Support Care Cancer DOI 10.1007/s00520-015-2754-1
ORIGINAL ARTICLE
A team-based multidisciplinary approach to managing peripherally inserted central catheter complications in high-risk haematological patients: a prospective study Natalia Curto-García 1 & Julio García-Suárez 1 & Marta Callejas Chavarria 1 & Juan José Gil Fernández 1 & Yolanda Martín Guerrero 1 & Elena Magro Mazo 1 & Shelly Marcellini Antonio 1 & Luis Miguel Juárez 1 & Isabel Gutierrez 1 & Juan José Arranz 2 & Irene Montalvo 2 & Carmen Elvira 2 & Pilar Domínguez 2 & María Teresa Díaz 2 & Carmen Burgaleta 1
Received: 28 March 2014 / Accepted: 6 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Use of peripherally inserted central catheters (PICCs) has markedly increased during the last decade. However, there are few studies on use of PICCs in patients with haematological malignancies (HM) receiving intensive chemotherapy. Preliminary data suggest a higher rate of PICCrelated complications in these high-risk patients. This prospective observational single-centre study aimed to investigate PICC-related complications after implementation of a multidisciplinary approach to PICC care and compared it with previous literature. Methods A total of 44 PICCs were inserted in 36 patients (27.3 %, thrombocytopenia <50×109/L at insertion) over 5045 PICC days (median duration, 114.5 days). Results No major insertion-related complications were observed. Major late complications were obstruction in 13.6 %
(1.19/1000 PICC days) of patients, catheter-related bloodstream infection in 6.8 % (0.59/1000 PICC days), and catheter-related thrombosis in 4.5 % (0.39/1000 PICC days). Premature PICC removal occurred in 34 % (2.97/1000 PICC days) of patients. The overall rate of potentially major dangerous complications was particularly low (11.36 %, 0.99/1000 PICC days) compared with previous studies. Conclusions This study highlights the utility of a multidisciplinary approach for PICC care in adults with HM receiving intensive chemotherapy. We provide further data to support use of PICCs in such patient populations.
Natalia Curto-García and Julio García-Suárez are joint first authors. Natalia Curto-García currently works at the Royal Free Hospital-Barnet Hospital, London, UK.
Introduction
Electronic supplementary material The online version of this article (doi:10.1007/s00520-015-2754-1) contains supplementary material, which is available to authorized users. * Natalia Curto-García
[email protected] 1
Department of Haematology, University Hospital Príncipe de Asturias, Carretera Alcalá- Meco s/n, Alcalá de Henares, Madrid, Spain
2
Nursing Staff of the Haematology Unit, University Hospital Príncipe de Asturias, Carretera Alcalá- Meco s/n, Alcalá de Henares, Madrid, Spain
Keywords Peripherally inserted central catheters . Haematological malignancies . PICC-related bloodstream infection . PICC-related thrombosis
Tunnelled and non-tunnelled central venous catheters (CVCs) inserted into the upper venous system are standard treatment for patients with haematological malignancies (HM) undergoing intensive chemotherapy. However, potentially serious and life-threatening complications of CVCs are more frequent in this high-risk population, particularly in patients with severe thrombocytopenia and neutropenia episodes. CVCs with higher haemorrhagic and infectious risks are totally implantable CVCs and non-tunnelled CVCs, respectively [1, 2]. Other alternatives are required. Peripherally inserted central catheters (PICCs) may be an alternative to other available indwelling CVCs and devices in this vulnerable high-risk patient group. PICCs are easy to
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insert and remove by trained nurses at the bedside. PICCs are associated with a low risk of pneumothorax and bleeding complications in patients with severe thrombocytopenia [3]. Additionally, PICCs are comfortable and well tolerated by patients and are less expensive than other CVCs. Simple interventions are useful for reducing CVC-related complication rates and the opportunities to decrease these appear to be greatest when multidisciplinary programs are applied [4]. Nevertheless, significant complications may be associated with the use of PICCs, with a rate as high as 32.8 % [5]. The most important complications are device-related infections and thrombosis. A recent meta-analysis of 11 studies that compared the risk of thrombosis related to PICCs with that related to CVCs showed that PICCs were associated with an increased risk of catheter-related thrombosis (CRT) (odds ratio 2.55, 1.54–4.23, p<0.0001) [6]. Because of these concerns, only a few published studies have focused on the clinical usefulness and safety of PICCs in patients with HM, especially in those receiving intensive chemotherapy [2, 3, 7–12]. A comparison between these published studies and our current study needs to be carefully performed because the population, endpoints, and definitions greatly varied in these previous studies. Furthermore, most of these studies were retrospective cohort studies, the duration of PICC implantation was relatively short (range, 8.9–63 days), and a substantial proportion of patients in the series was treated with conventional chemotherapy and was considered as a single group together with those treated with intensive chemotherapy. We conducted a prospective surveillance study after implementation of a multidisciplinary approach with collaborative guidelines for PICC care to determine the rate of PICC-related complications. We studied a population of HM patients with intensive chemotherapy and a high risk of complications. We restricted our study population to these high-risk HM patients to address a limited number of unknown confounders. The current study was based on the premise that a multidisciplinary approach, involving a team trained in insertion and management of PICC lines, may result in a low rate of PICC complications.
