|Year : 2014 | Volume
| Issue : 2 | Page : 359-362
A comprehensive intervention program on the long-term placement of peripherally inserted central venous catheters
Wenfeng Chen1, Haoyu Deng2, Liangfang Shen1, Man Qin1, Lianxian He3
1 Department of Radiotherapy, Xiangya Hospital, Central South University, Changsha, China
2 Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
3 Department of Nursing, Xiangya Hospital, Central South University, Changsha, China
|Date of Web Publication||14-Jul-2014|
Department of Nuclear Medicine, Xiangya Hospital, Central South University, No. 87, Xiangya Road, Changsha, Hunan - 410 008
Source of Support: None, Conflict of Interest: None
Background: 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.
Materials and Methods: 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.
Results: 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.
Conclusion: Comprehensive intervention programs effectively reduce the incidence of complications in long-term PICCs lines.
Keywords: Cancer, complication, comprehensive intervention, nursing care, peripherally inserted central venous catheters
|How to cite this article:|
Chen W, Deng H, Shen L, Qin M, He L. A comprehensive intervention program on the long-term placement of peripherally inserted central venous catheters. J Can Res Ther 2014;10:359-62
|How to cite this URL:|
Chen W, Deng H, Shen L, Qin M, He L. A comprehensive intervention program on the long-term placement of peripherally inserted central venous catheters. J Can Res Ther [serial online] 2014 [cited 2021 Jun 22];10:359-62. Available from: https://www.cancerjournal.net/text.asp?2014/10/2/359/136657
| > Introduction|| |
The peripherally inserted central catheters (PICCs) are a relatively safe and cost-effective method to provide long-term intravenous access. , In clinical studies, PICCs are conventionally used to provide long-term intravenous cannulation, chemotherapy, parenteral nutrition, or antibiotics administration. 
PICCs is frequently used in intensive care and chemotherapy.  Although the insertion of PICCs is easier to be performed compared with central venous catheters, the insertion of PICCs requires surgical expertise and sometimes carries risks of complications.  Previous studies have shown many complications of PICCs including venous thrombosis, infection, catheter occlusion, phlebitis, catheter dislodgement, chronic venous insufficiency, and pulmonary embolus. ,,, The infection rate in PICCs lines is considered high in immunocompromised patients. , A sutureless adhesive-backed device is demonstrated to help reduce catheter-related blood stream infections.  Despite the devices used to reduce complications in the insertion and postinsertion, including improvements in the biocompatibility of biomaterials and related surface-coating techniques, complication rate is still high. 
The maintenance of long-term placement of PICCs is essential for chemotherapy in patients. Unfortunately, the duration is not long enough in previous studies. In this paper, we performed four courses of chemotherapy with the duration of at least 90 days, comparing favorably with previously published reports of 19.5  , 40,  and 60  days for inpatient. A comprehensive intervention for nursing care to reduce complications in the therapy was started at the beginning of catheterization and lasted the whole process of catheter insertion and maintenance.
| > Materials and methods|| |
All human studies have been approved by China Ethics Committee and performed in accordance with the ethical standards. Meanwhile, informed consent was provided by each patient. Tumor patients in the Department of Radiotherapy, Xiangya Hospital (Central South University), were selected as the subjects. A total of 217 cases with the average age of 46-year old (ranging from 17 to 78 years) receiving PICCs before intervention were retrospectively studied from April 2011 to January 2012 (the control group). Clinical data of 243 patients aged from 16 to 74 years (average age 47) receiving PICCs after intervention were prospectively collected from February 2012 to November 2012 (the test group). Characteristics of the two groups were not significantly different, including age, gender, and diagnosis [P > 0.05, [Table 1]].
|Table 1: Characteristics of the cases before intervention and after intervention, including average age, gender, and diseases (P>0.05)|
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All the cases who received PICCs were the first time underwent radiotherapy and chemotherapy. A 4-F single lumen catheter, constructed of silicone elastomer (Bard Inc., USA) was inserted blindly into patients of the control group. In contrast, catheters were catheterized ultrasound guided when it is needed into patients in the test group. The catheters were positioned 2 cm below the elbow (avoiding the dominant hand when it is possible). Basilic vein was preferred, otherwise intermedian cubital vein or cephalic vein was chosen. Cases in other departments or hospitals were excluded.
