|Year : 2021 | Volume
| Issue : 1 | Page : 10-12
A study of complications associated with peripherally inserted central catheters in patients receiving chemotherapy in a tertiary hospital
Jeffrey Lewis1, Nishitha Shetty2
1 Department of General Medicine, Father Muller Medical College, Mangalore, India
2 Department of Medical Oncology, Father Muller Medical College, Mangalore, India
|Date of Submission||02-Mar-2021|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||31-Jul-2021|
Dr. Nishitha Shetty
Department of Medical Oncology, Father Muller Medical College Hospital, Father Muller Road, Kankanady, Mangaluru.
Source of Support: None, Conflict of Interest: None
Background: Chemotherapeutic agents are often caustic or irritant solutions that require large high flow venous conduits for safe delivery, provided adequately by central venous access. Peripherally inserted central catheters (PICCs) are widely used among hospitalised patients and out-patients for chemotherapy and parenteral nutrition. In this study, we aimed to evaluate the rates of PICC-related complications in a tertiary hospital. Materials and Methods: This was an observational study of 100 patients in whom peripherally inserted central catheters was conducted over a period of two years at a tertiary care hospital. Pertinent demographics as well as catheter related data was collected and analysed. Results: The most commonly inserted line was Groshong 4 Fr, with the most common indication being poor venous access, followed by infusion of 5-fluorouracil and adriamycin chemotherapy. The PICC line was removed in 94 cases after completion of chemotherapy, three lines were removed due to infection (0.29 per 1000 catheter days), and one due to catheter blockage (0.097 per 1000 catheter days). Conclusions: This study showed that PICC lines have a number of advantages, including ease of insertion by trained nursing staff and can be used for various indications, including but not limited to chemotherapy and parenteral nutrition. Proper care ensures fewer complications, which leads to lesser instances of removal.
Keywords: Peripherally Inserted Central Catheters, PICC, Central venous catheterization, Catheter associated infection, Central venous catheter thrombosis, Deep vein thrombosis
|How to cite this article:|
Lewis J, Shetty N. A study of complications associated with peripherally inserted central catheters in patients receiving chemotherapy in a tertiary hospital. J Curr Oncol 2021;4:10-2
| Introduction|| |
Peripherally inserted central catheters (PICCs) are thin, long, flexible catheters of silicone or polyurethane, inserted percutaneously into the basilic or cephalic vein in the forearm or antecubital fossa, and then advanced into the central circulation, most often in the superior vena cava. It is used in the administration of medications instead of central venous catheters (CVCs). PICCs form an important part of the management of patients with cancer due to the complexity of therapy regime, prolonged treatment, need for other supportive intravenous products, and even in palliative care. The advantages of PICCs over other vascular access devices include ease of insertion, fewer complications (like pneumothorax, arterial puncture), safer approach, and lesser expense and can be placed by trained nurses without radiographic guidance and less chances of hemorrhage.
PICC-related complications include blood stream and local infections, thrombosis, and mechanical complications (occlusion, accidental withdrawal). The risk of these complications is higher in patients with diabetes, metastases, and hematological malignancies. These complications can be minimized through careful monitoring by personnel with expertise in the management of PICC lines. Studies regarding the incidence of PICC complications from South India are sparse and hence the need for this study.
| Review of Literature|| |
The PICC line can be used for administration of chemotherapy, for drawing blood samples, for maintenance i.v. fluids, for blood transfusions, and for albumin or total parenteral nutrition infusions. This circumvents the need for multiple i.v. cannulations, especially in cases with poor venous access, as was found in this study, and is less painful.
The rate of complications in PICC line usage varies in outpatient and inpatient settings, usage of strict protocols for insertion, duration of use, and PICC line care. A study by Cotogni et al. found that the overall complication rate was 17.5% (in 250 patients with PICCs receiving chemotherapy or home parenteral nutrition). The incidence of catheter-related bloodstream infections (CRBSIs) was 0.05 per 1000 catheter days, thrombosis was 0.05 per 1000 catheter days, and mechanical complication was 0.63 per 1000 catheter days. The study found that if managed according to evidence-based protocols, the risk of complications could be significantly reduced and catheter life prolonged.
Another study by Grau et al. showed that the overall rate of complications was 30.2% (11.1% per 1000 catheter days), with occlusion, accidental withdrawal, and infection being the most common complications. The study also found that the complication rate was higher in hospitalized patients than in the outpatient setting.
Chopra et al. demonstrated that PICCs were associated with a lower risk of CRBSIs than CVCs with a relative risk of 0.62. In a study by Green et al., PICC use was associated with all-cause venous thromboembolism (hazard ratio 3.16), upper extremity thrombosis (hazard ratio 10.49), and lower extremity thrombosis (hazard ratio 1.48).
Aims and objectives
The aim of the study was to record the incidence of complications associated with PICC insertion among patients receiving chemotherapy as inpatient.
| Materials and Methods|| |
Source of data, study design, and study population
The present study was an observational chart-based study that included all patients with PICC lines inserted during the period March 1, 2016 to February 28, 2018 (24 months), admitted in a tertiary care center in South India.
