Mandatory Approval of Peripherally Inserted Central Venous Catheters

BackgroundCentral line-associated bloodstream infections result in thousands of deaths and billions of dollars annually. At the Augusta University Medical Center (AUMC), it was identified that ~50% of peripherally inserted central venous catheters (PICCs) that were placed for intravenous (IV) antibiotic administration were unnecessary. A novel initiative was implemented, which required antimicrobial stewardship/infectious diseases approval for PICC insertions if the indication was for IV antibiotic administration only. The objective of this study was to determine the impact of this initiative.MethodsA retrospective observational study was conducted at the AUMC. All adult patients with a PICC line insertion order for IV antibiotic administration, between December 2017 and May 2019 were included. The vascular access team would forward requests for PICC insertions to the antimicrobial stewardship pharmacist. The pharmacist would approve/disapprove the PICC or recommend an infectious diseases consult. The variables collected were: infection types, infectious diseases consultation, reason for PICC denial and 30-day PICC-related complications.ResultsA total of 215 requests for PICC insertion (for IV antibiotics) were placed. Of these, 54% of the requests were denied, while 46% were approved. The reasons for PICC denial included: midline catheter preferred (47%), switched to oral antibiotics (33%), further work-up required (10%), or no antibiotics needed (7%). The types of infections treated were: bone and joint infections (28%), urinary tract infections (13%), intra-abdominal infections (12%), endocarditis/endovascular infections (11%), skin soft tissue infections (9%), pneumonia (7%), catheter-related bloodstream infections (6%), central nervous system infections (6%), bacteremia (4%) and others (4%).The infectious diseases consult team was involved in the care of 79% of the patients. Of those that received a PICC line, only 5% experienced any PICC-related complications. The overall cost savings for PICCs that were denied was ~ $294,000.ConclusionMandatory antimicrobial stewardship/infectious diseases approval for PICC insertion can decrease healthcare cost and reduce the number of unnecessary PICC lines placed.Disclosures All Authors: No reported disclosures

36 Contrast Enhanced Radiography for Peripherally Inserted Central Venous Catheter Tip localization- Is it really needed for all infants?

Abstract Background Contrast enhanced radiography (CER) is considered one of the best available methods for localizing the tip of a peripherally inserted central venous catheters (PICC) in neonates, which was the standard practice at our NICU. It was observed that multiple catheter readjustments and radio-graphs were required due to contrast jet appearing radio-graphically as a distal extension of the catheter creating a false impression of deep location of the PICC tip. This raised the question of whether we need to use contrast routinely for all infants or can we selectively use contrast when needed. Objectives The intention of this quality improvement project was to adopt the use of plain radiography (PR) as the first modality for PICC tip localization and use CER only if localization was unsuccessful in the first instance. The objective was to examine the effect of this change of clinical practice on the: a) number of radio-graphs taken for PICC insertions b) the frequency of intravenous contrast use in PICC insertion. Design/Methods This was a QI initiative conducted over a 7 month period. After educating all care providers who insert PICC, we changed our practice to use plain radiography as first modality for PICC tip visualization starting June 1, 2019. CER was only used if catheter tip was not visualized on plain radiography. We collected the information on infants who had PICC inserted in the NICU before and after the implementation of the initiative for a given period. Outcome measures were a) proportion of infants with PICC tip visualized on first plain radiography (b) proportion of infants who received CER (c) Number of X-rays per line insertion. We compared the data regarding the above outcomes between the two time periods. Results Of the 113 PICC inserted, 39 PICCs were inserted during routine CER period, and 74 PICCs were inserted during PR period. The mean gestational age (26 ± 2.8 vs 27± 3.5), birth weight (878 ± 406g vs 1024g ± 559g, site of insertion - upper limb PICC (74% vs 69%) were comparable between the two groups. Catheter was visualized on first plain radiography in 56/74 (75%) in the PR period. Overall, the CER was performed in 30/74 (40%), of which 18 were for non-visualization of tip on first plain radio-graph and 11 for non-visualization after subsequent manipulation. There was no difference in the median (IQR) number of radio-graphs between CER period and PR period [2 (2-3) vs 2 (1-3), p =NS] with similar proportion of infants requiring 2 or less X-rays (71% vs 67%). Conclusion The use of plain radiography as the initial imaging modality is a safe alternative, without increasing radiation exposure and it minimizes the use of intravenous contrast in neonates undergoing PICC insertions. In spite of being superior for tip visualization, CER does not reduce the number of X-rays taken for the same purpose.

