Abstract

Approximately 4.3 million peripherally inserted central catheters (PICCs) are placed each year. Currently, there are no national-level comparative data registries to gather information regarding PICC placement, care, or maintenance, and there are no benchmarks or quality measures for vascular access specialists. As the specialty of vascular access evolves from placing peripheral intravenous catheters and administering infusions to the placement of more advanced devices such as PICCs and other central venous access devices, the lack of national comparative data becomes more significant. Without consistent, comparative data, vascular access specialists cannot demonstrate the high level of clinical outcomes provided for patients or justify the value of the specialty to hospital administrators or third-party payers. Data collection must evolve to improve quality and show cost-effectiveness. National-level comparative data collection has been used for decades by physicians to implement quality initiatives and improve patient care. Comparative data can now easily be provided using informatics technologies like the Internet to collect and analyze data for improved clinical outcomes. Vascular access teams must begin using data registries for collecting comparative data, allowing the development of benchmarks and improved quality measures.

Abstract

Objective: To provide evidence for selecting an appropriate peripherally inserted central catheter (PICC) insertion technique by comparing the insertion success rate and the incidence of complications with 3 PICC insertion techniques.

Methods: We assigned enrolled patients to 3 groups according to the insertion technique selected by the individual patient: Group A, usual insertion technique (traditional, blind insertion); Group B, Modified Seldinger Technique (MST) insertion without ultrasound guidance; and group C, ultrasound-guided MST insertion. We compared the insertion success rate and the incidence of complications among these groups.

Results: When comparing these 3 PICC insertion techniques, no significant difference was seen with respect to the insertion success rate and the incidence of catheter malposition (P > 0.05), although a significant difference existed in the incidence of bleeding at the insertion site after the PICC procedure (P < 0.05), with the ultrasound-guided MST insertion technique superior to the other 2 techniques; the incidence of mechanical phlebitis and catheter occlusion during the use of PICC had no significant difference among the 3 groups (P > 0.05); but a significant difference was seen in the incidence of thrombosis and catheter-related infections (P < 0.05), with a lower incidence in the ultrasound-guided MST insertion group than that in the other 2 groups.

Conclusions: Ultrasound-guided MST insertion technique may address the problems occurring in patients with poor vascular access during the PICC procedure, whereas the usual insertion technique is the best choice for patients with good vascular access and poor economic status. Therefore, the selection of an appropriate insertion technique should be based on the economic and vascular status of the individual patient in clinical practice.

Abstract

Background: The Cook Vital Port system was observed with fluoroscopy before elective removal. A previous publication noted that catheter fracture with this device occurred at the entry of the catheter into the vein used for catheter deployment. We hypothesized that catheter rupture at the vein entry site may be due to ballooning of the catheter during injection, or possibly due to angulation of the catheter during arm movements.

Methods: Port system contrast injection and fluoroscopy was performed for 50 consecutive patients who attended for elective arm vein port removal. Assessment of the angle of entry of the catheter into the arm vein was performed with the arm in anatomic position and during arm movements.

Results: There was no evidence of catheter ballooning or distortion during contrast injection. There was no evidence of fibrin sheath formation at the catheter tip. One catheter was observed to leak at the vein entry site with the injection of contrast. The only arm movement that affected the angle of the catheter at the vein entry site was flexion at the elbow. The average change in the angle of the catheter between anatomic position and full elbow flexion was 22.4°C.

Conclusions: The hypothesis of ballooning of the catheter at the vein entry site during injection was not confirmed. We observed a wide variation in catheter angulation with elbow flexion. The exact cause for catheter fracture remains unknown.

Abstract

Background: Peripherally inserted central catheters (PICCs) are increasingly inserted by trained registered nurses, necessitating the development of specialized skills such as the use of ultrasound. The selection of an adequately sized vein is an important factor in reducing adverse events such as deep vein thrombosis. However, PICC nurses may receive minimal training in the use of ultrasound for vein measurement.

Objective: We aimed to demonstrate the reliability of a vein measurement protocol using ultrasound by a PICC nurse trained in sonography.

Methods: The diameter of the basilic, brachial, and cephalic veins in the left arms of healthy participants (n =12) were measured using ultrasound by a PICC nurse and a sonographer. A PICC nurse performed the measurement twice and the sonographer once; the PICC nurse's results were compared for intra-rater reliability and compared with the sonographer for inter-rater reliability. The results were analyzed using intraclass correlation coefficients (ICCs).

Results: Inter-rater reliability between the PICC nurse and the sonographer was adequate, the ICC for the brachial vein was 0.60 (95% confidence interval [CI], 0.06–0.87), basilic vein ICC was 0.87 (95% CI, 0.58–0.96) and cephalic vein ICC was 0.77 (95% CI, 0.39–0.93). Intra-rater reliability of the PICC nurse was higher; the ICC for the brachial vein was 0.80 (95% CI, 0.44–0.94), basilic vein ICC was 0.92 (95% CI, 0.67–0.98), and cephalic vein ICC was 0.78 (95% CI, 0.40–0.93).

Conclusions: Using a suitable protocol, a PICC nurse was able to measure vein diameter reliably when compared with a sonographer and consistently replicate these results.

Abstract

Background: The insertion of a long line can be a dreaded aspect of receiving courses of intravenous antibiotics for respiratory exacerbations associated with cystic fibrosis. Our study evaluates the use of ultrasound guidance in a pilot scheme to improve the experience of line insertion.

Methods: Fifty-five patients commencing intravenous antibiotics for respiratory exacerbation had a long line inserted using conventional Seldinger technique, whereas 18 patients had a line inserted after the introduction of ultrasound guidance. Patients completed a questionnaire to score their satisfaction with line placement and longevity. Complication rates of the lines inserted were recorded prospectively.

Results: No significant difference was found in satisfaction with line placement, line longevity, or number of attempts required to insert the line. Qualitative assessment suggests that patients preferred the use of ultrasound.

Conclusions: Our study shows that routine ultrasound guidance is not associated with improvement in clinical variables, but it does have a role in the management of cystic fibrosis in adult patients.