- Email: [email protected]
Greece reports prototype intervention with first peripherally inserted central catheter: Case report and literature review
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Greece reports prototype intervention with first peripherally inserted central catheter: Case report and literature review Evangelos A. Konstantinou, RN, PhD, Emmanuil Stafylarakis, RN, MSc(c), Maria Kapritsou, RN, PhD(c), Aristotelis P. Mitsos, MD, PhD(c), Theofanis G. Fotis, RN, PhD, Panagiotis Kiekkas, RN, PhD, Theodoros Mariolis-Sapsakos, MD, PhD, Eriphyli Argyras, MD, PhD, Irini Th. Nomikou, MD, and Antonios Dimitrakopoulos, MD, PhD
Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-yearold male patient suffering from a recent chemical pneumonia with a history of Alzheimer’s disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team. (J Vasc Nurs 2012;30:88-93)
The placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantages over any other method for central venous catheterization. Its ultrasonographical orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy. PICCs provide
From the Evgenidion University Hospital, Nurse Anaesthesia Department, National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; Hellenic-Anticancer Institute, ‘‘Saint Savvas,’’ National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; University of Peloponnese, Sparta, Greece; Highest Technological Educational Institute of Patras, Patra, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Medical School, Athens, Greece; Evgenidion University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Aegenitio Hospital, National and Kapodistrian University of Athens, Athens, Greece. Corresponding author: Evangelos A. Konstantinou, RN, PhD, Assistant Professor in Nurse Anaesthesiology, University of Athens, Faculty of Nursing, Surgical Nursing Section 123 Papadiamantopoulou str., 11527 Athens, Greece (E-mail: [email protected]). 1062-0303/$36.00 Copyright Ó 2012 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2012.03.001
WHAT’S NEW? The first successful insertion of PICCs in Greece by a nurse An encouragement in inserting PICCs in Greece by a nurse
long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition.1 PICCs are especially useful for short-term treatments and in patients undergoing certain neurosurgical, otolaryngological, oncosurgical and other major surgical procedures involving massive fluid shifts, or when free access to the neck and clavicle is either not possible or not desirable. PICCs also avoid the physical discomfort and psychological distress associated with Trendelenburg position.2
HISTORY The first central venous catheterization was performed during the French–Algerian war in 1952. That year, for the first time, Robert Aubaniac (Figure 1), the innovator of the central venous catheterization, probed into the subclavian vein on a battlefield during the Algerian war. This innovative procedure was recorded in his unique publication with regard to this exceptionally important event in 1952.3 The same year, Seldinger invented the eminent J wire, which happened to be a true revolution, because its utilization ceased the occurrence of endothelium wounds and improved
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Figure 1. Robert Aubaniac. (The photograph was kindly provided to the prime author, by his son, Professor Jean Manuel Aubaniac).
dramatically the atraumatic puncture of vessels. It is also worth mentioning that following this technique, the other complications of the catheterization were considerably decreased.4 The first equipment for peripheral venous catheterization — although its use was not established by images or testimonials — was found in a surgeon’s house in the ruins of ancient Pompeii dating from 67 A.D. and looked like syringes, needles and catheters. Earlier, before 1550 BCE, the Egyptians had described 22 veins that were believed to transport air and liquids. They had also noticed the relation between heart and blood vessels, as recorded in the manuscripts of Edwin Smith. Furthermore, Hippocrates had proposed the midway of the elbow as an anatomical area suitable for the transaction of phlebotomy, the vein that is called the median basilica today.5 In 1616, Harvey first described blood circulation anatomy and physiology in his report Excercitatio Anatomica de Moto Cordis et Sanguinus in Animalbus. He was the one who discovered that the heart is responsible for the circulation of blood; prior to his discovery, in his era it was believed that the center of circulation was the liver and the flow of the blood was related to respiration. However, 200 years after that important medical announcement by that enlightened doctor and researcher, it was believed that bleeding could be controlled by shock bleeding, whereas phlebotomy promoted the coagulation of blood and achieved hemostasis. Harvey’s report offered the theoretical background for Folly to perform the first transfusion of blood from animal to animal in 1654, using a silver and bone venous catheter. The first intravenous case was recorded in 1656 by Wren, who venipunctured dogs and administrated opium, beer and wine to them, using a makeshift syringe made by goose’s feather and pig’s urinary bladder.6 The first report of intravenous administration in humans was published in Clysmatica Nova by Escholtz in 1665; in 1733 Hales tried to measure the human central venous pressure for the first time.7 The first cardiac catheterization to an animal is described in 1844 by Bernard, who also had described the first complication of catheterization (a rupture of the heart) during the effort. In 1818 Blundell performed the first successful blood transfusion. The first successful administration of water and serum in dehydrated patients was carried out by O’Shaughnessy and Latta in victims of cholera, whereas in 1891 Matas dealt with the intravenous administration of similar solutions in patients with shock.8 In 1924, Matas also administered the continuous drip of glucose solution for