Causes of catheter removal and complications depending on the insertion side of peripherally inserted central venous catheter in patients with hematologic disorders

Central venous catheter (CVC) insertion is an essential medical procedure in patients with hematologic disorders. Recently, the use of peripherally inserted central venous catheters (PICCs) for CVC insertion has been increasing. However, the suitable arm for PICC insertion has not been fully discussed. This study retrospectively examined catheter-related complications on the insertion side of PICC in patients with hematologic disorders. Total 809 PICCs were inserted in 316 patients with hematologic disorders. The insertion side was the right upper arm for 515 PICCs and the left upper arm for 294 PICCs. In a direct comparison between the insertion side groups, there was no obvious difference in the basic demographic characteristics of the patients except the age at the time of insertion. Moreover, there was no significant difference in the reasons for PICC removal, and the incidence of catheter-related bloodstream infection was similar and low in both the study groups. During the selection of the insertion side for PICC, it may be possible to consider the side that seems more suitable for insertion by confirming the vessels in both upper arms with ultrasonography, and, if the conditions are equivalent, to consider the side where the patient wishes to insert the PICC.

Peripherally Inserted Central Catheter-Related Vein Thrombosis in Patients With Lung Cancer.

Peripherally inserted central venous catheters (PICCs) are widely used in patients with cancer. Catheter usage is one of the risk factors for venous thromboembolism. We aimed to scrutinize the incidence and risk factors for PICC-related upper extremity venous thrombosis (UEVT) in patients with lung cancer receiving chemotherapy. We performed a retrospective cohort study of patients with lung cancer with PICC insertion undergoing chemotherapy. Symptomatic PICC-UEVT was diagnosed by ultrasound. The relationship between chemotherapeutic agent exposure and PICC-UEVT was evaluated. Patient-, catheter-, and insertion-related factors were analyzed in univariable and multivariable logistic regression to identify significant independent risk factors for PICC-UEVT in patients with lung cancer. A total of 328 patients with lung cancer having PICC undergoing chemotherapy were included, for a total of 34 895 catheter days. Seventeen (5.2%) patients developed PICC-related UEVT, with an incidence of 0.49 per 1000 catheter days. In multivariable logistic analysis, advanced disease was shown to be a significant risk factor for PICC-UEVT (odds ratio [OR]: 4.9; 95% confidence interval [CI]: 1.4-16.7; P = .011). Patients treated with etoposide had a higher risk of PICC-related UEVT (OR: 3.6; 95% CI: 1.1-12.1; P = .042). Patients were followed up after PICC removal for a median duration of 246 days. None of the patients developed pulmonary embolism. Patients with lung cancer harboring an advanced disease or treating with etoposide were at higher risk of PICC-UEVT.

Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit

PurposeThere are limited contemporary data describing the rates of catheter-related deep vein thrombosis (CRDVT) and central line–associated bloodstream infection for peripherally inserted central venous catheters (PICCs) and centrally inserted central venous catheters (CICCs) in the medical intensive care unit (ICU). MethodsWe performed a retrospective cohort study of 200 PICCs (dual/triple lumen) and 200 CICCs (triple/quadruple lumen) placed in medical ICU adults at Mayo Rochester between 2012 and 2013. Central lines were followed from insertion time until hospital dismissal (primary analysis) or ICU discharge (secondary analysis). Symptomatic CRDVT was determined by Doppler ultrasound. Central line–associated bloodstream infection was defined according to federal reporting criteria. ResultsDuring 1730 PICC days and 637 CICC days, the incidence of CRDVT when followed until hospital dismissal was 4% and 1% (4.6 and 3.1 per 1000 catheter-days), respectively, P = .055. When censored at the time of ICU dismissal, the rates were 2% and 1% (5.3 and 3.7 per 1000 catheter-days), P = .685. Only 1 central line–associated bloodstream infection occurred in a PICC following ICU dismissal, P > .999. ConclusionsThrombotic and infectious complications were uncommon following PICC and CICC insertion, with no significant difference in complication rates observed. Half of PICC DVTs occurred on the general floor, and like all central catheters placed in the ICU, PICCs should be aggressively discontinued when no longer absolutely needed.

Peripherally inserted central catheter-related vein thrombosis in breast cancer patients.

