a comprehensive intervention program on the long term placement of peripherally inserted central venous catheters

E‑mail: denghaoyudhy @hotmail.com A comprehensive intervention program on the long‑term placement of peripherally inserted central venous catheters ABSTRACT Background: Peripherally i

Wenfeng Chen, Haoyu Deng 1 , Liangfang Shen, Man Qin, Lianxian He 2

Departments of Radiotherapy,

1 Nuclear Medicine and 2 Nursing, Xiangya Hospital, Central South University, Changsha, China

For correspondence:

Dr Haoyu Deng, Department of Nuclear Medicine, Xiangya Hospital, Central South University,

No 87, Xiangya Road, Changsha, Hunan ‑ 410 008, China

E‑mail: denghaoyudhy

@hotmail.com

A comprehensive intervention program on

the long‑term placement of peripherally

inserted central venous catheters

ABSTRACT

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.

KEY WORDS: Cancer, complication, comprehensive intervention, nursing care, peripherally inserted central venous catheters

Original Article

INTRODUCTION

The peripherally inserted central catheters (PICCs)

are a relatively safe and cost‑effective method

to provide long‑term intravenous access.[1,2] In

clinical studies, PICCs are conventionally used

to provide long‑term intravenous cannulation,

chemotherapy, parenteral nutrition, or antibiotics

administration.[3]

PICCs is frequently used in intensive care and

chemotherapy.[1] 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.[4] Previous studies have shown many

complications of PICCs including venous thrombosis,

infection, catheter occlusion, phlebitis, catheter

dislodgement, chronic venous insufficiency, and

pulmonary embolus.[5‑8] The infection rate in PICCs

lines is considered high in immunocompromised

patients.[9,10] A sutureless adhesive‑backed device

is demonstrated to help reduce catheter‑related

blood stream infections.[11] 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.[12]

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[13], 40,[14] and 60[15] 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 Clinical data

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

Access this article online Website: www.cancerjournal.net DOI: 10.4103/0973-1482.136657 PMID: ***

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Chen, et al.: A comprehensive intervention program on the PICCs

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].

Surgery procedures

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

Intervention

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

Statistical analysis

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 Tables 3 and 4

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

Table 1: Characteristics of the cases before intervention and after intervention, including average age, gender, and

diseases (P>0.05)

Before

Table 2: Complications and nursing care in PICCs insertion and maintenance

Complications Nursing cares

Tube feeding difficulty Inform the patients about the general process of insertion, emphasize that there is no pain in the

procedure, make sure that patients are relaxed and cooperate with nurses

Adjust the position of the body Puncture again when necessary Catheter

dislodgment Replace the catheter with a computed tomographic simulator

A reintubation was performed if the catheter was not successfully resetted

Post-insertion nursing care education

The first day: Teach the patients to relax the body, take food as normal; avoid lateral position

to oppress the arm; call the nurse in time when uncomfortable; do not rub, twist or pinch the uncomfortable site

The second day: Change the transparent dressing, provide the guidebooks and stress balls equipped with the catheter, teach the patients to use the ball Catheter

obstruction Prevention: Make sure the tip of the catheter one third at the distal end of the precava, change liquid

in time during transfusion, maintain the liquid surface at a certain level

Declot timely with heparinized saline under negative pressure

Rub the exposed blood clot gently before decloting with heparin

Phlebitis Teach the patients to use a Comfeel plus

transparent dressing (Coloplast, Danmark) when uncomfortable

Teach the patients to avoid clinostatism and keep the body relaxed

Inform the hospitals nearby for catheter maintenance

Post-PICC nursing care education

Teach the patients to keep the dressing perfectly Provide disposable dressing sets to the patients and teach them to use the dressing sets themselves at home

PICCs=Peripherally inserted central venous catheters

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.[16] 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.[17] 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] andthree 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.[18,19] Catheter infection is a mechanical complication

that can be prevented by rigorous and professional nursing

care.[20] 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,[21] 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.[22]

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.[23] The risk of catheter fracture, embolization, and serious consequences might be increased in long‑term dwelling of PICCs.[24] 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.[25]

CONCLUSION

In conclusion, comprehensive intervention programs effectively reduced the incidence of complications in PICCs lines PICCs were suited to the patients with cancers who

Figure 1: Catheter dislodgment to jugular vein catheter Figure 2: A local infection at the catheter insertion site

Table 3: Comparison of the unplanned extubations rates in

the control group and the test group (P<0.01)

Chen, et al.: A comprehensive intervention program on the PICCs

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

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Cite this article as: 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.

Source of Support: Nil, Conflict of Interest: None declared.

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