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Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery
Heart & Lung xxx (2016) 1e8
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Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery Adam Fabiani, RN a, Lorella Dreas, MD a, Gianfranco Sanson, RN, MSN b, c, * a
Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Strada di Fiume 447, 34148, Trieste, Italy School of Nursing, University of Trieste, Piazzale Valmaura 9, 34147, Trieste, Italy c Azienda Sanitaria Universitaria Integrata, Strada di Fiume 447, 34148, Trieste, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 May 2016 Received in revised form 23 September 2016 Accepted 28 September 2016 Available online xxx
Objectives: To analyze success rate, dwell-time, and complications of long peripheral venous catheters (L-PVCs) inserted under ultrasound guidance. Background: In difficult venous access (DVA) patients, L-PVC can represent an alternative to central or midline catheters. Methods: Prospective observational study. L-PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. Results: A 100% placement success rate was documented. The catheter dwell-time was 14.7 11.1 days. Most catheters were removed at end-use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter-days. Two thrombophlebitis (1.91/1000 catheter-days) and 1 catheter-related bloodstream infection (0.96/1000 catheter-days) occurred. Conclusions: L-PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients’ discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications. Ó 2016 Elsevier Inc. All rights reserved.
Keywords: Difficult venous access Peripheral venous catheterization Nursing Ultrasonography Complications
Introduction Positioning a peripheral venous catheter (PVC) is the most common invasive practice in acute care hospitals, involving up to 70% of patients.1 The use of a PVC is rarely associated with a bloodstream infection,2 and one of the most common complications in cases of prolonged use is phlebitis,3 with a reported incidence of 7e27%.4 The opportunity to position a PVC is limited to superficial veins lying close enough to the skin to be visible or at
Abbreviations: PVC, peripheral venous catheter; DVA, difficult venous access; CVC, central venous catheter; US, ultrasound; PICC, peripherally inserted central catheter; L-PVC, long peripheral venous catheter; APIC, advanced peripheral insertion and management of catheters team; IV, intravenous; CR-BSI, catheterrelated bloodstream infection; VIPS, visual infusion of the phlebitis scale; CFU, colony-forming units; SD, standard deviation; IQR, interquartile range. Conflict of interest: The authors declared no conflict of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author. School of Nursing, University of Trieste, Piazzale Valmaura 9, 34147, Trieste, Italy. E-mail address: [email protected] (G. Sanson). 0147-9563/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2016.09.003
least palpable. For this reason, sometime the peripheral venous cannulation may be challenging, with a failure rate that can reach 25%.5 This condition is known as difficult venous access (DVA), a clinical condition in which multiple peripheral intravenous attempts failed, due to a lack of readily visible or palpable veins.6 In these cases, a central venous catheter (CVC) might be chosen as an alternative, even if this option is related to the risk of immediate or delayed complications, resulting in significant morbidity and mortality.7 Ultrasound (US)-guided insertion of midline catheters or peripherally inserted central catheters (PICCs) should be an alternative, but are indicated for medium-term access (from a few weeks to a few months),4 and are more expensive.8 However, the US guide can also be used to place a PVC in deeper vessels not recognizable through inspection or physical examination.9,10 Two meta-analyses showed that the use of US by physicians, nurses, or emergency technicians increased success rates of peripheral venous cannulation both in adult and pediatric DVA populations when compared with traditional techniques.11,12 Unfortunately, the conventional PVCs are short (<5 cm), since they are designed to be inserted into superficial veins. Consequently, a high likelihood of complications (e.g. extravasation or displacement)
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and a shorter dwell time are easily predictable when a conventional PVC is placed in deeper vessels13e16; the need to relocate the PVC because of a complication increases the risk of phlebitis by 4.4 times.17 Therefore, when a peripheral access was needed in DVA patients, the only effective choice was the US-guided insertion of a midline catheter, even if a short-term intravenous (IV) therapy was planned. To overcome these limitations, the use of longer (8e15 cm) PVCs with integrated guide wire (L-PVC) has been explored. These kinds of devices have also been called “short midlines,” “long peripheral cannulas,” or even considered to be “midlines”, indiscriminately,18 since they combine some features of traditional short peripheral catheters (reduced time of positioning, low risk of complication) with the features of standard midlines (more biocompatible materials, considerable length, potentially longer dwell time). However, L-PVCs differ from the standard midlines not because of their length, but primarily because of the procedure used to insert them. L-PVCs are inserted via a faster “direct” Seldinger technique (direct insertion of the catheter through the guide wire), while the standard midline catheters require a more complex and longer “modified” Seldinger technique (catheter positioned via a micro introducer previously introduced through the guide wire). Moreover, L-PVCs are less expensive; their price is almost one-sixth of the price of a standard midline catheter. The few available studies on L-PVCs report an overall high success rate and a low frequency of complication events,19e22 significantly lower when compared with traditional short PVCs.21 However, these studies evaluated different DVA populations, using different catheters and considering different outcome measures, so that the risk and benefit ratio of prolonged deep-arm vein infusion after L-PVC placement is still undetermined.19
Characteristics of the catheters and placement procedure Polyethylene catheters (Leader-CathÒ, Vygon, France), commercialized for both arterial and central or peripheral venous cannulation, were employed. The catheters were available in the following measures (internal area, external diameter, length): 1) 20G, 3Fr, 8 cm catheter (Fig. 1a); 2) 18G, 4Fr, 10 cm catheter (Fig. 1b); 3) 18G, 4Fr, 18 cm catheter (Fig. 1c). Each catheter was packed together with a dedicated steel needle and a straight tip guide wire. All procedures were carried out by a nurse, specialized in vascular access and member of the “Advanced Peripheral Insertion and management of Catheters (APIC)” team. The catheters were inserted through the Seldinger technique under US guidance; a Philips HD11XE ultrasound device, revision 2.0.4 (Philips ultrasound, Andover, MA, USA) with an L 12-3 linear transducer, was also used. The patient was placed in a supine position, placing her/ his upper arm in abduction with an external rotation of the shoulder. A preliminary US examination of the veins of the upper arm was done, in order to identify the most suitable vessel to cannulate; the measure of the catheter to be placed was determined according to both the caliber and the anatomical straight course of the selected vein. Nerves and the brachial artery were also identified before proceeding with the cannulation. For each procedure, the following aseptic barriers were adopted: a surgical mask, sterile drape, sterile transducer cover, and sterile ultrasound gel and sterile gloves. A wide skin surface around the puncture site was scrubbed with 2% chlorhexidine in a 70% alcohol solution. A tourniquet was positioned by a collaborator at the level of the proximal third of the arm. The identified vein was visualized in short axis, and then it was punctured with the needle under direct US guidance by using an
Aims The primary aim of this study was to analyze the success rate and the immediate complications in US-guided L-PVC positioning. Moreover, we evaluated the mean dwell time of the catheters, the presence of any late complications, and the factors related to those complications. Methods Design and setting This was an observational prospective study carried out in the Cardiac Surgery Unit of the University Hospital of Trieste, Italy, from January 2014 to December 2015. Population All consecutive patients 18 years old who presented with DVA and who already had one or more PVCs during hospitalization were candidates for the placement of a US-guided venous access. DVA situations were identified in the presence of patients with a lack of readily visible or palpable veins, when at least 3 IV attempts failed.6 Patients were enrolled for an L-PVC if they expected to need a peripheral venous access for up to 7e10 days.4 Patients with immediate life-threatening conditions were excluded, as well as patients needing a central venous access (e.g., need for medications not infusible peripherally, nominated for a PICC) or requiring a medium-term (up to 4 weeks) peripheral venous access (nominated for a standard midline catheter).4
Fig. 1. The catheters used in this study: a) 20G, 3Fr, 8 cm catheter; b) 18G, 4Fr, 10 cm catheter; c) 18G, 4Fr, 18 cm catheter.
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“out-of-plane” approach. Once the needle tip was visualized within the vein (Fig. 2a) and the blood flowed back through the needle (Fig. 2b), the guidewire was introduced and the needle removed (Fig. 2c). Subsequently, the catheter was moved forward into the vein over the guidewire, according to the Seldinger technique (Fig. 2d). Successful cannulation was confirmed by aspiration of blood (Fig. 2e) and by the direct US visualization of the catheter in the vessel. In the case of an unsuccessful procedure, the catheter was removed and the procedure was re-started; each needle puncture of the skin was considered a distinct attempt. A maximum of three attempts was established before giving up. At the end of the procedure, the catheter was secured with two sterile adhesive strips and the exit-site covered with a transparent semipermeable dressing (Fig. 2f).