To identify clinical incidence, risk factors and treatment of peripherally inserted central venous catheters (PICCs)-related upper extremity venous thrombosis (UEVT) in breast cancer patients undergoing chemotherapy. We performed a retrospective cohort study of breast cancer patients with PICC insertion undergoing chemotherapy. PICC-related UEVT was diagnosed by ultrasound. Patient-, catheter- and insertion-related factors were analyzed in univariable and multivariable logistic regression to identify significant independent risk factors for PICC-related UEVT. The incidence and treatment of PICC-related UEVT were also analyzed. A total of 568 breast cancer patients with PICC undergoing chemotherapy were included, for a total of 54,769 catheter days; 8 patients (1.4%) developed PICC-related UEVT. The median time of developing UEVT was 11 days (range of 3 to 79 days). In multivariable analysis, metastasis (p = 0.002) and malposition (p = 0.013) were shown to be significant risk factors for PICC-related UEVT. All patients were treated with low-molecular-weight heparin (LMWH) and followed until PICCs were removed. None of the patients developed pulmonary embolus. Metastasis and malposition were significant risk factors for PICC-related UEVT in breast cancer patients. With early diagnosis and standardized anticoagulant treatment, a better clinical outcome could be achieved. Further prospective and large sample studies are needed.

Peripherally inserted central catheter complications in neonates – our experiences

The aim of this study was to investigate the incidence and risk factors of peripherally inserted central venous catheters (PICCs) in critically ill premature neonates; A retrospective analysis of 30 infants with very low and extremely low birth weights (VLBW, ELBW) who underwent PICC placement over a three-year period, from January 2012 till January 2015. Gestational age, birth weight (BW), sex, site of catheter placement, reason for catheter removal, duration of catheter use, proven sepsis, type of reported organism and rate of complications were collected. The infants were classified into two groups according to BWs: Group 1—VLBW infants (BW between 1,000 and 1,500 g) and Group 2— ELBW infants (BW <1,000 g). During the study period PICCs were attempted in 40 patients. A PICC was successfully inserted into 30 patients (75%). PICCs placed in either the upper or the lower extremity. There were no differences in complication rates. The median time of catheter inser tion was 13 (1-35) days for Group 1 and 11 (6-19) days for Group 2. The median du ration of PICCs was 10.5 (2-16) and 12.2 (3-25) days. Statistical analysis showed that there was a significant difference between the groups for both catheter insertion day and mean duration of PICCs (p= 0.241, respectively). There were no significant differences between groups for the reasons for catheter removal (p=0.598). PICCs are convenient for the administration of long course antibiotics and parenteral nutrition for both VLBW and ELBW infants, but there are many risks associated with the insertion of PICCs, including serious and fatal complications.

Increased frequency of peripheral venipunctures raises the risk of central-line associated bloodstream infection in neonates with peripherally inserted central venous catheters.

Central-line associated bloodstream infection (CLA-BSI), which is mostly caused by coagulase-negative staphylococcus, is an important morbidity in neonatal intensive care units. Our study is aimed to identify the risk factors of CLA-BSI in neonates with peripherally inserted central venous catheters (PICCs). A retrospective cohort study of neonatal intensive care unit patients with a PICC insertion between January 1, 2011 and December 31, 2012 was conducted. We performed univariate and multivariate analyses with a logistic regression model to investigate the risk factors and the association between increased frequency of peripheral venipunctures during PICC use and the risk of CLA-BSI while adjusting for other variables. There were 123 neonates included in our study. Thirteen CLA-BSIs were recorded within the follow-up period. The incidence of PICC-associated CLA-BSI was 4.99 per 1000 catheter-days. There was no statistically significant association between the risk of CLA-BSI and gestational age, birth weight, chronological age, or other comorbidities. However, the odds of CLS-BSI increased to 12 times if the patient received six or more venipunctures within the period without concurrent antibiotic use [odds ratio (OR), 11.94; p < 0.001]. The OR of CLA-BSIs increased by 16% per venipuncture during PICC use (OR, 1.14; p = 0.003). During PICC use, increased frequency of venipunctures, especially when there was no concurrent antibiotic use, substantially raises the risk of CLA-BSI. By decreasing unnecessary venipunctures during PICC use, PICC-associated CLA-BSI and further morbidities and mortalities can be prevented.

The ISP (Safe Insertion of PICCs) protocol: a bundle of 8 recommendations to minimize the complications related to the peripherally inserted central venous catheters (PICC)

The ISP (Safe Insertion of PICCs) protocol: a bundle of 8 recommendations to minimize the complications related to the peripherally inserted central venous catheters (PICC). The insertion of a peripherally inserted central venous catheter (PICC) is not without risks. The Italian Group for the Study of Long-Term Central Venous Access Devices (GAVeCeLT) has developed a protocol (SIP: Safe Implantation of PICCs) with the aim of minimizing the risks which may be associated with the placement of PICCs. The protocol is based on recommendations available in the literature and on the main clinical practice guidelines. The SIP protocol, a bundle of evidence-based recommendations, it is is easy to use, inexpensive, and cost-effective. If routinely used and carefully inplemented, it greatly reduces complications such as failure of venipuncture, accidental arterial puncture, damage of median nerve, infection and catheter related venous thrombosis.

