Support Care Cancer (2017) 25:2843–2847 DOI 10.1007/s00520-017-3699-3

ORIGINAL ARTICLE

Prospective evaluation of systematic use of peripherally inserted central catheters (PICC lines) for the home care after allogeneic hematopoietic stem cells transplantation J. Cornillon 1 & J.A Martignoles 1 & E. Tavernier-Tardy 1 & M. Gire 1 & P. Martinez 1 & C. Tranchan 1 & A. Vallard 2 & K. Augeul-Meunier 1 & B. Hacquard 3 & D. Guyotat 1

Received: 6 October 2016 / Accepted: 31 March 2017 / Published online: 6 April 2017 # Springer-Verlag Berlin Heidelberg 2017

Abstract Purpose Long-term catheters are often necessary for outpatient care after an allogeneic hematopoietic stem cell transplantation (HSCT), However, there is paucity of data on the use of peripherally inserted central catheter (PICC) in postHSCT setting. Methods We prospectively evaluated the systematic use of PICC in 37 consecutive patients returning home after HSCT. Results In 6 out of 37 patients, the PICC was exclusively used for weekly blood controls. In 31 patients, the PICC line was used at home for hydration (18), antibiotics (3), intravenous human Ig (7), transfusions (10), extracorporeal photopheresis (3), chemotherapy (2), artificial nutrition (1), and/or palliative care (1). PICC complications were reported in ten patients (27%), causing eight PICC removals. At the end of the study, 35 patients had their PICC removed. PICCs were used with a median duration of 67 days. Reasons for removal were that PICC was not considered to be useful any longer (16), suspicion of infection (inflammation without documentation) (5) or infection (2), patient’s wish (4), death (4), accidental withdrawal (2), puncture site bleeding (1), and catheter change due to extracorporeal photopheresis (1). Three venous thromboses were reported (8%), requesting one PICC removal

* J. Cornillon [email protected]

1

Department of Clinical Hematology, Institut de Cancérologie Lucien Neuwirth, 42171 St, Priest en Jarez, France

2

Department of Radiation Oncology, Institut de Cancérologie Lucien Neuwirth, 42 St, Etienne, France

3

Department of Interventional Radiology, Institut de Cancérologie Lucien Neuwirth, 42-St, Etienne, France

because of associated infection. In other cases, an antithrombotic treatment was initiated. Conclusions Although the number of patients included in the study was small, our results suggest that PICC is a safe longterm venous access for home care after HSCT. Keywords PICC line . Allogeneic hematopoietic stem cell transplantation . Home care

Introduction Patients returning home after an allogeneic hematopoietic stem cell transplantation (HSCT) are closely monitored for months. Long-term day hospital care or home care are sometimes performed, with intravenous (IV) rehydration, parenteral nutrition, or antibiotics, for instance. Furthermore, the hematopoietic and immune recovery might be a long process, requiring iterative blood transfusions. Finally, patients often undergo treatments requesting a long-term venous access device. However, the management of these catheters is challenging, with frequent complications (infection, thrombosis, occlusion…). Peripherally inserted central catheters (PICCs) are increasingly used in onco-hematological patients [1–6]. Indeed, the PICC insertion is considered to be a simple and safe procedure compared to classical central venous catheter placement. PICC is inserted in a peripheral vein in the arm (cephalic vein, basilic vein, or brachial vein), neither requiring a general anesthesia procedure nor a surgical incision. The bleeding risk is extremely low, which is a clear asset in patients with frequent and/or severe thrombocytopenia. To maintain PICC patency, regular care can be performed by a trained nurse. Finally, the removal of a PICC line is a simple, safe, and fast procedure that can be carried out at home. Although PICCs are widely

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used in onco-hematological patients, in compliance with recent guidelines [7], there is no evidence regarding their benefit after an allogeneic HSCT. Thus, it is of primary interest to report data on PICC safety in order to evaluate its real therapeutic index. The aim of the present prospective monocentric survey was to report on the systematic use of PICC for outpatient care after an allogeneic HSCT.

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performed to maintain PICC patency. PICC dressing and PICC operating functions were assessed twice a week at day hospital during the blood sampling. All PICC complications (real or suspected) were managed at the day hospital and data were simultaneously collected. Criteria for diagnosis of the complications were as follows: –

Material and methods All patients undergoing an allogeneic HSCT between January 2014 and June 2015 were enrolled in the present survey. Data were prospectively collected in real time by hematology nurses in our department. The institutional review board approved the study, which was conducted in compliance with the Declaration of Helsinki and Good Clinical Practice guidelines. All patients provided written inform consent before enrollment.

–

–

Thrombosis: defined by a symptomatic deep vein thrombus, proved by vascular Doppler ultrasound; Catheter-related bloodstream infection (CRBSI): defined by Bthe presence of the same organism grow from at least 1 percutaneous blood culture and from a culture of the catheter tip, or that 2 blood samples be drawn (one from a catheter hub and the other from a peripheral vein) that, when cultured, meet CRBSI criteria for quantitative blood cultures or differential time to positivity^ [7–9]. Inflammation of the exit site: defined by an uncomplicated exit-site infection without systemic infection, positive blood culture, or purulence. [10].