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Catheter management recommendations After the placement of the catheter, a list of catheter management recommendations for each patient was handed to the ward nurses, according to the hospital’s policies (Table 1). In particular, we recommended avoiding routine replacement of the catheter and removing it immediately only when it was no longer needed, or if a complication occurred.4 Moreover, we recommended avoiding infusion of parenteral nutrition and vesicant drugs through the LPVC and only infusing antibiotics after appropriate dilution.23 In case of complications, before removing the catheter, the possible presence of thrombosis was evaluated sonographically by the vascular access nurse, evidenced as the incompressibility of the vessel by the US probe or as the presence of a blood clot in the vein
Fig. 2. The cannulation procedure. a) Ultrasound visualization in short axis of the needle (arrow) within the vein; b) puncture of the vein with the needle under direct US guidance (“out-of-plane” approach); c) introduction of the guidewire through the needle; d) introduction of the catheter over the guidewire; e) confirmation of the successful cannulation by aspiration of blood; f) stabilization of the catheter and dressing of the exit-site.
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Data collection
Table 1 Instructions for catheter maintenance after placement. Topics
Recommendations
Hands hygiene
Decontaminate the hands with an alcohol-based hand rub or by washing with antibacterial soap and water immediately before every contact with the device Use aseptic technique every time the device is accessed (e.g., change the exit site dressing, administer intravenous medications, flush the catheter) Use sterile barrier precautions (wearing sterile gloves, cap, and mask) for direct exit site care Inspect the exit site daily Use 2% chlorhexidine gluconate in 70% isopropyl alcohola to scrub the skin and the exit site during dressing changes Use a sterile, transparent, semi-permeable polyurethane dressing to cover the catheter exit-siteb Change the dressing every 7 days, or with shorter interval if it is damaged or if moisture is present under it Flush the line with 10 ml of saline solution using the “stop and go” technique after delivering drugs, solutions, or blood components or to lock the catheter Immediately remove the catheter when it is no longer needed or if a complicationc occurs
Aseptic technique
Aseptic barriers Exit-site care
Line maintenance
Removal a
Use povidone iodine in alcohol for patients with sensitivity to chlorhexidine. Use a sterile gauze dressing if a patient has profuse perspiration or if the exit site is bleeding, and replace it with a transparent semi-permeable dressing as soon as possible. c Complete catheter occlusion, drug leakage from the exit-site, phlebitis (see Methods for the definition). b
lumen. Patients discharged or transferred to other regional healthcare facilities with the catheter still in dwelling were monitored by the researchers in order to verify the date and the cause of catheter removal. Table 2 Main clinical and demographic characteristics of the study population. Variables
N (%)
Sex Males Females Age (years)
37 (52.1%) 34 (47.9%)
Modality of hospital admission Planned Urgent Emergency Reason for hospitalization Ischemic heart disease Valvular heart disease Valvular/ischemic heart disease Aortic dissection Atrial myxoma Main comorbidities Heart disease Diabetes mellitus Kidney disease Peripheral vascular disease Previous malignancy Cerebrovascular disease COPD Liver disease Charlson co-morbidity index (points)
Mean SD (range) Median (IQR)
73.1 9.2 (37e86) 75 (69.5e79.0) 18 (25.4%) 48 (67.6%) 5 (7.0%) 40 (56.3%) 21 (29.6%) 6 (8.5%) 3 (4.2%) 1 (1.4%)
7 2.2 (2e12) 7 (6e9) 21 (26.6%) 13 (18.3%) 13 (18.3%) 7 (9.9%)
Mortality
2 (2.8%)
Study outcomes The primary outcome of the study was the successful cannulation rate in relation to the number of attempts. The secondary outcome was the dwell time of the catheters and the reasons for their removal. First, the aggregated rate of “early removal” events was considered in order to measure the overall rate of any event resulting in unplanned catheter removal before completing the IV treatment (i.e., thrombophlebitis, infiltration, occlusion, accidental or inappropriate removal, local infection, catheter-related bloodstream infection (CR-BSI), or patient death); a similar indicator was already employed in previous studies.26,27 However, we considered as “complications” only thrombophlebitis, extravasation, occlusion, local infection, and CR-BSI, given that these conditions have been described as potentially related to the characteristics of the catheter (length and gauge), of the cannulated vein (depth and diameter), and of the positioning and management procedures.28,29 The incidences of both CR-BSIs and thrombophlebitis were also analyzed separately as a further outcome. Phlebitis, defined as the presence of two or more signs of pain, erythema, purulence, streak formation, or a palpable venous cord,30 were also analyzed according to the Visual Infusion of the Phlebitis Scale (VIPS).31 Considering the diagnostic tests available in the hospital laboratory, CR-BSI was defined according to the following criteria: 1) a positive semiquantitative culture (>15 colony-forming units-CFU/ catheter segment) whereby the same microorganism (species and antibiogram) is isolated from the catheter tip and peripheral blood; 2) a differential period of catheter culture versus a peripheral blood culture positivity of >2 h.3 Ethical considerations
69 (97.2%) 31 (43.7%) 25 (35.2%) 19 (26.8%) 13 (18.3%) 12 (17.0%) 9 (12.7%) 8 (11.3%)
Postoperative complications Infection/dehiscence of surgical wound Respiratory complications Infections, sepsis Total hospital length of stay (days)
Data concerning both the patient (gender, age, comorbidity factors potentially related to PVC complications as a history of previous thrombotic events, cancer, obesity, and diabetes)6,24 and the venous access (type, diameter and depth of the vein, and complications) were recorded. The level of general comorbid medical conditions was also calculated using the Charlson Comorbidity Index; a Charlson Index 5 indicated severe comorbidity.25 The depth of the cannulated vein was measured as the distance in millimeters between the skin surface and the middle of the vein lumen; the diameter of the vessel was measured as the distance in millimeters between its inner walls. The dwell time of the catheter was calculated, in days, as the difference between the date of the removal and the date of the placement. Each drug or fluid administered at least once through the catheter was registered.
The study was conducted according to the ethical principles stated by the Declaration of Helsinki. At hospital admission, all enrolled patients authorized the use of their clinical data for study purposes. Before surgery, the patient signed an informed consent to anesthesia, surgery, and all necessary diagnostic and therapeutic procedures, comprising any vascular access placement. Given that the placement of peripheral venous access was a routine activity for usual patient care, a formal approval from the Institutional Review Board was not required, according to the hospital authorities. Data analysis
55 56.7 (8e228) 30 (16e66)
SD: standard deviation; IQR: interquartile range; COPD: chronic obstructive pulmonary disease.