Complications of peripherally inserted central venous catheters in neonates: Lesson learned over 2 years in a tertiary care centre in India.

The objective of this study was to assess the complications of peripherally inserted central venous catheters (PICC) in neonates admitted to neonatal surgical intensive care unit (NSICU). Retrospective analysis of 237 neonates admitted to NSICU from January 2010 to December 2011 was done. Mean age at presentation was 5.8 days and mean weight was 1.94 kg. Mean number of attempts was 1.14, mean duration of insertion 8.4 min and mean duration of patency of catheter 3.14 days. Most common site of catheter insertion was upper extremity (basilic followed by cephalic). Overall complications were seen in 47 (23%) cases. Infectious complications were seen in 22 (10.7%) and non-infectious in 25 (12.2%) cases. Significant correlation existed between non-infective complications and insertion site (P = 0.03) and duration of PICC (P = 0.04). Precautions should be taken and position must be confirmed during and after PICC insertion to avoid undue complications.

Risk Factors for Upper Extremity Venous Thrombosis Associated with Peripherally Inserted Central Venous Catheters

To identify clinically important risk factors associated with upper extremity venous thrombosis following peripherally inserted central venous catheters (PICC). A retrospective case control study of 400 consecutive patients with and without upper extremity venous thrombosis post-PICC insertion was performed. Patient data included demographics, body mass index (BMI), ethnicity, site of insertion, size and lumen of catheter, internal length, infusate, and co-morbidities, such as diabetes mellitus, congestive heart failure, and renal failure. Additional risk factors analyzed were active cancer, any history of cancer, recent trauma, smoking, a history of prior deep vein thrombosis, and recent surgery, defined as surgery within three months prior to PICC insertion. The prevalence of trauma, renal failure, and infusion with antibiotics and total parenteral nutrition (TPN) was higher among patients exhibiting upper extremity venous thrombosis (UEVT), when compared to controls. Patients developing UEVT were also more likely to have PICC line placement in a basilic vein and less likely to have brachial vein placement (P<.001). Left-sided PICC line sites also posed a greater risk (P=.026). The rate of standard DVT prophylaxis with low molecular weight heparin and unfractionated heparin and the use of warfarin was similar in both groups. Average length of hospital stay was almost double among patients developing UEVT, 19.5 days, when compared to patients undergoing PICC line insertion without thrombosis, 10.8 days (t=6.98, P<.001). In multivariate analysis, trauma, renal failure, left-sided catheters, basilic placement, TPN, and infusion with antibiotics, specifically vancomycin, were significant risk factors for UEVT associated with PICC insertion. Prophylaxis with low molecular weight heparin, unfractionated heparin or use of warfarin did not prevent the development of venous thrombosis in patients with PICCs. Length of hospital stay and cost are markedly increased in patients who develop PICC-associated upper extremity venous thrombosis.

Central Line-Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit

Increasingly, peripherally inserted central venous catheters (PICCs) are placed for prolonged intravenous access. Few data exist regarding risk factors for central line-associated bloodstream infection (CLABSI) complicating PICCs in hospitalized children, especially children hospitalized outside the intensive care unit (ICU). We identified all children with a PICC inserted at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 and used Poisson regression models to identify risk factors for PICC-associated CLABSIs. A total of 2592 PICCs were placed in 1819 children. One hundred sixteen CLABSIs occurred over 44,972 catheter-days (incidence rate [IR], 2.58 cases per 1000 catheter-days; 95% confidence interval [CI], 2.07-3.00 cases per 1000 catheter-days). Independent predictors of CLABSI in the entire cohort included PICC dwell time of > 21 days (IR ratio [IRR], 1.53; 95% CI, 1.05-2.26), parenteral nutrition as indication for insertion (IRR, 2.24; 95% CI, 1.31-3.84), prior PICC-associated CLABSI (IRR, 2.48; 95% CI, 1.18-5.25), underlying metabolic condition (IRR, 2.07; 95% CI, 1.14-3.74), and pediatric ICU exposure during hospitalization (IRR, 1.80; 95% CI, 1.18-2.75). Risk factors for CLABSI in children without PICU exposure included younger age, underlying malignancy and metabolic conditions, PICCs inserted in the lower extremity, and a prior PICC-associated CLABSI. Prolonged catheter dwell time, pediatric ICU exposure, and administration of parenteral nutrition as the indication for PICC insertion are important predictors of PICC-associated CLABSI in hospitalized children. A careful assessment of these risk factors may be important for future success in preventing CLABSIs in hospitalized children with PICCs.

