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The Michigan Appropriateness Guide for Intravenous Catheters(MAGIC): Results From a Multispecialty Panel Using the RAND/UCLAAppropriateness MethodVineet Chopra, MD, MSc; Scott A. Flanders, MD; Sanjay Saint, MD, MPH; Scott C. Woller, MD; Naomi P. O’Grady, MD;Nasia Safdar, MD, PhD; Scott O. Trerotola, MD; Rajiv Saran, MD, PhD; Nancy Moureau, BSN, RN; Stephen Wiseman, PharmD;Mauro Pittiruti, MD; Elie A. Akl, MD, MPH, PhD; Agnes Y. Lee, MD, MSc; Anthony Courey, MD; Lakshmi Swaminathan, MD;Jack LeDonne, MD; Carol Becker, MHSA; Sarah L. Krein, PhD, RN; and Steven J. Bernstein, MD, MPH

Use of peripherally inserted central catheters (PICCs) has grownsubstantially in recent years. Increasing use has led to the real-ization that PICCs are associated with important complications,including thrombosis and infection. Moreover, some PICCs maynot be placed for clinically valid reasons. Defining appropriateindications for insertion, maintenance, and care of PICCs is thusimportant for patient safety.

An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use ofPICCs. After systematic reviews of the literature, scenarios re-lated to PICC use, care, and maintenance were developed ac-cording to patient population (for example, general hospitalized,critically ill, cancer, kidney disease), indication for insertion (infu-sion of peripherally compatible infusates vs. vesicants), and du-ration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days).Within each scenario, appropriateness of PICC use was com-pared with that of other venous access devices.

After review of 665 scenarios, 253 (38%) were rated as appro-priate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappro-priate. For peripherally compatible infusions, PICC use was ratedas inappropriate when the proposed duration of use was 5 orfewer days. Midline catheters and ultrasonography-guided pe-ripheral intravenous catheters were preferred to PICCs for usebetween 6 and 14 days. In critically ill patients, nontunneled cen-tral venous catheters were preferred over PICCs when 14 orfewer days of use were likely. In patients with cancer, PICCs wererated as appropriate for irritant or vesicant infusion, regardless ofduration.

The panel of experts used a validated method to develop ap-propriate indications for PICC use across patient populations.These criteria can be used to improve care, inform quality im-provement efforts, and advance the safety of medical patients.

Ann Intern Med. 2015;163:S1-S39. doi:10.7326/M15-0744 www.annals.orgFor author affiliations, see end of text.

Reliable venous access is a cornerstone of safe andeffective care of hospitalized patients. Spurred by

technological advances, several venous access devices(VADs) for use during and beyond hospitalization areavailable to meet this need. In recent years, peripher-ally inserted central catheters (PICCs) have becomepopular for venous access in hospital settings (1, 2).Compared with traditional central venous catheters(CVCs), PICCs offer several advantages, including saferinsertion in the arm, cost-effective and convenientplacement via vascular access nursing teams, and self-care compatibility that facilitates use beyond hospital-ization (3–5). It is therefore not surprising that use ofPICCs has grown considerably worldwide (6–8).

Despite these advantages, PICCs are central ve-nous catheters that may lead to important complica-tions (9). For instance, problems such as luminalocclusion, malpositioning, and dislodgement occur fre-quently with these devices (10–12). Similarly, superficialthrombophlebitis or infection at the site of PICC inser-tion may occur despite uneventful and optimal place-ment (13, 14). In addition, PICCs are associated withmorbid complications, including venous thromboem-bolism and central line–associated bloodstream infec-tion (15–17). Ensuring appropriate use of PICCs is thusvital to preventing these costly and potentially fatal ad-verse events.

A growing number of studies suggest substantialvariation and potentially inappropriate use of PICCs inhospitalized patients. For example, in a study from a

large academic medical center, many PICCs were notactively used or were inserted in patients who also hadperipheral intravenous catheters (18). In a decade-longstudy conducted in a tertiary hospital, changes in pat-terns of PICC use, including shorter dwell times andambiguous indications for insertion, were reported(19). Additional cause for concern comes from a recentstudy, which found that 1 in 5 inpatient providers didnot know that their patients had CVCs, with lack ofawareness being greatest for PICCs (20). Surveys of in-patient providers have also demonstrated knowledgegaps related to appropriate indications and care prac-tices for PICCs (21, 22). Collectively, these data havenot only led to reviews of PICC use in hospitals (23) butalso to calls by the Choosing Wisely initiative to im-prove PICC practices across the United States (24, 25).

The concepts of inappropriate overuse and under-use of medical devices are by no means unique toPICCs. Rather, such issues accompany the diffusion ofmany novel health technologies. In many such in-stances, a key barrier to achieving appropriate use is

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the fact that evidence at a level of detail needed toapply to the range of patients seen in everyday practiceis not available. Nevertheless, clinicians must makechoices regarding such innovations on a daily basis,potentially fueling inconsistent practice. In the absenceof high-quality evidence, an approach that combinesavailable data with the experience and insight of clini-cal experts is valuable as it would provide guidancewhere none is otherwise available.

Given this background, we organized and con-ducted a multidisciplinary meeting of national and in-ternational experts to develop appropriateness criteriafor use, care, and management of PICCs and relatedVADs in hospitalized patients. Our objectives were to 1)develop a list of appropriate indications for use ofPICCs in relation to other VADs, 2) define the appropri-ateness of practices associated with the insertion andcare of PICCs, 3) determine appropriate practices fortreatment and prevention of PICC complications, and4) rate the appropriateness of peripheral intravenouscatheter use in situations that prompt PICC placement.

METHODSOverview of the RAND/UCLA AppropriatenessMethod

We used the RAND Corporation/University of Cali-fornia Los Angeles (RAND/UCLA) AppropriatenessMethod to create criteria for appropriate use of PICCsand related VADs (10). Introduced in the 1980s, theRAND/UCLA method was developed to enable mea-surement of overuse of medical and surgical proce-dures. According to this methodology, a procedure isconsidered appropriate when the “expected healthbenefits (e.g., increased life expectancy, relief of pain,reduction of anxiety or pain) exceed the expected neg-ative consequences (e.g., mortality, morbidity, anxiety,pain) by a sufficiently wide margin such that the proce-dure is worth doing, exclusive of cost.” The approachhas thus been applied to an array of procedures, in-cluding coronary angiography (26), surgical proce-dures (27, 28), cataract removal (29), and transplant or-gan allocation (30). Recently, the method was also usedto develop criteria for appropriate use of urinary cath-eters in hospitalized patients (31).

The RAND/UCLA method was particularly valuablefor developing PICC appropriateness criteria for sev-eral reasons. First, the approach allowed the synthesisof the best available evidence with practice-based,domain-specific insights from experts. This uniquecombination ensured both clinical relevance and evi-dentiary support for the developed recommendations.Second, unlike other group-rating methods, the focusof the RAND/UCLA approach is not to ensure consen-sus, but minimize artifactual disagreement that mayarise from misunderstanding of scenarios being rated.This nuance is highly relevant in the case of PICCs, be-cause available evidence is derived from heteroge-neous study designs (for example, retrospective, case–control studies and randomized trials), populations (forexample, critically ill, cancer), and clinical specialties

(nursing, radiology, medical or surgical disciplines) andis thus prone to misinterpretation. Because the RAND/UCLA method pairs clear instructions and precise clin-ical definitions with a systematic, reliable, and repro-ducible rating system (27), the recommendationsgenerated will have high internal validity. Finally,should clinical scenarios lack sufficient detail to makean informed judgment regarding appropriateness, theRAND/UCLA method encourages clarification by pan-elists so as to make ratings more relevant and precise.In this fashion, generalizability and external validity ofthe developed appropriateness indications are alsoensured.

Proper conduct of the RAND/UCLA Appropriate-ness Method requires the sequential performance ofseveral steps, including information synthesis, panelistselection, creation of scenarios, rating process, andanalysis of results.

Information SynthesisThe first step of the RAND/UCLA Appropriateness

Method is to systematically review and synthesize theavailable literature. With the assistance of 2 researchlibrarians, we searched for English-language articles(between 12 November 2012 and 1 July 2013) by usingthe following databases: MEDLINE via Ovid (1950 topresent), EMBASE (1946 to present), BIOSIS (1926 topresent), and the Cochrane Central Register of Con-trolled Trials via Ovid (1960 to present). The searchstrategy incorporated Boolean logic, controlled vocab-ularies (for example, Medical Subject Heading terms)and free-text words. Because the panel was focused ondetermining the appropriateness of PICC use in hospi-talized adults, articles that included only pediatric pa-tients or devices not comparable with PICCs (for exam-ple, arterial or hemodialysis catheters) were excluded.

We also included relevant guidelines, such as theInfusion Nursing Society Standards of Practice (32),Centers for Disease Control and Prevention/HealthcareInfection Control Practices Advisory Committee centralline–associated bloodstream infection preventionguidelines (33), American Society of AnesthesiologyTask Force on Central Venous Access (34), AmericanCollege of Chest Physicians Antithrombotic Therapyand Prevention of Thrombosis Guidelines (35), and In-ternational Clinical Practice Guidelines for the Treat-ment and Prophylaxis of Thrombosis Associated WithCentral Venous Catheters in Patients With Cancer (36).

All retrieved articles were independently scannedfor eligibility by 2 of the authors. Disagreements on el-igibility were resolved by consensus, and a final list ofeligible studies and tables summarizing the evidencewere created. The search strategy is provided inAppendix Table 1 (available at www.annals.org), andTable 1 (on page S25) summarizes the included articles.

Participant and Panelist SelectionViewpoints related to PICC use are known to vary

across specialties; thus, what may be appropriate inone field may not be appropriate in another. To fosterdiscussions about these issues, specialists representingvascular access nursing, hospital-based medicine, inter-

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nal medicine, infectious disease, critical care, nephrol-ogy, hematology/oncology, pharmacy, surgery, and in-terventional radiology were considered necessary toensure representativeness of the panel. Leading na-tional and international experts from each of these pro-fessions who are eminent scholars or researchers, rep-resent relevant medical societies, or have substantialclinical experience in the field were invited to participate.

To ensure that deliberations took into accountpatient-centered viewpoints, we also invited a patientto participate on our panel. We recognized that theideal patient had to be able to speak about experi-ences with PICCs and related VADs. We recruited sucha patient from our university practice in Ann Arbor,Michigan. Owing to the scientific nature of the material,however, the patient panelist did not rate scenarios andinstead contributed to panelist discussions. Throughthis process, 15 multispecialty panelists were recruitedto develop the Michigan Appropriateness Guide for In-travenous Catheters (MAGIC) (Appendix Table 2, avail-able at www.annals.org).

Creation of ScenariosOn the basis of articles found through the system-

atic literature searches, we created clinical scenarios torate the appropriateness of insertion, maintenance, andcare of PICCs. To accurately reflect clinical decisionmaking, devices, including peripheral intravenous cath-eters, ultrasonography-guided peripheral intravenouscatheters, midline catheters, nontunneled CVCs, tun-neled CVCs, and ports, were compared with PICCs(Figure 1). Scenarios were crafted so as to allow judg-ment of real-world use of PICCs; thus, areas of consen-sus, controversy, and ambiguity were purposefully in-cluded. To further ensure validity, we asked eachexpert to provide a list of concerns related to PICC usethat were most relevant to their practice (Appendix Ta-ble 3, available at www.annals.org). If not already rep-resented, these issues were also incorporated into sce-narios of appropriateness.

We developed a conceptual framework to ensurethat scientific content, clinical indications, relevantVADs, and contextual factors were adequately repre-sented when drafting scenarios (Figure 2). Thus, indica-tions for PICC insertion were systematically categorizedinto 1) duration of venous access (≤5 days, 6 to 14 days,15 to 30 days, ≥31 days); 2) type of infusate (for exam-ple, irritants or vesicants, including parenteral nutritionand chemotherapy); and 3) use for specific reasons,such as frequent obtaining of blood samples, poor ordifficult venous access, and continuation of intravenoustherapies in the outpatient setting. For each of theseinstances, clinical scenarios incorporating 1) patient-specific factors (for example, critical illness, cancer di-agnosis, stage of chronic kidney disease [CKD]), 2)device-specific factors (number of lumens, gauge, typeof PICC, alternative VADs), and 3) provider-specific fac-tors (the operator inserting the PICC, technique forPICC insertion) were created. In addition, scenarios re-garding appropriate practices for care, management,and treatment of PICC complications were written. Fi-

nally, because lack of peripheral access often promptsPICC use for specific clinical needs (for example, needfor contrast-based studies or blood transfusion), sce-narios related to use of peripheral intravenous catheterin such settings were created.

We pilot-tested all scenarios with 2 hospital-medicine physicians and further edited them for con-tent and clarity on the basis of their feedback. In thismanner, 665 scenarios and 391 unique indications forPICCs and related VADs were developed.

