Peripherally Inserted Central Venous Catheters Lines Research Articles

Peripherally inserted central cathether migration in neonates: Incidence, timing and risk factors

PICC line use is a common practice in neonatal units, but it is associated with various complications. Catheter migration is the most common complication in neonates. Periodic imaging is recommended to monitor the tip position of the PICCs, but the optimal frequency is undetermined. The incidence, timing and risk factors that are associated with PICC migration have not been fully investigated beyond 24 hrs in neonates. The aim of the study was to determine the incidence, timing and risk factors that are associated with peripherally inserted central venous catheter (PICC) migration in neonates. This was a single center, retrospective study of 168 PICCs placed in 141 neonates in the neonatal intensive care unit (NICU) between 2015 and 2016. The incidence of catheter migration was determined radiographically at 12-24 hrs and every third day after insertion until it was removed. Overall incidence of PICC migration was 28%and most commonly was detected within the first three days after PICC placement (83%). The incidence of PICC migration was higher in males. The PICC migration was associated with difficulty advancing the PICC at the time of insertion and PICC dressing change. Serial evaluation of PICC placement in neonates is required to maintain proper position. Based on our experience in our unit, we recommend periodic imaging at 12-24 hrs and on the third day after PICC placement as most migration occurred within three days after insertion.

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

Inpatient Peripherally Inserted Central Venous Catheter Complications: Should Peripherally Inserted Central Catheter Lines Be Placed in the Intensive Care Unit Setting?

Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.

Peripherally Inserted Central Venous Catheters in Pediatric Hematology/Oncology Patients in Tertiary Care Setting: A Developing Country Experience.

Peripherally inserted central venous catheters (PICC) have been successfully used to provide central access for chemotherapy and frequent transfusions. The purpose of this study was to assess the feasibility of PICCs and determine PICC-related complications in pediatric hematology/oncology patients in a resource-poor setting. All pediatric patients (age below 16 y) with hematologic and malignant disorders who underwent PICC line insertion at Aga Khan University Hospital from January 2008 to June 2010 were enrolled in the study. Demographic features, primary diagnosis, catheter days, complications, and reasons for removal of device were recorded. Total of 36 PICC lines were inserted in 32 pediatric patients. Complication rate of 5.29/1000 catheter days was recorded. Our study showed comparable complication profile such as infection rate, occlusion, breakage, and dislodgement. The median catheter life was found to be 69 days. We conclude that PICC lines are feasible in a resource-poor setting and recommend its use for chemotherapy administration and prolonged venous access.

Central venous catheters: incidence and predictive factors of venous thrombosis.

Aims: Central venous catheter access in an acute setting can be a challenge given underlying disease and risk for venous thrombosis. Peripherally inserted central venous catheters (PICCs) are commonly placed but limit sites for fistula creation in patients with chronic renal failure (CKD). The aim of this study is to determine the incidence of venous thrombosis from small bore internal jugular (SBIJ) and PICC line placement. This investigation identifies populations of patients who may not be ideal candidates for a PICC and highlights the importance of peripheral vein preservation in patients with renal failure. Materials and methods: A venous Doppler ultrasound was performed at the time of SBIJ insertion and removal to evaluate for thrombosis in the internal jugular vein. Data was collected pre- and post-intervention to ascertain if increased vein preservation knowledge amongst the healthcare team led to less use of PICCs. Demographic factors were collected in the SBIJ and PICC groups and risk factor analysis was completed. Results: 1,122 subjects had PICC placement and 23 had SBIJ placement. The incidence of thrombosis in the PICC group was 10%. One patient with an SBIJ had evidence of central vein thrombosis when the catheter was removed. Univariate and multivariate analysis demonstrated a history of transplant, and the indication of total parenteral nutrition was associated with thrombosis (p < 0.001). The decrease in PICCs placed in patients with CKD 6 months before and after intervention was significant (p < 0.05). Conclusions: There are subsets of patients with high risk for thrombosis who may not be ideal candidates for a PICC.