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the first time, and in 1944 Dennis, apart from hypertonic glucose, also provided insulin and proteins of plasma to surgical patients.8 On March 17, 1943, Willem Kolff, a young doctor in the small hospital of Kampen, first performed blood dialysis for kidney patients by using metallic and plastic tubes to insert catheters intravenously.9 In 1945, Zimmermann used the polyethylene IV catheter for the first time, which was inserted through a needle already probed in the vein. Later, especially protective mechanisms were added in that system to avoid the cut of the end of the catheter and the subsequent pulmonary embolism.10 The ancestor of venous catheters including the needles we use today was manufactured in 1950 by Dr. Massa, a specialized anesthesiologist at the Mayo Clinic. This was a revolution in probing a peripheral venous catheter, increasing his rates of success, facilitating the mobility of the patients and mainly abolishing the bleeding by the point of entrance that was observed in previous venous catheters, as the needle-driver had a larger diameter than the catheter imported through this.11 In 1949 Duffy announced the hospitalization of 43 patients with central venous catheterization via the external jugular vein or femoral vein.12 The choice of the subclavian catheterization was solidified by extended literature as well as through clinical experience by Keeri in 1956. In 1966, Dudrick, Vars and Rawnsley inserted central venous catheters in dogs via the internal jugular vein.7 In 1960 Quinton, Dillard and Scribner developed an arteriovenous (AV) TeflonÔ shunt, which was inserted near the wrist in the forearm, one into the radial artery and the other into the adjacent cephalic vein. The external ends were connected by a curved TeflonÔ bypass tube.13 After that progress, venous cut-down was established as an emergency procedure during which the vein was exposed surgically and then a cannula was inserted into the vein (usually the saphenous vein) under direct vision. In 1969 Erben probed a catheter in the subclavian vein with a tube made of TeflonÔ and created a revolution in nephrology, allowing the blood dialysis in patients who urgently needed it. The blood dialysis via central venous catheter had complications, the most important being the stenosis of the subclavian vein, when the blood flow was increased inside the circuit.14 At the beginning of 1980, the improvement of these catheters concerned the utilization of tetraflouroethylene, polyurethane or silicon and the addition of one more tube, at the prototype of Hickman catheter. Since then and until recently the provisional catheters of blood dialysis consisted of polyurethane or polyvinyl. Even if they are inflexible and hard materials, they change attitude and become flexible in body temperature, whereas the last pivotal catheters of double tubes in 1987 were made of silastic and silicon, thus allowing their promotion as closer to the right atrium increasing the speed flow of the blood dialysis.7,15 In 1970, the central venous catheterization was the basis for the attainment of a catheterization with the Swan-Ganz catheter of the pulmonary artery, whereas in 1973 Broviac created the implantable partially central venous catheter made of silicon and elastic, the long subcutaneous course that provided the ideal conditions for lasting longer.16 In 1974 Blewitt, Kyger and Patterson, using the Seldinger technique, replaced an existing central venous catheter for the first time with the help of a wire without using a new puncture.17
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The Broviac catheter was enhanced by Hickman in 1979, which increased its useful breadth, using thinner walls and adding a second tube that did not communicate with the first one, so as to administer medicines or solutions simultaneously, the co-administration of which was prohibited with only one line. Then, one more tube was added through which blood aspiration for laboratory examinations were possible, thus abolishing numerous painful peripheral venous punctures for the patients.18 The permanently implanted subcutaneous bells of chemotherapy communicating with the superior vena cava used today, were presented in 1982, and similar devices communicating via a peripheral vein appeared in 1989. Early reports dating from the 1970s described placement of a PICC using silicone tubing, inserted into the peripheral venous system via a cannula-style peripheral IV device. After the tubing reached the vena cava, the IV cannula was withdrawn and a 25-gauge blunt butterfly needle was attached to the distal end of the tubing to serve as the catheter hub. Two skin-closure strips applied in an X configuration covered the coiled, external portion of the catheter to prevent dislodgement.19 The old PICC systems consisted of a needle importer with a particularly large diameter so as to be accessible by the nurse professional by sight and were blindly promoted. Thereby, the median basilic vein was usually selected and following the successful entry to the vein stem, it was promoted to the angle that shapes the innominate vein with the inner jugular vein.19 Their colonizing has been performed with the silk stitch 2.0, whereas the test for a successfully standard placement was made by the venous return following the application of negative pressure through the catheter. The prevalence of thrombophlebitis, however, was particularly high, whereas the edge of the catheter could be only accidentally found in the superior vena cava or in the right atrium. Using this technique, even if we overcame the anatomical difficulties, we did not have the ability to localize the position of the catheter, except with the aid of x-ray methods; however those methods were expensive, time-consuming, laborious and ergonomically unacceptable either in the ward or in the operation room.19 The placement of PICCS has a clear advantage over other methods of central vessel access. The spectacle of a catheter earring from the patient’s head due to an inner jugular vein central line is a common phenomenon in the nursing wards. However it definitely causes significant discomfort in the patient, who cannot comfortably deal with personal hygiene alone and, if a male, cannot shave himself.19 The complications that are reported in the use of central venous catheterization include the rupture of the carotid and damage to adjacent molecules even if its probing occurs under ultrasonic control. On the other hand, insertion of PICCs is performed in a relatively large vessel under ultrasonic guidance. The localization of the vessel takes place by using a smalldiameter needle; there are no adjacent organs such as the trachea, the thyroid gland or the carotid, and the catheter is well tolerated or even invisible when connected with a drip. The patient is able to stroll in the hospital, go home or even go to work with the catheter in place!20 PICC placement can be done in the programs of home care nursing and is one of the challenges that community health nursing has to deal with in the near future. It is widely known that nurses can perform PICC placement.21 This is an official, inter-
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nationally vested nursing action that requires the simultaneous utilization of imaging methods, specifically the ultrasound. Although the cost currently is still higher than that of the simple central catheterization, that cost can be significantly reduced by the use of fewer luxury sets and more limited ancillary equipment involved, making PICCs a cost-effective procedure.22