Rating ProcessRating of scenarios and indications were con-

ducted over 2 rounds. In round 1, each panelist re-ceived the literature review, definitions of all termsused, a rating document, and instructions for rating.Panelists were asked to dedicate at least 4 hours tocomplete the rating document. In accordance with theRAND/UCLA method, panelists were instructed not toconsider cost when making judgments; rather, theywere asked to use the available scientific evidence andbest clinical judgment in rating appropriateness (Sup-plement, available at www.annals.org). To ensure thatappropriateness was rated exclusive of confoundingcircumstances (such as specialist availability), panelistswere also instructed to assume availability of all re-sources related to the scenarios.

For each indication, panel members rated appro-priateness by considering the benefit–harm ratio on ascale of 1 to 9, where 1 indicated that harms outweighbenefit and 9 signified that benefits outweigh harm;Appendix Table 4 (available at www.annals.org) pro-vides examples of this process. A middle rating of 5signified that harms or benefits were equal, or that therater could not make an informed judgment on the in-dication. For a series of indications where 2 deviceswere appropriate, we asked panelists to rate prefer-ence for use of one device compared with the other,regardless of cost. Median ratings on opposite ends ofthe scale (for example, 1 to 3 or 7 to 9) were used toindicate preference of one device over another; a rat-ing in the range of 4 to 6 suggested no preference.

Each panelist rated every scenario twice in a2-round, modified Delphi process. In the first round,ratings were made individually and no interaction be-tween panelists occurred. In the second round, panelmembers traveled to Ann Arbor, Michigan, for an in-person meeting where individualized documents show-ing their ratings along with the distribution of all first-round ratings of the panel were provided.

Over 2 days, a RAND/UCLA methodology expertand a scientific content expert moderated a panel dis-cussion of all indications and scenarios. The sessionswere structured to encourage debate and discussionspecifically about ratings where disagreement (oppo-site ratings) or neutrality/uncertainty (ratings of 4 to 6)occurred in round 1. For instance, it often became ap-parent in the second round that panelists had dis-agreed not on the indication, but on the patient or cir-cumstances being considered because of inherentassumptions, specialty-specific views, or ambiguity in

Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT







the scenario itself. When this occurred, the scenariowas rewritten with input from the entire panel such thatclarifying language or necessary specification wasincluded.

For example, ratings for PICC insertion in patientswith CKD were found to be widely disparate in round 1.During round 2, our panel nephrologist clarified that

placement of PICCs in patients with stage 3b or greaterCKD was specifically contraindicated. Therefore, for in-dications that included CKD, 2 sets of scenarios werecreated (stage 3a or lower vs. stage 3b or higher), usingXs and Os on the rating form to distinguish these rat-ings. Panelists then rerated each of the scenarios, im-proving validity and agreement of their responses.

Figure 1. Vascular access devices reviewed to formulate appropriateness ratings.

A. Peripheral IV Catheter

B. US-Guided Peripheral IV Catheter

C. Midline Catheter

E. Tunneled Central Venous Catheter

F. Implanted Port

D. Nontunneled Central Venous Catheter

G. Peripherally InsertedCentral Catheter

IV = intravenous; US = ultrasonography. A. Peripheral IV catheter. These devices are typically 3 to 6 cm, enter and terminate in the peripheral veins(cross-section), and are often placed in the upper extremity in veins of the hand. B. US-guided peripheral IV catheter. Ultrasonography may be usedto facilitate placement of peripheral intravenous catheters in arm veins that are difficult to palpate or visualize. “Long” peripheral IV catheters(typically ≥8 cm) that are specifically designed to reach deeper veins are also available for insertion under US guidance. C. Midline catheter. Thesedevices are 7.5 to 25 cm in length and are typically inserted in veins above the antecubital fossa. The catheter tip resides in the basilic or cephalicvein, terminating just short of the subclavian vein. These devices cannot accommodate irritant or vesicant infusions. D. Nontunneled central venouscatheter. Also referred to as “acute” or “short-term” central venous catheters, these are often inserted for durations of 7 to 14 d. They are typically15 to 25 cm and are placed via direct puncture and cannulation of the internal jugular, subclavian, or femoral veins. E. Tunneled central venouscatheter. These differ from nontunneled catheters in that the insertion site on the skin and site of ultimate venipuncture are physically separated,often by several centimeters, reducing the risk for bacterial entry into the bloodstream and facilitating optimal location of the catheter for care of theexit site. Tunneled devices may be cuffed or noncuffed; the former devices have a polyethylene or silicone flange that anchors the catheter withinthe subcutaneous tissue and limits entry of bacteria along the extraluminal surface of the device. F. Implanted port. Ports are implanted in thesubcutaneous tissue of the chest and feature a reservoir for injection or aspiration (inset) and a catheter that communicates from the reservoir to adeep vein of the chest, thus providing central venous access. Ports are cosmetically more desirable than other types of central venous catheter andcan remain in place for months or years. G. Peripherally inserted central catheter. These long vascular access devices (>45 cm) are inserted intoperipheral veins of the upper arm in adults and advanced so that the tip of the catheter resides in the lower portion of the superior vena cava orupper portion of the right atrium. They are similar to central venous catheters in that they provide access to the central circulation, but they do sowithout the insertion risks associated with direct puncture of deep veins in the neck, chest, or groin.




Data Processing and AnalysisFirst-round ratings were submitted either electron-

ically via an online survey system or through paperforms. Data obtained from paper ratings were manuallyentered into a study database (Qualtrics Research SuitePackage, Qualtrics USA) and checked in duplicate fortranscription errors. Descriptive statistics (mean, me-dian, mode) were calculated for all variables. A sum-mary result document was created that listed the fre-quency of responses, median responses, and eachindividual panelist's response for every scenario. In ac-cordance with the RAND/UCLA method, all indicationswere classified into 3 levels of appropriateness:

1. Appropriate: panel median score of 7 to 9, with-out disagreement;

2. Uncertain/neutral: panel median score of 4 to 6,or with disagreement regardless of median; and

3. Inappropriate: panel median score of 1 to 3,without disagreement.

Disagreement was said to have occurred when atleast 5 of the 15 panel members rated an indication asappropriate (median score, 7 to 9) and at least 5panelists rated the same indication as inappropriate(median score, 1 to 3). Only indications withoutdisagreement were classified as inappropriate orappropriate.

DefinitionsTo ensure consistency, standardized definitions of

devices (for example, PICC, midline), populations (ac-tive cancer, “special” populations), indications (for ex-ample, frequent obtaining of blood samples, hemody-namic monitoring), and infusates (irritant, vesicant)were provided to panelists. A complete glossary ofterms and definitions used is provided in the ratingsdocument in the Supplement (available at www.annals.org).

Figure 2. Concep ual framework used for the development of scenarios and indications of appropriateness.

AppropriatenessIndications

Proposed durationof venous access

Indication forvenous access Nature of infusate

Patientcharacteristics

Devicecharacteristics

Providercharacteristics

Systematic Review of the Literature

Clin

ical

Par

adig

ms

and

Pane

list L

ists

A

reas of Controversy, A

mbiguity, or U

ncertainty

Maintenance andcare practices

Treatment ofcomplications

Developmentof

ClinicalScenarios

To develop a conceptual framework, systematic reviews of the literature were conducted to determine the evidence base. With input from panelists,areas of controversy and ambiguity were identified and contextualized within clinical paradigms and lists of common problems associated withperipherally inserted central catheters. By methodologically pairing selection of venous access device with indication, duration, and nature ofvenous access and specific patient, device, and provider variables (center boxes), scenarios for panelists were created. These scenarios formed thebasis for the appropriateness indications.






Role of the Funding SourceThis project was supported by a Young Researcher

Award from the Society of Hospital Medicine to Dr.Chopra. Funds were used to support panelist lodging,meals, transportation, and venue. Blue Cross BlueShield of Michigan provided salary support for 3 of theauthors through a grant to the University of Michigan.Neither funder had a role in the design, conduct, oranalysis of the project or the decision to submit themanuscript for publication.

RESULTSWithin the 665 scenarios reviewed, panel members

rated 391 unique indications for PICCs and relatedVADs. During the first round, the panel rated 237 sce-narios as appropriate (36%), 267 as inappropriate(40%), and 161 as neutral/uncertain (24%). After thesecond round of in-person interactions, 253 scenarioswere rated as appropriate (38%), 288 as inappropriate(43%), and 124 as neutral/uncertain (19%). Thus, duringthe second round of discussions, better distinction ofneutral/uncertain indications as being appropriate orinappropriate indications occurred. A substantial pro-portion of this convergence in ratings reflected resolu-tion of disagreement (30 of 37 scenarios) from round 1to round 2.

1. Appropriateness of PICC Insertion in SpecificPopulationsA. Appropriateness of PICC Insertion in HospitalizedMedical Patients

In hospitalized medical patients, panelists rated in-sertion of PICCs for infusion of peripherally compatibleinfusates as inappropriate if the expected duration ofuse was 5 or fewer days. In such scenarios, use of pe-ripheral intravenous catheters or ultrasonography-guided peripheral intravenous catheters was rated asappropriate.

If the proposed duration of infusion was 6 to 14days, panelists rated PICC use as appropriate butindicated a preference for midline catheters andultrasonography-guided peripheral intravenous cathe-ters over PICCs for this period. This rating reflected ev-idence from observational studies that suggested bothefficacy and lower risk for complications associatedwith these devices compared with PICCs for this inter-val (37–41).

When the proposed duration of infusion was 15 ormore days, PICCs were preferred to midline catheters,given the possibility of failure of the latter beyond thisperiod (42, 43). However, panelists recognized thatmidline catheters may be used for up to 4 weeks andare approved for such duration of use (32).

Use of tunneled catheters and implanted portswere rated appropriate only if the proposed duration ofinfusion was 31 or more days. Panelists noted thatthese more invasive devices should be reserved for in-stances when use of PICCs is not feasible (for example,no suitable vein or site of insertion for PICC is identi-fied), is relatively contraindicated (for example, recent

history of thrombosis), or when episodic infusions overseveral months are necessary (Figure 3).

For infusion of irritants or vesicants, such as paren-teral nutrition or chemotherapy, PICC use was rated asappropriate at any proposed duration of use. Becauseperipheral intravenous catheters, ultrasonography-guided peripheral intravenous catheters, and midlinecatheters would not provide central venous access,these VADs were rated as inappropriate for this indica-tion for all durations of use.

If skilled operators are available, panelists rateduse of nontunneled CVCs as appropriate when the ex-pected duration of use was 14 or fewer days. Panelistsalso rated use of tunneled, cuffed catheters and im-planted ports as appropriate for infusion of irritants orvesicants, but only when the proposed duration of ther-apy was 15 or more days or 31 or more days, respec-tively (Figure 4).

Panelists disagreed on the appropriateness ofPICC placement when the indication was frequent ob-taining of blood samples (≥3 phlebotomies per day) ordifficult or poor peripheral venous access for proposeddurations of 5 or fewer days. Our patient panel mem-ber actively participated in this discussion, suggestingthat such decisions should be individualized betweenthe patient and provider after discussing risks and ben-efits related to PICC use and alternative options. Inser-tion of PICCs was rated as appropriate when the pro-posed duration of use for frequent phlebotomy ordifficult venous access was 6 or more days. In patientswith difficult venous access, ultrasonography-guidedperipheral intravenous catheters and midline catheterswere preferred over PICCs when the expected durationof use was 14 or fewer days. Panelists rated use ofCVCs for both difficult venous access and frequentphlebotomy as appropriate, provided the proposedduration of use was 14 or fewer days. Placement oftunneled catheters for patients with difficult venous ac-cess was rated as appropriate only if the proposed du-ration of use was 31 or more days. Ports were rated asinappropriate for frequent obtaining of blood samplesat all durations and appropriate for difficult venous ac-cess if use for 31 or more days was expected (Figures 5and 6).

B. Appropriateness of PICCs in Patients With CKD,Cancer, or Critical Illness

Panelists rated the appropriateness of PICC place-ment in patients with CKD according to disease stageas defined by the Kidney Disease: Improving GlobalOutcomes CKD Work Group (44). Among patients withstage 1 to 3a CKD (estimated glomerular filtration rate≥45 mL/min), rating of indications for PICC use fol-lowed those of general medical patients. However, thepanel noted that managing such patients on the basisof CKD stage alone might be imperfect because myriadfactors, including age, magnitude of albuminuria, race,and blood pressure, influence progression of renal dis-ease (45–49). The panel therefore recommended con-sultation with a nephrologist before PICC insertion if




ambiguity regarding the severity of underlying kidneydisease exists. However, for patients with stage 3b CKDor greater (estimated glomerular filtration rate <45 mL/min), panelists acknowledged the imperative to pre-serve peripheral and central veins for possible hemodi-alysis or creation of arteriovenous fistulae and grafts(49). Thus, regardless of indication, insertion of devices(PICCs, midline catheters) into arm veins was rated asinappropriate in such patients. When venous access for5 or fewer days was necessary, panelists recommendplacement of peripheral IVs in the dorsum of the hand(avoiding the forearm veins) for infusion of peripherallycompatible infusates. If venous access for longer dura-tions or infusion of a non–peripherally compatible drugis needed, use of tunneled small-bore central catheters(for example, 4-French single-lumen or 5-Frenchdouble-lumen catheters inserted in the jugular vein andtunneled toward the chest) was rated as appropriate(50). For patients receiving any form of renal replace-ment therapy, panelists also recommended consulta-tion with a nephrologist to discuss the possibility ofdrug administration during or toward the end of thedialysis procedure.