G423 Service evaluation of the management of osteoarticular infection over 8 years in a single centre

Aims There is no national consensus on the management of osteoarticular infection (OAI). Practice varies widely throughout the United Kingdom, with differences in duration of antibiotic treatment, switching from intravenous (IV) to oral antibiotics and requirement for peripherally inserted central venous catheters (PICC). Data about recurrence and complication rates is scant. We aimed to evaluate local practice: analyse demographic data, antibiotic course duration and administration route, use of invasive lines and associated complications with a view to guideline development. Methods OAI in children aged 0–17 years, presenting to one centre, from 01/09/2006–01/09/2014, identified through hospital coding, clinician and microbiology records. Results Demographic Data 82 confirmed OAI cases: 55% male, 45% female, mean age 4.8 years. Preliminary data from the first 24 cases revealed none had significant co–morbidities, sickle cell disease or immuno–suppression. Pathogenesis Tibia most commonly affected site, followed by femur. Organisms isolated in under half the cases. 2 cases of severe PVL-MSSA disease identified Management Median duration of antibiotic course (IV and Oral) was 45 (range 7–358) days. Median duration of IV antibiotic course was 20 (range 6–75) days. Oral switch occurred in 76%, after a median of 18 (range 3–17 days) of IV antibiotics. Most had PICC lines inserted, complications included line sepsis (x1). Complication of OAI included hyperesthesia, and prolonged chronic OAI Conclusions The first 24/82 cases analysed confirm wide variation in management, partly due to the diversity in age, presentation and organism. This highlights the difficulties for guideline development for this heterogeneous group. Full analysis will be presented at the conference. It will provide a comprehensive picture of current local practice, and add to national data being collected as part of the DINOSAUR study, to further understanding of this serious condition.

Peripherally inserted central venous catheter line removal leading to brachial vein stripping- Need for more caution.

Use of central venous catheter is a standard of care in the management of critically ill patients and during major surgery. Their use in long-term fluid management, antibiotic therapy, parenteral nutrition, electrolyte replacement and inotropic drug therapy is well-established. Although there is limited scientific evidence to support the superiority of peripherally inserted central venous catheters (PICCs) over traditional central lines,[1] they are increasingly being used due to cost effectiveness, ease of insertion and lesser chances for serious complications. We report an unusual complication that happened during removal of PICC line.

A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters.

Peripherally inserted central venous catheters (PICCs) are being increasingly placed at the bedside by trained vascular access professional such as nurses. This is to increase the availability of the service, for cost containment, and to reduce the workload on the interventional radiologist. We describe a single institution experience with over 700 PICC lines placed by trained nurses at the bedside and determine the success rate, malposition rate of the PICC line , degree of support needed from the Interventional radiologist, and factors affecting a successful placement of a PICC line by the nurses. Seven hundred and five PICC lines were placed at the South Nassau Communities hospital between July 2011 and November 2012 by trained vascular access nurses with interventional radiology backup. Bedside ultrasound was used for venous access, an electromagnetic catheter tip detection device was used to navigate the catheter into the desired central vein and catheter tip position was confirmed using a portable bedside chest X-ray. The nurses, with a malposition rate of 3.8%, successfully placed 91.6% (646/705) catheters. Interventional radiology support was needed for 59 cases (8.4%) and 17 cases (2.4%) for failed placement and catheter malposition adjustment, respectively. Risk factor such as presence of pacemaker wires and multiple attempts at insertion were factors predictive of an unsuccessful placement of a PICC line by the nurses. Bedside placement of PICC line by trained vascular nurses is an effective method with a high success rate, low malposition rate and requires minimal support from interventional radiology.

A comprehensive intervention program on the long-term placement of peripherally inserted central venous catheters.

Peripherally inserted central venous catheters (PICCs) have been increasingly utilized in treating patients in intensive care. The purpose of this study is to analyze the related complications and to evaluate effect of a comprehensive intervention on long-term PICCs. We selected 217 and 243 cases before and after comprehensive intervention respectively from the department of radiotherapy in our hospital. Various possible factors affecting PICCs insertions and maintenance were analyzed. A quality control circle was formed for nursing care. The comprehensive intervention was performed both on catheter insertion and post-PICCs care. Complication rates were compared before and after the intervention. The duration for PICCs was 90 days. In the control group (before intervention), the complications were as follows: Tube feeding difficulties (23.5%), catheter dislodgment (23.5%), infection (17.6%), catheter obstruction (17.6%), puncture failure (5.9%), allergy (5.9%), and pain (5.9%). The incidence of unplanned extubations was 7.8%. The incidence of complications was significantly decreased in the test group (after intervention). Moreover, one episode of catheter obstruction (5.9%) and one episode of allergy (5.9%) were found (P < 0.01) in this study. Comprehensive intervention programs effectively reduce the incidence of complications in long-term PICCs lines.