Material and methods Design This prospective observational single-centre study was performed between July 2010 and May 2013. The aims of the study were as follows: (1) to measure the incidence of PICCrelated complications in high-risk HM after implantation of a multidisciplinary care plan for PICC management, (2) to assess the impact of a multidisciplinary competence program on PICC-related complications, and (3) to delineate the possible risk factors for these complications. All patients signed an
informed consent and the institution ethics committee approved the study. Setting and study population Príncipe de Asturias is a 450-bed university hospital in Spain. The adult Haematology Department comprises a 14-bed ward (four beds have HEPA air filtration and positive air pressure reverse isolation) and an outpatient unit with 20 beds. Autologous, but not allogeneic, stem cell transplantation is performed. From July 2010 to May 2013, all adult (>18 years) patients with HM who were undergoing intensive chemotherapy and were fitted with PICCs were eligible for inclusion in this prospective surveillance study. Patients were followed through inpatient and outpatient periods. Patients who were admitted for stem cell transplantation were not included because of our limited experience in PICC use in this group. For the purposes of this study, Bintensive chemotherapy^ was defined as any chemotherapeutic regimen aimed to achieve the maximum tumour response, associated with a high risk (>20 %) of myelosuppression-related events and estimated neutropenia for more than 7 days. Exclusion criteria included documented septicaemia, pregnancy, patients with renal failure who may require haemodialysis and later fistulas, and patients who refused informed consent. Each positioning of a PICC was considered a single case for the study. Consequently, a patient who had completed the scheduled observation period was registered as a new case for the study if other PICCs were inserted. Multidisciplinary PICC care program In 2010, six members representing the Haematology and Medical Microbiology Departments formed a multidisciplinary team comprising three physicians (two haematologists and one medical microbiologist) and three haematologist nurses to design a novel approach for decreasing the risk of PICCrelated complications in our unit. The team’s goals were to develop multidisciplinary, evidence-based guidelines and an education program that would allow strict adherence to known antiseptic techniques. Another goal was stimulation of further research to develop the best clinical practice guidelines. Since its inception and to maximize the potential for high proficiency ratings among the nurses, strict entry criteria were required as follows: 2 years of venous access experience and ability in venepuncture and central line care and competency demonstrated by observation of the procedure, assistance with the procedure, conducting the procedure with coaching, and three successful consecutive insertions without coaching. The expertise of our PICC team is widely recognized by clinicians within the University Hospital Príncipe de Asturias. Bimonthly meetings were performed to develop the content of the
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protocol, to determine the resources required, and to implement the protocol. A literature review was completed and a timeline was established. Manager nurses from the intensive care unit and emergency department were asked to join the team to assist with planning and implementation, as staff who would be involved in its use. Meeting attendance was mandatory and fluid communication among members ensured collaboration and coordination. The compliance of the protocol was high (>90 %). The multidisciplinary approach prevention strategy, targeted at the insertion and maintenance of PICC lines, is shown in Table S1.
transfusion was considered for maintaining levels in these cases. Possible complications, such as pulmonary embolism, were carefully noted. Removal of PICCs was considered in the following situations: septicaemia, suppurative thrombophlebitis, endocarditis, catheter-related bloodstream infection (CRBSI) that continued despite >72 h of antimicrobial therapy to which the infecting microbes were susceptible, and infections due to Candida spp., Mycobacterium spp. or Staphylococcus aureus. PICCs were removed after 3–5 days of LMWH treatment (until 6 weeks were completed) in patients who developed CRT but no longer required a PICC or it was no longer functioning.
