Transcript picc complications

Vascular access in neonates:
what we have vs. what we could have
Vs.
Dr. Diana N. Diaz
Assistant Professor of Pediatric Surgery
ZUMS
much
responsibility for
Nurses assume
the administration of intravenous
therapy…
With these consequences…
General surgeons feel
overconfident when
dealing with children…
With these consequences…
Neither residents of Pediatrics
nor Neonatology fellows get
formal training in i-v line
placement
Just blood sampling….
Necrotic hand
In the end, the pediatric Surgeon is
called……….
…..just for this
…and what do we have?
1. Loneliness
2. Inadequate materials
3. Moribund patients
The materials
List of venous access devices (CHOP,
April 2009)
List of venous access devices (CHOP,
April 2009)
Materials
Our setting
CUT-DOWN
Peripheral i-v line
If unsuccessful
Sick neonate
Intraosseous line
Vascular access in children requires
skill, time, patience, and the
appropriate equipment.
Surg Clin North Am. 1992 Dec;72(6):1267-84.
Vascular access techniques and devices in the pediatric patient.
So...
What do we need?
1.Cooperation = TEAM WORK
2. Adequate materials = PICC
(?)
3. Patients in better shape =
THINK AHEAD
The importance of a
VASCULAR ACCESS
SERVICE
VAS team is multidisciplinary
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i-v team
Interventional Radiology nurses
Technologists
Physicians, NEONATOLOGISTS!
Infection/prevention control specialists
Information systems control personnel
JPSN Vol.11, Number 4, October,2006
i-v team
1.
2.
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5.
Criteria for team membership
NICU experience,
Communication and organization skills,
Motivation,
IV insertion expertise,
Schedule flexibility
Neonatal Peripherally Inserted Central Catheter Team: Evolution and Outcomes of a Bedside-Nurse–
Designed Program Advances in Neonatal Care Issue: Volume 7(1), February 2007, p 22–29
Training of the Team
1.
2.
3.
4.
Review of PICC manufacturer guidelines,
Insertion and dressing techniques,
Radiographic confirmation of placement,
Recognition and management of
complications
Clinical practicum
• 5 successful insertions, initially supervised
• Groups of 2 nurses trained at a time
Catheter Care Committee
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Oncologist
Pediatric Surgeon
Advanced Practice Nurse manager
Infection prevention and control specialists
Materials management personnel
Quality practice specialist
Patient safety specialist
JPSN Vol.11, Number 4, October,2006
PICC
Peripherally Inserted
Central Catheters
PICC
Since 1971 showed to be superior to
CUT-DOWNS
Filston HC,Jhonson DG.Percutaneous venous canulation in neonates and
infants.A method of catether insertion without cut-down.Pediatrics 1971 ;48
896-901
Although a PICC is
inserted peripherally,
the tip terminates in the
superior vena cava
Indications of PICCs
“Infusion Nurses Society” 2006,
RNAO guide “Registered Nurses'
Association of Ontario” (RNAO
2004) and RCN Standards “Royal
College of Nursing” (RCN 2005),
Indications
1. Medication with pH < 5 or pH > 9.
2. Drugs with osmolarity >600 mOsm/L (INS
2006) or 500 mOsm/L (RNAO 2004).
3. Parenteral Nutrition with osmolarity superior
glucose 10% or 5% aminoacids.
4. Administration of irritant drugs
5. Safe route for cardiovascular drugs
Indications (cont.)
6. Parenteral Nutrition inferior to 3-4 weeks
duration.
7. Keep vascular integrity
8. Minimum child manipulation due to
pathology (Pulmonary
hypertension,VLBW)
9. Treatments longer than 6 days
Indications (cont.)