Duration of study and sample size
The study was completed within 2 months of obtaining permission from the Institutional Ethical Committee. All patients fulfilling the selection criteria were included in the study, with a sample size of 100 subjects.
The study included consecutive patients admitted for oncology treatment with PICC line insertion. The PICC line was inserted by specially trained nurses, after following strict aseptic precautions. The modified Seldinger technique using anatomical landmarks was used for insertion, with the basilic vein being the preferred vein. The length of the catheter required was estimated by measuring the straight line from the site of insertion to the upper third of the sternum with the patient’s arm outstretched laterally. Chest radiograph was done immediately after insertion to locate the position of the catheter. Maintenance of the PICC line, including asepsis during usage, regular flushing, and dressing, was done by the trained nurses. Dressing with chlorhexidine gluconate gel was done once in 7–10 days, on an outpatient basis if required. The connectors and catheter hubs were changed on a regular basis, with flushing of the catheter with heparin and saline. Patients were instructed regarding adequate limb mobilization to reduce the instances of thrombosis. The catheters were examined regularly for signs of complications.
The medical records of the selected patients were assessed, and information was documented on the preformatted data collection sheet. Data included standard demographic details, history regarding the current illness, history of preceding illness (if any), timeline of progression, details of hematological and biochemical investigations, culture reports, duration of hospital stay, and outcome. The data obtained were tabulated and analyzed.
- Patients admitted in the Oncology ward, and with a PICC line inserted between March 1, 2016 and February 28, 2018.
- Patients who underwent a surgical procedure during the admission.
- Patients diagnosed with venous thrombosis 6 months prior to PICC insertion.
Data collected were analyzed using SPSS v20.0 and interpreted as frequencies, proportions, means, and medians.
| Results|| |
The mean age of the subjects included in the study was 46.85 (±13.22) years, 30% of them were male and 70% were female. The most common site of malignancy was breast (25%), followed by colon (15%), ovary (10%), acute lymphoblastic lymphoma (7%), lymphoma (7%), acute myeloid leukemia (6%), stomach (6%), rectum (4%), lung (3%), esophagus (2%), multiple myeloma (2%), and others (13%).
The most commonly used PICC line was Groshong 4 Fr (91%), followed by Basic (3%), BioFlo 5 Fr (3%), and others (3%). The most common indication for insertion of PICC line was poor venous access (37%), followed by 5FU (5-fluorouracil) infusion chemotherapy (28%), adriamycin chemotherapy (23%), and induction chemotherapy (12%). Two PICC lines were inserted under fluoroscopic guidance.
The most commonly used site of access was the basilic vein (73%), followed by the cephalic vein (18%) and the median cubital vein (9%). Of the PICC lines inserted in the basilic vein, 58% were in the right basilic vein with an average length of 41.52 cm, and 15% were in the left basilic vein with an average length of 41.61 cm. Of the PICC lines inserted in the cephalic vein, 12% were in the right cephalic vein with an average length of 41.75 cm and 6% were in the left cephalic vein with an average length of 43.16 cm. Among the nine PICC lines inserted in the median cubital vein, one was in the right vein with a length of 45 cm and eight were in the left vein with an average length of 40.75 cm. This is similar to a study by Cotogni et al., in which the right basilic vein was most commonly used (78%). The study by Grau et al. used the basilic vein in 66.5% of the cases. The total number of catheter days was 10,273, with a mean in-dwelling time of 102.73 days.
Of the 100 inserted PICC lines, 94 were removed on completion of chemotherapy and 3 were removed due to clinical features of infection, amounting to an infection rate of 0.29 per 1000 catheter days. On culture test, one of the three cases showed growth of Acinetobacter baumannii, whereas culture was sterile in other two cases. Two patients succumbed to illness with the PICC line in situ. One PICC line was removed due to catheter blockage (catheter blockage rate of 0.097 per 1000 catheter days). This was comparable to a study by Cotogni et al. in which 269 PICCs were inserted, with an incidence of CRBSI of 0.05 per 1000 catheter days and symptomatic thrombosis of 0.05 per 1000 catheter days. The rate of complications was lower when compared with the study by Grau et al. on 163 PICC line insertions, with CRBSI of 2.3 per 1000 catheter days and a higher incidence of occlusion at 3.2 per 1000 catheter days.
In 98% of the cases, the PICC line was inserted by a trained nurse without ultrasound guidance. There were no instances of PICC line thrombosis, and only three instances of line removal due to infection, and one due to catheter occlusion, which shows that with proper handling, regular flushing, and strict aseptic precautions, the rate of thrombosis and infection can be drastically reduced.
| Conclusion|| |
PICC lines have numerous advantages over central catheters, including ease of insertion by trained nursing staff, fewer complications, and thereby lesser instances of removal due to complications, and can be used for myriad indications, including chemotherapy and parenteral nutrition. PICC lines can be kept in situ for longer durations of time, with minimal complications if adequate precautions are taken and a protocol is followed.
We would like acknowledge Mr John Paul D’Souza and Harish from the Department of Medical Oncology, Father Muller Medical College and Ms Arpitha Shetty from the Department of Medical Oncology, Father Muller Medical College, Mangalore, Karnataka, India for their valuable guidance and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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