PICC procedures Data collection At our institution, 5-French, polyurethane, double-lumen PICCs (PowerPICC®, Bard Access Systems, Salt Lake City, UT, USA) were inserted by a BPICC team^ comprising eight nurses with special training. This was performed under strict asepsis and maximal barrier precautions in the medical daycare unit or the patient’s room. All of the patients received PICC lines of the same model. Peripheral veins in the arm (basilica or cephalic) were cannulated under local anaesthesia without sedation. Specific PICC care procedures that were followed during insertion and maintenance are shown in Table S1. All intravenous therapies that were administered (including blood products and total nutrient admixtures) and the phlebotomies obtained were performed through PICCs. Definition and management of PICC-related complications Immediate complications included all adverse events that occurred within 24 h of PICC insertion and as a direct result of the procedure. Late (after 24 h) major PICC-related complications were defined as any potentially dangerous complication requiring a prolonged hospitalization, systemic antibiotics or anticoagulation. Late minor complications were described as events requiring no prolongation of hospitalization >24 h. Definitions, aetiology and management of PICC-related complications are shown in Table S2. Management of PICCrelated infections was based on the Infectious Diseases Society of America guidelines [13, 14]. In the case of fever or other symptoms/signs of systemic infection, blood culture samples from suspected catheters and peripheral veins were obtained before starting empiric broad-spectrum antibiotics, while awaiting blood culture results. Doppler ultrasound confirmed diagnosis of CRT. There is no consensus on the treatment of these complications in patients with HM. Therefore, our policy consisted of administering low-molecular-weight heparin (LMWH) (dose, 1 mg/kg/bd daily sc) alone for 6 weeks and then stopping it. The LMWH dose was adjusted according to renal function and platelet levels <50 × 10 9 /L. Platelet
The following information was collected in a dedicated electronic database: patients’ main characteristics (e.g. demographic data, disease details and reasons for using PICCs) and risk factors for CRBSI (underlying disease, thrombocytopenia <50×109/L, and neutropenia <0.5×109/L at catheter insertion, previous CRBSI, exit-site infection, days of neutropenia and total PICC days) and CRT (age, sex, previous thromboembolic disease, side of catheter insertion, insertion site, diabetes mellitus, advanced disease, duration of catheter use and units of transfused red blood cells). Data were collected every 2 weeks while the patient was in the study until PICC removal or 12 months, whichever was sooner. Statistical analysis The primary endpoint for this study was the occurrence of major complications of PICCs. Secondary endpoints included occurrence of immediate complications, minor complications, risk factors for complications after positioning of PICCs, and the rate of PICC removal. The complication rate per 1000 PICC days was calculated by dividing the number of complications by the number of PICC days and multiplying the result by 1000 [15]. Univariate and multivariate logistic regression analyses were performed to identify risk factors for main PICC-related complications. Descriptive statistics included frequencies and percentages for categorical variables and means, standard deviations and medians for continuous variables. Analyses were performed using the IBM SPSS statistics software, version 20.0 (IBM Corp., Armonk, NY, USA).