10. VLBW patients who cannot be fed for
more than 7 days
11. Inadequate peripheral access
12. Patient in need of more than one
peripheral vascular access
Medications that are considered irritants due to chemical structure,
pH or osmolarity
Acyclovir pH 10.5
Penicillin pH 10
Amphotericin B irritant
Bactrim pH 10
Cipropraxin pH 3.3
Dilantin pH 12
Dobutamine pH 2.5
Phenergan pH 4.0
Potassium pH 4.0 hypertonic
Rocephin mixed hypertonic Tobramycin pH3.0
TPN and PPN hypertonic > 600m Osm
Vancomycin pH 2.4
Doxycycline pH 1.8
Erythromycin irritant
Gancyclovir pH 11
Lidocaine
Morphine pH 2.5
Nafcillin pH 10
Dopamine pH 2.5
Pentamidine pH 4.09
Contraindications
• Sepsis: if a patient has a positive blood
culture, it may be indicated to treat the
patient with peripheral antibiotics for 48 to 72
hours and confirm a negative blood culture
before a PICC is placed.
Contraindications
• Peripheral neuropathy,
• Circulatory impairment, burns, or radiation to
the insertion site or along the intended path of
the catheter.
History of thrombosis
• Dermatitis, hematomas, or burns that would
prevent peripheral or antecubital access.
Contraindications
• Injury or infection to the extremity: if
a patient has osteomyelitis of the left shoulder,
you should not place a PICC in the left
extremity. Avoid PICCs in an extremity with an
injury or infection.
Advantages for Pediatric Surgeons
1. BETTER CARE
2. MORE TIME TO WORK AS
PEDIATRIC SURGEONS
3. REDUCE ANXIETY AND STRESS
4. HAPPIER NURSES
5. HAPPIER PARENTS
Peripheral IV cannula Vs PICC
☻ Conventional IV cannula - life
☻ Access sites
1-3 days.
rapidly exhausted.
☻Pain inflicted by repeated cannulation.
☻Rate of phlebitis and catheter associated infection higher.
☻Cost-benefit ratio unfavorable.
West J Med. 1994 Jan;160(1):25-30
PICC vs PIV
Phlebitis
– PICC 9,9%
– PIV34,5%
• Catheter Sepsis
– PICC 4,6%
– PIV 9%
• More duration
– PICC 11days
– PIV1,2 a 2,9 days
Efficacy of peripherally inserted central venous catheters placed in noncentral veins. Arch. Pediatr Adolesc Med.
1998. May;152(5):436-9
PICC vs PIV
• PICC insertion is successful in the great
majority of cases. Lower risk of infection
than multiple i-v line insertion in VLBW
• Take into account the pain due to multiple
punctures
Liossis G, Bardin C, Papageorgiou A, Comparison of risks from percutaneous central venous catheters and peripheral lines
in infants of extremely low birth weight: a cohort controlled study of infants < 1000 g. J Matern Fetal Neonatal Med.
2003 Mar; 13 (3) :171-4
Review of literature – PICC Vs CL
• Much safer Can be inserted by registered nurses at the
.
bedside.
• Lower rate of mechanical complications -
pneumothorax, haemothorax.
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Practically no contraindications.
• Cheaper, Easier to maintain, have a longer dwell
time.
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Smaller and more comfortable for the child.
• Allows early discharge and outpatient continuation of therapy
Singapore Med J 2003 Vol 44(10) : 531-535
IRC according to NEO-KISS
January 2000 – December 2004
VLBW < 500g
Bacteriemia associated to catheters
Central venous line 14.2
PICC 9.6
<1.000 g and 1000-1499 g
Bacteriemia associated to catheters
Central venous line 11,1
PICC 7,8
(Number of infections x 1000 patients/day)
Peter Heeg 2006
CVLine + hemothorax
Tunneled CVL Versus PICC Lines
• The pediatric surgeon places them!!... At the
femoral vein…
• There is no difference in efficacy or associated
complications between the two groups.
• Journal of Perinatology 2001; 21:525–530.
But….
24-gauge Quick Cath catheter
?
Again no materials…….