Collected data were entered into a Microsoft ExcelÒ worksheet. Statistical analysis was performed using the software IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY, US: IBM Corp.). Continuous variables (age, measurements, and time intervals) were
A. Fabiani et al. / Heart & Lung xxx (2016) 1e8
displayed as a mean standard deviation (SD), range, median, and interquartile range (IQR). Nominal variables (i.e. gender, comorbidities, type of catheter, complications, and medications) were displayed as absolute numbers and percentages and analyzed using contingency tables and the c2 test of independence. The Student’s ttest was used to analyze comparisons between means. One-way analysis of variance (ANOVA) was applied for all comparisons between the subgroups. Complication was expressed as percentages and as the relative incidence per 1000 catheter-days.32 For all tests, the accepted statistical level of significance was <0.05. Results During the study period, 128 patients showed the need for a USguided venous cannulation because of a DVA situation; in 23 cases (18%), a medium-term central venous access was required and a PICC was positioned; in 34 cases (27%), a medium-term PVC was required and a midline catheter was positioned. Finally, 71 patients (55%) were nominated for an L-PVC placement and were enrolled in the study. The main characteristics of the enrolled population are reported in Table 2. Patients were mostly males; no significant difference (p ¼ 0.185) between the male mean age (71.7 10.6) and the female mean age (74.6 7.2) was found. All patients were discharged from the Postoperative Intensive Care Unit (PICU) after receiving cardiac surgery. Three patients (4.2%) had a history of previous thrombotic events; 13 (18.3%) presented a malignancy in their clinical history; 26 (36.6%) were obese; and 31 (43.7%) presented diabetes mellitus. All enrolled patients had one or more traditional PVCs during the hospital stay (PICU and inpatient ward) and received more than one further peripheral cannulation attempt before the US-guided L-PVC positioning procedure. Three (4.2%) L-PVCs were positioned in PICU before discharge and 68 (95.8%) were positioned in the ward. Overall, the success rate of the catheter placement was 100%; in 65 cases (91.5%), the LPVC was correctly positioned at the first attempt; in 5 cases (7.0%), at the second attempt; and in 1 case (1.4%), at the third attempt. No immediate complication occurred. The most frequently implanted device was the 18G/4Fr/18 cm catheter (47; 66.2%), followed by the 18G/4Fr/10 cm catheter (15; 21.1%) and the 20G/3Fr/8 cm catheter (9; 12.7%). All catheters were positioned in the middle third of the upper arm. In 56 cases (78.9%), the basilic vein was cannulated; in 11 cases (15.5%), the brachial vein; and in 4 cases (5.6%), the cephalic vein. The average diameter of the cannulated veins was 4.6 1.2 mm (range: 1.6e7.9; median: 4.4; IQR: 4.0e5.5), while the average vein depth was 15.4 5.3 mm (range: 6.4e29.2 mm; median: 1.49; IQR: 1.17e1.90). All patients received drugs or fluids through the catheter. The more frequently administered medication was vancomycin (15 patients; 21.1%), followed by imipenem (9; 12.7%); ciprofloxacin and piperacillin/tazobactam (8; 11.3%); heparin, oliclinomel, and rifampicin (7; 9.9%); dobutamine (6; 8.5%); KCl (5; 7.0%); ceftriaxone, lysine acetylsalicylate, and meropenem (4; 5.6%); ampicillin, ceftazidime, furosemide, gentamicin, levofloxacin, and normal saline (3; 4.2%); amikacin, cefazolin, daptomycin, and levosimendan (2; 2.8%); amiodarone, amoxicillin/clavulanate, cefepime, colimycin, dopamine, fluconazole, linezolid, metronidazole, nitroglycerin, and oxacillin (1; 1.4%). Overall, the average dwell time of the catheters was 14.7 days (median 11), for a total of 1047 catheter days. The detailed reasons for the catheter removal relative to the dwell time are reported in Table 3. Most of the catheters were removed because they were no longer needed due to discontinuation of IV therapy administration. The aggregated “early removal” events rate was
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Table 3 Catheter dwell times and reasons for catheter removal. Reasons for catheter removal
Incidence N (%)
Dwell time (days) Mean SD (range) Median (IQR)
All reasons
71 (100%)
14.7 11.1 (3e55) 11 (7e19) 15.0 11.3 (5e55) 11 (6e19) 14.3 10.9 (3e49) 11 (7e16) 10.4 5.2 (3e16) 11 (6e15) 13.0 5.8 (5e21) 11 (9e20) 19.8 16.7 (4e46) 12 (11e26) 26.7 21.1 (7e49) 24 (7e49) 12.0 8.5 (6e18) 12 (6e18) 9.0 2.8 (7e11) 9 (7e11) 10 (10)
Removed at end of use
a
Early removalb Accidentally removed by patient Complete catheter occlusion
42 (59.2%) 29 (40.8%) 9 (12.7%) 7 (9.9%)
Patent catheter, drug leakage from the exit-site Inappropriately removedc
5 (7.0%)
Patient death
2 (2.8%)
Thrombophlebitis
2 (2.8%)
CR-BSI
1 (1.4%)
3 (4.2%)
SD: standard deviation; CR-BSI: catheter-related bloodstream infection. a Patent catheter but no longer clinically needed. b Unplanned catheter removal before completing the intravenous treatment. c Immediately removed due to the onset of low-grade fever (37.3e37.5 C), with neither shiver, nor signs of phlebitis; no microorganism isolated from the catheter tip and peripheral blood.
40.8%, corresponding to 27.7 cases for 1000 catheter-days. Fifteen (21.1%) catheters were removed early due to the occurrence of complications and 14 (19.7%) were removed early despite the presence of a well-functioning catheter (e.g. patient death, accidental removal, inappropriate or unnecessary removal). The cumulative rate of occlusions and thrombophlebitis was 12.7%. Among the considered conditions, only a history of previous deep venous thrombosis was significantly related to the occurrence of complications (Table 4). The complications were significantly related also to the infusion of the following medications: ciprofloxacin (p ¼ 0.009), ceftriaxone (p ¼ 0.028), rifampicin (p ¼ 0.032), and daptomycin (p ¼ 0.042). Three catheters were removed as a result of a CR-BSI or a thrombophlebitis. A single patient experienced a CR-BSI. This patient presented a small erythema (about 1 cm in diameter) around the exit site (VIPS 1) associated with the presence of a fever with shiver. No blood sample was withdrawable by the catheter, so a blood culture from the femoral vein was obtained and a culture of the catheter tip was made. The blood culture detected a Proteus mirabilis, whereas the culture of the tip isolated rare CFUs of the same microorganism. Due to the above limitation, the differential positivization time was not determined. The infection was treated effectively with a short course of antibiotics. The incidence of CRBSI was 1.4%, corresponding to 0.96 cases for 1000 catheter-days. Two cases of symptomatic thrombophlebitis (one with a VIPS of 1 and the other with a VIPS of 3) were found. The incidence of thrombophlebitis was 2.8%, corresponding to 1.9 cases for 1000 catheter-days. In the cases of complication, before removing the catheter, a compressive US-scan of the cannulated vessel was conducted, except for the single case of CR-BSI, where the US scan was not performed due to the temporary unavailability of a vascular access nurse. Among the 14 remaining patients, thrombosis was found in 10 cases (71.4%). In all cases, the lumen of the vein was explored up to the end of the axillary vein, without finding any further thrombus. No systemic complication related to the thrombosis was observed.
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Table 4 Variables related to the occurrence of complications. Variables Age Gender Vein
Diameter of the vein Depth of the vein Catheter
No. of attempts Dwell time (days) Prev. thrombosis Cancer Obesity Diabetes
Complications/ total N (%) Complications No complications Female Male Basilic Brachial Cephalic Complications No complications Complications No complications 20G/3Fr/8 cm catheter 18G/4Fr/10 cm catheter 18G/4Fr/18 cm catheter 1 2e3 Complications No complications No Yes No Yes No Yes No Yes
Mean SD
p-Value
73.7 7.8 73.0 9.6
0.797b
5/34 (14.7%) 10/37 (27.0%) 12/56 (21.4%) 2/11 (18.2%) 1/4 (25.0%)
0.204a 0.953a
0.45 0.47 1.56 1.54
0.13 0.12 0.62 0.51
1/9 (11.1%)
0.570b 0.867b 0.121a
6/15 (40.0%) 8/47 (17.0%) 0.627a
14/65 (21.5%) 1/5 (20.0%) 14.5 10.6 14.8 11.3 13/68 (19.1%) 2/3 (66.7%) 12/58 (20.7%) 3/13 (21.1%) 9/45 (20.0%) 6/26 (23.1%) 9/40 (22.5%) 6/31 (19.4%)
0.934b 0.048a 0.849a 0.760a 0.747a
SD: standard deviation, bold: statistically significant. a c2 test. b Student’s t-test.