An Evidence-Based Systematic Review of Literature for the Reduction of PICC Line Occlusions

Peripherally inserted central venous catheters (PICCs) are known to have difficulties with catheter occlusions. This paper evaluates the scope of PICC occlusions, their prevalence and severity, and potential interventions to decrease incidence. A systematic review of the literature is performed and demonstrates three potential interventions: utilization of a dedicated PICC insertion team, implementation of a valved PICC, and nursing education of PICC care. The evidence from the literature is evaluated, and implementation of the proposed interventions is discussed.

Patient-Reported Usefulness of Peripherally Inserted Central Venous Catheters in Terminally Ill Cancer Patients

Oral administration of medication is often difficult in terminally ill cancer patients, and a subcutaneous route is traditionally one of the most preferred parenteral routes. Recent studies suggest, however, that some patients and families prefer the intravenous route, and peripherally inserted central venous catheters (PICCs) are actively used in oncology settings. Nonetheless, in the palliative care setting, no empirical studies have investigated the patient-perceived usefulness of PICCs. The primary aim of this prospective observational study was to clarify the levels of patient-perceived comfort and convenience, in addition to procedure-related distress, resulting from the use of PICCs by terminally ill cancer patients. Among 219 patients admitted to a palliative care unit during the one-year study period, 39 (18%) patients underwent a PICC insertion trial (a total of 44 procedures were performed because five patients underwent PICC insertion twice). Of the 44 procedures, 38 (86%) were successful, requiring a mean of 23+/-7.9 minutes, without serious procedure-related complications. Patient-reported levels of procedure-related distress were not distressing (68%), slightly distressing (8%), and distressing (24%). Patient-reported comfort levels with parenteral access were becoming more comfortable (94%) and no change (6%). Patient-reported convenience levels of parenteral access were becoming more convenient (94%) and no change (6%). Complications were reversible catheter coagulation (10%), irreversible catheter coagulation (8%), and mild levels of edema of the upper extremity (8%). The PICCs remained in place in 82% of the patients until death. The median period of placement was 15 days, with the longest placement being 81 days. PICCs were safely inserted in about 90% of terminally ill cancer patients within about 20 minutes. Although 30% of the patients experienced transient mild procedure-related distress, more than 90% of the patients felt that the parenteral route was more comfortable and convenient after the procedure. PICCs may provide a safe, comfortable, and convenient alternative for terminally ill cancer patients, if placement of the PICC is individualized to the patient situation and after alternatives are considered. Further studies are needed to compare the superiority of the PICC and traditional subcutaneous route to clarify what types of patients are the most suitable for each procedure.

Catheter Duration and Risk of CLA-BSI in Neonates With PICCs

To determine whether the risk of central line-associated bloodstream infections (CLA-BSIs) remained constant over the duration of peripherally inserted central venous catheters (PICCs) in high-risk neonates. We performed a retrospective cohort study of NICU patients who had a PICC inserted between January 1, 2006, and December 31, 2008. A Poisson regression model with linear spline terms to model time since PICC insertion was used to evaluate potential changes in the risk of CLA-BSI while adjusting for other variables. Six hundred eighty-three neonates were eligible for analysis. There were 21 CLA-BSIs within a follow-up period of 10 470 catheter-days. The incidence of PICC-associated CLA-BSI was 2.01 per 1 000 catheter-days (95% confidence interval [CI]: 1.24-3.06). The incidence rate of CLA-BSIs increased by 14% per day during the first 18 days after PICC insertion (incidence rate ratio [IRR]: 1.14 [95% CI: 1.04-1.25]). From days 19 through 35 after PICC insertion, the trend reversed (IRR: 0.8 [95% CI: 0.66-0.96]). From days 36 through 60 after PICC insertion, the incidence rate of CLA-BSI again increased by 33% per day (IRR: 1.33 [95% CI: 1.12-1.57]). There was no statistically significant association between the risk of CLA-BSI and gestational age groups, birth weight groups, or chronological age groups. Our data suggest that catheter duration is an important risk factor for PICC-associated CLA-BSI in the NICU. A significant daily increase in the risk of CLA-BSI after 35 days may warrant PICC replacement if intravascular access is necessary beyond that period.

Evaluation of length of central venous catheter inserted via cubital route in Indian patients

Aim:Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning.Materials and Methods:A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR.Results:200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated.Conclusions:Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.