Traditional Central Venous Catheters Research Articles

The use of peripherally inserted central catheter reduced the incidence of phlebitis in heart failure patients: A randomized trial.

During decompensated heart failure, the use of intravenous inotropes can be necessary. With peripheral venous access, prolonged inotrope infusion can cause phlebitis. However, traditional central venous catheters have possible complications. Peripherally inserted central catheters (PICCs) may be an alternative to traditional catheters. Our objective was to compare the incidence of phlebitis between patients with PICC and those with peripheral venous access catheter indwelling. In a randomized clinical trial, the patients were randomized to PICC and control groups, with 40 patients in each group. The inclusion criteria were hospitalized patients with advanced heart failure, ejection fraction of <0.45, and platelet count of >50,000/mm3 and current use of continuous intravenous infusion of dobutamine. The patients were randomly assigned to receive a PICC or keep their peripheral venous access. The primary end point was the occurrence of phlebitis. The PICC and control groups included 40 patients each. The median age was 61.5 years; ejection fraction, 0.24; and dobutamine dose, 7.73 µg/(kg min). Phlebitis occurred in 1 patient (2.5%) in the PICC group and in 38 patients (95.0%) in the control group, with an odds ratio of 0.10% (95% confidence interval: 0.01%-1.60%, p < 0.001). In conclusion, in severe heart failure patients who received intravenous dobutamine, PICC use reduced the incidence of phlebitis when compared to patients with peripheral venous access. Therefore, the PICC use should considered over peripheral venous access for prolonged intravenous therapy in heart failure patients.

Correlation of Positive Blood Cultures with Peripherally Inserted Central Catheter Line Infection in Oncology Patients.

Introduction: The use of peripherally inserted central catheter (PICC) lines offers several advantages compared to traditional central venous catheters (CVCs) as the insertion procedure is minimally invasive, they may be retained safely for longer periods of time, and their use is associated with fewer catheter-related infections. Their use in patients suffering from a malignant disease is common but may pose a greater risk of complications due to the severe immunosuppression associated with treatment. This study was conducted to evaluate the safety of PICC lines in this group.Methods: This was a retrospective study of oncology patients being treated in a Mediterranean tertiary center. Patients with PICC lines were enrolled in the study if a positive blood culture necessitated the removal of the PICC and subsequent culture of the PICC tip. A comparison was conducted between patients with positive and negative PICC cultures.Results: Thirty patients were included, four of whom had a positive PICC culture. The most commonly isolated pathogens were coagulase-negative Staphylococci and Corynebacteria. No statistically significant difference was noted in white blood cell (WBC) counts, C-reactive protein (CRP), and Michigan PICC central line associated bloodstream infection (MPC) score between the two groups. Staphylococcus epidermidis was the most commonly isolated pathogen.Discussion: Though limited by a small sample size and the retrospective design, the findings of this study seem to corroborate existing literature on the subject which suggests that the use of PICC lines in oncology patients is feasible and does not pose unacceptable risk. Further research is indicated to determine subgroups which may be at greater risk of PICC related infections.

A review of peripherally inserted central catheters and various types of vascular access in very small children and pediatric patients and their potential complications

Accessing the veins for blood delivery, sampling or nutrition is a critical factor in the process of care and management of pediatric patients. In this regard, the peripherally inserted central catheter (PICC) is one of the main alternatives which could be applied effectively as traditional central venous devices in neonates and adults. Due to their essential role in providing safe central venous entry, PICCs could be applied extensively in patients who are critically ill. The main aims of the present study are to review approximately all relevant publications concerning PICC procedures, any possible complications, and the most appropriate decision for preventing these complications due to their high mortality rate. We carried out a comprehensive search on PubMed, HubMed, EMBASE, MEDLINE, Science Direct, Scopus, MEDLINE, and EMBASE databases for identifying the most relevant publications related to potential complications following the application and insertion of PICCs in hospitalized children and infants. Through appropriate care of catheters, the rate of possible infectious, mechanical and thrombotic complications would decrease considerably compared to those patients who received traditional central venous catheters. However, the process of vascular access in neonatal and children is very challenging. Any delay or denying treatment due to the lack of vascular access is intolerable. In this regard, anesthesiologists must achieve extra knowledge of various vascular devices.

Complete Blood Count Collected Via Venipuncture Versus Peripherally Inserted Central Catheter in Hematological Patients: A Comparison of 2 Methods.