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Introduction: Peripherally inserted central venous catheters (PICC) are widely used central venous system access devices. Reported complications associated with PICC line insertion are serious and life threatening. Centrally placed PICC lines have lower complication rates and optimal placement of these access devices is crucial. X-ray is the gold standard method used to confirm placement of these catheters; consequently, it is associated with radiation exposure and inability to adjust the PICC line position in real time. We propose the use of bedside focused ultrasound (FUS) study to establish PICC line position in children. Methods: Patients age 1 month to 18 years requiring PICC line placement were enrolled. Following successful catheter insertion the position of the catheter tip was evaluated using a SonoSite Ultrasound System. Bilateral IJ veins were evaluated, followed by a focused cardiac ultrasound consisting of three cardiac views. The cardiac views utilized included suprasternal, parasternal and subcostal view as described by Pediatric Council of the American Society of Echocardiography. The ultrasound was performed by a PICU fellow who was blinded to the x-ray results. Portable AP chest x-ray was used for final line position assessment. X-ray landmark for optimal PICC line location was bifurcation of trachea to two vertebral spaces below. X-ray report by radiologist was interpreted for final PICC line position assessment. The PICC line was adjusted based on x-ray report only. Results: Total of 43 catheter placement events were evaluated. Mean patient age was 8.1 years (SD 5.98). The most common reasons for PICC line insertion were antibiotic treatment (40%), parenteral nutrition (23%) and chemotherapy (21%). The overall number of PICC lines found to be malpositioned was 34 out of 43 (74%). Mean FUS time was 10.9 min (SD 3.06). Agreement between the X-ray and FUS reports on line position was observed in 36 out of 43 studies (84%). The FUS had sensitivity of 67%, specificity of 90%, NPV of 88%, and PPV of 73%. Gender, BMI, side, and site did not have significant associations with agreement of catheter position based on FUS vs. x-ray (p>0.05). Conclusions: Our study demonstrated that an FUS performed by an experienced operator provides precise information regarding the position of the PICC line tip with accuracy of 84% when compared to gold standard X-ray. Additional training and exposure of the ultrasonographer may improve the accuracy. We also showed that PICC line position was not affected by insertion site, side, BMI and gender. Future large sample size studies are needed to evaluate these associations and to show the full potential of this modality to decrease costs, radiation exposure, shorten procedure time and reduce length of sedation in pediatric population.

Comparison of peripherally inserted central venous catheters (PICC) versus subcutaneously implanted port-chamber catheters by complication and cost for patients receiving chemotherapy for non-haematological malignancies

Indwelling central venous catheters (CVCs) have been increasingly used to enable delivery of intravenous chemotherapy. We aimed to compare the safety and cost of two commonly used CVCs, peripherally inserted central venous catheter (PICCs) and ports, in the delivery of chemotherapy in patients with non-haematological malignancies. Seventy patients were randomly assigned to receive either a PICC or a port. The primary endpoint was occurrence of major complications, which required removal of the CVC and secondary endpoints included occurrence of any complications. Port devices were associated with fewer complications compared with PICC lines (hazard ratio of 0.25, CI, 0.09-0.86, P = 0.038). Major complication rate was lower in the port arm compared to the PICC arm (0.047 versus 0.193 major complications/100 catheter days, P = 0.034) with 6 versus 20 % of patients experiencing major complications, respectively. Thrombosis, the most common complication, was significantly higher in the PICC arm compared to the port arm (25 versus 0 %, P = 0.013). Quality of life and cost estimates did not differ significantly between the two arms. Port devices are associated with a lower risk of complications, with no difference in cost, compared to PICC lines in patients with non-haematological malignancies receiving intravenous chemotherapy.

Incidence of venous thromboembolism in patients with hematologic malignancies related to upper extremity peripherally inserted central venous catheters.