These recommendations notwithstanding, panel-ists acknowledged that recommendations for patients

with stage 3b CKD or greater would need to be indi-vidualized, taking into account such factors as the ur-gency of the situation; rationale for venous preserva-tion; likelihood of eventual renal replacement therapy;and availability of resources, such as tunneled small-bore central catheters.

Given the risks for and consequences of infectious(51, 52) and thrombotic (53–55) complications, as wellas the unique indication of chemotherapy, ratings forPICC placement in patients with cancer differed fromthose for general medical patients. Recognizing theheterogeneity of thrombosis risk in patients with can-cer, the panel discussion focused largely on patientswith solid tumors. Panelists debated on whether ratingsfor chemotherapy should be structured by cycles oftreatment versus time; given the desire for generaliz-ability, the panel agreed on time as a more practicalscale. Therefore, for infusion of nonirritant or nonvesi-cant chemotherapy, PICCs were rated as appropriateonly if the proposed duration of such treatment was 3or fewer months.

When peripherally administrable chemotherapy forless than 3 months was necessary, panelists disagreedon PICC appropriateness, given the availability of high-

Figure 3. Venous access device recommendations for infusion of peripherally compatible infusate.

Proposed Duration of Infusion

6–14 d 15–30 dDevice Type

Peripheral IVcatheter

No preference betweenperipheral IV and US-guided

peripheral IV cathetersfor use ≤5 d

US-guided peripheral IV catheter preferred to peripheral IVcatheter if proposed duration is 6–14 d

Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d

Midline catheter preferred to PICC if proposed duration is ≤14 d

PICC preferred to midline catheter if proposed duration of infusion is ≥15 d

PICC preferred to tunneledcatheter and ports for

infusion 15–30 d

Midline catheter

PICC

Tunneled catheter

Port

US-guidedperipheral IV catheter

Nontunneled/acutecentral venouscatheter

≤5 d ≥31 d

Appropriate Inappropriate DIsagreementNeutral

IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.




quality evidence regarding risk for thrombosis withthese devices in patients with cancer (16). However,members of the panel cited conflicting evidence re-garding nonthrombotic complications associated withPICC use (15, 56–58). Of note, a study published sincethe panel meeting (coauthored by one of our panelists)reported a low rate of PICC complications when propercare was ensured (59). Nevertheless, given the diver-gent data, panelists rated interval placement of periph-eral intravenous catheters with each chemotherapytreatment as the most appropriate strategy.

Like PICCs, tunneled, cuffed catheters were ratedas appropriate when at least 3 months of treatmentwere proposed or when PICCs were not feasible (forexample, peripheral veins were not available). Portswere rated as appropriate if the duration of treatmentwas projected to be 6 or more months, but neutral fordurations of 3 to 6 months. Panelists noted that earlieruse of ports may be appropriate but may be challeng-ing owing to coagulation abnormalities or availability ofinterventional radiology.

For infusion of irritant or vesicant chemotherapy,panelists rated PICC or tunneled, cuffed catheter use asappropriate at all time intervals; ports were rated asneutral at 3 to 6 months and appropriate at 6 or more

months. Panelists recommended tunneled, cuffed cath-eters over multilumen PICCs in settings where multipleor frequent infusions are required, citing lower risk forcomplications (60). However, panelists preferred PICCsto tunneled, cuffed catheters when managing patientswith coagulopathy and those with severe or prolongedthrombocytopenia (61). When the indication for PICCplacement was frequent phlebotomy or difficult periph-eral venous access in a hospitalized patient with cancer,panelists raised the threshold for PICC use comparedwith general medical patients. Thus, PICCs were con-sidered appropriate only if the proposed duration ofuse was 15 or more days; midline catheters were ratedas appropriate for 14 or fewer days of use.

Appropriateness of indications for PICC insertion incritically ill patients also differed from those for generalmedical patients, given the likely availability of intensiv-ists who could insert CVCs and concerns about hemo-dynamic stability, infection, and thrombosis. Panelistsconsequently rated PICC use as inappropriate for infu-sion of peripherally compatible infusates unless theproposed duration of treatment was 15 or more days.For the same indication, peripheral intravenous cathe-ters and midline catheters were rated as appropriatefor proposed durations of 5 or fewer days and 6 to 14

Figure 4. Venous access device recommendations for infusion of non–peripherally compatible infusates.




No preference between tunneled catheter and PICC for proposed durations ≥15 d

Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d

PICCs rated as appropriate at all proposed durations of infusion

No preference amongport, tunneled catheter, or

PICC for ≥31 d

Midline catheter

PICC

Tunneled catheter

Port



≤5 d ≥31 d


Tunneled catheter neutral for for use ≥15 d





days, respectively. Although limited data supportingthe recommendation for midline catheter use in criticalcare patients were available at the time of the meeting,a recent study reported favorable outcomes and costsavings with this device (62). Central venous catheterswere rated as appropriate when the proposed durationof treatment was 6 to 14 days in hemodynamically sta-ble patients; use of CVCs for proposed durations be-yond 15 days was rated as uncertain, with panelists ex-pressing concerns about infection and thrombosis.

In hemodynamically unstable patients or scenarioswhere invasive hemodynamic monitoring or central ac-cess was necessary, insertion of CVCs and PICCs wasrated as appropriate for durations of 14 or fewer daysand 15 or more days, respectively. Panelists preferredCVCs to PICCs in patients who were hemodynamicallyunstable or were actively receiving vasopressors. In thissetting, urgent requests for PICC placement were ratedas inappropriate. Given the risk for insertion complica-tions, panelists preferred use of PICCs to CVCs in criti-cally ill patients with coagulopathies (such as dissemi-nated intravascular coagulation or sepsis), especially ifuse for more than 15 days was proposed.

C. Appropriateness of PICC Insertion in SpecialPopulations

Panelists rated the appropriateness of PICCs inpopulations that need lifelong intravenous access (forexample, sickle cell anemia, short-gut syndrome, orcystic fibrosis) and populations residing in skilled nurs-ing facilities.

For populations that may require lifelong access,ratings were structured on the basis of how often pa-tients may be hospitalized within 1 year. For patientswho are infrequently hospitalized (≤5 hospitalizationsper year), PICC insertion was rated as inappropriatewhen the expected duration of use was 5 or fewer days.Insertion of a PICC was rated as uncertain when theexpected duration of use was between 6 and 14 days.The panel preferred midline catheters to PICCs for thisduration, assuming that peripherally compatible infus-ates were proposed (63). However, PICCs were rated asappropriate when the duration of use was expected tolast 15 or more days.

More permanent devices, such as tunneled, cuffedcatheters or ports, were not considered appropriate forpatients with infrequent hospitalizations, but our pa-tient panelist (reflecting on her experiences) com-

Figure 5. Venous access device recommendations for patients with difficult venous access.





peripheral IV cathetersfor use ≤5 d

US-guided peripheral IV catheters preferred to peripheral IVcatheters if proposed duration is 6–14 d

Central venous catheter preferred to PICC for use≤14 d in critically ill patients

Midline catheters preferred to PICC if proposed duration is ≤14 d

Midline catheter

PICC

Tunneled catheter

Port



≤5 d ≥31 d


Disagreement onappropriateness of PICC

for durations <5 dPICC use appropriate if proposed duration is ≥6 d; PICCs preferred to tunneled catheters for

durations of 15–30 d

No preference betweentunneled catheter or port for

use ≥31 d

Tunneled catheter neutral fordifficult IV access for

use ≥15 d





mented that an individualized approach would be nec-essary in such situations. In contrast, when patients inthis category are frequently hospitalized (≥6 hospital-izations per year), panelists rated use of tunneled,cuffed catheters as appropriate when the expected du-ration of venous access was 15 or more days. Portswere rated as appropriate when the proposed durationof use in frequently hospitalized patients was expectedto be 31 or more days. Panelists preferred placementof tunneled, cuffed catheters to PICCs when use for 15or more days was expected, citing the need to preserveveins to meet future, likely recurrent needs.

For patients residing in skilled nursing facilities,PICCs were rated as appropriate for infusion of nonirri-tant, nonvesicant treatments or frequent phlebotomy ifthe proposed duration of use was expected to be morethan 15 days. Appropriateness of PICC was rated asuncertain for durations of 6 to 14 days, where panelistsrated midline catheters as appropriate. For venous ac-cess of 5 or fewer days, peripheral intravenous cathe-ters were rated as being the most appropriate VAD.Given the variable resources in such facilities and chal-lenges in obtaining venous access, the appropriatenessof midline catheters was rated neutral for this period.For infusion of irritants or vesicants in this setting, pan-

elists rated PICCs as appropriate regardless of durationof use.

A summary of these ratings is provided in Table 2.

2. Appropriateness of PICC PracticesA. Appropriateness of PICC Insertion Practices

Before PICC insertion for specialty-specific indica-tions, panelists rated consultations with specialists asappropriate (for example, infectious diseases beforeplacement of a PICC for intravenous antibiotic therapy,or hematology–oncology before PICC insertion for che-motherapy). For patients who require prolonged anti-biotic infusions (for example, infections, such as osteo-myelitis), panelists rated PICC placement within 2 to 3days of hospital admission as appropriate in the ab-sence of bacteremia. In the presence of bacteremia,PICC placement was rated as uncertain owing to ambi-guities regarding pathogen, intensity of bacteremia,and clearance of infection, among other factors. Con-sultation with infectious diseases specialists was sug-gested in this setting.

Preferential placement of PICCs by interventionalradiology professionals was rated as appropriate when1) a suitable target vein for insertion cannot be identi-

Figure 6. Venous access device recommendations for patients who require frequent phlebotomy.




Midline catheter

PICC

Tunneled catheter

Port



≤5 d ≥31 d


Disagreement onappropriateness of PICC

for durations <5 dPICC use appropriate if proposed duration ≥6 d; PICC preferred to tunneled catheter for

durations of 15–30 d


peripheral IV catheterfor use ≤5 d

US-guided peripheral IVcatheter preferred if venous

access difficult

Midline catheter preferred to PICCs if proposed duration is ≤14 d

Central venous catheter preferred to PICC for use≤14 d in critically ill patients

Tunneled catheter neutral fordifficult intravenous access for

use ≥15 d

Ports inappropriate for frequent phlebotomy, regardless of proposed duration of use

Midline catheter neutral for frequent phlebotomy at

this duration





fied on bedside ultrasonography, 2) the guidewire orcatheter fails to advance during bedside placement, or3) the patient requests sedation that cannot be safelydelivered at the bedside. In addition, placement by aninterventional radiologist was rated as appropriate forpatients with bilateral mastectomy, altered chest anat-omy, or superior vena cava filters. For patients withpermanent pacemakers or defibrillators, preferentialplacement by an interventional radiologist rather than avascular nursing professional was rated as appropriateif the contralateral arm was not amenable to insertion.These ratings were largely driven by expert opinion.

Panelists rated the appropriateness of specificPICC insertion practices on the basis of availability ofthe contralateral arm for placement. In accordance withInfusion Nursing Society Standards of Practice (32),avoiding insertion over a bruised or corded venoussegment, near or over an open wound or burn, andinto veins below the elbow was rated as appropriate.Owing to heightened risk for thrombosis, panelistsrated avoiding PICC placement in a hemiparetic or im-mobile arm as appropriate when the opposite limb wasavailable (64). Avoiding PICC insertion in the dominantarm as a strategy to prevent complications was rated asinappropriate, given the lack of convincing data to sup-port this practice. However, our vascular nursing andpatient panelists recommended that technical aspectsand patient preferences be considered when selectingarm of insertion.

Prior to PICC use, radiographic verification of PICCtip position was rated as appropriate after blind bed-side PICC placement or admission to a hospital with anexisting PICC. Conversely, panelists rated routine ra-diographic verification of PICC tip position as inappro-priate when PICCs were placed with electrocardio-graphic guidance, provided that proficiency with thistechnology had been demonstrated and adequatetracings (such as P-wave deflections) were observed.

To limit the risk for thrombosis, the U.S. Food andDrug Administration and specialty societies recom-mend that CVCs terminate in the lower one third of thesuperior vena cava or cavoatrial junction; “higher” (suchas the upper one third of the superior vena cava) or“lower” positions (such as the right atrium) were notrecommended (32, 65, 66). Acknowledging these con-cerns, panelists rated adjustment of the PICC when thetip was in the upper or middle one third of the superiorvena cava or right ventricle as appropriate.

However, panelists deviated from existing recom-mendations in rating the right atrium as an appropriateposition for the PICC tip and one that does not warrantadjustment. This rating was made after extensive dis-cussions of clinical practice and review of contempo-rary evidence, which did not suggest that terminationof PICCs or CVCs in the right atrium was associatedwith adverse outcomes in adults (66–71). Panelists rec-ognized that supporting data were observational, and awell-conducted randomized, controlled trial would behelpful in supporting this recommendation.

