Single-lumen Peripherally Inserted Central Catheters Research Articles

Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis.

Inappropriate use of peripherally inserted central catheters (PICCs), including multilumen PICCs, may increase the risk of patient complications. Implement computerized decision support to: (a) increase the use of midline catheters over PICCs when appropriate and (b) decrease PICC lumens when a PICC is necessary. Quasi-experimental, interrupted time series. Single tertiary academic medical center. Hospitalized adults who received a midline or PICC during clinical care. Decision support on appropriate vascular access device choice via a set of electronic orders embedded within the electronic health record. Proportion of midline catheter and single-lumen PICCs placed between January 2, 2017 and November 19, 2017 (preintervention) versus November 20, 2017 to December 1, 2019 (postintervention). A total of 8758 midline and PICCs were inserted during the study period. A statistically significant increase in the insertion of midline catheters was observed during the intervention (p = .006). In parallel, single-lumen PICC insertion as a proportion of all PICCs also increased after the intervention (p = .035). Results were consistent across multiple disciplines, including internal medicine, surgery, and intensive care. After considering the hospital census, total PICC and midline utilization rates and rates of complications did not change over time. However, an increase in catheter exchanges from less to more invasive devices occurred. In this single-center study, the implementation of electronic decision support to inform appropriate catheter use led to a more appropriate midline catheter and single-lumen PICC insertion. Dissemination of this single, effective intervention to examine efficacy in other hospital settings would be welcomed.

Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system.

Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. Average single-lumen PICC utilization increased by 25.5%, from 44.4% to 69.9% (P < .001). CLABSI rates had a nonsignificant reduction by 26.7% from 2.44 to 1.79 infections per month (P = .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.

Central venous catheter-associated complications in pediatric patients diagnosed with Hodgkin lymphoma: implications for catheter choice.

PurposeThe purpose of this study was to determine the most optimal central venous catheter (CVC) for pediatric patients with Hodgkin lymphoma (HL) in terms of complications.MethodsA retrospective study including patients diagnosed with HL from 2015 to 2021 at the Princess Máxima Center was performed. Patients were followed from CVC insertion until removal or 06–2021, whichever came first. The primary outcome was the CVC-related complication incidence rate (IR) per 1000 CVC-days. Furthermore, the incidence rate ratio (IRR) was calculated by comparing complication IRs between peripherally inserted central catheters (PICC) and totally implantable venous access ports (TIVAP). Additionally, risk factors for central venous thrombosis (CVT) were identified.ResultsA total of 98 patients were included. The most frequently observed complications were local irritation/infections (18%; IR 0.93), malfunctions (15%; IR 0.88), and CVC-related CVTs (10%; IR 0.52). Single lumen PICCs were associated with a higher risk of complications (49% vs. 26%; IRR 5.12, CI95% 2.76–9.50), severe complications (19% vs. 7%; IRR 11.96, CI95% 2.68–53.42), and early removal (18% vs. 7%; IRR 9.96, CI95% 2.18–45.47). A single lumen PICC was identified as a risk factor for CVC-related CVT when compared to TIVAPs (12% vs. 7%, IRR 6.98, CI95% 1.45–33.57).ConclusionThe insertion of a TIVAP rather than a PICC should be recommended for pediatric patients with HL, especially in the presence of CVT-related risk factors. Future trials should evaluate the efficacy and safety of direct oral anticoagulants for the primary prevention of CVT in pediatric patients with a PICC and other CVT-related risk factors.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-022-07256-3.