Discussion In a population of DVA patients, a peripheral vascular access was ensured by inserting an L-PVC under US guidance into deep-arm veins, with a 100% success rate and without any immediate complications. The cannulation success rate seems to be similar to previous studies, ranging from 84% to 100%.18e22 The reasons for this study’s good result are probably multifactorial. The catheters were positioned by highly skilled specialist nurses, with advanced training in venous access management and extensive clinical experience in US-guided positioning of PICCs, standard midline and peripheral catheters. Moreover, the high success rates and the low immediate complication rates were probably also related to the advantages of using the direct Seldinger technique to position the L-PVCs. It should be noted that we enrolled a population of particularly critical and aged DVA patients with severe multiple co-morbidities, that had primarily undergone to surgery in urgent or emergency situations, and with a high rate of post-operative complications. These facts were associated with a length of hospital stay much longer than the median stay for patients in the cardiac surgery department (corresponding to 10 days) and the need to continue IV therapies for a long period of time. The catheters were left in place as long as needed, without any time limit, unless an “early removal” situation occurred; this strategy has proven to be safe and useful in reducing the nursing workload and costs, as well as in reducing patients’ discomfort related to multiple punctures.26,33e35 To our knowledge, only one other study analyzed L-PVCs without establishing a maximum dwell time, reporting an average lifetime of 6.2 (median 5) days.21 Other authors reported for L-PVCs a median lifetime of 120 and 719 days, whereas in a further study,18
in which most catheters were electively removed after 7e8 days, for catheters removed prematurely the mean duration was 2.3 days. The aggregated “early removal” event rate was 27.7/1000 catheter-days; previous studies, considering traditional short PVCs with no planned routinely replacement, reported an “early removal” events rate ranging from 6826 to 87/1000 catheter-days.27 It is well known that the presence of any intravascular device may induce the risk of complications, among which thrombophlebitis and CR-BSI are clinically significant. Thrombophlebitis is a relatively frequent complication associated with PVCs; its incidence is reported with extremely variable data (0.1e70%),36 depending on the adopted diagnostic procedures and the studied populations. The risk of thrombophlebitis is associated with the catheter dwell time, material and size, type of infusion (hypertonic solutions, intravenous antibiotics, or chemotherapeutic agents), and catheter-related infections.36 In the present study, when a complication occurred, a thrombosis was sonographically detected in more than 70% of the cases. Interestingly, in both cases of phlebitis, the thrombus was localized within the lumen occupied by the catheter, whereas in 5 out of 7 complete obstruction cases and in 3 out of 5 leakage cases, the thrombus was located only at the level of the catheter tip, and the patients were asymptomatic. These findings were similar to the results reported in other studies that systematically evaluated the vessel through compressive US examination before removing the L-PVCs. One such study19 reported that even if no patient developed symptomatic thrombophlebitis, in 4 cases a mobile thrombus hanging at the catheter tip without involving the vein wall was observed. Another study21 found a 20.9% thrombosis rate (34.6/1000 catheter-days), most of which were pericatheters; slightly over half the cases resulted in catheter occlusion or thrombophlebitis. Thus, it is probable that the formation of a thrombus within the vein accompanies and often precedes the development of the characteristic clinical signs and symptoms.36 Given this low correlation between the presence of thrombus and symptoms or complications, the L-PVC should be monitored in order to detect thrombus formation early.19 Previous studies reported a 7%19 and 11.4%21 rate for occlusions and thrombophlebitis, respectively, when considered together, whereas other studies18,20 reported no such complications. Unfortunately, the cited studies did not report the incidence as a number per 1000 catheter-days, so it is difficult to compare those findings with our data without considering the incidence of the complications in light of the different catheter dwell times. Moreover, a comparison of the results should also consider the kind of enrolled populations; indeed, some studies considered only Emergency Department patients18,20 while others19,21dsuch as the present studydenrolled patients who were already hospitalized and had already undergone multiple venipunctures or previous peripheral cannulations before considering the US-guided L-PVC positioning. Very few studies analyzed the incidence of CR-BSI related to PVCs. Current available data suggest incidence rates for CR-BSI ranging from 0.2 to 0.7/1000 catheter-days for PVCs, 0.2 for midline catheters, 1.7 for arterial catheters used for hemodynamic monitoring, and up to 2.1 for PICCs implanted in inpatients.2 In our study, a single case of CR-BSI occurred. A more detailed analysis of the management of this catheter showed that the infusions were discontinued 4 days after catheter placement because no medication was prescribed any longer, and a saline lock was adopted to keep the catheter patency; 6 days later, a nurse flushed the line with 10 ml of saline solution, and after a few minutes, the patient experienced the symptoms described in the paragraph reporting the results. We hypothesize that this catheter was not managed according to the recommendations, given the fact that it was not promptly removed when no longer needed.
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The complications were shown to be related neither to the characteristics of the catheter (length and gauge), nor to the cannulated vein (depth, caliber, and number of attempts), nor to the catheter dwell time. Instead, the complications were discovered to be related to a history of previous thrombotic events and to the infusion of four antibiotics. Only a few evidences can be obtained from the literature about the medications that had an infusion that contraindicated in a peripheral venous access. A literature review37 showed that no well-conducted human outcome study suggests that a pH solution, in and of itself, causes phlebitis, whereas there are numerous studies demonstrating that thrombophlebitis can be related to multiple other factors (e.g., anatomic location, gender, experience of the operators, etc.). Accordingly, the more recently published guidelines recommend the avoidance of using peripheral catheters only for continuous vesicant therapy, parenteral nutrition, or infusions with an osmolality greater than 900 mOsm/L.38 Up until now, no consensus exists about the best material to use for catheters.19 All vascular access devices are associated with both risks and benefits; therefore, the choice of the catheter to be used for a patient should be based on the assumption that it is effective for delivering the necessary treatment and that the benefits outweigh the potential risks.23 To our knowledge, this is the first study in which a polyethylene catheter was employed and evaluated for prolonged deep-arm veins cannulation, whereas other authors adopted polyurethane devices18e22; even considering the already emphasized differences between the studies, our results are encouraging and in line with previous cited reports.
7
of midline catheters in patients who require a PVC for short-term intravenous therapy. However, a CR-BSI rate of nearly 1 case for 1000 catheter-days was found. The impression resulting from our study is that a more careful catheter management in the days after the placement could further limit the complications and the cases of “early removal.” We recommend that these L-PVCs be considered and managed as midline catheters, thus adopting specific “bundles” aimed to achieve a higher level of safety for patients. Moreover, a systematic and planned US monitoring of the catheters could allow an early interception and treatment of the occurrence of thrombotic events. Further larger studies are needed in order to better analyze the risks and benefits of prolonged deep-arm vein infusion through an L-PVC; an important aspect to investigate is the followup of the catheter after proper positioning, possibly including extensive information on the medications infused through the catheter. Acknowledgements The authors thank the whole staff of the Cardiac Surgery Unit of Trieste, and in particular Dr. Aniello Pappalardo, MD, Head of Cardiac Surgery Unit, Mrs. Marisa Sacilotto, RN, Nurse Coordinator of Cardiac Surgery Intensive Care Unit, and Mrs. Antonella Franovich, RN, Nurse Coordinator of the Cardiac Surgery Inpatient Unit, for their valuable support. Special thanks are due to Dr. Lucio Petronio, MD, and to Dr. Maja Tenze, RN, “Casa di cura Pineta del Carso”, for their collaboration.
Limitations References This study has some limitations. First, we recruited a convenience sample of consecutively admitted DVA patients, without apriori calculation of the sample size; this issue may have influenced the results of the study. Second, it was not possible to determine with certainty if the catheter management was carried out according to the recommendations given to the nurses. This fact may have affected the rate of some “early removal” events and thus reduced the average lifetime of the catheters. Third, even though data about infused fluids and medications were collected regularly, we considered neither the specific endurance of each treatment, nor the possible simultaneity of the administrations; for these reasons, the results concerning the relationship between the infused drugs and the complications should be considered with caution. Finally, the US evaluation of the catheters was carried out only in the presence of a complication, so that the real rate of asymptomatic thrombosis was undetermined and most likely underestimated. Conclusions The US-guided cannulation of deep-arm veins represents a valid solution to ensure a peripheral venous access in DVA patients who have already undergone previous PVC attempts. Our data demonstrated a 100% success rate in catheter placement with no immediate complications, and an aggregated “early removal” events rate lower than previously published studies on short PVCs. The long lifetime of the studied L-PVC may reduce the need for frequent catheter replacements, also decreasing patient discomfort and the nursing workload. Our findings appear worth immediate translation into clinical practice; the adoption of US-guided L-PVCs in DVA situations should be considered early, sparing to the patient multiple, painful and often useless attempts. This option may offer an alternative to CVCs or PICCs in DVA patients who do not require a central venous access, and it can also reduce an inappropriate use
1. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated problem. Int J Antimicrob Agents. 2009;34(suppl 4):S38eS42. 2. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159e1171. 3. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 suppl 1):S1eS34. 4. Loveday HP, Wilson JA, Pratt RJ, et al. Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86(suppl 1):S1eS70. 5. Jacobson AF, Winslow EH. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions. Heart Lung. 2005;34(5):345e359. 6. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED patients. Am J Emerg Med. 2014;32(10):1179e1182. 7. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123e1133. 8. Robinson MK, Mogensen KM, Grudinskas GF, et al. Improved care and reduced costs for patients requiring peripherally inserted central catheters: the role of bedside ultrasound and a dedicated team. JPEN J Parenter Enter Nutr. 2005;29(5):374e379. 9. Au AK, Rotte MJ, Grzybowski RJ, et al. Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. Am J Emerg Med. 2012;30(9):1950e1954. 10. Gregg SC, Murthi SB, Sisley AC, et al. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care. 2010;25(3):514e519. 11. Egan G, Healy D, O’Neill H, et al. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J. 2013;30(7): 521e526. 12. Stolz LA, Stolz U, Howe C, et al. Ultrasound-guided peripheral venous access: a meta-analysis and systematic review. J Vasc Access. 2015;16(4):321e326. 13. Dargin JM, Rebholz CM, Lowenstein RA, et al. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1e7. 14. Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005;46(5):456e461. 15. Keyes LE, Frazee BW, Snoey ER, et al. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999;34(6):711e714. 16. Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105e1117.