CASE REPORT A 77-year-old man was referred by our consultant pathologist to the Nursing Department of Anesthesiology of our Hospital to have a 3-lumen PICC inserted. The patient was admitted for chemical pneumonia caused by aspiration 12 days earlier. The patient suffered from Alzheimer’s disease, which prevented communication with him. PICC insertion was chosen because of the lack of a catheterized peripheral vein and after several and repeatedly failed attempts by the nurses and physicians. His wife denied permission to insert a catheter into the internal jugular vein because she feared the complications. A Eutectic mixture of lidocaine and prilocaine ointment (Emla, Astra Zeneca), was placed to a large extent on the inner surface of the brachio 40 minutes before the start of the procedure. The patient was transferred to the operation room in a stimulated mood with the help of two orderlies. The only peripheral catheter (G20) that he had was not functional and we could not administer any sedative drugs, such as midazolam or propofol. The position of his hand was the characteristic position of the sports boxer because of hypertonia. The affiliate nurse, who participated in the insertion of the PICC, tried to open his hand in a mild manner and oral contact, a procedure that almost lasted 20 minutes. The patient was connected with a 3-lead monitor (Nihon Kohden, Japan) with the electrodes located on his right shoulder, his left shoulder and his left hip to provide the largest triangle possible. We administrated oxygen to him by using an oxygen mask (flow at 4 lt /minute) and connected him to a pulse oximeter and a noninvasive blood-pressure device. Although we considered that local anesthesia has been implemented by the ointment, after a thorough cleaning with a solution of a povidone-iodine, we locally infiltrated the skin and the subcutaneous tissues with a solution of lidocaine 2% (xylocaine 2%, Astra-Zeneca), 4 cc in total volume, using a 27 g needle. After the implementation of the sterilized screens, which offered us an interventional field of 10 cm 10 cm in dimension, we put a case on the head of the ultrasound. The basilic vein was easily recognized, located 13 cm to the upper flexural surface of the elbow, because of the decrease of its lumen after implementing pressure, a fact that did not influence the adjacent brachial artery, which remained incompressible during the implementation of the pressure (Figures 2 and 3). The basilic vein was punctured right after we placed the tourniquet, in the preselected point with a needle of a dimension 21g and afterwards completed the confirmation of the unhindered flow of the blood; it was advanced via a needle wire-driver (not J), according to the Seldinger technique, that was easily inserted. Then through the wire-driver we inserted the expander with the introducer. Once we achieved a dehiscence, we proceeded to the point of the entrance with a lance n11. We removed the wire-driver and the expander and we left the introducer. We
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Figure 2. Ultrasound visualization of the vein.
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Figure 4. Right cable connection, with the set’s wire.
Figure 5. P wave elevation. Figure 3. Disappearance of the vein following nurse’s compression.
observed the massive back flow of the blood and covered the end of the introducer with the finger so as to avoid unnecessary bleeding. Estimating patient body measures (height of the patient: 172 cm) and the length of the catheter (40 cm), we decided not to cut the end of the catheter so that the end of the stunt would not be sharp. We promoted the catheter with the driver that was included in the distal lumen via the introducer; we previously used heparin in the tubes and we disconnected the right electrode by the disk of the AgCl electrode of the patient‘s right shoulder and connected him to the wire which was included in the catheter. In this way, we substantially abolished the exterior electrode and replaced it with an internal electrode that was constituted by the system patient’s blood-catheter-serum–wire (Figure 4). When the type of wave P of the electrocardiogram indicated, the insertion of the end of the catheter from the superior vena cava exuded to the right atrium; it was successful, and we proceeded with the colonization of catheter and removed the wire which was included in the system (Figures 5 and 6). A diligent cleaning of the area with sodium chloride and sterilized patches was performed. After that we sprayed the area with Opsite (Smith and Nephew) and after a minute or so we colonized the catheter with the statlock system which applies to the points of the support of the catheter. At that point, 6 cm of the catheter was visible, which suggests that the optimal intervention
would have been to limit its length to 34 cm. The bandage had 4 transparent, sterilized patches. Its complete attachment was checked. The whole process from the moment when the local infiltration was performed to the standstill of the catheter lasted 20 minutes (Figure 7).
DISCUSSION The insertion of a central venous catheter is one of the most common invasive procedures performed today. The catheter should pass through the layers of the skin before entering the bloodstream.23 As Santolucito pointed out, 30% of PICCs are placed at patient discharge on day 8 of the hospital stay as an ‘‘emergency PICC.’’ The patient often has to stay an extra day or two to have a PICC placed in the costly interventional radiology department. This lack of proactive vascular access planning can result in losses amounting to 20% of the DRG payment, whereas proactive planning can result in a 2% overall loss of the DRG.24 Barton et al and Danek and Kilroy indicated that 13% of their study patients had 7 or more days of infusion therapy through short peripheral catheters, and that the vascular access needs of the patient were not met from the outset of a patient’s stay. After the implementation of a triage algorithm to plan vascular access, the hospital saved $500,000 in length of stay (LOS) costs in 1 year. This cost savings could have paid for an entire full-time infusion team.25 On the basis of financial data collected at Oregon Health Science University by Santolucito, a successful peripheral catheter
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Figure 6. Position of the catheter right before sino-atrial node. The superior vena cava and right atrium were dissected in a cadaveric specimen. Note the position of the catheter just before the sinoatrial point. (Cadaveric specimen properly prepared in our laboratory.)
