- Email: [email protected]
Complications associated with peripherally inserted central catheter use during pregnancy
Complications associated with peripherally inserted central catheter use during pregnancy Janelle M. Ogura, MD, Karrie E. Francois, MD, Jordan H. Perlow, MD, and John P. Elliott, MD Phoenix, Ariz OBJECTIVE: The purpose of this study was to evaluate the complications of peripherally inserted central catheter use in an obstetrics population at a single institution over a 5-year period. STUDY DESIGN: We conducted a descriptive retrospective review of all obstetrics patients with peripherally inserted central catheter insertion during the antepartum period at Good Samaritan Regional Medical Center, from January 1, 1997, through September 30, 2001. RESULTS: During the 5 years of the study, complete data regarding the primary admission diagnoses for peripherally inserted central catheter placement and associated complications were available for 52 cases. An associated complication rate of 50% (n = 26 cases) was noted. The complications included culture-proved line infection (n = 9/52 complications, 17%), presumed line infection (n = 6/52 complications, 12%), cellulitis (n = 4/52 complications, 8%), mechanical line failure (n = 4/52 complications, 8%), pain that required line discontinuation (n = 2/52 complications, 4%), and superficial thrombophlebitis (n = 1/52 complications, 2%). A χ2 analysis was performed, and preterm labor may be associated with an increased risk for peripherally inserted central catheter complication (P = .012). CONCLUSION: Patients who receive a peripherally inserted central catheter during pregnancy are at significant risk for infectious complications. Alternative treatment approaches are suggested, where appropriate. (Am J Obstet Gynecol 2003;188:1223-5.)
Key words: Peripherally inserted central catheter, pregnancy, infection, complication
Establishing and maintaining long-term intravenous access in the antepartum patient is a challenge for both patient and physician. The percutaneously placed central catheter is the traditional technique that is used to establish long-term intravenous access through the subclavian, internal jugular, or femoral veins. However, it is associated with risks of pneumothorax, hemorrhage, and infection and requires physician surgical skills for placement. The peripherally inserted central catheter (PICC) has gained popularity in recent years as an alternative to achieving intravenous access. It was first introduced in 1975 as a silicone elastomer catheter that was placed in the superior vena cava by access of the basilic or cephalic vein.1 Studies have shown it to be a safe and cost-effective technique.2 The costs are reduced significantly because registered nurses are capable of placing the PICC. It is associated with a 20% to 26% complication rate, most of which are phlebitis or mechanical problems that do not require premature removal.3,4 These studies were done in both men and women and did not include antepartum patients. At Good Samaritan Regional Medical Center, a small number of pregnant patients had a PICC placed From the Department of Obstetrics and Gynecology, Good Samaritan Regional Medical Center. Reprints not available from the authors. © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.332
during a 5-year period. An observation was made that many of these patients had premature discontinuation of the lines because of complications; therefore, we undertook this study in an effort to establish the complication rate of PICCs in antepartum patients. Methods We conducted this study as a descriptive retrospective review of all obstetrics patients with PICC insertion during the antepartum period at Good Samaritan Regional Medical Center from January 1, 1997, through September 30, 2001. Data were collected on indications and primary admission diagnoses for PICC insertion and any resultant complication that was related directly to PICC use (such as infection, mechanical dysfunction, phlebitis, and pain). A designated PICC team that consiste of registered nurses placed all PICCs. The insertion followed a strict sterile protocol: placement into the basilic, median cubital, or cephalic vein and chest radiograph verification of tip in the superior vena cava. All catheters (Arrow, Reading, Pa) were 5F with a double lumen. The catheters were assessed daily by the antepartum nursing staff for patency, erythema, edema, pain, drainage, and palpable cords. All the data were collected by chart review. Descriptive statistics included counts, proportions, and median values. Mann-Whitney U testing was used to compare the two groups when the data were not normal. χ2 testing was used to compare proportions. A two-tailed probability value of <.05 was considered significant. 1223