The possibility of atrial tachyarrhythmia during orafter PICC insertion in this position was also debated(72). As with any CVC, placement of the PICC tip in theright atrium in the setting of an atrial arrhythmia wasnot recommended. However, in the absence ofcontraindications, repositioning the PICC tip simply be-cause it resides in the right atrium was rated asinappropriate.

Table 2. Guide for PICC Use

Appropriate indications for PICC useDelivery of peripherally compatible infusates when the proposed

duration of such use is ≥6 d*Delivery of non–peripherally compatible infusates (e.g., irritants or

vesicants), regardless of proposed duration of useDelivery of cyclical or episodic chemotherapy that can be administered

through a peripheral vein in patients with active cancer, provided thatthe proposed duration of such treatment is ≥3 mo†

Invasive hemodynamic monitoring or requirement to obtain centralvenous access in a critically ill patient, provided the proposed durationof such use is ≥15 d‡

Frequent phlebotomy (every 8 h) in a hospitalized patient, provided thatthe proposed duration of such use is ≥6 d

Intermittent infusions or infrequent phlebotomy in patients with poor/difficult peripheral venous access, provided that the proposedduration of such use is ≥6 d§

For infusions or palliative treatment during end-of-life care!!Delivery of peripherally compatible infusates for patients residing in

skilled nursing facilities or transitioning from hospital to home,provided that the proposed duration of such use is ≥15 d¶

Inappropriate indications for PICC usePlacement for any indication other than infusion of non–peripherally

compatible infusates (e.g., irritants or vesicants) when the proposedduration of use is ≤5 d

Placement in a patient with active cancer for cyclical chemotherapy thatcan be administered through a peripheral vein, when the proposedduration of such treatment is ≤3 mo and peripheral veins are available

Placement in a patient with stage 3b or greater chronic kidney disease(estimated glomerular filtration rate ≤44 mL/min) or in patientscurrently receiving renal replacement therapy via any modality

Insertion for nonfrequent phlebotomy if the proposed duration of suchuse is ≤5 d

Patient or family request in a patient who is not actively dying or inhospice, for comfort in obtaining daily blood samples for laboratoryanalysis

Medical or nursing provider request in the absence of other appropriatecriteria for PICC use

PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for infusion of peripherallycompatible infusates up to 14 d. In patients with poor peripheral ve-nous access, use of ultrasonography-guided peripheral intravenouscatheters and midlines is also preferred over use of PICCs.† In patients with cancer, the risk for thrombosis associated with PICCsmay outweigh benefits. Patients who are scheduled to receive multi-ple cycles of peripherally compatible chemotherapy for durations <3mo should do so via peripheral intravenous catheters with eachinfusion.‡ Use of nontunneled central venous catheters is preferred over use ofPICCs for central venous access or invasive hemodynamic monitoring<14 d and in patients with documented hemodynamic instabilitywhere urgent venous access is necessary.§ Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for patients with poor/difficultperipheral venous access.!! Placement of a PICC in a terminally ill patient is appropriate if itfacilitates comfort goals of care. PICCs may be left in place in suchpatients to attain similar goals.¶ Use of PICCs for home-based infusions or in skilled nursing facilities(where resources are limited) is inappropriate for short-term durations(<14 d). In such settings, use of peripheral intravenous catheters ormidlines was rated as appropriate.




B. Appropriateness of PICC Selection, Care, andMaintenance Practices

Without a documented rationale for a multilumenPICC (for example, multiple incompatible fluids), panel-ists rated default use of single-lumen devices as an ap-propriate and potentially important way to reduce PICCcomplications (73–75). Insertion of multilumen PICCs toseparate obtaining blood samples from giving infu-sions or to ensure a “backup” lumen was available wasalso rated as inappropriate. To clarify device needs,collaboration with pharmacists or vascular access oper-ators before ordering a PICC was rated as appropriate.

Regarding dressings, panelists rated placement ofsterile gauze between the PICC entry site and adhesivedressing for the first 1 to 2 days of insertion as appro-priate; thereafter use of clear, transparent dressingsthat permit site examination and weekly or more fre-quent changes of wet, loose, or soiled dressings wasrated appropriate. Use of cyanoacrylate products (“su-per glue”) to prevent oozing or discharge from the exitsite or to secure catheters was rated as neutral by pan-elists, who noted lack of substantial evidence or expe-rience to support this recommendation (76). In accor-dance with available guidelines (33), routine use ofchlorhexidine dressings without documented adher-ence to basic infection-prevention efforts or in the ab-sence of high rates of central line–associated blood-stream infection was rated as inappropriate.

Panelists rated use of normal saline rather thanheparin to maintain catheter patency and prevent lu-men occlusion as appropriate, as reflected in recentrecommendations (77, 78). Regardless of how far outthe PICC was dislodged, panelists rated advancementof migrated PICCs as inappropriate; in this setting,guidewire exchange of the PICC was rated as appropri-ate, provided that there are no signs of local or sys-temic infection. Guidewire exchange was also rated asappropriate when changes to existing PICC character-istics (such as number of lumen or power-injectioncompatibility) were desired. Should a PICC no longerbe functional, exchange over a guidewire was rated asappropriate, provided that an indication warrantingcontinued PICC use was present. Ratings regardingguidewire exchanges were driven largely by expertrecommendation.

C. Appropriateness of Management of PICCComplications

In patients with a centrally positioned, otherwisefunctional PICC that is complicated by image-confirmed PICC-related deep venous thrombosis(DVT), panelists rated PICC removal as appropriate onlywhen 1) the PICC is clinically no longer necessary; 2)the PICC is only being used for phlebotomy, but pe-ripheral veins are available; 3) symptoms of venous oc-clusion (arm pain, swelling) persist despite therapeuticanticoagulation for 72 or more hours; and 4) bactere-mia with objective evidence of line-related infection ex-ists. Panelists rated removal of a functional PICC in thepresence of DVT as inappropriate when 1) irritants or

vesicant infusions remain necessary; 2) the patient haspoor peripheral venous access and requires frequentphlebotomy (and may thus require another PICC); and3) the patient has minimal improvement in symptoms ofvenous occlusion, but therapeutic anticoagulation hasbeen provided for 72 or fewer hours. Panelists wereneutral regarding PICC removal when 1) a patientcould not receive systemic anticoagulation, but thePICC remained clinically necessary and 2) a line-relatedinfection was suspected, but not confirmed. In general,these ratings mirrored existing evidence-based recom-mendations (35, 53, 79).

When treating PICC-related DVT, panelists ratedprovision of at least 3 months of anticoagulation at atreatment dose as appropriate. Shorter durations of an-ticoagulation or removal of the PICC as definitive ther-apy (in the absence of contraindications to anticoagu-lation) was rated as inappropriate. When treating withwarfarin, panelists recommended targeting anticoagu-lation to an international normalized ratio of 2 to 3;lower or higher international normalized ratio targetswere rated as inappropriate. Use of low-molecular-weight heparin over warfarin was preferred in patientswith cancer. Owing to insufficient evidence, preferen-tial use of target-specific oral anticoagulants over tradi-tional agents among patients with cancer was rated asinappropriate. Panelists rated urgent referral to inter-ventional radiology for catheter-directed treatment ofPICC-related DVT as appropriate when symptoms ofvenous occlusion were associated with phlegmasiacerulea dolens (swollen, enlarged, painful, and purplishdiscoloration of the affected limb).

Panelists rated the appropriateness of placementof a new PICC in patients who experienced PICC-related DVT within the past 30 days. In this scenario,panelists strongly urged against placement of a PICC,given the high risk for recurrent thrombosis. Placementof a PICC was specifically rated as inappropriate if theindication for insertion was 1) frequent phlebotomywhen peripheral access was available, or 2) patient re-quest for comfort in non–end-of-life settings. Insertionof a PICC was also considered inappropriate if the pa-tient were to require surgery lasting 1 hour or longer,owing to heightened risk for DVT in this situation (67).

In the setting of PICC-related DVT, appropriatenessof PICC insertion for parenteral antibiotics for 10 ormore days was rated as uncertain; panelists recom-mended a midline catheter in this scenario. If a PICCwas absolutely necessary in a patient with recent PICC-related DVT, panelists rated use of the smallest cathetergauge and least number of lumens as appropriate (74,75, 80). Placement in a vein in the contralateral armfollowing at least 3 months of anticoagulation for thePICC-related DVT was also rated as appropriate in thissetting.

Panelists rated the appropriateness of practices re-lated to management of PICC-related bloodstream in-fections. Regardless of clinical context and in accor-dance with recommendations (33, 81), panelists rateduse of PICCs as a strategy to reduce bloodstream infec-tion as inappropriate. In the setting of bacteremia or




fever, PICC removal in the absence of confirmatory ev-idence of line-related infection was rated as uncertain.Panelists stated that these approaches would be dic-tated by such factors as pathogen, intensity of bacter-emia, and clinical stability, among others, and consulta-tion with infectious disease would be appropriate.

In patients with confirmed PICC-related blood-stream infection, continued treatment using the af-fected PICC, guidewire exchange, or placement of anew device in the contralateral arm without docu-mented clearance of infection was rated as inappropri-ate. After a line-free interval (typically 48 to 72 hours)and negative blood cultures, panelists rated placementof a PICC or other acute CVC as appropriate only if anindication warranting central catheter use was present.Panelists preferred use of peripheral IVs in such pa-tients wherever possible.

D. Appropriateness of PICC RemovalIn contradistinction to indwelling urinary catheters

(82), panelists rated PICC removal without physiciannotification as inappropriate. After physician notifica-tion, panelists rated PICC removal as appropriate when1) the PICC has not been used for any clinical purposefor 48 hours or longer; 2) the patient no longer has aclinical indication for a PICC, or the original indicationfor use has been met (for example, an antibiotic coursehas been completed); or 3) the PICC is only used forroutine obtaining of blood samples in a hemodynami-cally stable patient and peripheral veins are available.Panelists rated routine removal of a PICC in a hemody-namically stable patient with poor venous access or he-modynamically unstable patients as uncertain. Removalof a PICC by clinicians who have received training toremove CVCs, but not PICCs, was rated as inappropri-ate (32).


3. Appropriateness of Peripheral IntravenousCatheter Use in Specific Scenarios

Because PICC use is often driven by difficult pe-ripheral venous access, we asked panelists to rate ap-propriateness of peripheral intravenous catheter use invarious clinical scenarios that often prompt PICC use. Inthe absence of other indications for central venous ac-cess, panelists rated use of ultrasonography-guidedperipheral intravenous catheters as appropriate beforeinsertion of a PICC in general medical, critically ill, andcancer populations with difficult venous access (39, 68).However, use of ultrasonography-guided peripheral in-travenous catheters in patients with stage 3b or greaterCKD was rated as inappropriate. If a suitable arm veincould not be found, panelists rated placement of a pe-ripheral intravenous catheter catheter in the externaljugular vein of the neck as appropriate only if the pro-posed duration of use was 96 hours or less or in anemergency situation. Panelists rated placement of a pe-ripheral intravenous catheter in the lower extremity asappropriate only in emergencies.

Citing the results of a Cochrane systematic review(83) and a randomized trial (84), panelists rated re-

placement of peripheral intravenous catheters as ap-propriate when prompted by clinical signs and symp-toms rather than prespecified durations. Panelistsnoted that such practice might extend availability of pe-ripheral venous access (83), reduce cost (85), and limituse of PICCs, but recognized that these data were lim-ited to 1 randomized trial and low event rates in theliterature. When PICC placement was requested forblood transfusions, panelists rated 16-, 18-, and 20-

Table 3. Guide for PICC Insertion, Care, and MaintenancePractices

Appropriate PICC practicesBefore ordering a PICC, consult relevant specialists (e.g., infectious

diseases, oncology), operators (vascular access professional), and/orhospital pharmacists to determine optimal device choice andcharacteristics*

After non-EKG or non–fluoroscopically guided PICC insertion, verify PICCtip position via chest radiography

Only adjust PICCs that terminate in the upper or middle one third of thesuperior vena cava or right ventricle

In the absence of indications for a multilumen PICC, use a single-lumenPICC of the smallest gauge

Use normal saline rather than heparin to flush PICCs after infusion orphlebotomy

Exchange PICCs to change device features (e.g., number of lumens) ortreat dislodgement over a guidewire

Provide ≥3 mo of uninterrupted systemic anticoagulation for treatmentof PICC-related DVT in the absence of contraindications to suchtherapy†

Use the smallest sized catheter and vein on the contralateral arm after≥3 mo of therapeutic anticoagulation when placing a PICC in a patientwith history of PICC-related DVT‡

Provide a "line-free" interval to ensure clearance of bacteremia whenmanaging PICC-related bloodstream infections

Inappropriate PICC practicesUrgent requests for PICC placement in a hemodynamically unstable

patient in the wards or ICUPreferential placement of a PICC on the basis of arm dominanceChest radiography verification of the PICC tip after placement via verified

EKG guidance or fluoroscopy§Adjustment of PICC tips that reside in the lower one third of the superior

vena cava, cavoatrial junction, or right atriumAdvancement of a partially dislodged PICC in the setting of external

migration of the catheter of any lengthRemoval of PICCs that are clinically necessary, centrally positioned, and

otherwise functional in the setting of PICC-related DVTRoutine removal or replacement of PICCs that are clinically necessary

without objective evidence of catheter-associated bloodstreaminfection in febrile patients

Removal of a PICC by a health care team member not trained to removethis device

DVT = deep venous thrombosis; EKG = electrocardiography; ICU =intensive care unit; PICC = peripherally inserted central catheter.* Consultations with nephrologists for patients with stage 1 to 3achronic kidney disease was rated as neutral owing to challenges re-lated to determining stage of kidney disease in hospitalized patients.In such patients, consultation is recommended especially if hospital-ized with acute kidney injury or fluctuating renal function.† In patients with cancer, use of low-molecular-weight heparin overwarfarin for systemic anticoagulation was rated as preferred. Extend-ing the duration of anticoagulation beyond such periods if the PICCremained in place was rated as appropriate.‡ If the contralateral arm is not available, selection of a vein not in-volved with the original PICC-DVT in the ipsilateral arm was rated asappropriate.§ When forgoing chest radiographs for PICC tip position, technicalproficiency in the placement of PICCs via EKG guidance is assumed.Additionally, verification of tip-positioning via EKG (adequate P-wavedeflection/mapping) is assumed. If concerns regarding positioning ex-ist, obtaining a chest radiograph is appropriate.




gauge peripheral intravenous catheters as appropriateand preferable to PICC use. For administering intrave-nous contrast through radiographic injectors, panelistsrated use of 16- to 20-gauge peripheral intravenouscatheters as appropriate and preferred over PICCs;use of 22-gauge devices or larger was rated asinappropriate.