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sional collaboration across a variety of practice settings. The outcome was the development of recommendations for vocabulary, communication, and care/maintenance activities, which could be used by vascular nurses to enhance patient care coordination.27 PICC by nurses provides competent PICC line placement, reduces costs and procedure delays for the patient, and maintains a reasonable revenue stream to the facility. By utilizing a PICC nurse service, the costs to the patients are reduced. In the example hospital, the price for PICC line placement by the nurse is 25% of the cost when performed by an interventional radiologist. In the example hospital, if the radiology practitioner assistant repositions the PICC, the cost is still only 50% of the interventional radiologist. In many institutions, PICC nurses are needed and are valuable assets. In a busy hospital setting where the interventional radiology department services a broad range of critically ill patients, the service can free physicians and their extenders to focus on duties that they are uniquely capable of providing.28 An infusion team can provide the hospital with even greater savings in the form of vascular access planning.
CONCLUSION
Figure 7. Final stabilization of the catheter.
insertion costs $32. If that data is integrated with the studies done by Barton et al and Danek and Kilroy, a successful peripheral catheter insertion is shown to cost $69.76. At what cost to the hospital is the elimination of the highly skilled infusion team when a legal litigation of an infiltration with resultant nerve injury could cost $650,000?26 Growing interest in PICCs led to the development of the PICC Council. This council was established to provide a resource of information for the area nurses involved in PICC use and care. The group went through various developmental stages as they sought to establish cohesiveness and profes-
Many challenges face vascular access nurses as technology improves and patients require more numerous and lengthy intravenous therapies. Nurses began placing PICCs at the patient bedside in an effort to defray costly interventional radiology procedures and provide for patient comfort. In recent years, the numbers of PICC procedures have increased, and the procedure itself has become more technologically advanced. With these advances have come new logistical, environmental, and ergonomic challenges.29 Due to the current financial circumstances in Greece, the effort to develop a new approach for the central venous access is quite difficult, and it would deteriorate if Greece does not have nongovernmental support as well as the personal efforts of health system professionals. PICCs are routinely placed in a many health systems worldwide. In the Greek health system, we have recorded the first successful insertion in human patients and this procedure was performed by a nurse. Although we have not used specialized systems for the localization of the end of the catheter for obvious financial reasons, we believe that we can have equally successful results with a considerably limited cost. As a single case cannot guarantee the safety and efficacy of a method in general, a larger series of studies of Greek patients is mandatory. Such a series is currently under development, and we are putting our best efforts toward this end.
ACKNOWLEDGMENTS The authors wish to thank Teleflex Hellas for providing the portable ultrasound and particularly Mr. Dimitrios Karampinis who always supported the research as representative of the company; Dr Mauro Pittiruti and his collaborators in the Sacro Cuore Hospital in Rome, who trained the nurse who performed the operation; and specially the General Director of Evgenidion Hospital, Mr. George Savvides, who
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was a valued helper and a great supporter in any effort of growth of nursing science, even in the current difficult times in Greece.
REFERENCES 1. Evans RS, Linford LH, Sharp JH, et al. Computer identification of symptomatic deep venous thrombosis associated with peripherally inserted central catheters. AMIA Annu Symp Proc 2007;226-30. 2. Joshi S, Kulkarni A, Bhargava AK. Evaluation of length of central venous catheter inserted via cubital route in Indian patients. Indian J Crit Care Med 2010;14(4):180-4. 3. Aubaniac R. A new route for venous injection or puncture: the subclavicular route, subclavian vein, brachiocephalic trunk. Sem Hop 1952;28:3445-7. 4. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta Radiol 1953; 39(5):368-76. 5. Hasselgren PO. Total parentral nutrition and the surgical patient: history, definitions, and applications. Astra USA, Inc.; 1994. 6. Bendiner E. The revolutionary physician of kings: William Harvey. Hosp Pract 1978;13:129-48. 7. Barsoum N, Kleeman C. Now and then, the history of parenteral fluid administration. Am J Nephrol 2002;22; 284-28. 8. Baskett TF. William O’Shaughnessy, Thomas Latta: the origins of intravenous saline. Resuscitation 2002;55(3):231-4. 9. Konner Klaus. History of vascular access for haemodialysis. Nephrol Dial Transplant 2005;20:2629-35. 10. Zimmerman B. Intravenous tubing for parenteral therapy. Science 1945;567. 11. Massa D, Lundy JS, Faulconer A Jr, Ridley RW. A plastic needle. Proc Staff Meet Mayo Clin 1950;25(14):413-5. 12. Duffy BJ. The clinical use of polyethylene tubing for intravenous therapy. Ann Vasc Surg 1949;929-36. 13. Quinton WE, Dillard DH, Scribner BH. Cannulation of blood vessels for rolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960;6:104-13. 14. Erben J, Kvasnicka J, Bastecky J, et al. Experience with routine use of sucblavian vein cannulation in haemodialysis. Proc EDTA 1969;6:59-64.