After analyzing data from the control group, we found that risk factors of PICCs-related complications were controllable. Thus, we set up a quality control circle (QCC) to identify potential issues and teach paramedics the method of PICCs insertion and maintenance. All the paramedics were collected to participate in quality control of PICCs to achieve independent management. Head nurses were commanded to participate in national conferences of intravenous therapy. Moreover, training course for PICC and intravenous therapy conferences were conducted by the hospital for all the nurses. Nurses were demanded to study PICCs insertion and maintenance. Besides, we made sure that the first-line nurses were skillful to deal with complications of post-PICCs insertion. Treatments of normal complications are shown in [Table 2].
|Table 2: Complications and nursing care in PICCs insertion and maintenance|
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The incidences of complications associated with unplanned extubations between the two groups were compared with SPSS 13.0 (SPSS, USA). Data were analyzed with a χ2 test. P value < 0.05 was considered statistically significant.
| > Results|| |
Before the intervention
There were 17 episodes of unplanned extubations (7.8%) in the control group, including four episodes of tube feeding difficulty (23.5%), four episodes of catheter dislodgment (23.5%), and one episode of puncture failure (5.9%) in catheter insertion. Moreover, three episodes of obstruction (17.6%), three episodes of infection (17.6%), one episode of allergy (5.9%), and one episode of pain (5.9%) were found during the long-term catheter maintenance. Details are shown in [Table 3] and [Table 4].
|Table 3: Comparison of the unplanned extubations rates in the control group and the test group (P<0.01)|
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After the intervention
The rate of unplanned extubations in the test group was reduced remarkably compared with that in the control group (0.8% vs. 7.8%, P < 0.01). There were only one case of catheter obstruction and one case of allergy after the intervention [Table 4].
| > Discussion|| |
In this paper, we demonstrated that unplanned extubations in the control group were mainly caused by subsequent complications related to both insertion and maintenance of PICCs lines. Comprehensive intervention programs were performed in the test group and effectively reduced the incidence of complications in PICCs lines. In the control group, nine episodes were found in catheter insertion including one episode of puncture failure, four episodes of tube feeding difficulty, and four episodes of catheter dislodgment. Complications manifested as turgor, phlebitis, catheter obstruction, and thrombus were mainly caused by factors in catheter insertions.  In comparison, unplanned extubations caused by puncture failure were avoided in the test group. Moreover, in the control group, an assistant was commanded to oppress the jugular vein in patients with tube feeding difficulty; while in the test group, patients were informed to adjust the position under the introduction of clinicians. Episodes of tube feeding difficulty were decreased.
There are two most common complications in PICCs lines: Catheter dislodgment and infection. A previous study reported that the incidence of complications in PICCs lines was about 6% to 10%, including the migration of right atrium or ventriculus dexter.  In this paper, we used a real-time monitoring to ensure the catheter tips in location. The catheter tips were resetted timely when dislodgment occurred [Figure 1], otherwise, a second time puncture was performed. Thus, catheter dislodgment was not found after the intervention. It is also demonstrated that failure of long-term catheter placement was mainly caused by infections including sepsis and phlebitis. However, our results were not in agreement with that especially in the test group. We found only one episode of allergy, one episode of catheter obstruction and without infection in the test group, meanwhile, three episodes of infection [including one local infection, [Figure 2]] and three episodes of catheter obstruction in the control group. Reasons for this discrepancy might be associated with insertion techniques, biomaterials of the PICCs, nursing experience, and length of stay in hospital. , Catheter infection is a mechanical complication that can be prevented by rigorous and professional nursing care.  Another mechanical complication is catheter obstruction. The decreased incidence of catheter obstruction after intervention might be attributed to standardized principles of insertion and maintenance in PICCs lines. Although occlusion rates in catheters will be decreased with the antireflux device,  professional nursing care is very important. Our result was in accordance with the previous study, which has identified that a significant decrease in the catheter occlusion rate is associated with the increase of expertise of nurses and self-efficacy related to the care of PICCs. 