Catheter insertion procedure Statistical analysis All PICC insertions were performed by a trained radiologist in our radiology department. All patients were informed of the risks of the procedure. Radiologist’s hand hygiene was performed according to surgery processes, using hydroalcoholic gel. Patient skin asepsis was carried out based on alcoholic antiseptic. Brachial zone was covered by sterile drapes. A local anesthesia was performed, based on a 5-ml subcutaneous injection of lidocaïne. The type of PICC was PICC LINE COOK® of 4F or 5F. Venous access was systematically tracked using ultrasound (through a mobile ultrasonography apparatus). Permeability of the subclavian axis was evaluated before the insertion. The catheter length was calculated by the radiologist at the time of the insertion according to the patient characteristics. The PICC line was then inserted into the basilic vein or the brachial vein. The choice of the vascular access depended on the 60% minimal diameter of the lumen (for example 3 mm for a PICC 4F). If possible, basilica vein was preferentially chosen. The catheter position was fluoroscopically monitored. The aim was to place the PICC extremity 2 cm beyond the tracheal spur. The catheter was sutured on the skin. Finally, the PICC position was controlled on chest radiography, and a sterile dressing was applied. The first PICC dressing change was performed 24 h after the initial insertion. Care of PICC Home-care supplies and nurse training were procured by a service provider. At home, dressing and needle-free connector were concomitantly changed once a week. The PICC insertion zone was kept visible, using transparent dressings. Twice a week, a 10-ml flushing of normal saline solution was

A descriptive statistical analysis was performed using the software SPSS 13.0©.

Results Patient characteristics From January 2014 to June 2015, 54 patients received an allogeneic HSCT. A PICC insertion was performed in 37 patients, after neutrophil recovery and after being discharged from the protective environment. The rest of the patients had a totally implantable venous access device. One patient was contra-indicated to PICC due to a medical history of multiple thromboses. No failure of PICC insertion was reported. Regarding the chemotherapy regimen, 25 patients underwent reduced intensity conditioning (RIC) and 12 underwent myeloablative conditioning (MAC). Hematopoietic stem cells (HSC) were provided by 15 matched related donor and 22 matched unrelated donor. HSC were extracted from peripheral blood stem cell (PBSC, 31 patients), from bone marrow (4 patients), and from cord blood unit (CBU, 2 patients). Indications for allogeneic HSCT were myeloid disorders (86.5%: acute myeloid leukemia, myelodysplastic syndrome or myelofibrosis) and lymphoid diseases (13.5%: malignant non-Hodgkin lymphoma, Hodgkin lymphoma and multiple myeloma). The median age was 56 years old (range: 21–70). The median time from diagnosis to transplantation was 253 days (range: 58–623). At the end of follow up, nine patients had died because of relapse.

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PICC follow up After HSCT, the PICC was used (at least once) for another indication than blood tests in 31 patients (84%). Main indications were home hydration (n = 18, 49%), hydration during a hospitalization (n = 15, 41%), transfusion (n = 10, 27%), intraveinous prophylactic human gammaglobulin (n = 7, 19%), home intravenous antibiotic therapy (n = 3, 8%), and extracorporeal photopheresis (n = 3, 8%) (Table 1). The median time from PICC insertion to removal was 67 days (range: 36–98). Regarding home hydration, the median duration of PICC use was 32 days (range: 13–129). The median time from PICC insertion to use for hydration was 1.5 days. PICC complications were reported in 10 patients (27%), causing eight removals. A catheter-related thrombosis was diagnosed in three patients (8%), causing one removal because of associated infection. An anticoagulant therapy based on low molecular weight heparin was initiated for 6 months in these patients. CRBSI was identified in two patients, with infections related to Staphylococcus epidermidis (1 patient) and to Pseudomonas aeruginosa (1 patient). Pseudomonas aeruginosa infection occurred during a severe neutropenia (5.4%, 0.6/1000 days PICC), resulting in the only PICC removal due to CRBSI. The severe neutropenia stemmed from a relapsed disease requesting chemotherapy. Five PICC lines generated a painful local inflammation around the insertion area and were therefore removed. Only one catheter colonization (i.e., germ cultured from the tip or from the catheter blood but not from peripheral blood) was identified after removal, with Staphylococcus epidermidis. However, no additional treatment was initiated for this patient, in the absence of clinical symptoms of sepsis and of biological evidence of bacteremia. Finally, seven PICCs were removed because of local inflammation or infection 7 (19%, 2.1/1000 days-PICC). The last complication requesting PICC removal was a puncture site bleeding. No death could be related to the PICC. Only the two microbiologically documented PICC infections led to hospitalization. All the other complications were either Table 1

Indications for Picc use Nb. patients (%)

Blood tests Transfusion Gammaglobulin infusion During hospitalization Home hydration/alimentation Photopheresis Home antibiotherapy Other Each patient can have several indications

37 (100%) 10 (29%) 6 (18%) 15 (44%) 17 (50%) 3 (9%) 3 (9%) 4 (11%)

managed at home or at the hospital if the patient was already hospitalized for other reasons. No complication was reported among the six patients exclusively using PICC for blood controls. At the end of our survey, two patients still had their PICC. For the other patients, reasons for removal were: PICC wasn’t considered to be useful any longer (16 patients, 46%), suspicion of infection (inflammation without documentation) (5 patients, 46%) or infection (2, 6%), patient’s wish (4 patients, 11%), death (4 patients, 11%), accidental withdrawal (2 patients, 6%), puncture site bleeding (1 patient, 3%), and because another catheter type was requested to perform extracorporeal photopheresis (1 patient, 3%) (Fig. 1). The median duration of the PICC appeared not to differ according to the occurrence of a complication (67 days (95% CI 48–81)) or not (77 days (95% CI 38–116)).