DISCUSSIONOur 15-member multidisciplinary panel success-

fully applied the RAND/UCLA Appropriateness Methodto generate novel criteria for use, care, and manage-ment of PICCs in hospitalized patients. In addition, pan-elists rated the comparative utility of other VADs in re-lation to PICCs, providing new insights for decisionmaking in venous access. The implication of this work issubstantial, because it provides a potential means to

quantify appropriateness, qualify existing use, and im-prove care of PICCs and related devices in hospitalizedpatients. Given an international team of experts thatrepresented multiple subspecialties and the inclusionof a patient to formulate panelist ratings, these criteriaare well-positioned to broadly improve the quality andsafety of venous access in hospitalized adults.

As with many health care innovations, PICCs wereintroduced to solve an important clinical problem in adefined population (86). However, over time, the use ofPICCs has evolved to span diverse indications and pa-tient populations. In hospital settings, accumulating ev-idence suggests that placement of PICCs may occur forpotentially inappropriate reasons (18, 87). Notwith-standing such benefits as convenience, comfort, andeconomic efficiency (4, 88), PICC insertion may intro-duce unnecessary risk and potential for preventableharm (15, 16, 73). Despite this fact, no framework toinform use of these devices has been developed todate.

These observations were the motivation underlyingthis project, which sought to incorporate existing evi-dence with the knowledge of clinicians and content ex-perts to define criteria for appropriate PICC use. Unlikeexisting recommendations, our appropriateness criteriarepresent a departure from the status quo in severalways.

First, they offer clinical granularity for clinicians. Forexample, existing guidelines recommend “use of mid-line catheters or PICCs instead of a short peripheralintravenous catheter when the duration of IV [inter-venous] therapy will likely exceed six days” (33). Ourcriteria build on this advice by adding such details aswhat patient-specific considerations should be incorpo-rated in this decision, which other devices may be ap-propriate, and when PICC use for shorter durationsmight be reasonable.

Second, whereas existing recommendations targetproceduralists or specialties that most often insert de-vices, our criteria are the first to provide direction toclinicians, such as internists or hospitalists, who orderPICCs. Thus, these criteria fill a critical gap, bringingrecommendations to those that drive the decision toplace such devices.

Finally, by tackling some of the most controversialtopics of venous access—including when to adjust thePICC position, appropriate indications for removal, andindications for reinsertion of PICCs after complications—our criteria advance the science of vascular access inimportant and innovative ways.

Some aspects of panelist deliberations and ratingsmerit further discussion. First, patterns of recommenda-tions for PICC appropriateness often hinged on 2 vari-ables: the nature of the infusate and duration ofvenous access. Thus, non–peripherally compatible infu-sions or scenarios where venous access was necessaryfor 6 days or longer often led panelists to rate PICC useas appropriate; conversely, shorter duration of use withperipherally compatible infusions led to a recommen-dation for use of a peripheral intravenous catheter,ultrasonography-guided catheter, or midline catheter.

Table 4. Guide for Peripheral Intravenous CatheterPractices

Appropriate peripheral intravenous catheter practicesInsert a peripheral intravenous catheter in the external jugular vein if the

proposed duration of use is ≤4 d or an emergent/life-threateningsituation exists

Place a peripheral intravenous catheter in the foot only in the setting ofan emergent, life-threatening situation

Use ultrasonographic guidance to place short or long peripheralintravenous catheters in patients with difficult venous access whorequire treatment for ≤5 d*

Remove peripheral intravenous catheters in the setting of redness,swelling, or phlebitis over the vein of insertion

In hospitalized patients who are likely to require ≥15 d of intravenousantibiotics, transition from a peripheral intravenous catheter to a PICCor midline catheter as soon as possible†

Use a 16-, 18-, or 20-gauge peripheral intravenous catheters in anupper-extremity vein rather than a PICC when venous access isneeded for blood transfusion or performance of a contrast-basedradiographic study

Inappropriate peripheral intravenous catheter practicesRemoval of peripheral intravenous catheters on the basis of a routine

schedule or in the absence of redness, swelling, or other signs ofinflammation is inappropriate; site rotation should be driven byclinically warranted change‡

Removal of a functioning peripheral intravenous catheter that has beeninserted in the field (e.g., ambulance or nonhospital site) in theabsence of redness, tenderness, or swelling over the insertion site isinappropriate

Placement of peripheral intravenous catheters on the same side as priorbreast surgery, axillary node dissection, or arteriovenous fistulae(regardless of whether the fistula is functional or not) is inappropriate

In the absence of a clinical indication warranting insertion, routineplacement of a peripheral intravenous catheter at the time ofadmission to the hospital is inappropriate

In the absence of a clinical indication warranting continued use, routinereplacement of a peripheral intravenous catheter is inappropriate

PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters isinappropriate in patients with advanced (stage 3b or greater) chronickidney disease. In such patients, consultation with a nephrologist anduse of a small-bore tunneled central catheter are appropriate.† Delaying transition from a peripheral intravenous catheter to a PICCbefore discharge may deplete available venous access sites and is notappropriate when intravenous antibiotic treatment beyond 15 d isclinically necessary.‡ Routine changes of peripheral intravenous catheters may result inloss of potentially available peripheral veins for infusion or therapy,inadvertently leading to greater use of PICCs in hospitalized patients.




Unlike existing standards, however, variation in risk forcomplications according to patient population influ-enced this pattern. This is well-illustrated in ratings forcritically ill patients and those with cancer, where atheme of limiting PICCs to durations of use of 15 daysor longer is evident.

Second, throughout deliberations, panelists notedthat it is often challenging for clinicians to estimate anexpected duration of venous access. Relatedly, a “max-imal” window within which PICCs may be safely used isnot known and depends on myriad factors, includingadequacy of care and differential risk for complications.Finally, panelists acknowledged that separation of indi-cations for PICC placement into individual categoriesand defining VADs by finite duration was artificial, be-cause venous access is rarely driven by a single clinicalpurpose or limited by duration.

On balance, panelists rationalized that clinicians of-ten do not reflect carefully enough on the nature ofvenous access or weigh its inherent risks and benefits.Panel members added that in many hospitals, the deci-sion to place a PICC is often dichotomous, with consid-eration of other devices lacking. Thus, an unforeseenadvantage of these criteria is the introduction of aphysician-directed “time-out” in vascular access deci-sion making. During this pause, reflection on the ap-propriate device, patient risk factors, and discussionswith specialists could conceivably improve outcomes inhospital settings.

Our approach has several limitations. First, we ex-cluded neonatal and pediatric studies when formulat-ing these recommendations, because considerable dif-ferences in PICC use exist between these patients andadults. However, because these populations often re-ceive PICCs, future panels should choose to focus onthese subsets.

Second, although our panel was multidisciplinary,we did not include bedside nurses, who often requestPICCs in hospitalized settings. However, vascularnurses and hospitalists are attuned to considerationsregarding PICC use from this group of providers andwere well-represented on our panel.

Third, the applicability of these recommendationswill vary on the basis of provider scope of practice, ed-ucation, and training. As echoed in other standards(89), provider availability, competence, and technicalexpertise should guide insertion and selection of ap-propriate VADs.

Finally, our panel was focused on appropriatenessof PICCs in relation to other devices. We acknowledgethat certain devices may be used for longer durations(for example, midline catheters for up to 28 days) orindications of different durations (for example, intrave-nous antibiotics for 6 weeks). These limitations werenecessary to ensure comparability among various de-vices and generalizability of these recommendations.

Despite these limitations, our appropriateness cri-teria represent a major multidisciplinary effort towardimproving decision making related to PICCs and re-lated VADs. Avoiding PICC use for inappropriate indi-cations, considering alternative devices, ensuring ap-

propriate consultations, and outlining instances wherePICC removal is appropriate are but a few examples ofhow these recommendations may be implemented toimprove practice. In addition, by including a patientwhose opinion influenced panel deliberations, we tookinto account the implications of provider decisionsfrom “the other side of the needle.” Finally, the criteriawe propose span not just indications for PICC insertionbut also best practices for use, care, and maintenance.Thus, we hope that our recommendations will provideclarity for management of complex situations not onlybefore, but also during and after, PICC placement.

Although optimal strategies to implement our cri-teria remain to be defined, an expansive range of op-tions is possible. For example, routine benchmarkingand feedback of metrics, such as PICC dwell time, indi-cations for insertion, and practices related to manage-ment of complications, may serve to inform hospital-specific “PICC dashboards” and quality-improvementefforts. Alternatively, more sophisticated paradigms,such as decision aids and computerized physicianorder-entry taking into account proposed duration ofuse, indication, and patient characteristics, are alsoplausible.

Because many of our recommendations are algo-rithmic, Web sites or smartphone applications to deter-mine the appropriateness of PICCs before insertionseem to be feasible. We are beginning to explore theseoptions through 2 strategic partners. First, through theongoing Blue Cross Blue Shield/Blue Care Network–funded Hospital Medicine Safety collaborative qualityimprovement project, we will use our appropriatenesscriteria to evaluate and improve PICC utilization in 47Michigan hospitals (90). Because the Hospital MedicineSafety project is composed of diverse hospitals and isbuilt on a robust data platform, we will also seek tounderstand contextual barriers, facilitators, and unin-tended consequences related to use of our criteria.

Second, through work recently funded by the Vet-erans Affairs National Center for Patient Safety and theNo Preventable Harms Campaign, we will test ways inwhich to operationalize our criteria within the highly in-tegrated Veterans Affairs health system. Given the ad-vanced electronic medical record systems in thissetting, our experiences will shed new light on imple-mentation strategies that could inform our work withinand beyond this setting. Such research may take sev-eral forms. For instance, quasi-experimental designs,such as pre–post or interrupted time series that exam-ine the influence of specific appropriateness recom-mendations (for example, avoid use of PICCs for pe-ripherally compatible infusions lasting 5 days or less)within and between hospitals, could be tested in par-ticipating Michigan and Veterans Affairs sites. Alterna-tively, a “bundle” of best practices related to PICCs,including appropriateness criteria for insertion, care,and management, may be deployed, leveraging a step-wedge or cluster randomized approach to account forsecular trends.

More robust research designs, such as randomizedclinical trials, that utilize our criteria are also feasible.




For example, randomly assigning patients who requireless than 2 weeks of peripherally compatible infusionsto receive a midline catheter or PICC is not only feasi-ble but also relevant, because many PICCs are placedto deliver antibiotics for such intervals after hospital dis-charge. Such a study may be powered to ascertain thenoninferiority of midline catheters, rates of therapycompletion, or complications with either device. There-fore, several research designs that span one or morehospitals, and one or more of our recommendations,may be used as interventions to target clinical out-comes, overall utilization, adverse events, and costs.

In conclusion, we used the RAND/UCLA Appropri-ateness Method to define best practices for PICC inser-tion, care, and management. Although a key first step,these criteria offer but a blueprint of best practices. Tomake MAGIC truly happen, diffusion, uptake, and re-finement from the providers and stakeholders engagedin vascular access is necessary. Through use of a sys-tematic rating process, a multidisciplinary internationalpanel, and patient representation, we hope to achievethis goal. Our patients deserve nothing less.