Results Patients’ and PICCs’ characteristics Forty-four consecutive PICCs were inserted into 36 patients with HM. Twenty-eight of them had one catheter inserted and
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eight had two inserted. Twenty-three patients were men and 13 were women, with a median age of 49 years (range, 18– 77 years). The most frequent underlying diseases were acute leukaemia (54.6 %) and aggressive non-Hodgkin lymphoma (27.3 %). All of the patients received intensive chemotherapy (previously defined) and most of the PICCs were inserted in the induction phase (54 %). Clinical characteristics of the patients are shown in Table 1. The median duration that catheters remained in situ was 114.5 days (range, 4–425 days). Three (6.8 %) PICCs were in place by the end of monitoring. Thrombocytopenia (<50×109/L) at catheter insertion was present in 27.3 % of patients. Severe neutropenia (ANC <0.5×109/L and <0.1×109/L) occurred in 75 and 68.2 % of patients, lasting for a mean of 18.3 and 6.3 days, respectively. Previous venous thrombotic events were reported in 9 % of patients. PICCs were on the left side in 41 % of patients and on the right in 59 %. A total of 347 (median, 5.5) red blood cells and 359 (median, 4.5) platelets were transfused during monitoring.
place at end of study, with a median duration of 35 days (range, 31–75 days). Elective removal after completion of the chemotherapy program was the most common cause (52 %, 4.56/1000 PICC days), followed by premature removal (34 %, 2.97/1000 PICC days) and death (n=3, 6.8 %). Causes of premature PICC removal are shown in Table 3. Thirty-five catheter tips were cultured on removal of the PICC with negative results, except for three patients where CRBSI was confirmed. No device-related death was observed.
PICC-related complications
Discussion
Immediate complications were observed in four (0.79/1000 PICC days) patients, with primary malposition of the tip of PICCs, and these were successfully repositioned in all of the patients (95 % in our haematology unit and 5 % in the intensive care unit). The overall rate of late PICC complications was 16.05/1000 PICC days, of which 11 (2.18/1000 PICC days) were considered major and 70 (13.87/1000 PICC days) were considered minor complications (Table 2). The most common late major complication was mechanical obstruction due to partial catheter dislodgement, which occurred in six patients (13.6 %, 1.19/1000 PICC days). CRBSI was reported in three patients (6.8 %, 0.59/1000 PICC days) and the involved microorganisms were Enterobacter cloacae, Pseudomonas aeuroginosa and coagulase-negative Staphylococcus. The mean time from catheter insertion to diagnosed CRBSI was 59.3 days (range, 38–85 days) and all patients required PICC removal. PICC-related symptomatic thrombosis was observed in two patients (4.5 %, 0.39/1000 PICC days), occurring 4 and 6 days after PICC placement. In both patients, the PICC was removed and adjusted LMWH was administrated for 6 weeks. None of these patients developed pulmonary embolism. A second PICC was inserted in both patients. Among late minor complications, PICC occlusion was the most common and occurred in 127 % of patients (11.10/1000 PICC days), but all of these catheters remained following thrombolysis with urokinase. Exit-site infection occurred in ten patients (22.7 %, 1.98/1000 PICC days), and three of them (6.8 %, 0.59/1000 PICC days) required catheter removal after failure of conventional antibiotherapy (Table 2). Overall, 41 (93.2 %) PICCs were removed during the study period. The median duration from insertion to removal was 119.68 days (range, 4–425 days). Three PICCs were still in
To the best of our knowledge, this is the first prospective study to examine all types of PICC-related complications in a haematology unit involving various interventions in a multidisciplinary manner. Additionally, our study involved healthcare professionals who inserted and maintained PICCs and healthcare managers who allocated resources and trained patients and family. Notably, we exclusively included a highrisk population with HM who required intensive chemotherapy, while previous reports of PICCs studied between 8.7 and 100 % of this population (Table 4). Additionally, the median duration of PICC placement in our series (114.5 days) is considerably longer than that in other studies of PICC use in HM (Table 4). These factors suggested that our cohort of patients represented a special high-risk group. There is compelling evidence that ultrasound-guided venepuncture (by real-time ultrasonography) is associated with a lower incidence of complications and a higher rate of success than Bblind^ venepuncture [16]. Therefore, current evidence-based guidelines strongly recommend real-time ultrasound-guided venepuncture for all CVC insertions [17]. In the present study, ultrasound-guided insertion was not performed because of the limited availability of appropriate ultrasound equipment. Despite this limitation, our success rate in a high-risk population is similar to previous studies using realtime ultrasound-guided venepuncture, with a low rate of acute and major complications [7]. We suggest that ultrasound guidance should be used for PICC insertion as previously highlighted by other authors [9]. Although there is controversy, positioning of PICCs within the lower superior vena cavacavoatrial junction leads to decreased rates of catheter-related complications and increases malfunction, CRT, and duration of catheters [9, 18, 19].