Umbilical venous catheters
• Very sick newborn or very inmature
during the first 48 H of life
• For exchange transfusion
• Any type of drugs can be infused,
blood and byproducts (except platelets)
• In VLBW could last from 7-14 days
J.Perinatal 1996;16:461-6
Complications
Umbilical Artery
Ischemia
Massive
bleeding
Distal
necrosis.
Thrombosis
Umbilical Vein
Air
Embolism
Pulmonary
Bleeding
Embolism
Thrombosis
Arterial spasm
After manipulation of umbilical catheters arterial & venous
NB 27 WGA. 2º day of life.PDA.
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1 Paulson PR, Miller KM Neonatal peripherally inserted central catheters: recommendations for
prevention
of insertion and postinsertion complications. Neonatal Netw. 2008 Jul-Aug; 27(4):245-57
2 López Sastre J B, Fernández Colomer B, Coto Collado G D y Ramos Aparicio A. Estudio prospectivo
sobre catéteres epicutáneos en neonatos. Grupo de Hospitales Castrillo. Anales Españoles de
Pediatréa.
2000 ; 53 ( 2).
3 Cartwright D W.. Central venous lines in neonates: a study of 2186 catheter. Arch Dis Child Fetal
Neonatal Ed 2004;
89: F504 – F508.
4 Pettit, J. Technological advances for PICC placement and management. Advances in Neonatal
Care.
2007; 7: 122–131.
5 Pettit J. Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the
most
frequently occurring complications. Adv Neonatal Care. 2002 Dec;2(6):304-15.
6 Pettit J. Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less
frequently occurring complications. Adv Neonatal care, 2003, February; 3(1):14-26.
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7 Amerasekera SS, Jones CM, Patel R, Cleasby MJ. Imaging of the complications of peripherally
inserted
central venous catheters. Clin Radiol. 2009 Aug;64(8):832-40. Epub 2009 Jun 16.
8 Todd T. Nowlen, Geoffrey L. Rosenthal, Gregory L. Johnson, Deborah J. Tom and Thomas A. Vargo.
Pericardial Effusion and Tamponade in Infants With Central Catheters. Pediatrics 2002;110;137-142.
Downloaded from www.pediatrics.org by on March 9, 2010
9 Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal
continuing
medical education: do conferences, workshops, rounds, and other traditional continuing education
activities change physician behavior or health care outcomes? JAMA 1999; 282:867-74. Metaanálisis
10 O 'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Reuniones y talleres de
educación
continua: efectos sobre los resultados en la práctica profesional y la asistencia sanitaria. Base de
Datos
Cochrane de Revisiones Sistemáticas (Cochrane Database of Systematic Reviews) 2001,
11 Filston HC,Jhonson DG.Percutaneous venous canulation in neonates and infants.A method of
catethe
Shaw, J.C.L. Parenteral Nutrition in the Management of Sck Low Birthweight
Infants.Pediatric Clinics of
NorthAmerica 1973 29 (2) 333-358 A14
13 García-Alix A, Pérez J, Serrano M, López JC, Quero J. Retained central venous lines in
the newborn:
Report of one case and systematic review of the literature. Neonatal Networ
March/April 2007. Vol. 26, Nº
2,
14 Bueno T M, A. I. Diz, P. Q. Cervera, J. Pérez-Rodríguez, J. Quero. Peripheral insertion
of double-lumen central venous catheter
using the Seldinger technique in newborn. Journal of Perinatology 2008; 28(4), 282–
286.
15 Goñi Orayen C., R. Ruiz Cano, M. C. Carrascosa Romero, M. S. Vázquez García, A.
Martínez Gutiérrez. Accesos venosos
centrales por técnica de Seldinger en Neonatología. Cir Pediatr 1999; 12: 165-167.
16 Mickler PA. Neonatal and Pediatric Perspectives in PICC Placement. J Infus Nurs.
2008 SepOct;31(5):282-5.
Upper Versus Lower Extremity Insertion. Pediatrics 2008 May; 121(5):e1152-9.
Not even ONE article that
proved the superiority of
CUT-DOWNS over PICCs.