From University of Michigan Medical School, Patient SafetyEnhancement Program of the Veterans Affairs Ann ArborHealthcare System, and the Institute for Healthcare Policy andInnovation, University of Michigan Ann Arbor, and OakwoodHospital, Dearborn, Michigan; Intermountain Medical Center,Murray, and the University of Utah School of Medicine, SaltLake City, Utah; Clinical Center, National Institutes of Health,Bethesda, and Greater Baltimore Medical Center, Baltimore,Maryland; William S. Middleton Memorial Veterans AffairsHospital and Division of Infectious Diseases, University of Wis-consin Medical School, Madison, Wisconsin; Perelman Schoolof Medicine, University of Pennsylvania, Philadelphia, Pennsyl-vania; PICC Excellence, Hartwell, Georgia; Catholic University,Rome, Italy; American University of Beirut, Lebanon; and Uni-versity of British Columbia, Vancouver, British Columbia,Canada.

Portions of this work were presented at the 2015 Annual So-ciety of Hospital Medicine Meeting, Washington, DC, and the2015 Society for Healthcare Epidemiology of America Meet-ing, Orlando, Florida.

Acknowledgment: The authors thank Tanya Boldenow, MD,and Aaron Berg, MD, for reviewing early drafts of the appro-priateness document; Andy Hickner, MSI, and Marisa Conte,MSI, for assistance with literature searches; and GeorgiannZiegler, their patient panelist, whose views greatly influencedpanel discussions.

Disclosures: Dr. Chopra reports grants from the Society ofHospital Medicine and Agency for Healthcare Research andQuality during the conduct of the study. Dr. Flanders reportsgrants from Blue Cross Blue Shield of Michigan during theconduct of the study and consultancy for the Institute forHealthcare Improvement and the Society of Hospital Medi-cine; employment by the University of Michigan; one expertreview per year as expert testimony; grants or grants pendingfrom the CDC Foundation, Blue Cross Blue Shield of Michi-

gan, Michigan Hospital Association, and Agency for Health-care Research and Quality; honoraria for various talks at hos-pitals as a visiting professor; and royalties from WileyPublishing outside the submitted work. Dr. Saint reports serv-ing on the medical advisory board of Doximity (a social net-working site for physicians) and receiving an honorarium forbeing a member of this medical advisory board, and servingon the scientific advisory board of Jvion (a health care tech-nology company) outside the submitted work. Dr. Woller re-ports a grant paid by Bristol Myers-Squibb to IntermountainHealthcare, with no financial support to Dr. Woller, outsidethe submitted work. Dr. Trerotola reports personal fees fromUniversity of Michigan during the conduct of the study andgrants from Vascular Pathways; personal fees from Bard Pe-ripheral Vascular, B. Braun, Orbimed, Teleflex, Cook, W.L.Gore, and Lutonix outside the submitted work. Dr. Moureaureports PICC Appropriateness Panel reimbursement duringthe conduct of the study and serving as chief executive officerof PICC Excellence, Inc.; vascular access specialist and teammember at Greenville Hospital System, Greenville, South Car-olina; and associate adjunct professor and member of Alli-ance for Vascular Access Device Training and Research (AVA-TAR), Griffith University, Brisbane, Australia, outside thesubmitted work. Dr. LeDonne reports personal fees from Tele-flex, Ethicon, Bard International, SonoSite, and 3M outside thesubmitted work. Ms. Becker reports grants from the Society ofHospital Medicine and Blue Cross Blue Shield of Michiganduring the conduct of the study. Dr. Bernstein reports grantsfrom Department of Veterans Affairs National Center for Pa-tient Safety and Blue Cross Blue Shield of Michigan during theconduct of the study; in addition, he is a member of the BlueCare Network Clinical Quality Committee, which reviews is-sues related to quality of care, and although peripherally in-serted central venous catheters have not been considered inthe past, their use may be reviewed in the future. Dr. Bern-stein is also director of quality for the University of MichiganMedical Group; if the appropriateness of peripherally insertedcentral venous catheter criteria developed as part of this pro-cess are widely adopted, they could be applied to the Univer-sity of Michigan by outside agencies. Authors not named herehave disclosed no conflicts of interest. Disclosures can alsobe viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0744.

Grant Support: By a Young Researcher Award from the Soci-ety of Hospital Medicine and a career development award(1-K08-HS022835-01) from the Agency for Healthcare Re-search and Quality to Dr. Chopra and by Blue Cross BlueShield and Blue Care Network of Michigan, which providedsalary support for Drs. Flanders and Bernstein and Ms. Beckerthrough the Michigan Hospital Medicine Safety Consortium.

Requests for Single Reprints: Vineet Chopra, MD, MSc, Insti-tute for Healthcare Policy and Innovation, University of Michi-gan, North Campus Research Complex, 2800 Plymouth Road,Building 16, Room 432W, Ann Arbor, MI 48109; [email protected].

Current Author Addresses: Dr. Chopra: Institute for Health-care Policy and Innovation, University of Michigan, NorthCampus Research Complex, 2800 Plymouth Road, Building16, Room 432W, Ann Arbor, MI 48109.




http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0744

http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0744

mailto:[email protected]

Dr. Flanders: Taubman Medical Center, University of Michi-gan, 1500 East Medical Center Drive, SPC 5376, Ann Arbor,MI 48109.Dr. Saint: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 432W, Ann Arbor, MI48109.Dr. Woller: Intermountain Medical Center, PO Box 57700,5169 South Cottonwood Street, Suite 307, Murray, UT 84107.Dr. O’Grady: Critical Care Medicine Department, Clinical Cen-ter, National Institutes of Health, 10 Center Drive, Building 10,Room 2C145, Bethesda, MD 20892.Dr. Safdar: University of Wisconsin Medical School, MFCB5221, 1685 Highland Avenue, Madison WI 53705.Dr. Trerotola: Department of Radiology, University of Pennsyl-vania Medical Center, 1 Silverstein, 3400 Spruce Street, Phil-adelphia, PA 19104.Dr. Saran: Division of Nephrology, Department of InternalMedicine, University of Michigan Medical School, 1415 Wash-ington Heights, SPH I, Suite 3645, Ann Arbor, MI 48109-2029.Ms. Moureau: PICC Excellence, Inc., 1905 Whippoorwill Trail,Hartwell, GA 30643.Dr. Wiseman: Veterans Affairs Ann Arbor Healthcare System,VISN 11, 2215 Fuller Road, Department of Pharmacy (119),Ann Arbor, MI 48105.Dr. Pittiruti: Catholic University, Via Malcesine 65, 00135Rome, Italy.Dr. Akl: American University of Beirut Medical Center, PO Box11-0236 Riad-El-Solh 1107 2020, Beirut, Lebanon.Dr. Lee: Division of Hematology, University of British Colum-bia, 2775 Laurel Street, 10th Floor, Vancouver, British Colum-bia V5Z 1M9, Canada.Dr. Courey: Taubman Medical Center, University of Michigan,1500 East Medical Center Drive, SPC 3918, Ann Arbor, MI48109-3918.Dr. Swaminathan: Division of Hospital Medicine, OakwoodHospital, 18101 Oakwood Boulevard, Dearborn, MI 48124.Dr. LeDonne: Department of Surgery, Greater Baltimore Med-ical Center, 10210 Breconshire Road, Ellicott City, MD 21041.Ms. Becker: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 476C, Ann Arbor, MI48109.Dr. Krein: Department of Veterans Affairs, 2800 PlymouthRoad, Building 16, Room 33W, Ann Arbor, MI 48109-2800.Dr. Bernstein: Institute for Healthcare Policy and Innovation,University of Michigan, North Campus Research Complex,2800 Plymouth Road, Building 16, Room 446E, Ann Arbor, MI48109.

Author Contributions: Conception and design: E.A. Akl, C.Becker, S.J. Bernstein, V. Chopra, S.A. Flanders, S.L. Krein, J.LeDonne, S. Saint, L. Swaminathan, S. Wiseman, S. WollerAnalysis and interpretation of the data: C. Becker, S.J. Bern-stein, V. Chopra, J. LeDonne, A.Y. Lee, M. Pittiruti, S. TrerotolaDrafting of the article: S.J. Bernstein, V. Chopra, A.J. Courey,N. O’Grady, S. Trerotola.Critical revision for important intellectual content: E.A. Akl, C.Becker, S.J. Bernstein, V. Chopra, A.J. Courey, S.A. Flanders,S.L. Krein, J. LeDonne, A.Y. Lee, N.L. Moureau, N. O'Grady, M.Pittiruti, N. Safdar, S. Saint, R. Saran, L. Swaminathan, S. Trero-tola, S. Wiseman, S. Woller.

Final approval of the article: E.A. Akl, C. Becker, S.J. Bernstein,V. Chopra, A.J. Courey, S.A. Flanders, S.L. Krein, J. LeDonne,A.Y. Lee, N.L. Moureau, N. O'Grady, M. Pittiruti, N. Safdar, S.Saint, R. Saran, L. Swaminathan, S. Trerotola, S. Wiseman, S.Woller.Provision of study materials or patients: V. Chopra, S.A. Flan-ders, A.Y. Lee.Statistical expertise: S.J. Bernstein, V. Chopra.Obtaining of funding: V. Chopra, A.J. Courey, S.A. Flanders,S. Saint.Administrative, technical, or logistic support: C. Becker, S.J.Bernstein, V. Chopra, S.A. Flanders, R. Saran.Collection and assembly of data: E.A. Akl, C. Becker, V. Cho-pra, S.A. Flanders, N.L. Moureau, N. O'Grady, L. Swaminathan,S. Trerotola, S. Wiseman, S. Woller.

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Table 1. Summary of Studies Included in the Literature Review

Study, Year (Reference) Participants,n

Design Focus or Overview Study Sample and Characteristics Device Findings and Comments

Abdullah et al, 2005 (91) 26 Prospective cohortstudy

Determine the incidence of DVT in patientswith PICCs as diagnosed with anupper-limb venogram at the time of PICCremoval

Patients aged 15–70 y with PICCs at the Universityof Malaya Medical Centre

PICC PICCs were associated with a significant rate ofDVT by venography; no correlation betweensize and insertion site of catheter and UEVTEwere noted.

Ahn et al, 2013 (57) 237 Retrospective cohortstudy

Ascertain risk factors associated withPICC-related DVT in cancer patients

Patients with cancer and PICCs at the Dallas VAmedical center from 2006 to 2009

PICC Antiplatelet agents were protective againstDVT whereas use of ESAs, hospitalization,and treatment dose anticoagulation wereassociated with DVT

Akers and Chelluri, 2009 (92) 5 Retrospective cohortstudy

Analysis of CVC use 18 mo before and aftera hospitalist training program to placePICCs

3 hospitalists were trained to place PICCs inpatients at 1 university-affiliated communityhospital

PICC After training, use of CVCs doubled, withPICCs representing over 80% of all devices

Akl et al, 2011 (93) 3611 Cochrane systematicreview

Evaluate the efficacy and safety ofanticoagulation in patients with cancer

Patients with cancer and CVCs from 12 RCTs CVC A clear rationale supporting use ofanticoagulants to prevent CRT could not bedefined

Alexandrou et al, 2014 (94) 3447 Prospective cohortstudy

Report characteristics and outcomes from aCVC insertion service offered by trainednurses

Adult patients with a CVC, PICC, high-flow dialysiscatheter, or midlines in one tertiary careuniversity hospital in Sydney, Australia, betweenNovember 1996 and December 2009

CVADs Trained vascular access nurses using US andbest practice can lower complication ratesduring insertion and may improve patientsafety

Alhimyary et al, 1996 (95) 231 Prospective cohortstudy

Report complications using PICCs for TPN innon-ICU patients compared to placementof CVCs in the subclavian vein

Non-ICU patients who needed TPN received PICCsinserted in the antecubital vein or CVCs at 1institution from July 1991 to March 1994

CVC, PICC Complication rates did not differ significantlybetween the 2 groups; PICCs can be usedsafely for exclusive TPN administration

Alkindi et al, 2012 (96) 16 Retrospective cohortstudy

Review outcomes related to implanted portplacement in patients with sickle celldisease who required red cellexchange/transfusion

Patients with sickle cell disease who werefrequently hospitalized at a single academicmedical center

Port Of 24 devices placed, 17 required removalowing to infection or thrombosis. Themedian working life of the ports was 688.5 d(range, 39–3925 d). The number ofinfections was significantly correlated withthe number of ports (Pearson r = 0.66;P < 0.01)

Allan et al, 2012 (97) 10 In vivo comparisonstudy

Rabbit model used to evaluate theperformance of antimicrobial(chlorhexidine)–coated PICCs in a clinicalsetting, compared with uncoatedcatheters

Healthy, 15-week-old New Zealand white femalerabbits

PICC Chlorhexidine-coated catheters significantlyreduced microbial colonization andprevented microbial migration comparedwith uncoated devices

Allen et al, 2000 (98) 119 Retrospective cohortstudy

Evaluate the rate of DVT in patients who hadvenography before and after PICCplacement

354 PICCs were placed in 119 patients betweenApril 1992 and August 1998 at a single center;all patients underwent venography before andafter PICC placement

PICC Overall rate of DVT associated with PICCs was38%; incidence was highest for PICCsplaced in the cephalic vein (57%)

Al Raiy et al, 2010 (1) 1260 Prospective cohortstudy

Compare PICC-related CLABSI rates withthose associated with CVCs inhospitalized patients

