Dislodgement of a Power-Injectable Peripherally Inserted Central Catheter After Power Injection: A Case Report

A 63-year-old Malay woman had a 6-French dual-lumen power-injectable peripherally inserted central catheter (PICC) inserted and subsequently underwent a contrast-enhanced computed tomography scan with intravenous contrast medium administered via the PICC. After the scan, the tip of the PICC was noted to have displaced from its original position and lodged in 1 of the small branches of the right subclavian vein. This phenomenon was then demonstrated in real time under fluoroscopy during the process of repositioning the PICC tip. Although power-injectable PICCs are designed for use with power injectors, tip displacement can and does happen. A computed tomography scout view of the chest may be necessary after each use of power injectors to confirm that the PICC tip remains in a satisfactory position.     

Safety and effectiveness of central venous catheterization in patients with cancer: prospective observational study

This study investigated the safety and effectiveness of each type of central venous catheters (CVC) in patients with cancer. We prospectively enrolled patients with cancer who underwent catheterization involving a subclavian venous catheter (SVC), peripherally inserted central venous catheter (PICC), or chemo-port (CP) in our department. From March 2007 to March 2009, 116 patients underwent 179 episodes of catheterization. A SVC was inserted most frequently (46.4%). Fifty-four complications occurred (30.1%): infection in 23 cases, malpositioning or migration of the tip in 18 cases, thrombosis in eight cases, and bleeding in five cases. Malpositioning or migration of the tip occurred more frequently with a PICC (P<0.001); infection occurred more often with a tunneled catheter (P=0.028) and was observed more often in young patients (P=0.023). The catheter life span was longer for patients with solid cancer (P=0.002) than for those with hematologic cancer, with a CP (P<0.001) than a PICC or SVC, and for an indwelling catheter with image guidance (P=0.014) than a blind procedure. In conclusion, CP is an effective tool for long term use and the fixation of tip is important for the management of PICC.     

Precision in Central Venous Catheter Tip Placement: A Review of the Literature

BackgroundLong term venous catheters have been used to deliver specialized therapies since 1968. The ideal tip position of a central venous catheter provides reliable venous access with optimal therapeutic delivery, while minimizing short-and long-term complications. Ideal position limits have evolved and narrowed over time, making successful placement difficult and unreliable when depending exclusively on the landmark technique.ObjectiveTo review and analyze contemporary literature and calculate an overall accuracy rate for first attempt placement of a PICC catheter in the ideal tip position.MethodsKey PICC placement terms were used to search the database PubMED-indexed for MEDLINE in June and October, 2009. The selection of studies required: a patient cohort without tip placement guidance technology; a documented landmark technique to place catheter tips; data documenting initial catheter placement and, that the lower third of the SVC and the cavo-atrial junction (CAJ) were included in the placement criteria. With few exceptions, articles written between 1993 and 2009 met the stated selection criteria. A composite of outcomes associated with tip placement was analyzed, and an overall percent proficiency of accurate catheter tip placement calculated.ResultsNine studies in eight articles met the selection criteria and were included for analysis. Rates of first placement success per study ranged from 39% to 75%, with the majority (7/9) being single center studies. The combined overall proficiency of these studies calculated as a weighted average was 45.87%.     

Managing Peripherally Inserted Central Catheter Thrombosis Risk: A Guide for Clinical Best Practice

PurposeThe purpose of this study was to evaluate the effectiveness of clinical practice changes in an effort to reduce peripherally inserted central catheter thrombosis risk.Patients and MethodA retrospective analysis of adult patients in the acute care setting.ResultsA total number of 1307 charts of patients who received PICCs were reviewed encompassing the months of January 2008, October 2008 and August 2010. During the period from January 2008 to October 2008, clinical practice changes were made to include the use of ultrasound guidance. Ensuring catheter tip termination in the superior vena cava with the addition of ultrasound technology as an insertion practice combined to decrease symptomatic PICC related deep vein thrombosis rates from 4.8% to 2.9%. During the period from October 2008 to August 2010, an additional practice was introduced that involved measurement and documentation of vein diameters(without the use of a tourniquet) prior to all PICC insertion procedures. Deep vein thrombosis (DVT) rates dropped further from 2.9% to 1.4% during this period.ConclusionObtaining central tip location and using ultrasound guidance for PICC placement are effective in reducing PICC related DVT. Additionally, routine measurement of vein diameters in their native state and use of that information to ensure that the vessel diameter is at least twice the outer diameter of the catheter is an effective practice to reduce DVT rates and reduce thrombosis risk.     