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17. Gallant P, Schultz AA. Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. J Infus Nurs. 2006;29(6):338e345. 18. Scoppettuolo G, Pittiruti M, Pitoni S, et al. Ultrasound-guided “short” midline catheters for difficult venous access in the emergency department: a retrospective analysis. Int J Emerg Med. 2016;9(1):3. 19. Meyer P, Cronier P, Rousseau H, et al. Difficult peripheral venous access: clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance. J Crit Care. 2014;29(5):823e827. 20. Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. 2007;50(1):68e72. 21. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 2012;30(5): 712e716. 22. Stone BA. Ultrasound guidance for peripheral venous access: a simplified Seldinger technique. Anesthesiology. 2007;106(1):195. 23. Moureau NL. Is the pH of vancomycin an indication for central venous access? J Vasc Access. 2014;15(4):249e250. 24. Sebbane M, Claret PG, Lefebvre S, et al. Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility. J Emerg Med. 2013;44(2):299e305. 25. Charlson ME, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245e1251. 26. Rickard CM, McCann D, Munnings J, McGrail MR. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Med. 2010;8:53. 27. Van Donk P, Rickard CM, McGrail MR, Doolan G. Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: a randomized controlled trial. Infect Control Hosp Epidemiol. 2009;30(9):915e917.
28. Panebianco NL, Fredette JM, Szyld D, et al. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. 2009;16(12):1298e1303. 29. Witting MD, Schenkel SM, Lawner BJ, Euerle BD. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. J Emerg Med. 2010;39(1):70e75. 30. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med. 1991;114(10):845e854. 31. Jackson A. Infection control e a battle in vein: infusion phlebitis. Nurs Times. 1998;94(4):68. 71. 32. Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare Safety Network report, data summary for 2011, device-associated module. Am J Infect Control. Apr 2013;41(4):286e300. 33. Morrison K, Holt KE. The effectiveness of clinically indicated replacement of peripheral intravenous catheters: an evidence review with implications for clinical practice. Worldviews Evid Based Nurs. 2015;12(4):187e198. 34. Bolton D. Clinically indicated replacement of peripheral cannulas. Br J Nurs. 2015;24(19):S4eS12. 35. Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2015;8:CD007798. 36. Di Nisio M, Peinemann F, Porreca E, Rutjes AW. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev. 2015;11:CD011015. 37. Caparas JV, Hu JP. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. J Vasc Access. JuleAug 2014;15(4):251e256. 38. Gorski L, Hadaway L, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):159.
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Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery Adam Fabiani, RN a, Lorella Dreas, MD a, Gianfranco Sanson, RN, MSN b, c, * a
Cardiac Surgery Intensive Care Unit, Azienda Sanitaria Universitaria Integrata, Strada di Fiume 447, 34148, Trieste, Italy School of Nursing, University of Trieste, Piazzale Valmaura 9, 34147, Trieste, Italy c Azienda Sanitaria Universitaria Integrata, Strada di Fiume 447, 34148, Trieste, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 May 2016 Received in revised form 23 September 2016 Accepted 28 September 2016 Available online xxx
Objectives: To analyze success rate, dwell-time, and complications of long peripheral venous catheters (L-PVCs) inserted under ultrasound guidance. Background: In difficult venous access (DVA) patients, L-PVC can represent an alternative to central or midline catheters. Methods: Prospective observational study. L-PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. Results: A 100% placement success rate was documented. The catheter dwell-time was 14.7 11.1 days. Most catheters were removed at end-use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter-days. Two thrombophlebitis (1.91/1000 catheter-days) and 1 catheter-related bloodstream infection (0.96/1000 catheter-days) occurred. Conclusions: L-PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients’ discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications. Ó 2016 Elsevier Inc. All rights reserved.
Keywords: Difficult venous access Peripheral venous catheterization Nursing Ultrasonography Complications
Introduction Positioning a peripheral venous catheter (PVC) is the most common invasive practice in acute care hospitals, involving up to 70% of patients.1 The use of a PVC is rarely associated with a bloodstream infection,2 and one of the most common complications in cases of prolonged use is phlebitis,3 with a reported incidence of 7e27%.4 The opportunity to position a PVC is limited to superficial veins lying close enough to the skin to be visible or at
Abbreviations: PVC, peripheral venous catheter; DVA, difficult venous access; CVC, central venous catheter; US, ultrasound; PICC, peripherally inserted central catheter; L-PVC, long peripheral venous catheter; APIC, advanced peripheral insertion and management of catheters team; IV, intravenous; CR-BSI, catheterrelated bloodstream infection; VIPS, visual infusion of the phlebitis scale; CFU, colony-forming units; SD, standard deviation; IQR, interquartile range. Conflict of interest: The authors declared no conflict of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author. School of Nursing, University of Trieste, Piazzale Valmaura 9, 34147, Trieste, Italy. E-mail address: [email protected] (G. Sanson). 0147-9563/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2016.09.003
least palpable. For this reason, sometime the peripheral venous cannulation may be challenging, with a failure rate that can reach 25%.5 This condition is known as difficult venous access (DVA), a clinical condition in which multiple peripheral intravenous attempts failed, due to a lack of readily visible or palpable veins.6 In these cases, a central venous catheter (CVC) might be chosen as an alternative, even if this option is related to the risk of immediate or delayed complications, resulting in significant morbidity and mortality.7 Ultrasound (US)-guided insertion of midline catheters or peripherally inserted central catheters (PICCs) should be an alternative, but are indicated for medium-term access (from a few weeks to a few months),4 and are more expensive.8 However, the US guide can also be used to place a PVC in deeper vessels not recognizable through inspection or physical examination.9,10 Two meta-analyses showed that the use of US by physicians, nurses, or emergency technicians increased success rates of peripheral venous cannulation both in adult and pediatric DVA populations when compared with traditional techniques.11,12 Unfortunately, the conventional PVCs are short (<5 cm), since they are designed to be inserted into superficial veins. Consequently, a high likelihood of complications (e.g. extravasation or displacement)
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and a shorter dwell time are easily predictable when a conventional PVC is placed in deeper vessels13e16; the need to relocate the PVC because of a complication increases the risk of phlebitis by 4.4 times.17 Therefore, when a peripheral access was needed in DVA patients, the only effective choice was the US-guided insertion of a midline catheter, even if a short-term intravenous (IV) therapy was planned. To overcome these limitations, the use of longer (8e15 cm) PVCs with integrated guide wire (L-PVC) has been explored. These kinds of devices have also been called “short midlines,” “long peripheral cannulas,” or even considered to be “midlines”, indiscriminately,18 since they combine some features of traditional short peripheral catheters (reduced time of positioning, low risk of complication) with the features of standard midlines (more biocompatible materials, considerable length, potentially longer dwell time). However, L-PVCs differ from the standard midlines not because of their length, but primarily because of the procedure used to insert them. L-PVCs are inserted via a faster “direct” Seldinger technique (direct insertion of the catheter through the guide wire), while the standard midline catheters require a more complex and longer “modified” Seldinger technique (catheter positioned via a micro introducer previously introduced through the guide wire). Moreover, L-PVCs are less expensive; their price is almost one-sixth of the price of a standard midline catheter. The few available studies on L-PVCs report an overall high success rate and a low frequency of complication events,19e22 significantly lower when compared with traditional short PVCs.21 However, these studies evaluated different DVA populations, using different catheters and considering different outcome measures, so that the risk and benefit ratio of prolonged deep-arm vein infusion after L-PVC placement is still undetermined.19
Characteristics of the catheters and placement procedure Polyethylene catheters (Leader-CathÒ, Vygon, France), commercialized for both arterial and central or peripheral venous cannulation, were employed. The catheters were available in the following measures (internal area, external diameter, length): 1) 20G, 3Fr, 8 cm catheter (Fig. 1a); 2) 18G, 4Fr, 10 cm catheter (Fig. 1b); 3) 18G, 4Fr, 18 cm catheter (Fig. 1c). Each catheter was packed together with a dedicated steel needle and a straight tip guide wire. All procedures were carried out by a nurse, specialized in vascular access and member of the “Advanced Peripheral Insertion and management of Catheters (APIC)” team. The catheters were inserted through the Seldinger technique under US guidance; a Philips HD11XE ultrasound device, revision 2.0.4 (Philips ultrasound, Andover, MA, USA) with an L 12-3 linear transducer, was also used. The patient was placed in a supine position, placing her/ his upper arm in abduction with an external rotation of the shoulder. A preliminary US examination of the veins of the upper arm was done, in order to identify the most suitable vessel to cannulate; the measure of the catheter to be placed was determined according to both the caliber and the anatomical straight course of the selected vein. Nerves and the brachial artery were also identified before proceeding with the cannulation. For each procedure, the following aseptic barriers were adopted: a surgical mask, sterile drape, sterile transducer cover, and sterile ultrasound gel and sterile gloves. A wide skin surface around the puncture site was scrubbed with 2% chlorhexidine in a 70% alcohol solution. A tourniquet was positioned by a collaborator at the level of the proximal third of the arm. The identified vein was visualized in short axis, and then it was punctured with the needle under direct US guidance by using an
Aims The primary aim of this study was to analyze the success rate and the immediate complications in US-guided L-PVC positioning. Moreover, we evaluated the mean dwell time of the catheters, the presence of any late complications, and the factors related to those complications. Methods Design and setting This was an observational prospective study carried out in the Cardiac Surgery Unit of the University Hospital of Trieste, Italy, from January 2014 to December 2015. Population All consecutive patients 18 years old who presented with DVA and who already had one or more PVCs during hospitalization were candidates for the placement of a US-guided venous access. DVA situations were identified in the presence of patients with a lack of readily visible or palpable veins, when at least 3 IV attempts failed.6 Patients were enrolled for an L-PVC if they expected to need a peripheral venous access for up to 7e10 days.4 Patients with immediate life-threatening conditions were excluded, as well as patients needing a central venous access (e.g., need for medications not infusible peripherally, nominated for a PICC) or requiring a medium-term (up to 4 weeks) peripheral venous access (nominated for a standard midline catheter).4
Fig. 1. The catheters used in this study: a) 20G, 3Fr, 8 cm catheter; b) 18G, 4Fr, 10 cm catheter; c) 18G, 4Fr, 18 cm catheter.