Patients with CVCs in non-ICUs and patients withPICCs hospital-wide at 1 institution

CVC, PICC CVCs and PICCs had similar rates of CLABSI;with surveillance and intervention, high-riskCVCs were removed; PICCs may be safer forlonger IV access

Al-Tawfiq et al, 2012 (99) 92 PICCs Prospective cohortstudy

Describe PICC-related BSI incidence in 1hospital setting

Hospitalized patients with PICCs at Dhahran HealthCare Center, Saudi Arabia, from January toDecember 2009

PICC Rates of PICC-related CLABSI varied accordingto patient factors, such as cancer and criticalillness

Amerasekera et al,2009 (100)

NA Review Overview of venous anatomy andcomplications related to PICC use withradiographic images

NA PICC To help diagnose PICC complications,radiologists should have good knowledgeof venous anatomy and imaging techniquesrelated to PICC insertion

Anderson, 2004 (42) 6004 midlinecatheters;337 PICCs

Review article andretrospectivecohort study

Examine midline catheter use as a bridgebetween peripheral and central cathetersover a 6-year period

Patients at Evangelical Community Hospital inLewisburg, PA

PIVC,midlinecatheter,PICCIV

Substituting a midline for a short peripheralcatheter led to improved outcomes,including reduced rates of venipuncture,decreased length of stay, and improved staffand patient satisfaction

Armstrong et al, 2013 (101) 49 Case–control study Compare bacteremia rates in patients withantibiotic (minocycline–rifampin)impregnated PICCs vs. those whoreceived conventional PICCs

Patients admitted to a regional burn center whorequired a PICC as part of clinical care

PICC Antibiotic-impregnated PICCs substantiallydecreased the rate of bacteremia in burnpatients (0% vs. 50%)

Association for VascularAccess, 2011 (102)

NA Guideline Position statement and recommendationsfor the insertion of CVADs by registerednurses using US guidance

NA CVC,midlinecatheter,PICC

US guidance for placement of CVADs bytrained nurses is safe and cost-effective andshould become part of routine practice

Aw et al, 2012 (103) 340 Retrospective cohortstudy

Determine the incidence of symptomaticPICC-related DVT in cancer patients

Patients with cancer who had PICCs placed by USguidance for delivery of chemotherapy

PICC Symptomatic PICC-related DVT is frequent inthis population; diabetes and chronicobstructive pulmonary disease are riskfactors for PICC-related DVT

Bai and Hou, 2010 (104) 37 Prospective cohortstudy

Explore feasibility of US-guided PICCinsertion in elderly adults using modifiedSeldinger technique

Elderly adults with PICCs inserted by US guidancein a Chinese medical center

PICC US-guided insertion of PICCs is safe andeffective for elderly adults with nonpalpableveins

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Bai et al, 2013 (105) 128 Prospective cohortstudy

Determine clinical outcomes in patients whoreceived chemotherapy via an indwellingIVs compared to PICCs

Patients with lung cancer in 1 radiation oncologydepartment in Shenyang, China

IV, PICC Patients undergoing combined radiationtherapy and chemotherapy prefer a PIVCover a PICC for intermittent chemotherapy

Barr et al, 2012 (106) 2766 Retrospective cohortstudy

Examine rates of complications andoutcomes in patients receiving outpatientantibiotic therapy by device type

Patients in the ambulatory care setting using theGlasgow outpatient antibiotic therapy service

Midlinecatheter,PICC,TCVC

Line infections were associated with durationof line use, female sex, and TCVCs; dwelltime was significantly associated with risk forline infection

Bates et al, 2012 (107) NA Guidelines fordiagnosis of DVT

Identify and recommend strategies fordiagnosis of DVT in ambulatory adults

Eligible studies included those that addresseddiagnostic accuracy and clinical outcomes

PICC, CVC For diagnosis of UEDVT, initial evaluation withcombined modality US over other tests,including venography and D-dimer, isrecommended

Baumgarten et al, 2013 (108) NR Prospective cohortstudy

Evaluate a training and implementationprogram to reduce CLABSI in the homehealth care environment

Ochsner home infusion outpatients who receivedPICC lines were included; a checklist for bestdressing practices and order sets wereevaluated

PICC After institution of a checklist and an order setto standardize care in home infusionpatients, PICC infection rates decreased by46% compared with prior years

Baxi et al, 2008 (109) 1350 PICCs Retrospective cohortstudy

Evaluate the association betweenpost-placement and risk for PICC-relatedBSI and DVT

Hospitalized patients from February to August2007 at a quaternary medical center in Michigan

PICC Post-placement adjustment of PICCs was notassociated with CLABSI or DVT. Factorsassociated with CLABSI were diabetes,immune suppression, and number oflumens; lumens were associated with risk forDVT and catheter thrombosis

Baxi et al, 2013 (110) 1652 Retrospective cohortstudy

Evaluate the association betweenpost-placement and risk for PICC-relatedBSI and DVT

Hospitalized patients from February to August2007 at a quaternary medical center in Michigan

PICC Post-placement adjustment of PICCs was notassociated with CLABSI or DVT. Factorsassociated with CLABSI were power-capablePICCs, diabetes, immune-suppression andnumber of lumens; lumens were alsoassociated with risk for DVT and thrombosis

British Committee forStandards in Haematology,1997 (69)

NA Guidelines British Committee for Standards inHaematology guidelines that review basicprinciples of the care of patients withCVCs

2007 update to the 1997 guidelines that providemajor recommendations for use of severaldevices in hospitalized and ambulatory patients

CVC, PICC,port

Major recommendations in this update includeuse of US during insertion, use of CVCs forshort-term access when peripheral access isnot possible, and use of tunneled cathetersor ports for longer-term access. Theseguidelines recommend avoidance of PICCsin inpatient settings because of thrombosis risk

Bellesi et al, 2013 (58) 24 Prospective cohortstudy

Evaluate the efficacy and safety of PICCs aslong-term VADs for chemotherapyadministration

Patients undergoing hematopoietic stem celltransplantation with PICCs inserted betweenMay and November 2008 in Italy

PICC The rate of CLABSI with PICCs was similar tothat of conventional CVCs

Bonciarelli et al, 2011 (111) NA Guideline Define recommendations for the correct andsafe use of implantable venous accessdevices for diagnostic procedures

Patients using ports for radiodiagnostics Port Patient safety, cost-effectiveness, andefficiency are important aspects in the use ofports in radiodiagnostics, especially inpatients with cancer

Bonizzoli et al, 2011 (112) 239 Prospective cohortstudy

Assess rates of thrombosis after PICCplacement in a cohort of critically illpatients

Patients discharged from the ICU with a centralvenous device at Careggi Teaching Hospital,Florence, Italy, from January to August 2008

CVC, PICC Higher risk for DVT in patients with PICCs wasnoted (27.2% vs. 9.6%). Female sex and theleft basilic vein as the access site wereassociated with PICC-related DVT

Bottino et al, 1979 (113) 81 Prospective cohortstudy

Assess risks related to long-term use ofperipherally inserted silicone elastomerCVCs in cancer populations

Patients with cancer requiring prolonged IVtherapy, including chemotherapy

PICC Although 6% of catheters were removed forphlebitis, peripherally inserted siliconeelastomer CVCs may be used for long-termcentral venous access

Burg and Myles, 2005 (114) 79 Cross-sectionalsurvey

Identify complications associated withantepartum PICC use

Antepartum patients with IV therapy records at St.Mary's Health Center from January 2000 toMarch 2005

PICC PICCs had a low risk for complications andwere otherwise effective for long-term IVaccess. One patient had a DVT, and 6% hadPICCs removed for other complications

Burns and Lamberth, 2010 (5) NA Review Discuss resources, costs, policies, andprocedures related to developingvascular access teams

A review of the formation of vascular access teamsin 2 hospitals and the costs and benefitsassociated with these programs

PICC,midlinecatheter,CVC

Vascular access teams, though associated withupfront costs, have important downstreambenefits and cost savings

Butler et al, 2011 (115) 185 Retrospective cohortstudy

Examine the association between PICCplacement and subsequent risk forcatheter-related infection in hemodialysispatients

Patients requiring hemodialysis with catheterplacements and exchanges at 1 universityhospital from September 2003 to September2008

PICC Prior PICC use was 2.46 times more likely to beassociated with catheter-related infectioncompared with patients who never receivedthis device

Caparas and Hu, 2014 (38) 54 Prospective,controlled,randomizedclinical trial

Assess whether vancomycin can be safelyadministered through a new midlinecatheter compared with PICCs

Patients scheduled to receive short-term IVvancomycin at a single medical center inQueens, New York

Midlinecatheter,PICC

Short-term midline catheters were safe andcost-effective for delivering vancomycin fordurations ≤6 d

Cape et al, 2013 (116) 66 Retrospective cohortstudy

Analyze PICC-related complications inpregnant women who received PICCs forvarious clinical indications

Pregnant women with PICCs inserted betweenJanuary 2000 and June 2006 at 1 medicalcenter

PICC PICC insertion in pregnant women wasassociated with high rates of bacteremiaand thrombosis.


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Catalano et al, 2011 (117) 500 Prospective cohortstudy

Analyze rates of catheter-related thoracicDVT in patients with cancer by usingmultidetector CT

Cancer patients who had a CVAD and underwentCT for any reason

CVC, PICC,port

CVC-related thrombosis is common in patientswith cancer and can be difficult to detect byclinical means

Chakravarthy et al,2005 (118)

31 Randomized,controlled clinicaltrial

Evaluate the incidence of PICC-related DVTin ICU patients

Critically ill patients who received a PICC duringroutine clinical care at 1 academic medicalcenter

PICC PICC-related DVT in critically ill patients iscommon (65%) and largely asymptomatic;vigilance for DVT in this population issuggested

Chemaly et al, 2002 (119) 2063 Retrospective cohortstudy

Assess the safety of PICCs used forlong-term IV antibiotic administration

Patients at the Cleveland Clinic Foundation whohad a PICC placed for IV antibiotics betweenJanuary 1994 and October 1996

PICC PICC use was associated with UEDVT. Patientswho were younger, had prior VT, orreceived amphotericin infusion through thePICC were at greater risk for DVT

Cheong et al, 2004 (120) 17 Retrospective cohortstudy

Document the frequency of PICCcomplications in patients with solidtumors

Patients with solid tumors treated at FlindersMedical Centre, South Australia, betweenJanuary 2000 and March 2001

PICC Compared with patients without cancer, a highrate of complications (sepsis, thrombosis,blockage, and leakage) was found inpatients with cancer who received PICCs

Chittick et al, 2013 (121) 265 Prospective cohortstudy

Compare patients with early- and late-onsetPICC-related CLABSI to assess risk factors

Patients who developed PICC-related CLABSI at 1academic center

PICC There are significant differences in themicrobiological characteristics of patientswith early- and late-onset CLABSI; thesedifferences may influence choice ofantibiotic and strategy of prevention

Chopra et al, 2012 (17) NA Review Describe evolution of PICCs and theiradoption in modern medicine; evaluateearly studies of DVT and CLABSI; providefocus for areas of uncertainty and risk

Human studies with specific keywords related toPICCs, CLABSI, and DVT; full text, abstracts, andposters were included

PICC Introduction of a conceptual model,highlighting uncertainties and knowledgegaps pertaining to PICCs and specificadverse outcomes

Chopra et al, 2012 (9) NA Review Examine the risk and benefit of PICC use inhospitalized patients

Evaluation of PICC decision making and changesin the epidemiology of CVC use in hospitalsettings

PICC Highlights the need for more PICC researchand caution in placing PICCs, given the riskfor adverse events

Chopra et al, 2013 (22) 144 Cross-sectionalsurvey

Web-based survey designed to understandhospitalist experience, practice, opinions,and knowledge related to PICC use, care,and management in Michigan

Hospitalists from 10 academic and communityhospitals in Michigan

PICC Substantial variation in hospitalist experience,practice, opinions, and knowledgeregarding PICCs was observed

Chopra et al, 2013 (21) 2112 Cross-sectionalsurvey

Web-based survey designed to understandhospitalist experience, practice, opinionsand knowledge related to PICC use, care,and management across the United States

Hospitalist providers who are members of theSociety of Hospital Medicine across the UnitedStates

PICC Hospitalist knowledge and experiences relatedto PICCs varied, with knowledge gapsrelated to the rationale for PICC tippositioning and outcomes related to PICCuse. Treatment of complications variedsubstantially, including in duration ofanticoagulation and catheter removal in thesetting of PICC-related DVT

Chopra et al, 2013 (15) 57 250 Systematic reviewand meta-analysis

Risk for CLABSI with PICCs vs. CVCs Twenty-three studies including adults who hadeither a PICC or CVC and reported CLABSI

PICC, CVC Hospitalized patients are just as likely todevelop CLABSI with PICCs as with CVCs; inoutpatients, PICCs were associated with alower risk for CLABSI

Chopra et al, 2013 (16) 29 503 Systematic reviewand meta-analysis

Risk for DVT with PICCs vs. nontunneledCVCs

64 studies including adult patients with PICCs orCVCs

CVC, PICC Patients with cancer and those with criticalillness had the highest rate of PICC-relatedDVT; PICCs were associated with 2.5 timesgreater risk for DVT compared with CVCs