The use of peripherally inserted central catheters (PICCs) in cancer care is increasing over traditional central venous catheters. Nurses frequently collect blood by venipuncture when a PICC is inserted, as there is no available evidence to confirm the reliability of blood tests collected through PICCs in adults. The aim of this study was to assess the reliability of blood samples for complete blood count (CBC) obtained through PICCs as an alternative to venipuncture. A cross-sectional design was used to recruit adult hematological patients. The blood samples were collected within 5 minutes of each other by a specialist nurse. Hemoglobin, hematocrit, and platelet count were evaluated. To determine method comparison, Passing-Bablok regression, test of linearity, Pearson product-moment correlation coefficient, and Bland-Altman plots were used. Thirty paired blood samples were collected in 29 hematological patients with a mean age of 66.8 years. A statistical difference was found for hemoglobin (P = .001) and hematocrit (P = .001) levels, but no clinical difference. The regression models revealed no systematic differences and no proportional differences with a linear relationship between the methods. Bland-Altman plots highlighted a good agreement between methods. Blood samples for CBC drawn by PICCs are as reliable as those collected via venipuncture. Blood sampling via PICC could be recommended in people with hematological malignancies in needs of frequent blood tests. Sampling through a PICC provides reliable laboratory results for CBC, and it could reduce patients' discomfort and increase the safety of professionals reducing the risk of accidental percutaneous needlestick injuries.

Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals.

To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward. Retrospective cohort study. Fifty-two hospital Michigan quality collaborative. Twenty-seven-thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization. Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p < 0.001) and more often associated with a complication (odds ratio, 1.30; 95% CI, 1.18-1.43; p < 0.001). Substantial variation in ICU peripherally inserted central catheter use and outcomes across hospitals was observed, with median peripherally inserted central catheter dwell time ranging from 3 to 38.5 days (p < 0.001) and complications from 0% to 40.2% (p < 0.001). Importantly, 87% (n = 45) of ICUs reported median peripherally inserted central catheter dwell times less than or equal to 14 days, a duration where traditional central venous catheters, not peripherally inserted central catheters, are considered appropriate by published criteria. Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate. Further study of vascular access decision-making in the ICU appears necessary.

2096. Evaluation of a Midline Catheter Program and Effect on Central Line-Associated Blood Stream Infections

BackgroundCentral line-associated blood stream infections (CLABSI) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVCs) placement. To improve vascular access device choice and reduce the potential risk of CLABSIs, we implemented a quality improvement initiative compromised of a new vascular access algorithm with introduction of midline utilization and sought to evaluate the impact of midline use on CLABSI rates.MethodsA prospective quality improvement assessment from October 2017 through March 2018 analyzed the infection rates of midline catheters and CVCs. When a consult was placed for a peripherally inserted central catheter (PICC) that the patient would be evaluated via the vascular access algorithm (Figure 1) for whether they should receive a midline catheter, a PICC or a traditional CVC. The midline catheters, PICCs, and CVCs were monitored for duration of indwell and bloodstream infections consistent with reportable CLABSI definitions.ResultsIn the month prior to implementation, the institutional CLABSI rate was 1.36 per 1,000 CVC (including PICC) days. Since October 2017, there have been 4,588 midline catheter days, with two midline infections, for a cumulative rate over those 6 months of 0.435 midline catheter infections per 1,000 midline days. This was compared with 26,575 CVC days, with 33 documented CLABSIs, for a rate of 1.242 per 1,000 CVC days. Since the vascular algorithm was implemented, the infection rate from the compilation of CVC and midline catheters is 1.12 per 1,000 catheter days.ConclusionThe implementation of a vascular access algorithm including midlines may effectively reduce central line insertions and thereby decrease CLABSIs through appropriate utilization of a lower risk device (midline). Further research into comparing additional risks, benefits, complications and costs of midline catheters and all styles of central venous catheters is warranted. Disclosures All authors: No reported disclosures.