1224 Ogura et al
May 2003 Am J Obstet Gynecol
Table I. Comparison of admission diagnosis and PICC complication
No PICC complication PICC complication Total
Preterm premature rupture of membranes
Total
Other
Hyperemesis
Preterm labor
Pregnancy-induced hypertension
5 8 13
8 2 10
6 15 21
4 1 5
3 0 3
26 26 52
Preterm premature rupture of membranes
Total
3 0 3
26 19 45
Table II. Comparison of admission diagnosis and PICC infection
No PICC infection PICC infection Total
Other
Hyperemesis
Preterm labor
Pregnancy-induced hypertension
5 5 10
8 1 9
6 12 18
4 1 5
Results During the 5 years of the study, 5040 antepartum admissions occurred at Good Samaritan Regional Medical Center. Of these admissions, 86 patients were identified to have had a PICC placed. Twenty-eight patients had PICCs placed after delivery, and 54 patients had PICCs placed during the antepartum period. Four charts were unobtainable for review. The 54 antepartum patients had a total of 66 PICCs placed. Complete data regarding the primary diagnoses for use and the associated PICC complications were available for 52 cases. Overall, a total of 1375 catheter days were reviewed; PICC duration ranged between 1 and 210 days. The primary indications for PICC placement were prolonged intravenous access for medication, intravenous fluids, and total parenteral nutrition. Most patients had difficult peripheral intravenous access, and PICCs were placed for comfort reasons. The primary admission diagnoses were preterm labor (n = 21 patients, 40%), hyperemesis gravidarum (n = 10 patients, 19%), pregnancy-induced hypertension (n = 5 patients, 10%), preterm premature rupture of membranes (n = 3 patients, 6%), and other (n = 13 patients, 25%). The other category consisted of pulmonary hypertension (n = 3 patients), pancreatitis (n = 2 patients), chronic pain (n = 2 patients), nephrolithiasis (n = 1 patient), breast cancer (n = 1 patient), pulmonary embolism (n = 1 patient), pyelonephritis (n = 1 patient), obstruction of the small bowel (n = 1 patient), and previa (n = 1 patient). Six patients had PICCs replaced after the previous one was discontinued because of a need for long-term intravenous access for medication. The six patients had a total of 14 PICCs and were found to have eight infectious complications and two mechanical complications; four patients had no complications. An infection in the previous line did not appear to dictate a predisposition for an infection in the next line.
The duration of PICC use for patients with complications was evaluated. The median was 10 days, with a mean of 22 days. This compared with a median of 16 days, with a mean of 32 days, for patients without complications (P = .527). Therefore, there was no significant difference in the duration of PICC use between the two groups. An associated complication rate in all patients of 50% (n = 26 complications) was noted. The complications included culture-proved line infection (n = 9/52 patients, 17%), presumed line infection (n = 6/52 patients, 12%), cellulitis (n = 4/52 patients, 8%), mechanical line failure (n = 4/52 patients, 8%), pain that required line discontinuation (n = 2/52 patients, 4%), and superficial thrombophlebitis (n = 1/52 patients, 2%). The overall infection rate (culture proved, presumed infection, and cellulitis) in the entire group was 37% (19/52 patients). Of the nine culture-proved line infections, four lines (3 patients) were identified as Staphylococcus aureus, two lines (1 patient) were identified with Enterobacter species, two lines (2 patients) were identified with Pseudomonas species (one line was a coinfection with Staphylococcus), one line (1 patient) was identified with Escherichia coli, and one line (1 patient) was identified with Acenetobacter baumannii. Of the 26 patients with PICC complications, the principal admission diagnoses included preterm labor (n = 14 patients, 56%), hyperemesis gravidarum (n = 2 patients, 8%), pregnancy-induced hypertension (n = 1 patient, 4%) and other (n = 8 patients, 31%). To determine whether the admission diagnoses influenced PICC complications, χ2 analysis was performed (Table I). The value was 12.95 (degrees of freedom, 4; P = .012), which indicates significant differences in the proportion of complications by admission diagnoses. From an inspection of Table I, fewer complications appear to develop in patients with hyperemesis and pregnancy-induced hypertension, and more complications appear to develop
Ogura et al 1225
Volume 188, Number 5 Am J Obstet Gynecol