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15. Hickman R, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-8. 16. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parentral alimentation. Surg Gynecol Obstet 1973;136:602-6. 17. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol 1953;39: 368-76. 18. Hickman R, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-8. 19. Ryder MA. Peripherally inserted central venous catheters. Nurs Clin North Am 1993;28(4):937-71. 20. Pikwer A, Akeson J, Lindgren S. Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia 2012;67(1):65-71. 21. Roslien J, Alcock L. The effect of an educational intervention on the RN’s peripherally inserted central catheters knowledge, confidence, and psychomotor skill. J Nurses Staff Dev 2009;25(3):E19-27. 22. Meyer BM. Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs 2012;35(1):34-42. 23. Elliott TS, Moss HA, Tebbs SE, et al. Novel approach to investigate a source of microbial contamination of central venous catheters. Eur J Clin Microbiol Infect Dis 1997;16:210-3. 24. Santolucito JB. The role of peripherally inserted central catheters in the treatment of the critically ill. JAVA 2007;12(4): 208-17. 25. Kokotis K. Cost Containment and Infusion Services. J Infus Nurs 2005;28(3):22-32. 26. Higuchi KA, Edwards N, Danseco E, et al. Development of an evaluation tool for a clinical practice guideline on nursing assessment and device selection for vascular access. J Infus Nurs 2007;30(1):45-54. 27. Papke L. The growth and development of an Intravenous Nurses Society chapter PICC council. J Intraven Nurs 1996;19(4):211-5. 28. Jenkins LC. PICC nurses in practice. Radiol Today 2009; 10(7):5. 29. Meyer BM. Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs 2012;35(1):34-42.
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
SEPTEMBER 2012
Greece reports prototype intervention with first peripherally inserted central catheter: Case report and literature review Evangelos A. Konstantinou, RN, PhD, Emmanuil Stafylarakis, RN, MSc(c), Maria Kapritsou, RN, PhD(c), Aristotelis P. Mitsos, MD, PhD(c), Theofanis G. Fotis, RN, PhD, Panagiotis Kiekkas, RN, PhD, Theodoros Mariolis-Sapsakos, MD, PhD, Eriphyli Argyras, MD, PhD, Irini Th. Nomikou, MD, and Antonios Dimitrakopoulos, MD, PhD
Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-yearold male patient suffering from a recent chemical pneumonia with a history of Alzheimer’s disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team. (J Vasc Nurs 2012;30:88-93)
The placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantages over any other method for central venous catheterization. Its ultrasonographical orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy. PICCs provide
From the Evgenidion University Hospital, Nurse Anaesthesia Department, National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; Hellenic-Anticancer Institute, ‘‘Saint Savvas,’’ National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; University of Peloponnese, Sparta, Greece; Highest Technological Educational Institute of Patras, Patra, Greece; National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece; National and Kapodistrian University of Athens, Medical School, Athens, Greece; Evgenidion University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Aegenitio Hospital, National and Kapodistrian University of Athens, Athens, Greece. Corresponding author: Evangelos A. Konstantinou, RN, PhD, Assistant Professor in Nurse Anaesthesiology, University of Athens, Faculty of Nursing, Surgical Nursing Section 123 Papadiamantopoulou str., 11527 Athens, Greece (E-mail: [email protected]). 1062-0303/$36.00 Copyright Ó 2012 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2012.03.001
WHAT’S NEW? The first successful insertion of PICCs in Greece by a nurse An encouragement in inserting PICCs in Greece by a nurse
long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition.1 PICCs are especially useful for short-term treatments and in patients undergoing certain neurosurgical, otolaryngological, oncosurgical and other major surgical procedures involving massive fluid shifts, or when free access to the neck and clavicle is either not possible or not desirable. PICCs also avoid the physical discomfort and psychological distress associated with Trendelenburg position.2
HISTORY The first central venous catheterization was performed during the French–Algerian war in 1952. That year, for the first time, Robert Aubaniac (Figure 1), the innovator of the central venous catheterization, probed into the subclavian vein on a battlefield during the Algerian war. This innovative procedure was recorded in his unique publication with regard to this exceptionally important event in 1952.3 The same year, Seldinger invented the eminent J wire, which happened to be a true revolution, because its utilization ceased the occurrence of endothelium wounds and improved
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Figure 1. Robert Aubaniac. (The photograph was kindly provided to the prime author, by his son, Professor Jean Manuel Aubaniac).
dramatically the atraumatic puncture of vessels. It is also worth mentioning that following this technique, the other complications of the catheterization were considerably decreased.4 The first equipment for peripheral venous catheterization — although its use was not established by images or testimonials — was found in a surgeon’s house in the ruins of ancient Pompeii dating from 67 A.D. and looked like syringes, needles and catheters. Earlier, before 1550 BCE, the Egyptians had described 22 veins that were believed to transport air and liquids. They had also noticed the relation between heart and blood vessels, as recorded in the manuscripts of Edwin Smith. Furthermore, Hippocrates had proposed the midway of the elbow as an anatomical area suitable for the transaction of phlebotomy, the vein that is called the median basilica today.5 In 1616, Harvey first described blood circulation anatomy and physiology in his report Excercitatio Anatomica de Moto Cordis et Sanguinus in Animalbus. He was the one who discovered that the heart is responsible for the circulation of blood; prior to his discovery, in his era it was believed that the center of circulation was the liver and the flow of the blood was related to respiration. However, 200 years after that important medical announcement by that enlightened doctor and researcher, it was believed that bleeding could be controlled by shock bleeding, whereas phlebotomy promoted the coagulation of blood and achieved hemostasis. Harvey’s report offered the theoretical background for Folly to perform the first transfusion of blood from animal to animal in 1654, using a silver and bone venous catheter. The first intravenous case was recorded in 1656 by Wren, who venipunctured dogs and administrated opium, beer and wine to them, using a makeshift syringe made by goose’s feather and pig’s urinary bladder.6 The first report of intravenous administration in humans was published in Clysmatica Nova by Escholtz in 1665; in 1733 Hales tried to measure the human central venous pressure for the first time.7 The first cardiac catheterization to an animal is described in 1844 by Bernard, who also had described the first complication of catheterization (a rupture of the heart) during the effort. In 1818 Blundell performed the first successful blood transfusion. The first successful administration of water and serum in dehydrated patients was carried out by O’Shaughnessy and Latta in victims of cholera, whereas in 1891 Matas dealt with the intravenous administration of similar solutions in patients with shock.8 In 1924, Matas also administered the continuous drip of glucose solution for