Proactive Planning for Vascular Access Therapy: One Hospital's Plan for Success

BackgroundVascular access is a critical component of care for patients in neonatal intensive care units (NICUs). Our NICU had only a small number of nurses cross-trained to perform peripherally inserted central catheter (PICC) insertions and was not able to provide coverage 24 hours a day, 7 days a week. We combined the vascular access team (VAT) and NICU PICC team to improve the timeliness of NICU PICC insertions, standardize care, and use ultrasound for all PICC placements.MethodsA paper guide tool was developed to prioritize PICC placements as emergent, same-day, or nonemergent. NICU nurses were trained to insert PICCs using ultrasound. Catheter insertion and care processes were standardized for the new centralized PICC team. NICU and VAT staff worked together to improve daily communication, hand-offs, and referrals. Criteria were developed to determine the appropriate hospital location for PICC insertions. Charge nurses began capturing information about patients with PICCs on daily planning sheets.ResultsFollowing implementation of the new combined VAT, the average wait time for emergent and same-day insertions decreased 10%. No adverse events were reported due to a delay in PICC placement or the PICC referral process.ConclusionsCombining the NICU PICC insertion nurses and the VAT into a new centralized PICC team provided an opportunity for growth in both areas. NICU PICCs are now placed efficiently based on patient acuity and referral prioritization throughout the hospital. NICU and VAT physicians and nurses have developed a strong partnership for the provision of PICC services for NICU patients.     

Maximum Flow Rates Achievable Through Peripherally Inserted Central Catheters Using Standard Hospital Infusion Pumps

PurposeTo determine maximum flow rates through peripherally inserted central catheters (PICCs) using a standard hospital infusion pump.BackgroundTwo questions asked with the use of PICCs and flow rates are (1) can a PICC be used to give nonemergent fluid boluses, and (2) can standard hospital infusion pumps develop enough pressure to rupture a catheter?MethodsNew PICCs of different brands and gauges were gathered. Six standard hospital infusion pumps and tubing of the same brand and model were used. The pressure sensor was set at 600 mm Hg. The pumps were connected through the access ports of each intravenous tube in a series fashion. The PICC end was submerged under 5 cm of water. All equipment and fluids were at 70°F. PICCs were trimmed to 45 cm. Fluids were run starting with the first pump at 999 mL/hour and then additional pumps were added until the pump's 600 mm Hg limit stopped the infusion or catheter rupture. Tests with the same PICC were repeated and recorded.ResultsFlow rates varied with the type, size, gauge, and brand of PICC catheter. Flows were achieved from 2,100 mL/hour to >6,000 mL/hour. None of the PICCs ruptured.ConclusionsMaximum flow rates through PICCs were limited by the maximum pressure allowed by the standard hospital infusion pump. A standard hospital infusion pump cannot generate enough pressure to rupture a new-out-of-the-package catheter.Implication for PracticeNonemergent fluid boluses can be given through PICCs and standard infusion pumps will not rupture a PICC.     

