PICCs deemed safe for extended use

Most children at a medical center in Israel did not experience complications related to peripherally inserted central venous catheters, but certain factors may contribute to the development of infectious and noninfectious health problems in pediatric patients, according to study data.

Despite the growing use of peripherally inserted central venous catheters (PICCs) in children, there is a deficit in research on the effects of their use in this population.

“Most of the current data on complications are derived from retrospective studies of the general adult population, or adult patients with cancer or small cohorts,” wrote researchers at the Schneider Children’s Medical Center of Israel. They also pointed out that researchers of other studies involving children focused on immunocompromised patients and did not define risk factors for the pediatric age group.

The researchers therefore conducted a prospective surveillance study on patients in whom PICCs had been inserted between August 2004 and October 2006 to describe PICC use in a hospitalized pediatric population. They also evaluated rates of PICC–associated complications and risk factors.

Children and youth aged 7 days to 21 years who underwent treatment via PICC in different hospital departments comprised the study sample, according to the researchers. Additionally, unlike at most medical centers, anesthesiologists inserted the PICCs as opposed to invasive radiologists or IV nursing teams. Inpatient nurses were responsible for PICC maintenance and care after insertion. The researchers performed follow-up throughout the study and documented all incidences of catheter insertion, even if repeated in the same patient.

Two hundred seventy-nine PICCs were inserted in 221 patients whose ages ranged from 10 days to 21 years. The researchers reported no complications at insertion, and the mean dwell time was 30 days.

Results indicated that 63% of placements had no complications during the study period, although 9.3% of PICCs were accidentally dislodged and 13.8% were removed for mechanical problems such as tears, leaks and obstructions. Infectious complications — including phlebitis, exit-site infection, catheter-associated bloodstream infection and catheter-related bloodstream infection — caused removal in 13.6% of the insertions, the researchers noted.

PICC colonization occurred in 12.5% of insertions. Coagulase-negative Staphylococcus was the most commonly isolated organism, and data also showed the presence of methicillin-susceptible S. aureus, gram-negative rods, Candida albicans and polymicrobial bacteria.

The researchers also identified risk factors for developing PICC–related complications. “The results showed that absence of infection at baseline, composite indication for PICC use and older patient age were significantly associated with infectious complications,” they wrote. The researchers said, however, that sex of the patient, site of insertion, side of insertion and dwell time did not significantly affect the probability of developing infectious complications.

The researchers also reported that mechanical complications were most often attributed to underlying malignancy (P=.04) and composite use of the PICC (P=.02).

“The present study suggests that PICCs, when inserted by an anesthesiologist, can be relatively safe when used for a variety of indications in infants and children, even for prolonged periods, and are associated with fewer bloodstream infections than tunneled central venous catheters,” the researchers wrote. – by Melissa Foster

Levy I. Pediatr Infect Dis J. 2010;29:426-429.

The researchers of this very nice prospective study accomplished the stated purpose of further characterizing the utility and complications related to PICCs in children, particularly the infectious complications. One would expect most of the results shown in the study, such as the finding that microbiology of infected PICCs are usually coagulase-negative Staphylococcus and S. aureus, followed by gram-negative rods and Candida. Also, the researchers indicated that the line was more likely to have an infectious complication if used for more than one purpose and less likely if being used to treat an infection such as osteomyelitis or septic arthritis — adding scientific evidence to what most of us had observed over the years.

However, the suggestion that placement of the PICC by anesthesiologists in the operating room is less likely to have an infectious complication was just a suggestion and not proven. It would seem to me that to prove that theory they would have needed a second team placing the PICC lines — such as interventional radiology or a special-trained team as many hospitals have, usually made up of critical care physicians and nurses — to compare with the anesthesia team, with the lines otherwise cared for by the same nursing staff in the same way after placement. It would obviously take more patients to accomplish this, but there is no shortage of PICC–managed patients nowadays.

Also, it would help to know how long after placement of the line that the infections occurred. There are placement-related infections that would be directly related to the environment and technique being used in placement of the line, such as a site infection, and would more likely occur within the first week after placement. Then there are use-related infections that might be more likely to cause a PICC–related or associated infection, which can occur anytime after the first few days but typically after it has been used for a couple of weeks or more, using improper technique. The number of days from placement to infection was not tabulated in the study. We use interventional radiology for the vast majority of our PICC placements in children at our institution, and our infection rate is no more than that found in the study. But then again, that is not an evidence-based statement.

Lastly, for certain PICC–related or associated infections, many centers (including ours) will use an antibiotic or medical grade ethanol in a protocol to dwell in the line in an attempt to clear the organism and save having to pull it. If a study like this is undertaken again, it might be useful to study a group of patients who might be good candidates for this PICC salvage technique and to add some prospective data to this rapidly growing aspect of hospital and home therapy using PICCs.

– James H. Brien, DO
Infectious Diseases in Children Editorial Board