Risk factors There was a relatively small number of patients and PICCs, as well as a small number of major events (CRBSI or CRT) in our case series. Therefore, we were unable to perform univariate and multivariate analysis of risk factors for major PICCrelated complications.
Support Care Cancer Table 1 Patient characteristics, underlying haematological disease, phase of treatment and risk factors for PICC complications Characteristic
Data
No. of PICCs No. of patients Age, mean (range) Female/male, n (%)
44 36 49 years (18–77) 13 (29.5)/23 (52.3)
Duration of catheterization, days Overall Mean (range) Median Disease, n (%) ALL AML Aggressive NHL HL MM MDS Phase of treatment, n (%) Induction Consolidation Salvage Risk factors for CRBSI ANC <1.0×109 at PICC insertion, n (%) Neutropenic (ANC <0.5×109/L) days during PICC monitoring, n (%) Duration of ANC <0.5×109/L, days (mean)b Platelet count <50×109/L at PICC insertion, n (%) Risk factors for CRT Left-sided placement, n (%) History of DVT, n (%) Diabetes mellitus, n (%) Advanced disease, n (%) Units of red blood cell transfused, median Platelets transfusions, median
5045 114,66 (4–425) 114.5 12 (27.3) 12 (27.3)a 12 (27.3) 3 (6.8) 3 (6.8) 2 (4.6) 24 (54.5) 9 (20.45) 11 (25) 7 (16) 33 (75) 806 (18.32) 12 (27.3 %)
18 (41 %) 4 (9 %) 7 (16 %) 11 (25 %) 5.5 4.5
ALL acute lymphoblastic leukaemia, AML acute myeloid leukaemia, APL acute promyelocytic leukaemia, TALL T acute lymphoma/leukaemia, HL Hodgkin lymphoma, NHL non-Hodgkin leukaemia, MM multiple myeloma, MDS myelodisplastic syndrome, ANC absolute neutrophil count a
Four cases were diagnosed of acute promyelocitic leukaemia
b
Duration of the neutropenia period was defined as the period (days) from the first day of ANC ≤0.5×109 /L to the first day of ANC >0.5× 109 /L
In our prospective study of PICCs that were solely used in a high-risk patient population, the overall rate of potentially dangerous complications, such as CRBSI and CRT, was markedly lower (11.3 %, 0.98/1000 PICC days) than that found in previous published studies of PICCs (Table 4). This finding is particularly notable, considering that the majority of patients in these reports did not receive intensive chemotherapy.
Interestingly, our rate of potentially serious complications is consistent with previously reported series of Hickman catheters (15.9 %, 6.26/1000 catheter days) [20] and non-tunnelled CVCs (22.5 %, 13.67/1000 catheter days) [2]. Finally, our rate of serious complications is similar to that defined in HM with Port-a-Caths (9.4 %, 0.40/1000 catheter days), which are catheters with the lowest incidence of CRBSI and CRT [21]. CRBSI is probably the most potentially serious complication. There is accumulating evidence that PICCs are associated with a lower rate of CRBSI compared with CVCs, probably because of an exit site that is less prone to contamination (upper mid-arm skin is characterized by lower bacterial colonization compared with skin at the neck or in the infraclavicular area) [22]. This low CRBSI rate was observed in our series (6.8 %, 0.59/1000 PICC days). Moreover, our results of CRBSI are similar to previous studies of PICCs (Table 4) and tunnelled (3 %, 2.2/1000 catheter days) [3] and non-tunnelled-CVCs (16 %, 10.27/1000 catheter days) [2] in HM. The main risk factors for CRBSI in patients with HM are severe neutropenia (ANC <0.5×109/L) at the time of catheter insertion [23], acute myeloid leukaemia receiving induction or consolidation therapy and previous invasive fungal disease [2, 24]. In our series, the incidence of CRBSI was too low to draw any conclusions. All three episodes of CRBSI occurred in acute myeloid leukaemia patients undergoing induction chemotherapy who had a prolonged duration of severe neutropenia (median, 32 days). However, only one of these patients was neutropenic at insertion of the PICC. The rate of symptomatic CRT, the