The EKG Method for Positioning the Tip of PICCs: Results from Two Preliminary Studies

Two preliminary studies were conducted to determine feasibility of using the electrocardiography (EKG) method to determine terminal tip location when inserting a peripherally inserted central catheter (PICC). This method uses the guidewire inside the catheter (or a column of saline contained in the catheter) as an intracavitary electrode. The EKG monitor is then connected to the intracavitary electrode. The reading on the EKG monitor reflects the closeness of the intracavitary electrode (the catheter tip) to the superior vena cava (SVC). The studies revealed that the EKG method was extremely precise; all tips placed using the EKG method and confirmed using x-ray were located in the superior vena cava. In conclusion, the EKG method has clear advantages in terms of accuracy, cost-effectiveness, and feasibility in conditions where x-ray control may be difficult or expensive to obtain. The method is quite simple, easy to learn and to teach, non-invasive, easy to reproduce, safe, and apt to minimize malpositions due to failure of entering the SVC.     

218例儿科经外周静脉置入中心静脉导管置管相关并发症分析及预防处理对策

目的：探讨经外周静脉置入中心静脉导管(peripherally inserted central catheter,PICC)在儿科患者应用中出现的常见并发症及预防处理对策对策,以期减少并发症的发生。方法：对我院儿科218例行PICC患者进行调查,分析其相关并发症,同时总结预防处理对策。结果：218例患儿均置管成功,置管后39例出现了置管相关并发症(12例导管出现2种以上并发症),其发生率为23.4%(51/218),其中静脉炎发生率最高,发生率为18(8.3%);非计划性拔管、导管堵塞、导管异位及导管相关血流感染发生率分别为12(5.5%)、7(3.2%)、6(2.8%)、5(2.3%)。结论：加强小儿PICC的围手术期护理和有效干预,对并发症进行积极有效的处理,可延长置管时间,减少并发症的出现。     

经外周静脉穿刺中心静脉置入术导管异位的影响因素

目的探讨经外周静脉穿刺中心静脉置入术(PICC)发生导管异位的相关因素,提出针对性的干预措施,以减少导管异位的发生。方法回顾性分析2016年1月至2018年12月在重庆市急救医疗中心神经外科行PICC的167例患者的临床资料,统计PICC导管异位情况,对可能引起导管路径异常的相关影响因素进行统计学分析。结果本组167例PICC患者中,导管异位16例(9.58%)。多因素logistic回归分析结果显示,气管切开(OR=1.569)、机械通气(OR=1.598)、经头静脉穿刺(OR=1.985)、患者意识障碍(OR=1.866)、送管次数大于2次(OR=1.265)、锁骨下静脉置管史(OR=1.632)是神经外科患者PICC导管异位的危险因素。结论神经外科有高危因素的患者行PICC置管时,建议首选经贵要静脉路径穿刺置管,肘正中静脉次之,同时应根据患者个体情况,给予针对性的干预措施,减少PICC导管异位发生率。     

Up for the Challenge: Eliminating Peripherally Inserted Central Catheter Infections in a Complex Patient Population

BackgroundIn response to Medicare reimbursement changes related to central line-associated blood stream infection (CLABSI) effective January 2011, a long-term acute care hospital implemented quality improvement measures to reduce these health care-associated infections. Improvements included alcohol-impregnated port protectors, chlorhexidine gluconate barrier dressings, and didactic/hands on training for care and maintenance. During 2010 the peripherally inserted central line (PICC) team at a neighboring Magnet hospital was asked to partner and develop strategies to further decrease CLABSI.MethodsThe PICC team evaluated the effects of an antimicrobial PICC device in an effort to further reduce the incidence of CLABSI. Upon initiation of the evaluation phase, a database was created to track infection/thrombus rate, insertion-related complications, dwell time, diagnosis, tip location, infusate, vein used, and catheter size. Data collection and reporting was managed by the PICC team.ResultsAcross a 2-year period (July 2011-July 2013), 100 devices were inserted with a total of 1,705 line days without any reported CLABSI. The majority of patients received a 4.5F single lumen device (59%). Dwell time ranged from 1 to 57 days with an average of 17 days. To date, no CLABSIs related to this device have been reported at the long-term acute care hospital.ConclusionsBased on 100 insertions yielding no infections this new product appears to improve patient safety and quality of care. Relative to these results sole use of this product has become their institutional standard for long-term intravenous needs.     