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“out-of-plane” approach. Once the needle tip was visualized within the vein (Fig. 2a) and the blood flowed back through the needle (Fig. 2b), the guidewire was introduced and the needle removed (Fig. 2c). Subsequently, the catheter was moved forward into the vein over the guidewire, according to the Seldinger technique (Fig. 2d). Successful cannulation was confirmed by aspiration of blood (Fig. 2e) and by the direct US visualization of the catheter in the vessel. In the case of an unsuccessful procedure, the catheter was removed and the procedure was re-started; each needle puncture of the skin was considered a distinct attempt. A maximum of three attempts was established before giving up. At the end of the procedure, the catheter was secured with two sterile adhesive strips and the exit-site covered with a transparent semipermeable dressing (Fig. 2f).
3
Catheter management recommendations After the placement of the catheter, a list of catheter management recommendations for each patient was handed to the ward nurses, according to the hospital’s policies (Table 1). In particular, we recommended avoiding routine replacement of the catheter and removing it immediately only when it was no longer needed, or if a complication occurred.4 Moreover, we recommended avoiding infusion of parenteral nutrition and vesicant drugs through the LPVC and only infusing antibiotics after appropriate dilution.23 In case of complications, before removing the catheter, the possible presence of thrombosis was evaluated sonographically by the vascular access nurse, evidenced as the incompressibility of the vessel by the US probe or as the presence of a blood clot in the vein
Fig. 2. The cannulation procedure. a) Ultrasound visualization in short axis of the needle (arrow) within the vein; b) puncture of the vein with the needle under direct US guidance (“out-of-plane” approach); c) introduction of the guidewire through the needle; d) introduction of the catheter over the guidewire; e) confirmation of the successful cannulation by aspiration of blood; f) stabilization of the catheter and dressing of the exit-site.
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Data collection
Table 1 Instructions for catheter maintenance after placement. Topics
Recommendations
Hands hygiene
Decontaminate the hands with an alcohol-based hand rub or by washing with antibacterial soap and water immediately before every contact with the device Use aseptic technique every time the device is accessed (e.g., change the exit site dressing, administer intravenous medications, flush the catheter) Use sterile barrier precautions (wearing sterile gloves, cap, and mask) for direct exit site care Inspect the exit site daily Use 2% chlorhexidine gluconate in 70% isopropyl alcohola to scrub the skin and the exit site during dressing changes Use a sterile, transparent, semi-permeable polyurethane dressing to cover the catheter exit-siteb Change the dressing every 7 days, or with shorter interval if it is damaged or if moisture is present under it Flush the line with 10 ml of saline solution using the “stop and go” technique after delivering drugs, solutions, or blood components or to lock the catheter Immediately remove the catheter when it is no longer needed or if a complicationc occurs
Aseptic technique
Aseptic barriers Exit-site care
Line maintenance
Removal a
Use povidone iodine in alcohol for patients with sensitivity to chlorhexidine. Use a sterile gauze dressing if a patient has profuse perspiration or if the exit site is bleeding, and replace it with a transparent semi-permeable dressing as soon as possible. c Complete catheter occlusion, drug leakage from the exit-site, phlebitis (see Methods for the definition). b
lumen. Patients discharged or transferred to other regional healthcare facilities with the catheter still in dwelling were monitored by the researchers in order to verify the date and the cause of catheter removal. Table 2 Main clinical and demographic characteristics of the study population. Variables
N (%)
Sex Males Females Age (years)
37 (52.1%) 34 (47.9%)
Modality of hospital admission Planned Urgent Emergency Reason for hospitalization Ischemic heart disease Valvular heart disease Valvular/ischemic heart disease Aortic dissection Atrial myxoma Main comorbidities Heart disease Diabetes mellitus Kidney disease Peripheral vascular disease Previous malignancy Cerebrovascular disease COPD Liver disease Charlson co-morbidity index (points)
Mean SD (range) Median (IQR)
73.1 9.2 (37e86) 75 (69.5e79.0) 18 (25.4%) 48 (67.6%) 5 (7.0%) 40 (56.3%) 21 (29.6%) 6 (8.5%) 3 (4.2%) 1 (1.4%)
7 2.2 (2e12) 7 (6e9) 21 (26.6%) 13 (18.3%) 13 (18.3%) 7 (9.9%)
Mortality
2 (2.8%)
Study outcomes The primary outcome of the study was the successful cannulation rate in relation to the number of attempts. The secondary outcome was the dwell time of the catheters and the reasons for their removal. First, the aggregated rate of “early removal” events was considered in order to measure the overall rate of any event resulting in unplanned catheter removal before completing the IV treatment (i.e., thrombophlebitis, infiltration, occlusion, accidental or inappropriate removal, local infection, catheter-related bloodstream infection (CR-BSI), or patient death); a similar indicator was already employed in previous studies.26,27 However, we considered as “complications” only thrombophlebitis, extravasation, occlusion, local infection, and CR-BSI, given that these conditions have been described as potentially related to the characteristics of the catheter (length and gauge), of the cannulated vein (depth and diameter), and of the positioning and management procedures.28,29 The incidences of both CR-BSIs and thrombophlebitis were also analyzed separately as a further outcome. Phlebitis, defined as the presence of two or more signs of pain, erythema, purulence, streak formation, or a palpable venous cord,30 were also analyzed according to the Visual Infusion of the Phlebitis Scale (VIPS).31 Considering the diagnostic tests available in the hospital laboratory, CR-BSI was defined according to the following criteria: 1) a positive semiquantitative culture (>15 colony-forming units-CFU/ catheter segment) whereby the same microorganism (species and antibiogram) is isolated from the catheter tip and peripheral blood; 2) a differential period of catheter culture versus a peripheral blood culture positivity of >2 h.3 Ethical considerations
69 (97.2%) 31 (43.7%) 25 (35.2%) 19 (26.8%) 13 (18.3%) 12 (17.0%) 9 (12.7%) 8 (11.3%)
Postoperative complications Infection/dehiscence of surgical wound Respiratory complications Infections, sepsis Total hospital length of stay (days)
Data concerning both the patient (gender, age, comorbidity factors potentially related to PVC complications as a history of previous thrombotic events, cancer, obesity, and diabetes)6,24 and the venous access (type, diameter and depth of the vein, and complications) were recorded. The level of general comorbid medical conditions was also calculated using the Charlson Comorbidity Index; a Charlson Index 5 indicated severe comorbidity.25 The depth of the cannulated vein was measured as the distance in millimeters between the skin surface and the middle of the vein lumen; the diameter of the vessel was measured as the distance in millimeters between its inner walls. The dwell time of the catheter was calculated, in days, as the difference between the date of the removal and the date of the placement. Each drug or fluid administered at least once through the catheter was registered.
The study was conducted according to the ethical principles stated by the Declaration of Helsinki. At hospital admission, all enrolled patients authorized the use of their clinical data for study purposes. Before surgery, the patient signed an informed consent to anesthesia, surgery, and all necessary diagnostic and therapeutic procedures, comprising any vascular access placement. Given that the placement of peripheral venous access was a routine activity for usual patient care, a formal approval from the Institutional Review Board was not required, according to the hospital authorities. Data analysis
55 56.7 (8e228) 30 (16e66)
SD: standard deviation; IQR: interquartile range; COPD: chronic obstructive pulmonary disease.