A Quality Improvement Project to Reduce Unnecessary Use of Multilumen PICCs

Background: Peripherally inserted central catheters (PICCs) are an increasingly common vascular access device. At our institution, &gt;4,000 devices are placed per year by a trained team of vascular access nurses. Although PICCs are generally safe and effective, they do carry the risk of infection and thrombosis, and this risk increases exponentially with increasing number of lumens. As part of a multidisciplinary quality improvement effort to address rising CLABSI rates, we designed interventions to improve PICC utilization. Methods: The project team used 6-σ methodology, specifically following the DMAIC (define, measure, analyze, implement, control) framework to guide analysis and interventions. Process mapping, semistructured interviews with key stakeholders, electronic surveys, and audits were performed to identify gaps and inform interventions. The interventions consisted of 3 components: changes to the electronic ordering system, education (presentations to ordering providers and an online toolkit), and clinical decision support in the form of a team of vascular-access subject-matter experts who provided guidance on line selection. Results: In total, 4,655 PICCs and 434 midlines were inserted in the 12 months before the intervention, and 7,457 PICCs and 929 midlines were placed in the 24 months after the intervention. Following the implementation of the intervention, proportions of triple-lumen catheter utilization decreased from 31.9% to 22.3% (P &lt; .0001). Concurrently, the proportion of single-lumen catheters has increased from 28.5% to 41.9% (P &lt; .0001). Overall PICC utilization decreased in the postintervention period from an average of 387.9 PICCs placed per month to 310.7. The proportion of midline catheters increased from 8.5% of total lines inserted to 11.4% in the postintervention period (P &lt; .001). Conclusions: Our intervention reduced overall PICC use and triple-lumen PICC use and increased relative utilization of single-lumen PICCs and midline catheters. Optimization of electronic orders, in conjunction with targeted education and decision support, can have a sustained impact on provider ordering behaviors and can shift the culture of utilization, even in a large academic medical center with frequent turnover of trainees.Funding: NoneDisclosures: Consulting fee- Merck (Priya Sampathkumar)

A quality improvement project to decrease utilization of multilumen peripherally inserted central catheters

We performed a quality improvement project to decrease utilization of multilumen peripherally inserted central catheters (PICCs) in favor of single-lumen PICCs and midline catheters. Through optimization of electronic orders, education and decision support, we decreased utilization of multilumen PICCs, changed provider ordering patterns, and showed a downward trend in CLABSIs.

Use of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease: A Prospective Cohort Study.

Existing guidelines, including Choosing Wisely recommendations, endorse avoiding placement of peripherally inserted central catheters (PICCs) in patients with chronic kidney disease (CKD). To describe the frequency of and characteristics associated with PICC use in hospitalized patients with stage 3b or greater CKD (glomerular filtration rate [GFR] <45 mL/min/1.73 m2). Prospective cohort study. 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Hospitalized medical patients who received a PICC between November 2013 and September 2016. Percentage of patients receiving PICCs who had CKD, frequency of PICC-related complications, and variation in the proportion of PICCs placed in patients with CKD. Of 20545 patients who had PICCs placed, 4743 (23.1% [95% CI, 20.9% to 25.3%]) had an estimated GFR (eGFR) less than 45 mL/min/1.73 m2 and 699 (3.4%) were receiving hemodialysis. In the intensive care unit (ICU), 30.9% (CI, 29.7% to 32.2%) of patients receiving PICCs had an eGFR less than 45 mL/min/1.73 m2; the corresponding percentage in wards was 19.3% (CI, 18.8% to 19.9%). Among patients with an eGFR less than 45 mL/min/1.73 m2, multilumen PICCs were placed more frequently than single-lumen PICCs. In wards, PICC-related complications occurred in 15.3% of patients with an eGFR less than 45 mL/min/1.73 m2 and in 15.2% of those with an eGFR of 45 mL/min/1.73 m2 or higher. The corresponding percentages in ICU settings were 22.4% and 23.9%. In patients with an eGFR less than 45 mL/min/1.73 m2, PICC placement varied widely across hospitals (interquartile range, 23.7% to 37.8% in ICUs and 12.8% to 23.7% in wards). Nephrologist approval for placement could not be determined, and 2.7% of eGFR values were unknown and excluded. In this sample of hospitalized patients who received PICCs, placement in those with CKD was common and not concordant with clinical guidelines. Blue Cross Blue Shield of Michigan and Blue Care Network.

Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial

BackgroundCentrally inserted totally implanted vascular access ports (PORTs) and peripherally inserted central catheters (PICCs) are widely used for the administration of chemotherapy. Our aim was to study the incidence of catheter-related deep venous thrombosis in patients with cancer receiving chemotherapy through either a PICC or a PORT. MethodsAdults with non-haematological cancer (mainly breast and colorectal) from two Swedish oncology centres were included and followed for up to 1 yr. Patients were randomly assigned to receive a single-lumen PICC or PORT. The primary end point was the occurrence of a clinically significant catheter-related deep venous thrombosis, and the secondary end point was a composite of adverse events related to the catheter: insertion complication, thrombosis, occlusion, infection, and mechanical problems. ResultsThe trial recruited 399 participants (PICC, n=201; PORT, n=198) between March 2013 and February 2017. The PICCs were associated with 16 (8%) deep venous thromboses compared with two (1%) in the PORT group (HR=10.2; 95% confidence interval, 2.3–44.6; P=0.002). The overall incidence of composite adverse events was higher for patients with a PICC compared with those with a PORT (HR=2.7; 95% confidence interval, 1.6–4.6; P<0.001). ConclusionsPICCs are associated with higher risk for catheter-related deep venous thrombosis and other adverse events when compared with PORTs. This increased risk should be considered when choosing a vascular access device for chemotherapy, especially in patients with solid malignancy. Clinical trial registrationNCT01971021.

Less Lumens‐Less Risk: A Pilot Intervention to Increase the Use of Single‐Lumen Peripherally Inserted Central Catheters

To reduce risk of complications, existing guidelines recommend use of peripherally inserted central catheters (PICCs) with the minimal number of lumens. This recommendation, however, is difficult to implement in practice. We conducted a pilot study to increase the use of single-lumen PICCs in hospitalized patients. The intervention included (1) education for physicians, pharmacists, and nurses; (2) changes to the electronic PICC order-set that set single lumen PICCs as default; and (3) criteria defining when use of multilumen PICCs is appropriate. The intervention was supported by real-time monitoring and feedback. Among 226 consecutive PICCs, 64.7% of preintervention devices were single lumen versus 93.6% postintervention (P < .001). The proportion of PICCs with an inappropriate number of lumens decreased from 25.6% preintervention to 2.2% postintervention (P < .001). No cases suggesting inadequate venous access or orders for the placement of a second PICC were observed. Implementing a single-lumen PICC default and providing education and indications for multilumen devices improved PICC appropriateness.

Infectious complications in home parenteral nutrition: A long-term study with peripherally inserted central catheters, tunneled catheters, and ports.

Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVCs) being the preferred route of administration. Peripherally inserted central catheters (PICCs) have been used increasingly, but whether they should be preferred over other types of CVCs is still controversial. The aim of this study was to evaluate catheter-related complications of CVC in patients receiving HPN. All patients treated at our center for HPN from 2007 to 2017 were prospectively included. A specialized intravenous therapy team took care of these patients. Catheter-related bloodstream infections (CRBSI) were confirmed with positive, simultaneous, differential blood cultures drawn through the CVC and peripheral vein and then semiquantitative or quantitative culture of the catheter tip. In all, 151 patients received HPN during the 11-y study period. Of these patients, 95 were women (63%) and 55 were men (37%), with a mean age of 58 ±13 y. Twenty-six were non-cancer patients (17%) and the remaining 125 patients had an underlying malignancy (83%). Regarding the CVC, 116 were PICCs, 18 Hickman, and 36 ports. Confirmed CRBSI per catheter-days showed 0.15 episodes per 1000 catheter-days for PICCs, 0.72 for Hickman, and 2.02 for ports. PICCs had less-confirmed CRBSIs per 1000 catheter-days than ports (φ = 0.54, P = 0.005), but no difference between PICCs and Hickman was found (φ = 0.32, P = 0.110). Confirmed episodes of CRBSI (2 versus 13%, χ2 = 6.625, P = 0.036) were more frequent with multilumen catheters. In our setting, single-lumen PICC and Hickman catheters showed low infectious complications.

Association between delivery methods for red blood cell transfusion and the risk of venous thromboembolism: a longitudinal study