A Controlled Randomized Prospective Comparative Pilot Study to Evaluate the Ease of Use of a Transparent Chlorhexidine Gluconate Gel Dressing Versus A Chlorhexidine Gluconate Disk in Healthy Volunteers

Products and technologies that aid health care professionals in vascular access practice save staff time, and while promoting patient safety and prevention of infection can provide excellent opportunities for evaluations to support evidence- based practice. This was an industry sponsored, prospective, single site, controlled, randomized clinical evaluation pilot study of two catheter dressings, 3M™ Tegaderm™ Chlorhexidine Gluconate (CHG) IV Securement Dressing (CHG gel dressing) (3M Health Care, St. Paul, MN) and BIOPATCH^® Antimicrobial Dressing with Chlorhexidine Gluconate (BIOPATCH^® Protective Disk with CHG, Johnson & Johnson, Somerville, NJ). Twelve intravascular (IV) therapy health care professionals (Clinicians) were asked for their professional evaluations of the catheter dressings: the ease of application and performance factors featured in specific questions. Catheters were secured on 12 healthy volunteers to simulate inserted jugular catheters (IJ) and peripherally inserted central catheters (PICC) using StatLock^® PICC Plus and 3M™ Steri-Strip™. Each clinician applied and removed one CHG gel dressing and one CHG disk on one simulated PICC and one simulated IJ site, according to the manufacturers' instructions.The clinicians concluded, based upon a 1 to 5 rating scale, that the CHG gel dressing is better in regard to ease of application, ease of applying correctly, ease of removal, ability to visualize the insertion site, ease of training another clinician to apply the dressing, and more intuitive application. Twelve out of 12 clinicians favored the CHG gel dressing over the CHG disk in overall performance.     

急性白血病患者PICC置管相关性感染因素及对策分析

目的：分析急性白血病患者经外周静脉置入中心静脉导管(peripherally inserted central catheter, PICC)相关性感染因素,为有效防治提供理论依据。方法：选取保定市第一医院2009年8月至2015年6月100例急性白血病患者及100例实体肿瘤患者行PICC置管,分析急性白血病PICC置管相关性感染发生率及原因。结果：100例急性白血病发生PICC置管相关性感染患者21例,置管相关性感染发生率为21.00%,其中局部感染12例,占12.00%,全身性感染9例,占9.00%;明显高于实体肿瘤患者10.00%(10/100),P<0.05,与患者年龄、性别、急性白血病类型、选择静脉、置管长度无显著相关。而中性粒细胞计数<0.5×109/L、粒细胞缺乏时间≥7 d,CD4/CD8<1.00、置管留置时间≥60 d患者置管相关性感染发生率明显升高。结论：白血病患者PICC置管相关性感染明显高于实体肿瘤患者,其中与中性粒细胞计数、粒细胞缺乏时间,CD4/CD8比值、置管留置时间密切相关,因此对急性白血病患者要严格执行PICC操作流程及无菌操作以减少患者置管相关性感染发生率。     

思乐扣固定对PICC置管新生儿置管质量和安全性的影响

目的:探讨思乐扣固定对经外周静脉穿刺中心静脉导管（PICC）置管新生儿置管质量和安全性的影响。 方法:选取2014年3月至2017年3月鄂东医疗集团黄石市中心医院收治的PICC置管新生患儿100例,依据固定方法分为思乐扣组和敷贴组,每组50例,敷贴组给予3M透明敷贴固定干预,思乐扣组给予思乐扣固定干预,比较分析两组置管质量和安全性。 结果:思乐扣组干预后7、15 d的自制《PICC置管新生患儿舒适量表》评分明显高于敷贴组,差异有统计学意义（P<0.05）;思乐扣组置管并发症发生率、PICC脱落率明显低于敷贴组,思乐扣组PICC留置时间明显高于敷贴组,差异有统计学意义（P<0.05）。 结论:思乐扣固定可有效改善PICC置管新生患儿置管舒适度,有利于提高新生患儿的置管质量和安全性,值得临床作进一步推广。     