Front-Line Vascular Access Devices in Acute Leukemias – Peripherally Inserted Central Catheter (PICC) Versus Traditional Central Venous Catheter (CVC): A Phase IV Randomized Trial (NCT02405728)

Front-Line Vascular Access Devices in Acute Leukemias – Peripherally Inserted Central Catheter (PICC) Versus Traditional Central Venous Catheter (CVC): A Phase IV Randomized Trial (NCT02405728)

Peripherally Inserted Central Venous Catheters (PICCs): An Opportunity for Antimicrobial Stewardship

BackgroundPICCs are often used in hospitalized patients who require prolonged intravenous (IV) antibiotic therapy. PICCs offer the advantage of ease and safety of insertion over traditional central venous catheters (CVCs) but still carry the risks of venous occlusion, phlebitis, dislodgement and central line associated blood stream infection (CLABSI).The objective of this analysis was to determine the impact of an ASP’s prospective audit and feedback when PICCs are ordered for antibiotic therapy.MethodsPharmacists from the Antimicrobial Stewardship Program (ASP) and Nurses from the PICC team reviewed the electronic medical record of patients ordered a PICC for IV antibiotics to determine whether either antibiotic therapy could be changed to the oral route or if therapy was complete per current infectious disease treatment guidelines. If either alternative to the PICC was approved by the ASP physician, the medical team was contacted to discuss discontinuation of the PICC order as well as the antibiotic recommendation.ResultsFrom January 1, 2016 through March 30, 2017, placement of 35 PICCs was prevented through prospective Stewardship review of PICC orders indicated for antibiotic use. A total of 361 PICC days and 378 IV antibiotic days of therapy (DOT) were avoided. Antibiotic therapy was stopped for 6 patients; 27 patients were prescribed an oral antibiotic alternative including 9 patients who were receiving IV vancomycin.For the 35 patients where a PICC was not placed, $8,700.00 to $10,380.00 was avoided in materials utilized for catheter placement and approximately 52 hours in IV nursing time was avoided for PICC placement. Additionally, approximately $14,400.00 in antibiotic expenditures was also avoided.ConclusionThe opportunity exists for ASPs to reduce IV antibiotic DOT, avoid patient risk for CLABSI and reduce the cost of hospitalization and PICC nurse workload through screening PICC orders for IV antibiotic therapy.Disclosures All authors: No reported disclosures.

Peripherally Inserted Central Catheters (PICCs) Implantation in the Clinical Management of Oncohematologic Patients: Results of a Large Multicenter, Retrospective Study of the REL Group (Rete Ematologica Lombarda - Lombardy Hematologic Network, Italy)