second most serious complication, was only 4.5 % (0.39/1000 PICC days), which is low compared with the literature (Table 4). Our decision to only look for symptomatic CRT was based on the consideration that the clinical impact of asymptomatic CRT is still under discussion. Currently, there are no studies where patients with PICC were screened for thrombosis. Previous reports have suggested that the thrombogenicity of PICC devices could relate to endothelial injury and phlebitis following insertion of devices [25]. Our data and previous studies appear to support the aforementioned hypotheses because the majority of CRT occurred within 3 weeks after insertion of PICCs. These data are consistent with results from a study of 1307 PICCs that suggested that a proper insertion technique decreased the incidence of thrombosis to 1.4 % [26]. Previously described risk factors for symptomatic CRT in cancer patients (e.g. diabetes mellitus, previous thrombosis episodes, side of the line and transfusion) were not predictive of PICC-related thrombosis in our study [8]. However, our small number of events and population limited this analysis, and no definite conclusion can be made concerning risk factors for predicting CRBSI and CRT. Another aim of our study was to evaluate the incidence of late minor complications. Although there was a high rate of PICC occlusions (11.10/1000 PICC days), this rate is lower
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PICCs complications
Number total complications Immediate complications Mechanical complications Malposition Late major complications Symptomatic PICC-related thrombosis Catheter-related bloodstream infection Mechanical obstruction Late minor complications Phlebitis Exit-site infection Catheter occlusion Mechanical disfunction a
All of them due to partial catheter dislodgement
b
16 PICCs had more than one occlusion
No. of PICC (%)
95 % confidence interval
No. of events per 1000 PICC days
85 4 (9.1) 0 4 (9.1) 11 (25) 2 (4.5) 3 (6.8) 6 (13.6)a 70 (159.1) 4 (9.1) 10 (22.7) 56 (127.3)b NA
0.6; 17.6 0.0; 0.0 0.6; 17.6 12.2; 37.8 −1.6; 10.7 −0.6; 14.3 3.5; 23.8 – 0.6; 17.6 10.3; 35.1 –
16.85 0.79 0 0.79 2.18 0.39 0.59 1.19 13.87 0.79 1.98 11.10 NA
than that found by Lim et al.’s [20] study with a similar population (20.43/1000 PICC days). No catheter was removed for this complication in either of the studies, which suggests that this did not influence the rate of PICC removal. Finally, in our study, the above-mentioned complications led to premature PICC removal in 34 % of patients (2.97/1000 PICC days), which is comparable to that found in previous studies of PICCs on HM (Table 4). Dislodgement of PICCs resulted in PICC removal in 13.6 % of patients (1.19/1000 PICC days), which is higher than in previous reports [9]. Therefore, more effective fixation methods are desirable. Our rates of PICC removal are also comparable to previous studies of nontunnelled CVCs (30 %) [27] and tunnelled CVCs (4– 25 %) in similar populations [1, 21, 28]. However, the median duration of catheter use in our study was longer than that for other types of CVCs and could be an important risk factor to consider [27]. Table 3
A number of limitations are present in this study. First, this was a single-centre series with a relatively small number of patients. Historical data were not available because we did not have access to reliable information. Although the lack of historical data precludes comparisons between results before and after implementation of the multidisciplinary approach, our data serve as a baseline for future similar studies. Second, we evaluated a relatively heterogeneous high-risk population of HM patients, although most patients had acute leukaemia (54.6 %) and aggressive lymphomas (27.3 %) and were receiving intensive chemotherapy. Third, our limited access to ultrasound guidance for PICC insertion was reflected in the rates of mechanical and malposition complications. Fourth, there was the limitation of methodology of indirect comparisons and a lack of unpublished or ongoing randomized controlled trials. Finally, another potential limitation of our study was that we did not evaluate outcomes other than PICCrelated complications. As a result, we cannot determine