Collected data were entered into a Microsoft ExcelÒ worksheet. Statistical analysis was performed using the software IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY, US: IBM Corp.). Continuous variables (age, measurements, and time intervals) were
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displayed as a mean standard deviation (SD), range, median, and interquartile range (IQR). Nominal variables (i.e. gender, comorbidities, type of catheter, complications, and medications) were displayed as absolute numbers and percentages and analyzed using contingency tables and the c2 test of independence. The Student’s ttest was used to analyze comparisons between means. One-way analysis of variance (ANOVA) was applied for all comparisons between the subgroups. Complication was expressed as percentages and as the relative incidence per 1000 catheter-days.32 For all tests, the accepted statistical level of significance was <0.05. Results During the study period, 128 patients showed the need for a USguided venous cannulation because of a DVA situation; in 23 cases (18%), a medium-term central venous access was required and a PICC was positioned; in 34 cases (27%), a medium-term PVC was required and a midline catheter was positioned. Finally, 71 patients (55%) were nominated for an L-PVC placement and were enrolled in the study. The main characteristics of the enrolled population are reported in Table 2. Patients were mostly males; no significant difference (p ¼ 0.185) between the male mean age (71.7 10.6) and the female mean age (74.6 7.2) was found. All patients were discharged from the Postoperative Intensive Care Unit (PICU) after receiving cardiac surgery. Three patients (4.2%) had a history of previous thrombotic events; 13 (18.3%) presented a malignancy in their clinical history; 26 (36.6%) were obese; and 31 (43.7%) presented diabetes mellitus. All enrolled patients had one or more traditional PVCs during the hospital stay (PICU and inpatient ward) and received more than one further peripheral cannulation attempt before the US-guided L-PVC positioning procedure. Three (4.2%) L-PVCs were positioned in PICU before discharge and 68 (95.8%) were positioned in the ward. Overall, the success rate of the catheter placement was 100%; in 65 cases (91.5%), the LPVC was correctly positioned at the first attempt; in 5 cases (7.0%), at the second attempt; and in 1 case (1.4%), at the third attempt. No immediate complication occurred. The most frequently implanted device was the 18G/4Fr/18 cm catheter (47; 66.2%), followed by the 18G/4Fr/10 cm catheter (15; 21.1%) and the 20G/3Fr/8 cm catheter (9; 12.7%). All catheters were positioned in the middle third of the upper arm. In 56 cases (78.9%), the basilic vein was cannulated; in 11 cases (15.5%), the brachial vein; and in 4 cases (5.6%), the cephalic vein. The average diameter of the cannulated veins was 4.6 1.2 mm (range: 1.6e7.9; median: 4.4; IQR: 4.0e5.5), while the average vein depth was 15.4 5.3 mm (range: 6.4e29.2 mm; median: 1.49; IQR: 1.17e1.90). All patients received drugs or fluids through the catheter. The more frequently administered medication was vancomycin (15 patients; 21.1%), followed by imipenem (9; 12.7%); ciprofloxacin and piperacillin/tazobactam (8; 11.3%); heparin, oliclinomel, and rifampicin (7; 9.9%); dobutamine (6; 8.5%); KCl (5; 7.0%); ceftriaxone, lysine acetylsalicylate, and meropenem (4; 5.6%); ampicillin, ceftazidime, furosemide, gentamicin, levofloxacin, and normal saline (3; 4.2%); amikacin, cefazolin, daptomycin, and levosimendan (2; 2.8%); amiodarone, amoxicillin/clavulanate, cefepime, colimycin, dopamine, fluconazole, linezolid, metronidazole, nitroglycerin, and oxacillin (1; 1.4%). Overall, the average dwell time of the catheters was 14.7 days (median 11), for a total of 1047 catheter days. The detailed reasons for the catheter removal relative to the dwell time are reported in Table 3. Most of the catheters were removed because they were no longer needed due to discontinuation of IV therapy administration. The aggregated “early removal” events rate was
5
Table 3 Catheter dwell times and reasons for catheter removal. Reasons for catheter removal
Incidence N (%)
Dwell time (days) Mean SD (range) Median (IQR)
All reasons
71 (100%)
14.7 11.1 (3e55) 11 (7e19) 15.0 11.3 (5e55) 11 (6e19) 14.3 10.9 (3e49) 11 (7e16) 10.4 5.2 (3e16) 11 (6e15) 13.0 5.8 (5e21) 11 (9e20) 19.8 16.7 (4e46) 12 (11e26) 26.7 21.1 (7e49) 24 (7e49) 12.0 8.5 (6e18) 12 (6e18) 9.0 2.8 (7e11) 9 (7e11) 10 (10)
Removed at end of use
a
Early removalb Accidentally removed by patient Complete catheter occlusion
42 (59.2%) 29 (40.8%) 9 (12.7%) 7 (9.9%)
Patent catheter, drug leakage from the exit-site Inappropriately removedc
5 (7.0%)
Patient death
2 (2.8%)
Thrombophlebitis
2 (2.8%)
CR-BSI
1 (1.4%)
3 (4.2%)
SD: standard deviation; CR-BSI: catheter-related bloodstream infection. a Patent catheter but no longer clinically needed. b Unplanned catheter removal before completing the intravenous treatment. c Immediately removed due to the onset of low-grade fever (37.3e37.5 C), with neither shiver, nor signs of phlebitis; no microorganism isolated from the catheter tip and peripheral blood.
40.8%, corresponding to 27.7 cases for 1000 catheter-days. Fifteen (21.1%) catheters were removed early due to the occurrence of complications and 14 (19.7%) were removed early despite the presence of a well-functioning catheter (e.g. patient death, accidental removal, inappropriate or unnecessary removal). The cumulative rate of occlusions and thrombophlebitis was 12.7%. Among the considered conditions, only a history of previous deep venous thrombosis was significantly related to the occurrence of complications (Table 4). The complications were significantly related also to the infusion of the following medications: ciprofloxacin (p ¼ 0.009), ceftriaxone (p ¼ 0.028), rifampicin (p ¼ 0.032), and daptomycin (p ¼ 0.042). Three catheters were removed as a result of a CR-BSI or a thrombophlebitis. A single patient experienced a CR-BSI. This patient presented a small erythema (about 1 cm in diameter) around the exit site (VIPS 1) associated with the presence of a fever with shiver. No blood sample was withdrawable by the catheter, so a blood culture from the femoral vein was obtained and a culture of the catheter tip was made. The blood culture detected a Proteus mirabilis, whereas the culture of the tip isolated rare CFUs of the same microorganism. Due to the above limitation, the differential positivization time was not determined. The infection was treated effectively with a short course of antibiotics. The incidence of CRBSI was 1.4%, corresponding to 0.96 cases for 1000 catheter-days. Two cases of symptomatic thrombophlebitis (one with a VIPS of 1 and the other with a VIPS of 3) were found. The incidence of thrombophlebitis was 2.8%, corresponding to 1.9 cases for 1000 catheter-days. In the cases of complication, before removing the catheter, a compressive US-scan of the cannulated vessel was conducted, except for the single case of CR-BSI, where the US scan was not performed due to the temporary unavailability of a vascular access nurse. Among the 14 remaining patients, thrombosis was found in 10 cases (71.4%). In all cases, the lumen of the vein was explored up to the end of the axillary vein, without finding any further thrombus. No systemic complication related to the thrombosis was observed.
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Table 4 Variables related to the occurrence of complications. Variables Age Gender Vein
Diameter of the vein Depth of the vein Catheter
No. of attempts Dwell time (days) Prev. thrombosis Cancer Obesity Diabetes
Complications/ total N (%) Complications No complications Female Male Basilic Brachial Cephalic Complications No complications Complications No complications 20G/3Fr/8 cm catheter 18G/4Fr/10 cm catheter 18G/4Fr/18 cm catheter 1 2e3 Complications No complications No Yes No Yes No Yes No Yes
Mean SD
p-Value
73.7 7.8 73.0 9.6
0.797b
5/34 (14.7%) 10/37 (27.0%) 12/56 (21.4%) 2/11 (18.2%) 1/4 (25.0%)
0.204a 0.953a
0.45 0.47 1.56 1.54
0.13 0.12 0.62 0.51
1/9 (11.1%)
0.570b 0.867b 0.121a
6/15 (40.0%) 8/47 (17.0%) 0.627a
14/65 (21.5%) 1/5 (20.0%) 14.5 10.6 14.8 11.3 13/68 (19.1%) 2/3 (66.7%) 12/58 (20.7%) 3/13 (21.1%) 9/45 (20.0%) 6/26 (23.1%) 9/40 (22.5%) 6/31 (19.4%)
0.934b 0.048a 0.849a 0.760a 0.747a
SD: standard deviation, bold: statistically significant. a c2 test. b Student’s t-test.