6586 Background: Central venous catheters (CVCs) are an integral part of management in patients with hematological malignancies (HMs). CVCs are not without risk however, including DVT which adds significant morbidity. Peripherally inserted central venous catheters (PICCs) via the brachiocephalic veins were the most common CVCs utilized at the Medical College of Wisconsin for patients with HMs. Recent evidence has indicated an increased risk of DVT in patients with PICCs. Methods: We retrospectively reviewed patients admitted to our institution from 2009-2011 with a HM and a CVC placed based upon CPT codes. A chart review was performed and those with a radiologic-confirmed DVT were identified. Results: From 2009-2011, 487 patients with HMs had 1091 CVCs placed. Diagnoses included lymphoproliferative disorders (35.8%), acute leukemia excluding APL (23.8%), APL (1.6%), plasma cell dyscrasias (34.6%), MDS (1.7%), CML (1.6%), and other diagnoses (0.7%). Of the CVCs placed 51% were in patients undergoing stem cell transplantation (HCT) and 49% were placed in non-HCT patients. A total of 91 DVTs were documented and confirmed. DVTs occurred in 85 of 728 PICCs (11.7%), 3 of 104 implanted ports (2.9%), 3 of 249 tunneled CVCs (1.2%), and 0 of 10 other CVCs. DVT rates were similar between HCT (47 of 556, 8.4%) and non-HCT (44 of 535, 8.2%) patients. The highest number of DVTs were associated with plasma cell dyscrasias (29 of 378, 7.7%) followed by lymphoproliferative disorders (28 of 391, 7.2%), acute leukemia (26 of 260, 10%), APL (3 of 18, 16.6%), MDS (3 of 19, 15.8%), and CML (2 of 17, 11.7%). Two DVTs occurred in the setting of warfarin therapy, 5 while on prophylactic and 9 while on therapeutic LMWH. The mean duration from line placement to DVT was 21 days (range 1-169). Using standard chi-squared evaluation, PICC lines were significantly more likely to be associated with DVTs than tunneled or implanted CVCs (p&lt;0.0001). Conclusions: Brachiocephalic PICC-lines are associated with a high incidence of DVT in patients with HMs compared to other CVCs. We have currently changed our practice to utilizing a tunneled internal jugular PICCs for central venous access.

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.

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.

Catheter-Associated Bloodstream Infection Incidence and Risk Factors in Adults with Cancer: A Prospective Cohort Study.

Abstract 1382Poster Board I-404 Background:Central venous catheter-associated blood stream infections (CA-BSI) cause considerable morbidity in adult patients with hematologic cancers and solid tumors. A range of central venous access devices (CVAD) may be used across differing patient diagnoses and for varying indications. The aim of our study was to determine the incidence and risk factors for CA-BSI. Methods:A prospective observational cohort study of consecutive adult patients requiring a CVAD in a hematology-oncology unit (including autologous but not allogeneic transplantation) was performed. All CVADs were inserted under ultrasound guidance in a dedicated interventional radiology facility with peripherally inserted central venous catheters (PICCs) inserted in the basilic or cephalic vein and tunnelled lines, non-tunnelled lines and implantable ports inserted via the internal jugular vein. Standardized surveillance methods for CA-BSI were applied and data on CVAD complications were recorded. Results:1119 CVADs were assessed in 723 patients over 50,478 line days. Median patient age was 55yrs and 56% were male. Patient diagnoses included aggressive hematologic malignancies (48%, includes AML (17%), MDS (1%), NHL (22%) and MM (8%)), Hodgkin lymphoma (3%), other hematologic malignancies (3%), oesophageal/colon/rectal cancers (26%), and all other solid tumors (20%). CVAD types included PICCs (71%), non-tunnelled lines (14%), tunnelled lines (14%), and implantable ports (1%). 291 lines were removed due to a clinical suspicion of infection, 133 of these had CA-BSI and 34 of these had a positive tip culture in addition to meeting the definition of CA-BSI. The four most common bacterial isolates were S. epidermidis (n=23), S. aureus (n=15), Pseudomonas sp (n=12) and Stenotrophomonas sp (n=10). The rate of CA-BSI per 1,000 line days was 2.63. In multivariate analysis, factors associated with CA-BSI included: type of CVAD (greatest for non-tunnelled lines (HR 3.67, p<0.0001) and tunnelled lines (HR 1.83, p=0.0062) compared to PICC lines); patient diagnosis (greatest for aggressive haematological malignancies (HR 2.95, p=0.0031) and least for oesophageal, colon and rectal cancers (HR 0.26, p=0.014) compared to other solid tumours); side of insertion (greatest for right-sided lines (HR 1.61, p=0.024)); and number or prior line insertions (HR1.2, p=0.016). In a subgroup analysis of patients with aggressive hematologic malignancies, the association between CA-BSI and line type (greater infection for tunnelled (HR 1.46, p=0.09) and non-tunnelled lines (HR 3.73, p<0.001) compared to PICCs) and side of line insertion (more infection with right sided lines (HR1.66, p=0.035)) remained. 4.8% of lines were complicated by symptomatic thrombosis which was less common in patients with oesophageal, colon and rectal cancer (HR 0.43, p=0.027) and in lines inserted in the internal jugular vein (HR 0.2, p=0.0083) compared to PICC lines. Conclusions:Incidence of CA-BSI in an Australian adult cancer population is comparable to other reports in the literature. This study highlights the utility of a standardised CA-BSI surveillance strategy in adult patients with cancer, provides further data to support the use of PICC lines in such patient populations, including patients with hematological malignancies, and suggests that the side of line insertion may influence CA-BSI. Disclosures:No relevant conflicts of interest to declare.