in patients with preterm labor. When a similar analysis was performed that compared the rate of line infection to admission diagnoses (Table II), the χ2 value was 11.43 (degrees of freedom, 4; P = .022), which indicates significant differences in the proportion of infections by admission diagnoses. From an inspection of the Table II, fewer infections appear to develop in patients with hyperemesis and pregnancy-induced hypertension, and more infections appear to develop in patients with preterm labor. Comment The complication rate for PICCs in the nonpregnant population is 20% to 26% and consists of 0.6% to 6.2% infection, 9.6% to 10.8% mechanical, 8.2% to 9.7% phlebitis, 2.6% pain, and 0.5% to 0.3% venous thrombosis.3,4 Some of these complications did not result in early discontinuation of the PICCs. From this study, there is a significantly increased risk of complication with PICCs in antepartum patients (50%). Most complications were infectious (37%), which is an increased rate compared with studies in the general population.3,4 Pregnant patients may be more susceptible to infection and sepsis than nonpregnant patients because of the altered immune function in pregnancy. There is a decrease in cellular immunity and an increase in humoral immunity by rising helper T2 cells and changing T1 cells.5 The increased PICC complications that are encountered in patients with preterm labor may have been the result of an already preexisting infection. Preterm labor has been associated with infection of the upper and lower genital tract and amniotic fluid. A resultant chain of events that include cytokine and prostaglandin release, neutrophil recruitment, and protease activity is thought to occur with choriodecidual bacterial colonization.6 Therefore, the patient’s preexisting conditions may play a role in the increased susceptibility to PICC infections. We did not encounter any deep venous thrombosis in our patient population. Although not included in this study, two antepartum patients were transported into our institution because of thrombosis complications that
were related directly to the PICC (placed in a different hospital). One patient had a basilic vein thrombosis that extended to the subclavian vein, and a pulmonary embolus from a basilic vein thrombosis developed in the other patient. Pregnant patients may also be susceptible to PICC thrombosis because of the hormonal and physical changes of pregnancy. This study indicates that patients who use a PICC during pregnancy are at significant risk for infectious complications. Practitioners should watch closely for signs and symptoms of infections in their pregnant patients with PICCs. Any possible intercurrent infectious process (such as preterm labor and pyelonephritis) should alert the physician to the possible seeding of organisms to the PICC. Blood cultures and removal of the PICC should be considered at that time. A thrombotic complication, although rare and not encountered in this study, can be serious, and precautions are warranted. Therefore, alternate treatment approaches to PICC, when appropriate, are suggested. We thank Richard D. Gerkin, MD, for the statistical consultation.
REFERENCES
1. Hoshal VL Jr. Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch Surg 1975;110:644-6. 2. Ng PK, Ault MJ, Ellrodt AG, Maldonado L. Peripherally inserted central catheters in general medicine. Mayo Clin Proc 1997;72:225-3. 3. Loughran SC, Borzatta M. Peripherally inserted central catheters: a report of 2506 catheter days. JPEN J Parenter Enteral Nutr 1995;19:133-6. 4. Merrel S, Peatross B, Grossman M, Sullivan J, Harker G. Peripherally inserted central venous catheters: low-risk alternatives for ongoing venous access. West J Med 1994;160:25-30. 5. Gordon MC. Maternal physiology in pregnancy. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 4th ed. Philadelphia (PA): Churchill Livingstone; 2002. p. 63-91. 6. Iams J. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 4th ed. Philadelphia (PA): Churchill Livingstone; 2002. p. 764-70.
Key words: Peripherally inserted central catheter, pregnancy, infection, complication