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the first time, and in 1944 Dennis, apart from hypertonic glucose, also provided insulin and proteins of plasma to surgical patients.8 On March 17, 1943, Willem Kolff, a young doctor in the small hospital of Kampen, first performed blood dialysis for kidney patients by using metallic and plastic tubes to insert catheters intravenously.9 In 1945, Zimmermann used the polyethylene IV catheter for the first time, which was inserted through a needle already probed in the vein. Later, especially protective mechanisms were added in that system to avoid the cut of the end of the catheter and the subsequent pulmonary embolism.10 The ancestor of venous catheters including the needles we use today was manufactured in 1950 by Dr. Massa, a specialized anesthesiologist at the Mayo Clinic. This was a revolution in probing a peripheral venous catheter, increasing his rates of success, facilitating the mobility of the patients and mainly abolishing the bleeding by the point of entrance that was observed in previous venous catheters, as the needle-driver had a larger diameter than the catheter imported through this.11 In 1949 Duffy announced the hospitalization of 43 patients with central venous catheterization via the external jugular vein or femoral vein.12 The choice of the subclavian catheterization was solidified by extended literature as well as through clinical experience by Keeri in 1956. In 1966, Dudrick, Vars and Rawnsley inserted central venous catheters in dogs via the internal jugular vein.7 In 1960 Quinton, Dillard and Scribner developed an arteriovenous (AV) TeflonÔ shunt, which was inserted near the wrist in the forearm, one into the radial artery and the other into the adjacent cephalic vein. The external ends were connected by a curved TeflonÔ bypass tube.13 After that progress, venous cut-down was established as an emergency procedure during which the vein was exposed surgically and then a cannula was inserted into the vein (usually the saphenous vein) under direct vision. In 1969 Erben probed a catheter in the subclavian vein with a tube made of TeflonÔ and created a revolution in nephrology, allowing the blood dialysis in patients who urgently needed it. The blood dialysis via central venous catheter had complications, the most important being the stenosis of the subclavian vein, when the blood flow was increased inside the circuit.14 At the beginning of 1980, the improvement of these catheters concerned the utilization of tetraflouroethylene, polyurethane or silicon and the addition of one more tube, at the prototype of Hickman catheter. Since then and until recently the provisional catheters of blood dialysis consisted of polyurethane or polyvinyl. Even if they are inflexible and hard materials, they change attitude and become flexible in body temperature, whereas the last pivotal catheters of double tubes in 1987 were made of silastic and silicon, thus allowing their promotion as closer to the right atrium increasing the speed flow of the blood dialysis.7,15 In 1970, the central venous catheterization was the basis for the attainment of a catheterization with the Swan-Ganz catheter of the pulmonary artery, whereas in 1973 Broviac created the implantable partially central venous catheter made of silicon and elastic, the long subcutaneous course that provided the ideal conditions for lasting longer.16 In 1974 Blewitt, Kyger and Patterson, using the Seldinger technique, replaced an existing central venous catheter for the first time with the help of a wire without using a new puncture.17
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The Broviac catheter was enhanced by Hickman in 1979, which increased its useful breadth, using thinner walls and adding a second tube that did not communicate with the first one, so as to administer medicines or solutions simultaneously, the co-administration of which was prohibited with only one line. Then, one more tube was added through which blood aspiration for laboratory examinations were possible, thus abolishing numerous painful peripheral venous punctures for the patients.18 The permanently implanted subcutaneous bells of chemotherapy communicating with the superior vena cava used today, were presented in 1982, and similar devices communicating via a peripheral vein appeared in 1989. Early reports dating from the 1970s described placement of a PICC using silicone tubing, inserted into the peripheral venous system via a cannula-style peripheral IV device. After the tubing reached the vena cava, the IV cannula was withdrawn and a 25-gauge blunt butterfly needle was attached to the distal end of the tubing to serve as the catheter hub. Two skin-closure strips applied in an X configuration covered the coiled, external portion of the catheter to prevent dislodgement.19 The old PICC systems consisted of a needle importer with a particularly large diameter so as to be accessible by the nurse professional by sight and were blindly promoted. Thereby, the median basilic vein was usually selected and following the successful entry to the vein stem, it was promoted to the angle that shapes the innominate vein with the inner jugular vein.19 Their colonizing has been performed with the silk stitch 2.0, whereas the test for a successfully standard placement was made by the venous return following the application of negative pressure through the catheter. The prevalence of thrombophlebitis, however, was particularly high, whereas the edge of the catheter could be only accidentally found in the superior vena cava or in the right atrium. Using this technique, even if we overcame the anatomical difficulties, we did not have the ability to localize the position of the catheter, except with the aid of x-ray methods; however those methods were expensive, time-consuming, laborious and ergonomically unacceptable either in the ward or in the operation room.19 