Challenges in the Accurate Identification of the Ideal Catheter Tip Location

The chest radiograph has been the primary tool to identify the catheter tip location after bedside placement of central venous access devices (CVADs), especially with peripherally inserted central catheters. The targeted ideal landing zone for a CVAD has evolved over time to the lower third of the superior vena cava, near the juncture of the right atrium. This article will discuss the evolution in the narrowing of the ideal targeted zone for landing the CVAD tip, and the issues around perception of “seeing” the catheter tip in the chest radiograph that can be imprecise and inaccurate. A brief overview of emerging technologies that capitalize on individual patient's internal physiologic characteristics to better identify this ideal landing zone will be presented.     

PICC Zone Insertion MethodTM (ZIMTM): A Systematic Approach to Determine the Ideal Insertion Site for PICCs in the Upper Arm

The consequences of random PICC practice can be serious and manifest as deep vein thrombosis, pulmonary embolism, catheter related bloodstream infection, and post thrombotic syndrome. Risk factors related to site selection have been well established for other central venous access devices, but not for ultrasound guided PICC insertion in the upper arm. The author presents observations of upper arm PICC insertion designated by color zones to highlight the variability of PICC practice. The author also details site risk factors associated with each color zone and proposes an ideal insertion location for upper arm ultrasound guided PICC procedures.The PICC Zone Insertion Method (ZIM) is a proposed system design for patient safety related to PICC insertions; performed by optimizing and organizing the clinical approach. It aids in identifying the Ideal Zone for upper arm needle insertion with ultrasound guidance. The significance of a systematic approach is that it is reproducible, measurable, and as a result will reduce variation in PICC insertion practice. The ZIM combines known mechanisms for vascular access insertion site complications with a systematic measuring and ultrasound scanning process, to reduce the impact of site risk factors. The impact of thrombosis cannot be underestimated, as it will likely limit the future use of veins for life saving vascular access. This issue should not be ignored by hospitals or clinicians, in fact, systematic solutions like PICC Zone Insertion Method, should be explored and supported as part of a comprehensive approach to vascular access care.     

Anatomical localization of submandibular gland for botulinum toxin injection

The aim of this study was to document the anatomical landmarks of the submandibular gland (SMG) for a botulinum toxin injection. Thirty-four SMGs from 20 cadavers were examined. The mean length of a reference line between the angle of the mandible and the gnathion was 94.8 ± 5.9 mm, the proximal and distal point of the SMG from the angle of the mandible was 10.6% (11.5 ± 3.5 mm) and 41.8% (40.9 ± 5.2 mm), respectively. The facial artery came out of the SMG at 11.6% (14.6 ± 3.4 mm) and the position of the intersection of the facial artery with the inferior border of the mandible was located at 24.4% (28.0 ± 5.5 mm) from the angle of the mandible. The shape of the SMG was generally triangular or irregular round on the anatomical position. The mean superior–inferior diameter, anterior–posterior diameter and medial–lateral diameter of the gland was 28.8 ± 4.1, 30.0 ± 6.1 and 15.1 ± 3.5 mm, respectively. The safety zone for the injection was 20–35% from the mandible angle on the inferior view and 1.5 cm below the inferior line of the mandible on the lateral view. In addition, the needle should be inserted to a depth of 2.0 cm from the skin surface on the inferior view. These results may assist in determining a accurate localization of injection sites for the SMG, particularly for injections without ultrasound guidance.     