Establishing and maintaining long-term intravenous access in the antepartum patient is a challenge for both patient and physician. The percutaneously placed central catheter is the traditional technique that is used to establish long-term intravenous access through the subclavian, internal jugular, or femoral veins. However, it is associated with risks of pneumothorax, hemorrhage, and infection and requires physician surgical skills for placement. The peripherally inserted central catheter (PICC) has gained popularity in recent years as an alternative to achieving intravenous access. It was first introduced in 1975 as a silicone elastomer catheter that was placed in the superior vena cava by access of the basilic or cephalic vein.1 Studies have shown it to be a safe and cost-effective technique.2 The costs are reduced significantly because registered nurses are capable of placing the PICC. It is associated with a 20% to 26% complication rate, most of which are phlebitis or mechanical problems that do not require premature removal.3,4 These studies were done in both men and women and did not include antepartum patients. At Good Samaritan Regional Medical Center, a small number of pregnant patients had a PICC placed From the Department of Obstetrics and Gynecology, Good Samaritan Regional Medical Center. Reprints not available from the authors. © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.332
during a 5-year period. An observation was made that many of these patients had premature discontinuation of the lines because of complications; therefore, we undertook this study in an effort to establish the complication rate of PICCs in antepartum patients. Methods We conducted this study as a descriptive retrospective review of all obstetrics patients with PICC insertion during the antepartum period at Good Samaritan Regional Medical Center from January 1, 1997, through September 30, 2001. Data were collected on indications and primary admission diagnoses for PICC insertion and any resultant complication that was related directly to PICC use (such as infection, mechanical dysfunction, phlebitis, and pain). A designated PICC team that consiste of registered nurses placed all PICCs. The insertion followed a strict sterile protocol: placement into the basilic, median cubital, or cephalic vein and chest radiograph verification of tip in the superior vena cava. All catheters (Arrow, Reading, Pa) were 5F with a double lumen. The catheters were assessed daily by the antepartum nursing staff for patency, erythema, edema, pain, drainage, and palpable cords. All the data were collected by chart review. Descriptive statistics included counts, proportions, and median values. Mann-Whitney U testing was used to compare the two groups when the data were not normal. χ2 testing was used to compare proportions. A two-tailed probability value of <.05 was considered significant. 1223
1224 Ogura et al
May 2003 Am J Obstet Gynecol
Table I. Comparison of admission diagnosis and PICC complication
No PICC complication PICC complication Total
Preterm premature rupture of membranes
Total
Other
Hyperemesis
Preterm labor
Pregnancy-induced hypertension
5 8 13
8 2 10
6 15 21
4 1 5
3 0 3
26 26 52
Preterm premature rupture of membranes
Total
3 0 3
26 19 45
Table II. Comparison of admission diagnosis and PICC infection
No PICC infection PICC infection Total
Other
Hyperemesis
Preterm labor
Pregnancy-induced hypertension
5 5 10
8 1 9
6 12 18
4 1 5
Results During the 5 years of the study, 5040 antepartum admissions occurred at Good Samaritan Regional Medical Center. Of these admissions, 86 patients were identified to have had a PICC placed. Twenty-eight patients had PICCs placed after delivery, and 54 patients had PICCs placed during the antepartum period. Four charts were unobtainable for review. The 54 antepartum patients had a total of 66 PICCs placed. Complete data regarding the primary diagnoses for use and the associated PICC complications were available for 52 cases. Overall, a total of 1375 catheter days were reviewed; PICC duration ranged between 1 and 210 days. The primary indications for PICC placement were prolonged intravenous access for medication, intravenous fluids, and total parenteral nutrition. Most patients had difficult peripheral intravenous access, and PICCs were placed for comfort reasons. The primary admission diagnoses were preterm labor (n = 21 patients, 40%), hyperemesis gravidarum (n = 10 patients, 19%), pregnancy-induced hypertension (n = 5 patients, 10%), preterm premature rupture of membranes (n = 3 patients, 6%), and other (n = 13 patients, 25%). The other category consisted of pulmonary hypertension (n = 3 patients), pancreatitis (n = 2 patients), chronic pain (n = 2 patients), nephrolithiasis (n = 1 patient), breast cancer (n = 1 patient), pulmonary embolism (n = 1 patient), pyelonephritis (n = 1 patient), obstruction of the small bowel (n = 1 patient), and previa (n = 1 patient). Six patients had PICCs replaced after the previous one was discontinued because of a need for long-term intravenous access for medication. The six patients had a total of 14 PICCs and were found to have eight infectious complications and two mechanical complications; four patients had no complications. An infection in the previous line did not appear to dictate a predisposition for an infection in the next line.