The placement of PICCS has a clear advantage over other methods of central vessel access. The spectacle of a catheter earring from the patient’s head due to an inner jugular vein central line is a common phenomenon in the nursing wards. However it definitely causes significant discomfort in the patient, who cannot comfortably deal with personal hygiene alone and, if a male, cannot shave himself.19 The complications that are reported in the use of central venous catheterization include the rupture of the carotid and damage to adjacent molecules even if its probing occurs under ultrasonic control. On the other hand, insertion of PICCs is performed in a relatively large vessel under ultrasonic guidance. The localization of the vessel takes place by using a smalldiameter needle; there are no adjacent organs such as the trachea, the thyroid gland or the carotid, and the catheter is well tolerated or even invisible when connected with a drip. The patient is able to stroll in the hospital, go home or even go to work with the catheter in place!20 PICC placement can be done in the programs of home care nursing and is one of the challenges that community health nursing has to deal with in the near future. It is widely known that nurses can perform PICC placement.21 This is an official, inter-
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nationally vested nursing action that requires the simultaneous utilization of imaging methods, specifically the ultrasound. Although the cost currently is still higher than that of the simple central catheterization, that cost can be significantly reduced by the use of fewer luxury sets and more limited ancillary equipment involved, making PICCs a cost-effective procedure.22
CASE REPORT A 77-year-old man was referred by our consultant pathologist to the Nursing Department of Anesthesiology of our Hospital to have a 3-lumen PICC inserted. The patient was admitted for chemical pneumonia caused by aspiration 12 days earlier. The patient suffered from Alzheimer’s disease, which prevented communication with him. PICC insertion was chosen because of the lack of a catheterized peripheral vein and after several and repeatedly failed attempts by the nurses and physicians. His wife denied permission to insert a catheter into the internal jugular vein because she feared the complications. A Eutectic mixture of lidocaine and prilocaine ointment (Emla, Astra Zeneca), was placed to a large extent on the inner surface of the brachio 40 minutes before the start of the procedure. The patient was transferred to the operation room in a stimulated mood with the help of two orderlies. The only peripheral catheter (G20) that he had was not functional and we could not administer any sedative drugs, such as midazolam or propofol. The position of his hand was the characteristic position of the sports boxer because of hypertonia. The affiliate nurse, who participated in the insertion of the PICC, tried to open his hand in a mild manner and oral contact, a procedure that almost lasted 20 minutes. The patient was connected with a 3-lead monitor (Nihon Kohden, Japan) with the electrodes located on his right shoulder, his left shoulder and his left hip to provide the largest triangle possible. We administrated oxygen to him by using an oxygen mask (flow at 4 lt /minute) and connected him to a pulse oximeter and a noninvasive blood-pressure device. Although we considered that local anesthesia has been implemented by the ointment, after a thorough cleaning with a solution of a povidone-iodine, we locally infiltrated the skin and the subcutaneous tissues with a solution of lidocaine 2% (xylocaine 2%, Astra-Zeneca), 4 cc in total volume, using a 27 g needle. After the implementation of the sterilized screens, which offered us an interventional field of 10 cm 10 cm in dimension, we put a case on the head of the ultrasound. The basilic vein was easily recognized, located 13 cm to the upper flexural surface of the elbow, because of the decrease of its lumen after implementing pressure, a fact that did not influence the adjacent brachial artery, which remained incompressible during the implementation of the pressure (Figures 2 and 3). The basilic vein was punctured right after we placed the tourniquet, in the preselected point with a needle of a dimension 21g and afterwards completed the confirmation of the unhindered flow of the blood; it was advanced via a needle wire-driver (not J), according to the Seldinger technique, that was easily inserted. Then through the wire-driver we inserted the expander with the introducer. Once we achieved a dehiscence, we proceeded to the point of the entrance with a lance n11. We removed the wire-driver and the expander and we left the introducer. We
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Figure 2. Ultrasound visualization of the vein.
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Figure 4. Right cable connection, with the set’s wire.
Figure 5. P wave elevation. Figure 3. Disappearance of the vein following nurse’s compression.
observed the massive back flow of the blood and covered the end of the introducer with the finger so as to avoid unnecessary bleeding. Estimating patient body measures (height of the patient: 172 cm) and the length of the catheter (40 cm), we decided not to cut the end of the catheter so that the end of the stunt would not be sharp. We promoted the catheter with the driver that was included in the distal lumen via the introducer; we previously used heparin in the tubes and we disconnected the right electrode by the disk of the AgCl electrode of the patient‘s right shoulder and connected him to the wire which was included in the catheter. In this way, we substantially abolished the exterior electrode and replaced it with an internal electrode that was constituted by the system patient’s blood-catheter-serum–wire (Figure 4). When the type of wave P of the electrocardiogram indicated, the insertion of the end of the catheter from the superior vena cava exuded to the right atrium; it was successful, and we proceeded with the colonization of catheter and removed the wire which was included in the system (Figures 5 and 6). A diligent cleaning of the area with sodium chloride and sterilized patches was performed. After that we sprayed the area with Opsite (Smith and Nephew) and after a minute or so we colonized the catheter with the statlock system which applies to the points of the support of the catheter. At that point, 6 cm of the catheter was visible, which suggests that the optimal intervention
would have been to limit its length to 34 cm. The bandage had 4 transparent, sterilized patches. Its complete attachment was checked. The whole process from the moment when the local infiltration was performed to the standstill of the catheter lasted 20 minutes (Figure 7).