Reasons for PICC removal
Elective removal (end of therapy) Premature removal CRT CRBSI Complicated exit-site infection Mechanical obstruction Accidental removal Death In use
No. of PICCs (%)
No. events per 1000 PICC days
Median duration, days (range)
23 (52.3) 15 (34) 2 (13.3) 3 (20) 3 (20) 6 (40) 1 (6.7) 3 (6.8) 3 (6.8)
4.56 2.97 0.39 0.59 0.59 1.19 0.20 0.59 0.59
154.8 (53–425) 57.4 (4–145) 5 (4–6) 59.3 (38–85) 73 (9–112) 69 (6–145) 40 161.67 (126–206) 35 (31–72)
CRT catheter-related thrombosis, CRBSI catheter-related bloodstream infection
Retrospective 899
Prospective
Tran H. et al. 2010
Worth LJ. et al. 2009
100 % AML 27.3 % ALL 27.3% AML 27.3 % NHL 6.8% HL 6.8 % MM 4.6 % MDS
NA
NA NA 1.5 (2/3.3 %)
23 % (mostly AL) 100 % 100 % 4.68 (17/33 %) 0.59 (3/27.3 %)
NA (3 %)
NA (2/3.8 %) 0.39 (2/18.2 %)
NA
NA (4/6 %)
7.71 (14/18.7 %)
NA (39/7.8 %)
NA (17/24 %) NA (4/21 %) 2.3 (3/5 %)
63 114.5
8.9
22
24.2
NA
NA NA 19
17 (32.7 %) 15 (34 %)
13 (20 %)
20 (28.6 %)
27 (36 %)
25 (71 %)
24 (26.1 %) 4 (21 %) 19 (31.6 %)
Phlebitis (11) Mechanical obstruction (6/40 %)
Leaking of catheter (7)
FN (4/6 %)
CRT (14/18 %)
CRT (25/71 %)
NA CRT (4) FUO (9/15 %)
CRBSI, events per CRT, events per PICCs duration, Premature PICC Main reason for premature 1000 PICC days (n/%) 1000 days catheter days (median) removal, n (%) PICC removal (n/%) (n/%)
21 % 6.61 (12/16 %) (mostly AML) 72 % NA (10/14 %)
77 %
NA NA 60 %
IC (%)
ALL acute lymphoblastic leukaemia, AML acute myeloid leukaemia, AL acute leukaemia, CRT catheter-related thrombosis, FN febrile neutropenia, FUO fever of unknown origin, HL Hodgkin lymphoma, HM haematological malignance, IC intensive chemotherapy, MM multiple myeloma, NA not available, NHL non-Hodgkin leukaemia, RCT randomized clinical trials
Retrospective 52 Retrospective 44
Strahilevitz J. et al. 2001 Our study
70
RCT
Harter C. et al. 2003
McDiarmid S. et al. 2006 Retrospective 70
66/75
Retrospective 92 Retrospective 340 Retrospective 60
Skaff E.R. et al. 2012 Aw A. et al. 2012 Bellesi S. et al.2012
100 % (AML) 55 (16 %) 45 % NHL 24 % MM 8.7 % AML 44 % AML 12% ALL 45 % NHL 21 % AML 62 % NHL 10% HL, 28 % MM 27 % AL
Type of study PICCs, HM (%) n
Studies of PICC-related complications in haematological patients
Reference
Table 4
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whether this intervention affected antibiotic use, length of hospital stay, mortality or antibiotic resistance patterns. Despite these limitations, this multidisciplinary approach may potentially reduce the rate of potentially dangerous catheter complications (CRBSI and CRT). The importance of implementing these control programs is increasingly being recognized as a requirement for optimal functioning of high-risk hospital floors. We consider that PICCs may be a safe and useful alternative to conventional catheters in patients with HM receiving intensive chemotherapy. Further prospective randomized studies with a larger number of patients are required to confirm our results. Acknowledgments We would like to thank all of the patients and their families for participating in the project. We also thank all of the physicians and nurse staff of our Haematology Department who were involved in the care of the patients over the years. We also thank the members from other departments that contributed to the study.
10.
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13.
Conflict of interest The authors have no conflicts of interest in this study. 14.
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