Brachial Arteriovenous Fistula as a Complication of Placement of a Peripherally Inserted Central Venous Catheter: A Case Report and Review of the Literature

Peripherally inserted central venous catheter (PICC) lines have become a frequently used method of intravenous access for long-term administration of antibiotics, chemotherapy, and parenteral nutrition. Catheter-related complications involving the arterial tree are rare. We report a case of a 25-year-old woman with a history of difficult PICC line placement that presented with an arteriovenous fistula in the left arm. Duplex ultrasound confirmed the diagnosis of a brachial artery-to-brachial vein arteriovenous fistula (AVF), and the patient underwent surgical repair. To our knowledge, this is the first reported case of an AVF resulting from PICC line placement. Correction of AVF is indicated to alleviate symptoms as well as to prevent future complications.

Journal scan

This American research raises doubts over the recent inclination of in-patient oncology and haematology units to preferentially use peripherally inserted central venous catheters (PICC) over cuffed and skin-tunnelled central venous catheters (CVC’s) for the administration of infusates. The authors suggest that the PICC line infection rates, vulnerability to thrombosis and premature dislodgement should merit precaution over their use.

Why are we trimming peripherally inserted central venous catheters?

PERIPHERALLY INSERTED CENTRAL venous catheters (PICCs) are used as the standard of care for longterm intravenous access in neonates treated in neonatal intensive care units. Little evidence supports many of the practices associated with PICC lines, however. Some practices needing more evidence include catheter tip placement in very low birth weight neonates, the catheter insertion site, the catheter material, insertion site dressings, and mechanisms to prevent catheter-related sepsis. Of particular concern is the practice of trimming the excess length off the distal end of the catheter prior to insertion.

The experiences of patients and nurses with a nurse-led peripherally inserted central venous catheter line service

Nurse-led Peripherally Inserted Central Venous Catheter (PICC) services are becoming commonplace in cancer centres across the UK. Research has shown that these services are cost-effective and are associated with fewer catheter-related complications, including infection and thrombosis, than skin-tunnelled catheters. This exploratory study aimed to explore patients' and nurses' experiences of a nurse-led PICC line service. Recorded interviews were conducted with 10 cancer patients with PICC lines inserted, five hospital-based nurses and five community-based nurses experienced in caring for patients with these lines. Respondents' recorded accounts were transcribed, coded and analysed to determine patients' and nurses' perceptions of the service and the extent to which collaborative practice was promoted. Findings were synthesized into five themes: Education, Formation of Expectations, Confidence, Sensory Experience and Adaptation. All respondent groups were positive about the PICC line service and the specialist oncology nurses working within it. The findings did identify some aspects of the service which could be improved, including the timing of information given to patients and the use of more innovative educational approaches. This study has informed the development of a potential flexible service structure which may be incorporated into established and differing care settings using existing resources.

Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

Background and aims: Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach for hospitalized patients who require TPN.Methods: One hundred and two hospitalized patients (age range, 18–88 years) who required TPN were prospectively randomized to receive therapy via a centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied.Results: Complication-free delivery rate (without the need to remove or replace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P<0.05). The overall infection rate was 4.9 per 1000 catheter days and was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the direct institutional costs for insertion and maintenance of PICC lines (US$22.32±2.74 per day) was greater than that for subclavian lines (US$16.20±2.96 per day;P<0.05).Conclusion: PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.