DISCUSSION The insertion of a central venous catheter is one of the most common invasive procedures performed today. The catheter should pass through the layers of the skin before entering the bloodstream.23 As Santolucito pointed out, 30% of PICCs are placed at patient discharge on day 8 of the hospital stay as an ‘‘emergency PICC.’’ The patient often has to stay an extra day or two to have a PICC placed in the costly interventional radiology department. This lack of proactive vascular access planning can result in losses amounting to 20% of the DRG payment, whereas proactive planning can result in a 2% overall loss of the DRG.24 Barton et al and Danek and Kilroy indicated that 13% of their study patients had 7 or more days of infusion therapy through short peripheral catheters, and that the vascular access needs of the patient were not met from the outset of a patient’s stay. After the implementation of a triage algorithm to plan vascular access, the hospital saved $500,000 in length of stay (LOS) costs in 1 year. This cost savings could have paid for an entire full-time infusion team.25 On the basis of financial data collected at Oregon Health Science University by Santolucito, a successful peripheral catheter
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Figure 6. Position of the catheter right before sino-atrial node. The superior vena cava and right atrium were dissected in a cadaveric specimen. Note the position of the catheter just before the sinoatrial point. (Cadaveric specimen properly prepared in our laboratory.)
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sional collaboration across a variety of practice settings. The outcome was the development of recommendations for vocabulary, communication, and care/maintenance activities, which could be used by vascular nurses to enhance patient care coordination.27 PICC by nurses provides competent PICC line placement, reduces costs and procedure delays for the patient, and maintains a reasonable revenue stream to the facility. By utilizing a PICC nurse service, the costs to the patients are reduced. In the example hospital, the price for PICC line placement by the nurse is 25% of the cost when performed by an interventional radiologist. In the example hospital, if the radiology practitioner assistant repositions the PICC, the cost is still only 50% of the interventional radiologist. In many institutions, PICC nurses are needed and are valuable assets. In a busy hospital setting where the interventional radiology department services a broad range of critically ill patients, the service can free physicians and their extenders to focus on duties that they are uniquely capable of providing.28 An infusion team can provide the hospital with even greater savings in the form of vascular access planning.
CONCLUSION
Figure 7. Final stabilization of the catheter.
insertion costs $32. If that data is integrated with the studies done by Barton et al and Danek and Kilroy, a successful peripheral catheter insertion is shown to cost $69.76. At what cost to the hospital is the elimination of the highly skilled infusion team when a legal litigation of an infiltration with resultant nerve injury could cost $650,000?26 Growing interest in PICCs led to the development of the PICC Council. This council was established to provide a resource of information for the area nurses involved in PICC use and care. The group went through various developmental stages as they sought to establish cohesiveness and profes-
Many challenges face vascular access nurses as technology improves and patients require more numerous and lengthy intravenous therapies. Nurses began placing PICCs at the patient bedside in an effort to defray costly interventional radiology procedures and provide for patient comfort. In recent years, the numbers of PICC procedures have increased, and the procedure itself has become more technologically advanced. With these advances have come new logistical, environmental, and ergonomic challenges.29 Due to the current financial circumstances in Greece, the effort to develop a new approach for the central venous access is quite difficult, and it would deteriorate if Greece does not have nongovernmental support as well as the personal efforts of health system professionals. PICCs are routinely placed in a many health systems worldwide. In the Greek health system, we have recorded the first successful insertion in human patients and this procedure was performed by a nurse. Although we have not used specialized systems for the localization of the end of the catheter for obvious financial reasons, we believe that we can have equally successful results with a considerably limited cost. As a single case cannot guarantee the safety and efficacy of a method in general, a larger series of studies of Greek patients is mandatory. Such a series is currently under development, and we are putting our best efforts toward this end.
ACKNOWLEDGMENTS The authors wish to thank Teleflex Hellas for providing the portable ultrasound and particularly Mr. Dimitrios Karampinis who always supported the research as representative of the company; Dr Mauro Pittiruti and his collaborators in the Sacro Cuore Hospital in Rome, who trained the nurse who performed the operation; and specially the General Director of Evgenidion Hospital, Mr. George Savvides, who
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was a valued helper and a great supporter in any effort of growth of nursing science, even in the current difficult times in Greece.
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15. Hickman R, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-8. 16. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parentral alimentation. Surg Gynecol Obstet 1973;136:602-6. 17. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol 1953;39: 368-76. 18. Hickman R, Buckner CD, Clift RA, et al. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-8. 19. Ryder MA. Peripherally inserted central venous catheters. Nurs Clin North Am 1993;28(4):937-71. 20. Pikwer A, Akeson J, Lindgren S. Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia 2012;67(1):65-71. 21. Roslien J, Alcock L. The effect of an educational intervention on the RN’s peripherally inserted central catheters knowledge, confidence, and psychomotor skill. J Nurses Staff Dev 2009;25(3):E19-27. 22. Meyer BM. Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs 2012;35(1):34-42. 23. Elliott TS, Moss HA, Tebbs SE, et al. Novel approach to investigate a source of microbial contamination of central venous catheters. Eur J Clin Microbiol Infect Dis 1997;16:210-3. 24. Santolucito JB. The role of peripherally inserted central catheters in the treatment of the critically ill. JAVA 2007;12(4): 208-17. 25. Kokotis K. Cost Containment and Infusion Services. J Infus Nurs 2005;28(3):22-32. 26. Higuchi KA, Edwards N, Danseco E, et al. Development of an evaluation tool for a clinical practice guideline on nursing assessment and device selection for vascular access. J Infus Nurs 2007;30(1):45-54. 27. Papke L. The growth and development of an Intravenous Nurses Society chapter PICC council. J Intraven Nurs 1996;19(4):211-5. 28. Jenkins LC. PICC nurses in practice. Radiol Today 2009; 10(7):5. 29. Meyer BM. Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs 2012;35(1):34-42.