Cut-down technique for intravenous infusion in
infants.
Wright JE.
1972
Med J Aust.
Jun 3;1(23):1203-6.
No abstract available.
We need a transition
Shifting from open surgical cut down to
ultrasound-guided percutaneous central venous
catheterization in children: learning curve and
related complications
Pediatric Surgery International 2010 Aug;26(8):819-24. Epub 2010 Jun
20.
PICC lines were excluded from the study
Percentage of CVCP-related complications in the 4 monthly data grouping. Learning
curve to achieve appropriate levels of competence in US-guided CVCP positioning may
explain the progressive decrease in complication rate especially in the second part of the
study
Pediatric Surgery International 2010 Aug;26(8):819-24. Epub 2010 Jun 20
Profesional staff
• Training of nurses in charge of indication,
insertion y maintenance Egginamp p ,et al. Lancet 2000; 355 :
1864-8
• Make sure that the staff acts according to
general policies
Meta-análisis JAMA 1999; 282:867-74
• Appropriate number of nurses: 1-2
patients / nurse
Vein Selection
Vein Selection
TIPS
1. Right arm basilic vein First OPTION
2. Scalp veins DILATE easily and do not have
valves
3. External jugular: Bleeds, risk of gas
embolism, hard to compress, fix, position.
Close to airway.
4. Lower limbs LESS INFECTIONS
Hoang V, Sills J, Chandler M, Busalani E, Clifton-Koeppel R and Modanlou H D. Percutaneously Inserted Central
Catheter for Total Parenteral Nutrition in Neonates: Complications Rates Related to Upper Versus Lower Extremity
Insertion. Pediatrics 2008 May; 121(5):e1152-9.
Vein Selection
TIPS
1. Saphenous access gives more phlebitis
Giraldo I, Quirós A, Mejía LA.Manejo de catéteres centrales de inserción periférica en
recién nacidos. Aquichan. 2008; Vol. 8, Nº. 2:257-265
2. Popliteal access is more difficult to reach
a central vein
3. Femoral vein too deep
¿PICC in lower limbs?
• Less infection than the ones inserted at upper
limbs
• Complications take longer to detect
• Less cholestasis in spite of long lasting TPN
Lower limbs can be used for PICC insertion
Hoang V, Sills J, Chandler M, Busalani E, Clifton-Koeppel R, Modanlou HD Percutaneously inserted
central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower
extremity insertion. Pediatrics. 2008 May;121(5):e1152-9.
PICC COMPLICATIONS
25% of total lines
PICC COMPLICATIONS
INSERTION COMPLICATIONS
POST-INSERTION COMPLICATIONS
PICC COMPLICATIONS
ALL COMPLICATIONS
ARE MANAGEABLE
INSERTION COMPLICATIONS
1. PAIN (Sacarose 2ml 24% BEST )Taddio A, Shah
V, Hancock R, Smith RW, Stephens D, Atenafu E, Beyene J, Koren G, Stevens
B, Katz J. Effectiveness of sucrose analgesia in newborns undergoing painful
medical procedures. CMAJ. 2008 Jul 1;179(1):37-43.
2. HEMORRAGE (introducer TOO BIG)
3. Arterial puncture (polyurethane)
4. Cardiac Arrhythmia
5. Nerve injury
6. Difficulty with advancing catheter
Complications
• Other complications
– Arritmias
– Carciac perforation(0,25%). Pericardiac effussion
Cardiac tamponade
• More incidence in PVC catheters
– Rupture & catheter migration
– Difficult in catheter removal
• More incidence in silicone catheters
Serrano M, García-Alix A, López JC, Pérez J, Quero J. Retained central venous lines in the newborn: report of one
case and systematic review of the literature. Neonatal Netw. 2007 Mar-Apr;26(2):105-10
Difficulty with advancing catheter
• Specially in children with
chronic
pathologies
• Long time with i-v therapy
• Massage, limb reposition and flushing
helps
POST-INSERTION COMPLICATIONS
1.