Discussion After an allogeneic HSCT, patients often need long term medical home care, therefore requesting a functional venous access device. The placement of a catheter in patients with immune weakness induces a risk of complications, especially with infections. The present prospective real-time study analyzed a cohort of patients who had a PICC for long term ambulatory care after allogeneic HSCT. No antithrombotic or infectious prophylaxis was used. The PICC insertion was carried out by trained radiologists using ultrasound-guidance procedures, in accordance with the American Society of Clinical Oncology (ASCO) guidelines [7]. PICC home care procedures were systematically given to patients and home nurses were previously trained. To our best knowledge, no study has been conducted in this specific patient population. In our series, PICCs were used at least once a week for blood sample collection, for a long period of time (median duration: 67 days). Although the frequent utilization was initially thought to increase the complication rate, the total complication rate was 27% (3/1000 days-PICC). This result is in accordance with previously reported complication rates, ranging from 11.7% to 34% (1.3–16/1000 days-PICC) [4, 6, 11, 12]. Furthermore, only two PICC complications led patients to hospitalization. It was previously described that the PICC thrombosis rate was higher with respect to other catheter types, and more particularly to a tunneled catheter. A recent retrospective survey, including patients with blood disorders, compared the thrombosis rate of 346 patients with a PICC and 237 patients with a tunneled catheter. A higher incidence of thrombosis was suggested in PICC patients (5.8 vs. 1.7% (p = .003)). However, groups were not comparable with more multiple myeloma (MM) patients in the tunneled catheter group, therefore receiving more thrombosis prophylactic treatment [1]. In

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Fig. 1 Reasons for PICC removal

patients undergoing an autologous HSCT, the estimated rate of thrombosis was 2.3/1000, with a shorter time of PICC use [5]. Regardless of indications and pathologies, authors reported thrombosis rates ranging from 4.5 to 8.3%, with a median rate of 8% [1, 4–6, 13, 14]. Despite a regular and prolonged PICC use, we reported a similar thrombosis rate (8%). The CRBSI incidence was studied in a large prospective survey including cancer patients. The infection rate was 2.5/ 1000 central venous catheter days. The type of central venous access device (CVAD) was identified as an independent risk factor. The non-tunneled catheters (HR = 3.5) and tunneled catheters (HR = 1.77) were associated with more infection than PICCs [2]. In a prospective study, Curto-Garcia et al. analyzed a cohort of patients carrying a PICC, treated with intensive chemotherapy for hematological malignancies excluding HSCT. No insertion complications were reported. Main reported complications were clogging/obstruction (13.6%, 1.19/1000 Picc-days), PICC-related bacteremia/ CRBSI (6.8%, 0.59/1000 PICC-days) and PICC-related thrombosis (4.5%, 0.39/1000 PICC-days). The global complication rate was 16.06/1000 PICC-days [4]. In the present cohort, we assessed a rate of CRBSI of 0.6/1000 days, in accordance with the literature (ranging from 0.59 to 2.5/1000 days of use) [2, 4–6, 11, 12, 15, 16]. Interestingly, Maki et al. suggested that incidence of PICC-related infections decreased in outpatients (1 vs. 2/1000 days) [17]. Finally, the main reason for PICC removal was because it was not medically useful anymore (for 2/3 of the patient) which is in accordance with the published literature [4]. Although our results are very similar to literature, our survey is based on a small cohort of homogeneous patients, unlike previously published studies. However, data should be corroborated by a larger prospective survey. Besides, the complication rate was not compared to another type of venous device. A comparative survey assessing the complication rate

of different venous devices in HSCT would be of primary interest. A quality-of-life evaluation (QOL) should be also carried out since the external PICC extremity might annoy patients. Although we did not collect QOL information, no patient reported daily-routine difficulties due to the PICC and some patient even asked to keep the PICC longer because of painless blood sample collections. Only two patients experienced an accidental removal of the PICC and four asked for its removal before the planned date. As a conclusion, the systematic use of the PICC in a population of outpatients returning home after an allogeneic HSCT seems feasible and safe, regarding the low rate of complication. A prospective survey comparing the PICC to another type of CVAD, such as the tunneled catheter, should be conducted in order to indentify the device with the lowest risk of complications, the higher quality of life, and the easiest management. Acknowledgements Authors thank Jeffrey Perkins for his Englishlanguage support. Compliance with ethical standards Conflicts of interest The authors declare no conflict of interest.

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