Mechanisms of red blood cell delivery and their contribution to the incidence of venous thromboembolism are not well understood in the clinical setting. We assessed whether red blood cell transfusion through peripherally inserted central catheters (PICCs) affects the risk of venous thromboembolism compared with transfusion through non-PICC devices. We implemented a prospective study between Jan 1, 2013, and Sept 12, 2015, in patients (age ≥18 years) admitted to a general medicine ward or intensive care unit who received a PICC for any reason during clinical care in 47 hospitals in Michigan, USA, with a maximum follow-up of 70 days. The exposure of interest was route of red blood cell transfusion. The primary outcome was symptomatic, radiographically confirmed, deep-vein thrombosis in the arm or leg or pulmonary embolism. We used Cox proportional hazards regression for analyses. Venous thromboembolism developed in 482 (5%) of 10 604 patients with PICCs. Of 788 patients who received a red blood cell transfusion through a multi-lumen PICC, 61 had venous thromboembolism. The adjusted hazard ratio (HR) for venous thromboembolism in all patients whose transfusions were administered through a multi-lumen PICC was 1·96 (95% CI 1·47-2·61; p<0·0001) compared with patients not receiving a transfusion, and was 1·79 (1·09-2·95; p=0·022) compared with patients transfused through a peripheral intravenous line. Compared with delivery through a peripheral intravenous line, venous thromboembolism risk was not elevated if transfusions were delivered through a single-lumen PICC (HR 0·98, 95% CI 0·44-2·14; p=0·95) or central venous catheter (1·50, 0·77-2·91; p=0·23). For every red blood cell unit transfused through a PICC, there was a significantly increased risk of venous thromboembolism (adjusted HR 1·24, 95% CI 1·01-1·52; p=0·037). Patients who received a transfusion through a PICC in the left arm were significantly more likely to develop a deep-vein thrombosis in the ipsilateral arm compared with the contralateral side (HR 23·44, 95% CI 2·96-185·83; p=0·0028). Similarly, patients transfused through a right-sided PICC were more likely to develop deep-vein thrombosis in the ipsilateral arm (HR 3·37, 95% CI 1·02-11·14; p=0·047). Red blood cell delivery through a multi-lumen PICC is associated with a greater risk of thrombosis than transfusion through a peripheral intravenous catheter. Careful monitoring for venous thromboembolism when transfusing red blood cells through multi-lumen PICCs seems necessary. Blue Cross Blue Shield of Michigan and Blue Care Network, as part of the BCBSM Value Partnerships program.

Power Injection of Contrast Media via Peripherally Inserted Central Catheters for CT

To evaluate patient safety, catheter rupture rates, and computed tomography (CT) image quality when using peripherally inserted central catheters (PICCs) in vivo for the power injection of CT contrast media at standard injection rates. A prospective study to evaluate the safety and effectiveness of power injection of contrast media via indwelling PICCs was performed. Single-lumen and double-lumen polyurethane PICCs (5 F) were injected in vivo with contrast media for clinical CT examinations at injection rates ranging from 1 mL/sec to 4 mL/sec. Data collected included PICC rupture rate, patient complications, injection rate, peak injection pressure, PICC length, PICC age, and quality of contrast enhancement on the CT images. One hundred ten power injections of PICCs for CT examinations were performed. There were 12 injections of single-lumen PICCs and 98 injections of double-lumen PICCs. The most common injection rate was 2 mL/sec, accounting for 89 of the 110 injections (81%). Two PICCs ruptured during power injection, both as a result of operator error. One of the PICCs that ruptured was clamped at the time of injection and the other one was kinked at its venous entry site. One additional PICC showed evidence of dysfunction; it ballooned without actually rupturing. No significant patient complications occurred. Contrast enhancement of the CT images was subjectively rated as average or above average in 95% of cases. Contrast media can be power-injected via PICCs for routine CT examinations at a rate of 2 mL/sec, yielding satisfactory image quality without exposing patients to significant additional risk. Power injection rates greater than 2 mL/sec, as are typically used in CT angiography applications, were not fully evaluated by this study.

Peripherally Inserted Central Catheters with Distal versus Proximal Valves: Prospective Randomized Trial

To evaluate whether peripherally inserted central catheters (PICCs) with a proximal valve have any advantage compared to those with a distal valve in regard to the incidence of occlusion, infection, or malfunction. One hundred patients (mean age, 46 y) were randomized to receive either a distal-valved Bard Groshong catheter (n = 48) or a proximal-valved Catheter Innovations Pressure Activated Safety Valve catheter (n = 52). All catheters were 4-F, single-lumen PICCs. Catheters were placed under fluoroscopic (n = 82) or sonographic (n = 18) guidance. Most (91%) were placed for the administration of antibiotics. The placement procedure, maintenance, and weekly follow-up were the same for both catheters. Percutaneous placement with the catheter tip in the central veins was successful in all patients. Mean dwell time was 36 days. There were 12 (25%) occlusive or infectious complications in the distal valve catheter group and six (11.5%) in the proximal valve group (P = .08). There were 25 fractures in 17 distal valve catheters (35.4%) and three (5.8%) proximal valve catheter fractures (P < .01). There was a marked difference in durability between the valved catheters, in favor of the catheter with a proximal valve. There was also a trend for fewer occlusive and infectious complications with the proximal valve catheter.