2.
3.
4.
5.
6.
7.
8.
Phlebitis
Occlusion and Clotting
Hemorrhage
Thrombosis and Deep Vein Thrombosis
Infection
Emboli, Air
Emboli, Catheter
Catheter Malpositioning and Migration
Most common catheter-related
complications
1. Catheter-related blood-stream infection (CRBSI;
incidence: 8.3 per 1000 catheter days),
2. Catheter occlusion (4.0 per 1000 catheter days),
3. Catheter site inflammation (3.5 per 1000 catheter
days),
4. Phlebitis (3.1 per 1000 catheter days).
The most common pathogen of CRBSI was
coagulase-negative staphylococcus (40.1%)
Neonatol. 2010 Dec;51(6):336-42.
Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous
catheters in very low birth weight infants: a center's experience in Taiwan.
Hsu JF, Tsai MH, Huang HR, Lien R, Chu SM, Huang CB.
Risk factors of CRBSI
• 1. Catheters inserted at femoral sites (increased
risk of CRBSI compared with nonfemoral
catheters: 1.76; 95% confidence interval, 1.013.07, p = 0.045)
• 2. Longer duration of PICC placement (p <
0.001).
• A low birth body weight and gestational age were not
found to significantly affect the risk of CRBSI.
Neonatol. 2010 Dec;51(6):336-42.
Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous
catheters in very low birth weight infants: a center's experience in Taiwan.
Hsu JF, Tsai MH, Huang HR, Lien R, Chu SM, Huang CB.
• PICCs have an infection rate of only 0.4% per
1,000 patient days, whereas acute care
noncuffed, noncoated, and nontunneled
catheters had an infection rate of
1,000 patient days.
2.2% per
Journal of Infusion Nursing Issue: Volume 28(1), January/February 2005, p
45–53
Occlusion and Clotting
• Partial occlusion
• One-way occlusion
• Total occlusion
PREVENTION IS THE
MOST IMPORTANT
Catheter malposition
Catheter malposition
Catheter malposition
Catheter malposition
Catheter malposition
Catheter malposition
Catheter malposition
Type of complications:
Central versus Non central
Complications
Central
n=1096
Non central
n=170
P Value
Phlebitis
16 (1.5%)
17 (10%)
<.001
Occlusion
19 (1.7%)
11 (6.5%)
<.001
Rupture
1 (.1%)
19 (11.2%)
<.001
Mechanic
4 (.3%)
2 (1.2%)
.187
Infection
2 (.2%)
0
1.000
Total
42 (3.8%)
49 (28.8%)
<.001
Jhon M. Ricardio, Darcy A. Doellman y cols. Pediatric Peripherally Inserted Central Catheters: Complication
Rates Related to Catheter tip localition . Pediatrics 2001;107;28
The two most serious complications are
infection and thrombosis.
Infection rates with PICCs continue to be low
(in one study as low as .4/1000 catheter days)
but varies with differing age groups
Prevention is the key to maintaining a
low complication rate
When shall we remove the
catheter?
The catheter should be removed when
• Its use can be no longer justified
• Bacteraemia and/or clinical symptoms
persisting beyond 48-72 hours despite
appropriate antibiotic therapy
• Septicaemia due to fungal infection
• Evidence of septic emboli or endocarditis
• Limb becomes increasingly oedematous
􀂄 Position the patient in a supine position.
􀂄 Apply sterile gloves.
􀂄 Remove the dressing.
􀂄 Grasp the catheter and have sterile gauze
ready in your other hand.
􀂄 Pull with gentle, steady pressure but stop the
removal if there is resistance.
• Contact the physician, apply heat, reposition
the limb and consider trying removal again
later or the next day.
• Do not pull against resistance.
In conclusion
The lack of correct vascular access
Raises morbidity and mortality
Prolongs hospitalization
Raises the sanitary expenditure
.
(Pratt et al. 2001; EPIC)
So…
Isn’t it worth to give a try with
PICCs?
Thank you