Background: PICCs are vascular devices inserted from a peripheral vein of the upper third of the arm under ultrasound guide, and provide a central venous access (CVA) with an intermediate duration between short term central venous catheters (CVCs), such as jugular or subclavian CVCs, and long term ones (port-a-caths).PICC insertion is ease and safe with no pneumothorax or hemothorax risk. Their extremity reaches a central vein, and can be used for cytostatic drugs, hyperosmolar solutions, and antibiotics infusion. Furthermore, patients (pts) at high risk of hemorrhage for thrombocytopenia or coagulopathy are eligible for PICC insertion.Nevertheless, some concern exists about the risk of infectious and thrombotic complications associated with PICC use in immunocompromised cancer pts characterized by a prothrombotic state.In particular, few clinical data from large oncohematologic pts series are available on PICCs' implants and their complications.Aims: To analyze the results of a large multicenter, retrospective study of the REL group (Rete Ematologica Lombarda-Lombardy Hematologic Network, Italy) aimed at clinically characterizing PICC use in oncohematologic patients management.Methods: Four REL Hematology Centers participate to the study. The clinical data of 453 implanted PICCs from January 2010 to June 2015, were retrospectively collected, for a total of 44,577 catheter days.Pts median age was 61 yrs (range 10-88).Patients' diagnoses were 197 non-Hodgkin's lymphoma, 10 chronic lymphocytic leukemia, 105 acute myeloid leukemia, 45 acute lymphoblastic leukemia, 33 Hodgkin's lymphoma, 39 multiple myeloma, 12 myelodysplastic/myeloproliferative syndrome, 6 miscellaneous.All pts received intravenous chemotherapy, long term anti infectious drugs (antibiotics and antifungals), and hypertonic solutions.PICCs were inserted by ultrasound-guided puncture of a peripheral vein of the arm, by microintroducer technique, under strict asepsis.Chest X-ray was performed to verify correct tip location (ideally in the proximity of cavo-atrial junction).Data on PICCs' lumen number are available in 423 cases: 292 (69%) were single-lumen and 131 were double-lumen (31%).Results: Median PICC life-span was 90 days (range 1-760, Kaplan-Meier method). No major insertion-related complications were observed.Late complications occurred in 172/453 PICCs (38%, 3.8/1000 catheter days): 93 infectious (20%, 2/1000 catheter days), 38 thrombotic (8%, 0.8/1000 catheter days), 37 mechanical (8%, 0.8/1000 catheter days), 5 (1%, 0.1/1000 catheter days) miscellaneous complications (patient intolerance, local pain and hematoma).Among infectious complications, we reported 24 cases (5%, 0.5/1000 catheter days) of fever of unknown origin (FUO) and 69 (15%, 1.5/1000 catheter days) catheter-related bloodstream infections.Mechanical complications consisted of 3 (1%) catheter dislocations, 19 accidental removals (4%), 16 (3%) lumen occlusions and 3 (1%) breakages of the external section of PICC.In 376/453 (83%) cases PICC was removed due to end of intravenous therapy in 160 patients (35%), death in 98 (22%) and to various complications in 118 (26%) cases. Specifically, FUO lead to PICC removal in 10 (2%), infection in 40 (9%), venous thrombosis in 25 (5%) cases, catheter dislocation or accidental removal in 22 (5%), lumen occlusion in 13 (3%), breakage of the external section of PICC in 2 (0,5%), other mechanical complication in 4 (1%), local pain and miscellaneous 2 (0,5%) each.In the case of a complication occured, the incidence of PICC removal was 68% (118/172): FUO/infections represented the removal cause in 50/172 (29%), mechanical complications in 40/172 (23%), thrombosis in 25/172 (14%) cases.Conclusions: Traditional CVCs are associated with significant complications, reported at varying frequencies in highly heterogeneous oncohematologic pts series: infections are reported from 4.6 to 23% and thromboses from 1.2 to 30.2% of the cases.We have clinically characterized a large series of PICCs in oncohematologic patients. Our data suggest that their implant, as an alternative to traditional CVCs, is a safe and effective way to provide oncohematologic patients at high risk of hemorrhagic and infective complications with a CVA. PICCs compare favorably with traditional CVCs reported complications, and facilitate the proper management of complex and prolonged therapeutic programs. DisclosuresNo relevant conflicts of interest to declare.

Clinical effects of bundle intervention strategy on the prevention of CVC-related bloodstream infections

Objective To study the clinical effects of bundle intervention strategy on the prevention of CVC-related bloodstream infections. Methods A total of 847 patients were enrolled, of whom 411 cases received central venous catheterization (CVC) from June 2008 to June 2010 were allocated to control group with 5760 catheter days and traditional central venous catheter care. While a total of 436 cases from September 2010 to September 2012 were allocated to observation group with 6110 catheter days and performed bundle intervention strategy. The site and duration of CVC, and incidence of CVC-related bloodstream infections between two groups were compared. Results The length of catheter indwelling in the observation group was (8±3)d which was shorter than (13±7)d in the control group (t=2.672, P=0.008). A total of 436 patients of observation group had total 6 110 d catheter indwelling time, in whom14 cases happened CRBSI with incidence rate 2.3 per one thousand catheter day; 411 patients of the control group had 5 760 d catheter indwelling time, in whom 38 cases occurred CRBSI with incidence rate 6.6 per one thousand catheter day; the difference of CRBSI rate in two groups had statistical significance (χ2=12.60, P=0.002). Conclusions The implementation of bundle intervention strategy can effectively minimize the incidence of CVC-related bloodstream infections. Key words: Central venous catheter; Intensive Care Unit; Bundle intervention; Catheter-related bloodstream infection

Do more with less: a surgery directed institutional model for resident central line training

BackgroundSimulation training can improve proficiency in central line placement, but it is expensive and resource intensive. The authors developed a 3-phase approach to central venous catheter placement training, including an online module, mannequin-based simulation using a single faculty member, followed by department directed clinical observation. The hypothesis was that standardizing institutional central venous catheter placement training would maintain training efficiency and reduce faculty and resource demands. MethodsPreintervention and postintervention assessments of the trainees' performance were collected to evaluate program effectiveness. Program surveys were collected to evaluate residents' satisfaction and comfort with the procedure. Resource utilization was compared between the period before program implementation and the 2 following years. ResultsMean pretest to posttest scores for the online module improved significantly from 7.0 to 8.4 in 2010 and from 7.1 to 8.4 in 2011. Video evaluation demonstrated significant improvement across all postgraduate year levels. Surveys revealed high resident satisfaction and increased procedural confidence. Overall resource costs and faculty requirements decreased. ConclusionsA standardized training program for an entire institution can maintain quality while being more cost effective than traditional central venous catheter placement training.