The duration of PICC use for patients with complications was evaluated. The median was 10 days, with a mean of 22 days. This compared with a median of 16 days, with a mean of 32 days, for patients without complications (P = .527). Therefore, there was no significant difference in the duration of PICC use between the two groups. An associated complication rate in all patients of 50% (n = 26 complications) was noted. The complications included culture-proved line infection (n = 9/52 patients, 17%), presumed line infection (n = 6/52 patients, 12%), cellulitis (n = 4/52 patients, 8%), mechanical line failure (n = 4/52 patients, 8%), pain that required line discontinuation (n = 2/52 patients, 4%), and superficial thrombophlebitis (n = 1/52 patients, 2%). The overall infection rate (culture proved, presumed infection, and cellulitis) in the entire group was 37% (19/52 patients). Of the nine culture-proved line infections, four lines (3 patients) were identified as Staphylococcus aureus, two lines (1 patient) were identified with Enterobacter species, two lines (2 patients) were identified with Pseudomonas species (one line was a coinfection with Staphylococcus), one line (1 patient) was identified with Escherichia coli, and one line (1 patient) was identified with Acenetobacter baumannii. Of the 26 patients with PICC complications, the principal admission diagnoses included preterm labor (n = 14 patients, 56%), hyperemesis gravidarum (n = 2 patients, 8%), pregnancy-induced hypertension (n = 1 patient, 4%) and other (n = 8 patients, 31%). To determine whether the admission diagnoses influenced PICC complications, χ2 analysis was performed (Table I). The value was 12.95 (degrees of freedom, 4; P = .012), which indicates significant differences in the proportion of complications by admission diagnoses. From an inspection of Table I, fewer complications appear to develop in patients with hyperemesis and pregnancy-induced hypertension, and more complications appear to develop
Ogura et al 1225
Volume 188, Number 5 Am J Obstet Gynecol
in patients with preterm labor. When a similar analysis was performed that compared the rate of line infection to admission diagnoses (Table II), the χ2 value was 11.43 (degrees of freedom, 4; P = .022), which indicates significant differences in the proportion of infections by admission diagnoses. From an inspection of the Table II, fewer infections appear to develop in patients with hyperemesis and pregnancy-induced hypertension, and more infections appear to develop in patients with preterm labor. Comment The complication rate for PICCs in the nonpregnant population is 20% to 26% and consists of 0.6% to 6.2% infection, 9.6% to 10.8% mechanical, 8.2% to 9.7% phlebitis, 2.6% pain, and 0.5% to 0.3% venous thrombosis.3,4 Some of these complications did not result in early discontinuation of the PICCs. From this study, there is a significantly increased risk of complication with PICCs in antepartum patients (50%). Most complications were infectious (37%), which is an increased rate compared with studies in the general population.3,4 Pregnant patients may be more susceptible to infection and sepsis than nonpregnant patients because of the altered immune function in pregnancy. There is a decrease in cellular immunity and an increase in humoral immunity by rising helper T2 cells and changing T1 cells.5 The increased PICC complications that are encountered in patients with preterm labor may have been the result of an already preexisting infection. Preterm labor has been associated with infection of the upper and lower genital tract and amniotic fluid. A resultant chain of events that include cytokine and prostaglandin release, neutrophil recruitment, and protease activity is thought to occur with choriodecidual bacterial colonization.6 Therefore, the patient’s preexisting conditions may play a role in the increased susceptibility to PICC infections. We did not encounter any deep venous thrombosis in our patient population. Although not included in this study, two antepartum patients were transported into our institution because of thrombosis complications that
were related directly to the PICC (placed in a different hospital). One patient had a basilic vein thrombosis that extended to the subclavian vein, and a pulmonary embolus from a basilic vein thrombosis developed in the other patient. Pregnant patients may also be susceptible to PICC thrombosis because of the hormonal and physical changes of pregnancy. This study indicates that patients who use a PICC during pregnancy are at significant risk for infectious complications. Practitioners should watch closely for signs and symptoms of infections in their pregnant patients with PICCs. Any possible intercurrent infectious process (such as preterm labor and pyelonephritis) should alert the physician to the possible seeding of organisms to the PICC. Blood cultures and removal of the PICC should be considered at that time. A thrombotic complication, although rare and not encountered in this study, can be serious, and precautions are warranted. Therefore, alternate treatment approaches to PICC, when appropriate, are suggested. We thank Richard D. Gerkin, MD, for the statistical consultation.
REFERENCES
1. Hoshal VL Jr. Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch Surg 1975;110:644-6. 2. Ng PK, Ault MJ, Ellrodt AG, Maldonado L. Peripherally inserted central catheters in general medicine. Mayo Clin Proc 1997;72:225-3. 3. Loughran SC, Borzatta M. Peripherally inserted central catheters: a report of 2506 catheter days. JPEN J Parenter Enteral Nutr 1995;19:133-6. 4. Merrel S, Peatross B, Grossman M, Sullivan J, Harker G. Peripherally inserted central venous catheters: low-risk alternatives for ongoing venous access. West J Med 1994;160:25-30. 5. Gordon MC. Maternal physiology in pregnancy. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 4th ed. Philadelphia (PA): Churchill Livingstone; 2002. p. 63-91. 6. Iams J. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 4th ed. Philadelphia (PA): Churchill Livingstone; 2002. p. 764-70.