So far, no clear evidence in the literature of complication rates in the course of insertion was found. Results presented in this study demonstrated that the intervention started at the insertion period decreased the rate of unplanned extubations dramatically. In addition, the extended application of PICCs is considered restricted by the durability in the previous study.  The risk of catheter fracture, embolization, and serious consequences might be increased in long-term dwelling of PICCs.  PICCs lines were used for a mean duration of 90 days in this study. Low complication rate of PICCs in this paper was associated with the long period in hospital that is effective for recovery. A long-term self-care and effective communication system is needed as well to prevent complications in post-PICCs care. 
| > Conclusion|| |
In conclusion, comprehensive intervention programs effectively reduced the incidence of complications in PICCs lines. PICCs were suited to the patients with cancers who require months of intensive chemotherapy. More long-term clinical trials of PICCs were warranted to confirm the advantages and incidences of complications of PICCs used for patients with cancer.
| > References|| |
|1.||Lam S, Scannell R, Roessler D, Smith MA. Peripherally inserted central catheters in an acute-care hospital. Arch Intern Med 1994;154:1833-7. |
|2.||Ng PK, Ault MJ, Maldonado LS. Peripherally inserted central catheters in the intensive care unit. J Intensive Care Med 1996;11:49-54. |
|3.||Miller KD, Deitrick CL. Experience with PICC at a university medical center. J Intraven Nurs 1997;20:141-7. |
|4.||Crowley JJ. Vascular access. Tech Vasc Interv Radiol 2003;6:176-81. |
|5.||Hogan MJ. Neonatal vascular catheters and their complications. Radiol Clin North Am 1999;37:1109-25. |
|6.||Ryder MA. Peripherally inserted central venous catheters. Nurs Clin North Am 1993;28:937-71. |
|7.||Kearns PJ, Coleman S, Wehner JH. Complications of long arm-catheters: A randomized trial of central vs peripheral tip location. JPEN J Parenter Enteral Nutr 1996;20:20-4. |
|8.||Frey AM. Pediatric peripherally inserted central catheter program report: A summary of 4,536 catheter days. J Intraven Nurs 1995;18:280-91. |
|9.||Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest 2005;128:489-95. |
|10.||Cheong K, Perry D, Karapetis C, Koczwara B. High rate of complications associated with peripherally inserted central venous catheters in patients with solid tumours. Intern Med J 2004;34:234-8. |
|11.||Yamamoto AJ, Solomon JA, Soulen MC, Tang J, Parkinson K, Lin R, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81. |
|12.||Walshe LJ, Malak SF, Eagan J, Sepkowitz KA. Complication rates among cancer patients with peripherally inserted central catheters. J Clin Oncol 2002;20:3276-81. |
|13.||Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012;13:231-8. |
|14.||Ng PK, Ault MJ, Ellrodt AG, Maldonado L. Peripherally inserted central catheters in general medicine. Mayo Clin Proc 1997;72:225-33. |
|15.||Loewenthal MR, Dobson PM, Starkey RE, Dagg SA, Petersen A, Boyle MJ. The peripherally inserted central catheter (PICC): A prospective study of its natural history after cubital fossa insertion. Anaesth Intensive Care 2002;30:21-4. |
|16.||Racadio JM, Doellman DA, Johnson ND, Bean JA, Jacobs BR. Pediatric peripherally inserted central catheters: Complication rates related to catheter tip location. Pediatrics 2001;107:E28. |
|17.||Amerasekera SS, Jones CM, Patel R, Cleasby MJ. Imaging of the complications of peripherally inserted central venous catheters. Clin Radiol 2009;64:832-40. |
|18.||Dubois J, Garel L, Tapiero B, Dubé J, Laframboise S, David M. Peripherally inserted central catheters in infants and children. Radiology 1997;204:622-6. |
|19.||Chait PG, Ingram J, Phillips-Gordon C, Farrell H, Kuhn C. Peripherally inserted central catheters in children. Radiology 1995;197:775-8. |
|20.||Vidal V, Muller C, Jacquier A, Giorgi R, Le Corroller T, Gaubert J, et al. Prospective evaluation of PICC line related complications. J Radiol 2008;89:495-8. |
|21.||Jasinsky LM, Wurster J. Occlusion reduction and heparin elimination trial using an antireflux device on peripheral and central venous catheters. J Infus Nurs 2009;32:33-9. |
|22.||Ngo A, Murphy S. A theory-based intervention to improve nurses′ knowledge, self-efficacy, and skills to reduce PICC occlusion. J Infus Nurs 2005;28:173-81. |
|23.||Raad I, Davis S, Becker M, Hohn D, Houston D, Umphrey J, et al. Low infection rate and long durability of nontunneled silastic catheters. A safe and cost-effective alternative for long-term venous access. Arch Intern Med 1993;153:1791-6. |
|24.||Chow LM, Friedman JN, Macarthur C, Restrepo R, Temple M, Chait PG, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003;142:141-4. |
|25.||Tzeng HM. Roles of nurse aides and family members in acute patient care in Taiwan. J Nurs Care Qual 2004;19:169-75. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]