Peripherally inserted central catheters in infants and children – indications, techniques, complications and clinical recommendations

Venous access required both for blood sampling and for the delivery of medicines and nutrition is an integral element in the care of sick infants and children. Peripherally inserted central catheters (PICCs) have been shown to be a valuable alternative to traditional central venous devices in adults and neonates. However, the evidence may not extrapolate directly to older paediatric patients. In this study, we therefore review the indications, methods of insertion and complications of PICC lines for children beyond the neonatal age to provide clinical recommendations based on a search of the current literature. Although the literature is heterogeneous with few randomised studies, PICCs emerge as a safe and valuable option for intermediate- to long-term central venous access in children both in and out of hospital. Insertion can often be performed in light or no sedation, with little risk of perioperative complications. Assisted visualisation, preferably with ultrasound, yields high rates of insertion success. With good catheter care, rates of mechanical, infectious and thrombotic complications are low and compare favourably with those of traditional central venous catheters. Even in the case of occlusion or infection, fibrinolytics and antibiotic locks often allow the catheter to be retained.

Performance comparison of peripherally inserted central venous catheters in gastrointestinal surgery: A randomized controlled trial

Peripherally inserted central venous catheters (PICC) are long-term vascular access devices inserted through a peripheral vein of the arm and serve as an alternative to traditional central venous catheters. Currently different types of PICCs are available. No data, however, are available in regard to materials and tip designs. We designed a prospective, randomized trial comparing two major PICCs with different material and tip design: a silicone catheter with distal side slits (Groshong Catheter) and a polyurethane catheter with open-end tip (PI Catheter). Twenty-six patients who underwent PICCs placement between August 2010 and December 2010 were enrolled in the study. The primary endpoint was the completion rate of PICC indication. Secondary endpoints were complications rate. The completion rate of PICC indication was not different significantly (81.8% and 92.9%, p=0.5648) and the total complication rate were also not different significantly (9.1% and 14.3%, P=1.0000) between two catheters. In detail, PI Catheter were associated with a significantly higher incidence of catheter occlusion, and Groshong Catheter were associated with a significantly hemorrhages after removal. There was no difference in the durability and the complication between Groshong Catheter and PI Catheter. (UMIN Clinical Trial Registry UMIN000005451).

Mechanical Lock of the Lumen: Researching towards new Approaches for Permanent Vascular Access

Theoretical proposals for two new vascular access devices (a central venous catheter (CVC) and a peripheral vascular access system, PVAS) are presented in this article. The new CVC concept is based on a mechanical obturator used for CVC locking. Compared to conventional locks, it should, theoretically, allow the reduction of bacterial contamination, biofilm and thrombotic formation. A new tunneling technique, based on a "rigid tunnel sheath" providing a more stable connection, as compared to a traditional CVC cuff, and an increasingly protected exit site, allows CVC changing changeover to take place through the sheath; therefore, avoiding surgical intervention. PVAS, based on the same mechanical lock concept, is structured from four components: obturator, soft graft, rigid tunnel sheath and foldable sheath. The total graft length is about 80 mm, its inner extremity being uncovered to allow a gentle curve reaching the native vessel. The outer extremity and bifurcation are reinforced by a titanium rigid sheath together with a Dacron cuff. The obturator is protected, and several technical solutions have been considered to guarantee sterility: the "accordion sheath", the "foldable sheath", and the "balloon obturator system". The major advantage of PVAS on CVC is the implant on the peripheral vessel which allows the saving of central veins and possibly avoiding life-threatening complications. As compared with an arterial-venous fistula or an arterial-venous graft, PVAS's main advantage should be the possibility of implanting even in "desperate" cases, so avoiding fistula needle positioning. It could be indicated for pediatric or psychiatric patients, for home-based or frequent dialysis schedules. Lower hemodynamic stress should therefore reduce vessel damage, such as aneurism, pseudo-aneurism, intimal hyperplasia and cardiac overload. The development of prototypes is in progress to verify both device usefulness and safety in clinical practice.