Discussion In a population of DVA patients, a peripheral vascular access was ensured by inserting an L-PVC under US guidance into deep-arm veins, with a 100% success rate and without any immediate complications. The cannulation success rate seems to be similar to previous studies, ranging from 84% to 100%.18e22 The reasons for this study’s good result are probably multifactorial. The catheters were positioned by highly skilled specialist nurses, with advanced training in venous access management and extensive clinical experience in US-guided positioning of PICCs, standard midline and peripheral catheters. Moreover, the high success rates and the low immediate complication rates were probably also related to the advantages of using the direct Seldinger technique to position the L-PVCs. It should be noted that we enrolled a population of particularly critical and aged DVA patients with severe multiple co-morbidities, that had primarily undergone to surgery in urgent or emergency situations, and with a high rate of post-operative complications. These facts were associated with a length of hospital stay much longer than the median stay for patients in the cardiac surgery department (corresponding to 10 days) and the need to continue IV therapies for a long period of time. The catheters were left in place as long as needed, without any time limit, unless an “early removal” situation occurred; this strategy has proven to be safe and useful in reducing the nursing workload and costs, as well as in reducing patients’ discomfort related to multiple punctures.26,33e35 To our knowledge, only one other study analyzed L-PVCs without establishing a maximum dwell time, reporting an average lifetime of 6.2 (median 5) days.21 Other authors reported for L-PVCs a median lifetime of 120 and 719 days, whereas in a further study,18
in which most catheters were electively removed after 7e8 days, for catheters removed prematurely the mean duration was 2.3 days. The aggregated “early removal” event rate was 27.7/1000 catheter-days; previous studies, considering traditional short PVCs with no planned routinely replacement, reported an “early removal” events rate ranging from 6826 to 87/1000 catheter-days.27 It is well known that the presence of any intravascular device may induce the risk of complications, among which thrombophlebitis and CR-BSI are clinically significant. Thrombophlebitis is a relatively frequent complication associated with PVCs; its incidence is reported with extremely variable data (0.1e70%),36 depending on the adopted diagnostic procedures and the studied populations. The risk of thrombophlebitis is associated with the catheter dwell time, material and size, type of infusion (hypertonic solutions, intravenous antibiotics, or chemotherapeutic agents), and catheter-related infections.36 In the present study, when a complication occurred, a thrombosis was sonographically detected in more than 70% of the cases. Interestingly, in both cases of phlebitis, the thrombus was localized within the lumen occupied by the catheter, whereas in 5 out of 7 complete obstruction cases and in 3 out of 5 leakage cases, the thrombus was located only at the level of the catheter tip, and the patients were asymptomatic. These findings were similar to the results reported in other studies that systematically evaluated the vessel through compressive US examination before removing the L-PVCs. One such study19 reported that even if no patient developed symptomatic thrombophlebitis, in 4 cases a mobile thrombus hanging at the catheter tip without involving the vein wall was observed. Another study21 found a 20.9% thrombosis rate (34.6/1000 catheter-days), most of which were pericatheters; slightly over half the cases resulted in catheter occlusion or thrombophlebitis. Thus, it is probable that the formation of a thrombus within the vein accompanies and often precedes the development of the characteristic clinical signs and symptoms.36 Given this low correlation between the presence of thrombus and symptoms or complications, the L-PVC should be monitored in order to detect thrombus formation early.19 Previous studies reported a 7%19 and 11.4%21 rate for occlusions and thrombophlebitis, respectively, when considered together, whereas other studies18,20 reported no such complications. Unfortunately, the cited studies did not report the incidence as a number per 1000 catheter-days, so it is difficult to compare those findings with our data without considering the incidence of the complications in light of the different catheter dwell times. Moreover, a comparison of the results should also consider the kind of enrolled populations; indeed, some studies considered only Emergency Department patients18,20 while others19,21dsuch as the present studydenrolled patients who were already hospitalized and had already undergone multiple venipunctures or previous peripheral cannulations before considering the US-guided L-PVC positioning. Very few studies analyzed the incidence of CR-BSI related to PVCs. Current available data suggest incidence rates for CR-BSI ranging from 0.2 to 0.7/1000 catheter-days for PVCs, 0.2 for midline catheters, 1.7 for arterial catheters used for hemodynamic monitoring, and up to 2.1 for PICCs implanted in inpatients.2 In our study, a single case of CR-BSI occurred. A more detailed analysis of the management of this catheter showed that the infusions were discontinued 4 days after catheter placement because no medication was prescribed any longer, and a saline lock was adopted to keep the catheter patency; 6 days later, a nurse flushed the line with 10 ml of saline solution, and after a few minutes, the patient experienced the symptoms described in the paragraph reporting the results. We hypothesize that this catheter was not managed according to the recommendations, given the fact that it was not promptly removed when no longer needed.
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The complications were shown to be related neither to the characteristics of the catheter (length and gauge), nor to the cannulated vein (depth, caliber, and number of attempts), nor to the catheter dwell time. Instead, the complications were discovered to be related to a history of previous thrombotic events and to the infusion of four antibiotics. Only a few evidences can be obtained from the literature about the medications that had an infusion that contraindicated in a peripheral venous access. A literature review37 showed that no well-conducted human outcome study suggests that a pH solution, in and of itself, causes phlebitis, whereas there are numerous studies demonstrating that thrombophlebitis can be related to multiple other factors (e.g., anatomic location, gender, experience of the operators, etc.). Accordingly, the more recently published guidelines recommend the avoidance of using peripheral catheters only for continuous vesicant therapy, parenteral nutrition, or infusions with an osmolality greater than 900 mOsm/L.38 Up until now, no consensus exists about the best material to use for catheters.19 All vascular access devices are associated with both risks and benefits; therefore, the choice of the catheter to be used for a patient should be based on the assumption that it is effective for delivering the necessary treatment and that the benefits outweigh the potential risks.23 To our knowledge, this is the first study in which a polyethylene catheter was employed and evaluated for prolonged deep-arm veins cannulation, whereas other authors adopted polyurethane devices18e22; even considering the already emphasized differences between the studies, our results are encouraging and in line with previous cited reports.
7
of midline catheters in patients who require a PVC for short-term intravenous therapy. However, a CR-BSI rate of nearly 1 case for 1000 catheter-days was found. The impression resulting from our study is that a more careful catheter management in the days after the placement could further limit the complications and the cases of “early removal.” We recommend that these L-PVCs be considered and managed as midline catheters, thus adopting specific “bundles” aimed to achieve a higher level of safety for patients. Moreover, a systematic and planned US monitoring of the catheters could allow an early interception and treatment of the occurrence of thrombotic events. Further larger studies are needed in order to better analyze the risks and benefits of prolonged deep-arm vein infusion through an L-PVC; an important aspect to investigate is the followup of the catheter after proper positioning, possibly including extensive information on the medications infused through the catheter. Acknowledgements The authors thank the whole staff of the Cardiac Surgery Unit of Trieste, and in particular Dr. Aniello Pappalardo, MD, Head of Cardiac Surgery Unit, Mrs. Marisa Sacilotto, RN, Nurse Coordinator of Cardiac Surgery Intensive Care Unit, and Mrs. Antonella Franovich, RN, Nurse Coordinator of the Cardiac Surgery Inpatient Unit, for their valuable support. Special thanks are due to Dr. Lucio Petronio, MD, and to Dr. Maja Tenze, RN, “Casa di cura Pineta del Carso”, for their collaboration.
Limitations References This study has some limitations. First, we recruited a convenience sample of consecutively admitted DVA patients, without apriori calculation of the sample size; this issue may have influenced the results of the study. Second, it was not possible to determine with certainty if the catheter management was carried out according to the recommendations given to the nurses. This fact may have affected the rate of some “early removal” events and thus reduced the average lifetime of the catheters. Third, even though data about infused fluids and medications were collected regularly, we considered neither the specific endurance of each treatment, nor the possible simultaneity of the administrations; for these reasons, the results concerning the relationship between the infused drugs and the complications should be considered with caution. Finally, the US evaluation of the catheters was carried out only in the presence of a complication, so that the real rate of asymptomatic thrombosis was undetermined and most likely underestimated. Conclusions The US-guided cannulation of deep-arm veins represents a valid solution to ensure a peripheral venous access in DVA patients who have already undergone previous PVC attempts. Our data demonstrated a 100% success rate in catheter placement with no immediate complications, and an aggregated “early removal” events rate lower than previously published studies on short PVCs. The long lifetime of the studied L-PVC may reduce the need for frequent catheter replacements, also decreasing patient discomfort and the nursing workload. Our findings appear worth immediate translation into clinical practice; the adoption of US-guided L-PVCs in DVA situations should be considered early, sparing to the patient multiple, painful and often useless attempts. This option may offer an alternative to CVCs or PICCs in DVA patients who do not require a central venous access, and it can also reduce an inappropriate use
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