The Effects of 3 Peripherally Inserted Central Catheter Insertion Techniques in Chinese Patients With Different Vascular Status

ObjectiveTo provide evidence for selecting an appropriate peripherally inserted central catheter (PICC) insertion technique by comparing the insertion success rate and the incidence of complications with 3 PICC insertion techniques.MethodsWe assigned enrolled patients to 3 groups according to the insertion technique selected by the individual patient: Group A, usual insertion technique (traditional, blind insertion); Group B, Modified Seldinger Technique (MST) insertion without ultrasound guidance; and group C, ultrasound-guided MST insertion. We compared the insertion success rate and the incidence of complications among these groups.ResultsWhen comparing these 3 PICC insertion techniques, no significant difference was seen with respect to the insertion success rate and the incidence of catheter malposition (P > 0.05), although a significant difference existed in the incidence of bleeding at the insertion site after the PICC procedure (P < 0.05), with the ultrasound-guided MST insertion technique superior to the other 2 techniques; the incidence of mechanical phlebitis and catheter occlusion during the use of PICC had no significant difference among the 3 groups (P > 0.05); but a significant difference was seen in the incidence of thrombosis and catheter-related infections (P < 0.05), with a lower incidence in the ultrasound-guided MST insertion group than that in the other 2 groups.ConclusionsUltrasound-guided MST insertion technique may address the problems occurring in patients with poor vascular access during the PICC procedure, whereas the usual insertion technique is the best choice for patients with good vascular access and poor economic status. Therefore, the selection of an appropriate insertion technique should be based on the economic and vascular status of the individual patient in clinical practice.     

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

Aim:

Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning.

Materials and Methods:

A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR.

Results:

200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated.

Conclusions:

Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.     

The Ideal Use of the Power Injectable Peripherally Inserted Central Catheter in the Pediatric Population

IntroductionThe peripherally inserted central catheter (PICC) is being used more frequently in pediatric populations in both hospital and home care settings in order to provide secure vascular access. In 2007, the Power PICC was introduced to pediatric populations. In contrast to traditional PICCs, the power injectable PICC withstands higher flow rates and can deliver contrast injections. Although effectiveness studies of power injectable PICCs have been performed in adults, only limited published research is available regarding pediatric populations.PurposeThis study aimed to develop criteria for identifying the ideal pediatric candidate for the power injectable PICC. A secondary aim was to identify contraindications and barriers to power injectable catheter use in pediatric populations.MethodsRetrospective and prospective chart reviews were used to analyze complication rates for 97 power injectable PICCs placed in patients aged 4 months to 17 years.ResultsA low incidence of catheter complications was identified during and post- insertion. Our documented infection rate of 1.30 per 1000 catheter days was similar to the infection rate of 1.27 per 1000 catheter days found in the Abedin & Kapoor (2008) study.DiscussionThe introduction into a pediatric hospital of power injectable PICCs for power injection scans for contrast injection was safe and effective in patients with many disease processes.ConclusionIn properly selected pediatric patients, the power injectable PICC is not associated with an increased risk to thrombosis or infection and can improve patient outcome.     

儿童与成人急性白血病患者外周静脉留置中心静脉导管置管并发症的差异

目的:比较儿童与成年急性白血病患者外周静脉留置中心静脉导管(peripherally inserted central catheter,PICC)置管的并发症发生率,为不同类型患者提供更好的护理和治疗策略.方法:选取保定市第一医院52例儿童及100例成人急性白血病化疗行PICC置管患者,观察两组PICC置管后不同并发症及其发生率,探讨儿童与成人急性白血病PICC并发症的不同.结果:在儿童急性白血病PICC置管后出现并发症的总发生率为55.8％,显著高于成人急性白血病PICC置管后并发症总发生率的39.0％(x2=3.89,P＜0.05).其中感染发生率36.5％ vs.21.0％(x2=4.26,P＜0.05)、导管阻塞发生率23.1％ vs.11.0％(x2=3.89,P＜0.05);机械性静脉炎发生率19.2％ vs.5.0％(x2=7.79,P＜0.05).平均置管日儿童[(98.7±58.7)d]显著低于成人[(130.6±71.8)d](t=2.76,P＜0.01).非计划拔管率儿童为17.3％,显著高于成人的5.0％(x2=4.81,P＜0.05).结论:PICC置管后儿童与成人急性白血病患者各种并发症发生率及平均置管时间存在一定差异,可能与配合程度及年龄特点密切相关.