Power injection of peripherally inserted central catheters

PURPOSETo study the tolerance of peripherally inserted central catheters (PICCs) of varying sizes and materials to power injection of radiographic contrast agents. MATERIALS AND METHODSEight different models of silicone and five different models of polyurethane single-lumen PICCs were injected with increasing rates of iothalamate 60% with use of a power injector. Tolerated and bursting rates and pressures were recorded. RESULTSThere was a wide range of tolerated rates and pressures, depending on the inner and outer diameters of the catheters and on the catheter material. Silicone PICCs tolerated rates between 0.4 and 7.0mL/sec and polyurethane PICCs tolerated rates between 0.6 and 10.2mL/sec, depending on the specific catheter. The 5 Fr silicone PICCs and the 4 Fr and 5Fr polyurethane PICCs tested all tolerated rates greater than 4mL/sec. Silicone catheters tolerated pressures between 107 and 184 psi, and polyurethane catheters tolerated pressures between l60 and 314 psi. CONCLUSIONSLarger single-lumen silicone and polyurethane PICCs may be suitable for power injection of contrast agents.

Power Injection of Peripherally Inserted Central Catheters

To study the tolerance of peripherally inserted central catheters (PICCs) of varying sizes and materials to power injection of radiographic contrast agents. Eight different models of silicone and five different models of polyurethane single-lumen PICCs were injected with increasing rates of iothalamate 60% with use of a power injector. Tolerated and bursting rates and pressures were recorded. There was a wide range of tolerated rates and pressures, depending on the inner and outer diameters of the catheters and on the catheter material. Silicone PICCs tolerated rates between 0.4 and 7.0 mL/sec and polyurethane PICCs tolerated rates between 0.6 and 10.2 mL/sec, depending on the specific catheter. The 5-F silicone PICCs and the 4-F and 5-F polyurethane PICCs tested all tolerated rates greater than 4 mL/sec. Silicone catheters tolerated pressures between 107 and 184 psi, and polyurethane catheters tolerated pressures between 160 and 314 psi. Larger single-lumen silicone and polyurethane PICCs may be suitable for power injection of contrast agents.

Interventional Radiologic Placement of Peripherally Inserted Central Catheters

This study examines the difference in success between bedside insertions of peripherally inserted central catheters (PICCs) performed by clinicians and fluoroscopically assisted insertions by cardiovascular/interventional (CV/I) radiologists. Four hundred four PICCs were inserted in 305 patients, with a mean age of 48 years (range, 8-78 years), who required intermediate and long-term central venous access. One hundred fifty patients underwent bedside insertion, and 155 patients underwent fluoroscopically assisted insertion. Dual- and single-lumen PICC devices were used depending on venous access needs. Central venous access with the PICC device was achieved in 111 (74%) of 150 bedside insertions and in 153 (98.7%) of 155 fluoroscopic insertions. Average PICC dwell time was 72.7 days (range, 2-307 days). Of the 305 patients, 244 (73.4%) completed planned therapy with a single catheter, 54 patients (17.7%) required two PICCs at the same site, 15 patients (4.9%) required three or more PICCs at the same site, and 12 patients (4.0%) required PICC replacement to a different site to complete therapy. Complications with bedside insertions included upper extremity thrombophlebitis (n = 4), entry site infection (n = 6), and PICC shear with migration (n = 2), while complications with fluoroscopic insertions included entry site infection (n = 2). Because of the far greater placement success achieved by CV/I radiologists, all PICCs are now inserted fluoroscopically. The devices complete favorably with surgically placed central catheters with regard to service interval, morbidity, and cost. Use of fluoroscopic techniques enables placement of these devices in virtually all patients, even those with seemingly no peripheral veins.