Chopra et al, 2014 (122) 747 Retrospective cohortstudy

Identify rates; patterns; and patient,provider, and device characteristicsassociated with PICC-related CLABSI

Patients who underwent PICC placement betweenJune 2009 and July 2012 at a VA medical centerin Michigan

PICC PICC-related BSI was associated with hospitallength of stay, ICU status, and number ofPICC lumens

Cortelezzia et al, 2003 (123) 126 Retrospective cohortstudy

Analyze the incidence of thrombotic andinfectious complications in CVCs vs. PICCsin cancer patients

Patients with hematologic cancer and low plateletcount with either a CVC or a PICC; patientsreceived DVT prophylaxis at the discretion ofthe provider

CVC, PICC Thrombosis occurred more frequently withPICCs than with CVCs; patients whoreceived LMWH were less likely toexperience DVT than those who receivedheparin

Cotogni et al, 2013 (59) 254 Prospective cohortstudy

Evaluate the incidence of VAD-relatedcomplications in cancer patients whoreceive home parenteral nutrition

Cancer patients who received parenteral nutritionbetween June 2008 to November 2009 at auniversity hospital in Italy

PICC,tunneledcatheter,port

Home parenteral nutrition was safe and welltolerated in patients with cancer; risk forcomplications across devices was low andacceptable

Couban et al, 2005 (124) 255 Multicenter,randomized,placebo-controlled clinicaltrial

Assesse whether low-dose daily warfarinreduces the incidence of symptomaticCVC thrombosis in patients with cancer

Patients who required a CVC for at least 7 d wererandomly assigned to receive 1 mg warfarindaily vs. placebo

CVC Symptomatic CVC-associated thrombosis wasless common than previously thought in thispopulation; daily 1-mg doses of warfarin didnot reduce symptomatic CVC-relatedthrombotic events

Crnich and Maki, 2002 (125) NA Review Invited article that examined use of novelapproaches, such as securement devices,dressings, catheter coatings, and locksolutions, in preventing CLABSI

Examining the risk for IVD-related infections,pathogenesis, prevention, and novel technologyavailable for control of BSI associated withlong-term devices

CVC, port,PICC

Newer technologies may help reduce CLABSI.;identification, adaptation, and evaluation ofthese novel approaches is necessary


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Curigliano et al, 2007 (126) 188 Prospective cohortstudy

Evaluate the efficacy and safety of low-doseaspirin for prevention of VTE

Patients with stage II–IV breast cancer with CVCsfor continuous chemotherapy from April 2000 toMarch 2004 in a single center

CVC Although no control or comparison arm wasincluded, low-dose aspirin was a reasonablywell tolerated method of DVT prevention inthis population

Daneman et al, 2012 (127) 348 Retrospective cohortstudy

Assess the risk for recurrent bacteremia inpatients with recent CLABSI within 6weeks

Bacteremic patients undergoing PICC insertion atan academic health center were reviewed forrisk for recurrent infection

PICC Recurrent bacteremia within 30 d of PICCinsertion occurred in 33 patients but ofteninvolved a different organism (25 patients);after adjudication, only 3 of 8 recurrentinfections were determined to be "true"relapses (0.9%)

Dariushnia et al, 2010 (68) NA Guidelines Guidelines from the Society of InterventionalRadiology that were written for qualityimprovement programs seeking to assesscentral venous access procedures

Comprehensive review of indications for centralvenous access, QI efforts, and management ofcomplications

PICC, CVC,port

These guidelines provide target success ratesfor insertion of various catheters as well asmajor complication rates and suggestedthresholds for venous access devices

Dawson et al, 2013 (128) NA Review Examined published evidence on midlinecatheters in reducing the risk for CLABSI

Calls for greater use of midline catheters as part ofa multifaceted effort to reduce CLABSI inhospitals

CVAD,CVC,PICC,midlinecatheter

Midline catheters are effective tools forintermediate-duration infusions that areperipherally compatible. They can be usedfor blood draws and infusion and, as part ofa multifaceted approach, can reducehospital rates of CLABSI

Debourdeau et al, 2013 (36) NA Guidelines Establishment of good clinical practicesguidelines for the management of CRT inpatients with cancer

Guideline examined prophylaxis and treatment ofthrombosis associated with CVCs in patientswith cancer

CVC Dissemination and implementation of theseguidelines is a public health priority in orderto reduce CRT

DeLemos et al, 2011 (129) 35 Prospective cohortstudy

Evaluation of PICCs as an alternative to CVCsin neurosurgical critical care settings

Neurologic critical care patients at 1 center whohad PICCs (as opposed to CVCs) for IV accessand monitoring

PICC, CVC Use of PICCs (rather than CVCs or pulmonaryartery catheters) reduced procedural andinfection risk

Del Principe et al, 2013 (56) 71 Retrospective cohort Assess rates of catheter-related thrombosisin relation to catheter exit site infection

Patients with acute myeloid leukemia whounderwent CVC placement before eachchemotherapy cycle

CVC Patients with sepsis and exit-site infections hadsignificantly higher rates of thrombosis thanthose without these events, independent ofother factors

Diaz et al, 2012 (130) 50 Prospective cohortstudy

Determine baseline CLABSI rates forED-inserted CVCs and describeindications, duration of use, and naturalhistory of these devices

Patients at a level I trauma, academic ED whorequired central catheter insertion

CVC No CLABSI events occurred; notably, 42% ofCVCs had no date of removal, suggestingthe need to improve documentation in thisregard

Di Nisio et al, 2010 (131) NA Systematic review Examine the utility of US to diagnosePICC-related DVT

17 articles assessing diagnostic accuracy of testsfor clinically suspected UEDVT

CVC, PICC Compression US is an acceptable alternative tovenography, given high sensitivity andspecificity for catheter thrombosis

Duerksen et al, 1999 (132) NR Prospective cohortstudy

Assess type of CVC and complicationsassociated with delivery of parenteralnutrition

Patients at St. Boniface General Hospital inWinnipeg, Manitoba, Canada, who received aCVC for nutrition between 1987 and 1997

CVC, PICC,tunneledcatheter

Over the 10-year study, use of PICCs increasedto replace CVCs in providing parenteralnutrition; PICCs did not increase risk forsepsis or thrombosis compared withhistorical cohorts

Durrani, 2009 (133) 623 Retrospective cohortstudy

Test whether anticoagulants can prevent VTin patients with PICCs

Patients admitted to a single medical centerbetween January 2004 to July 2009 whoreceived a PICC and antiplatelet agents

PICC Receipt of aspirin or clopidogrel duringhospitalization did not affect the risk forPICC-related DVT

Elia et al, 2012 (41) 100 Randomizedcontrolled trial

Compare survival rates betweenstandard-length catheters vs. longperipheral catheters inserted by US

100 patients in an urban high-dependency unitwere randomly assigned to receive either shortor long peripheral catheters

PIVC Both short and long peripheral cathetersplaced with US have a high success rate;catheter failure occurred more frequently inthe short catheter group (45% vs. 14%;P = 0.001)

El Ters et al, 2012 (49) 282 Case–control study Assess the association between history ofPICC use and subsequent malfunctioningor nonfunctioning arteriovenous fistula

Hemodialysis outpatients in 7 Mayo Clinic units inRochester, Minnesota

PICC A strong and independent association (3.2times greater odds of a nonfunctioningfistula) was noted in patients who hadreceived prior PICCs

Evans et al, 2010 (73) 1728 Prospective cohortstudy

Assess the prevalence and risk factorsassociated with symptomatic PICC-relatedDVT in hospitalized patients

Patients with PICC insertions at a largeuniversity-based health system

PICC PICC insertion in patients who have cancer,undergo surgery lasting greater than 1 h, orhave experienced prior thrombosis isassociated with greater risk for DVT;Catheter gauge is a strong and modifiablefactor associated with PICC DVT

Evans et al, 2013 (74) 5018 Prospective cohortstudy

Assess whether small-diameter PICCs mayreduce the risk for DVT in hospitalizedpatients

All patients with PICC insertions at 1 hospital fromJanuary 2008 to December 2010

PICC Use of smaller-gauge PICCs was associatedwith substantially lower rates of DVT

Faganani et al, 2007 (134) 1410 Prospective cohortstudy

Evaluate the association betweenantiplatelet therapy and risk ofsubsequent catheter-related thrombosis

Patients attending 1 of 18 participating hospitalswho had solid or hematological tumors and aCVC, PICC, or port

CVC, PICC,port

Antithrombotic prophylaxis did not preventcatheter-related VT in this high-risk cohort

Fearonce et al, 2010 (135) 31 Retrospective cohortstudy

Compare the use and safety of PICCs vs.CVCs in a cohort of patients admitted to aburn ICU

Burn patients at a single center who received oneor more PICCs between July 2005 and June2007

PICC, CVC Compared with PICCs, CVCs had a higher rateof catheter-related BSI; PICCs wereassociated with greater risk for DVT


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Fletcher and Bodenham,2000 (70)

501 Retrospective cohortstudy

Assess the incidence rate and clinicalsignificance of PICC-related DVT incritically ill patients in a neurologic ICU

479 patients who received 501 PICCs duringclinical care in a neurologic ICU at a quaternaryacademic medical center

PICC The incidence of symptomatic PICC-relatedDVT was 8.1%; PE attributable to the PICCoccurred in 15% of patients, often requiringanticoagulation or superior vena cava filterplacement

Fletcher et al, 2011 (136) 2150 Retrospective cohortstudy

Understand the incidence rate andsignificance of symptomatic PICC-relatedDVT in critically ill patients in aneurosurgical ICU

PICCs placed in neurosurgical ICU patientsbetween March 2008 and February 2010

PICC, CVC PICCs are associated with a high rate of DVT;placement in a hemiparetic arm and infusionof mannitol or vasopressors through thePICC were associated with greater odds ofDVT

Freixas et al, 2013 (137) 2176 healthcareworkers

Quasi-experimentalbefore-after study

Determine the effect of a multimodalintervention to reduce the incidence ofCLABSI outside the ICU

Adult patients hospitalized in non-ICU settingsbetween 2009 and 2010 at 11 affiliatedhospitals in Catalonia, Spain

PIVC, CVC Implementation of the program reducedCLABSI and CVC utilization; PIVC utilizationremained unchanged

Frizzelli et al, 2008 (138) 848 Prospective cohortstudy

Evaluate risk for US-confirmed DVT inpatients who received a CVC duringcardiac surgery

Patients recovering in the ICU after heart surgeryfor 5–7 d from 6 centers were included

CVC CVC-related DVT was a frequent outcome,occurring in 386 patients (48%). Patientswho received prophylactic anticoagulationdid not experience PE. Screening via US inthis high-risk cohort may be valuable to preventPE

Furuya et al, 2011 (139) 441 hospitals Cross-sectional study Assess the implementation of elementsembedded within the central line"bundle" across US hospitals and effect onsubsequent CLABSI rates

Hospitals must have conducted NationalHealthcare Safety Network CLABSI surveillancein 2007 to be included

CVC Reduction in CLABSI was only observed inICUs that had a CLABSI policy, monitoredadherence, and had >95% adherence rate

Gong et al, 2012 (140) 180 Prospective cohortstudy

Compare PICC complications via use of amodified Seldinger technique with USguidance vs. the traditional method ofplacement

Patients with cancer who had PICCs at theDepartment of Chemotherapy in JiangsuCancer Hospital

PICC PICCs placed using a modified Seldingerapproach and US were less likely toexperience thrombotic complications

Göransson and Johansson,2012 (141)

83 Prospective cohortstudy

Investigate the association betweenprehospital PIVC placement andfrequency of phlebitis

Hospitalized patients who underwent PIVCplacement before hospitalization by ambulancecrews in Stockholm, Sweden

PIVC Of 83 patients, 45% developedthrombophlebitis (54%); no associationbetween thrombophlebitis and prehospitalrisk factors was found

Grant et al, 2008 (142) 189 Retrospective cohortstudy

Examine characteristics of patients whodeveloped PICC UEDVT

Patients who underwent PICC placement at UCLAMedical Center between January 2003 andDecember 2006

PICC Patients who experienced multiple PICCinsertions had a 4-fold greater risk for DVTthan those who had only 1 insertion

Grant et al, 2012 (143) NA Review Provide a summative and clinically relevantapproach for the diagnosis, managementand prevention of UEDVT in high-riskpatients with and without catheters

Narrative review PICC, CVC,port

Pharmacologic thrombosis prophylaxis is noteffective in reducing risk for UEDVT inpatients with CVCs; anticoagulation iscommonly used for treatment of UEDVT andis recommended largely from extrapolationof studies involving lower-extremity DVT

Gregg et al, 2010 (144) 59 Retrospective cohortstudy

Report success and complications related toUS-guided PIVC placement in critically illpatients

Critically ill patients who underwent US-guidedPIVC placement as part of their routine care at asingle medical center in the United States

PIVC, CVC Of the 148 PIVCs requested, 147 were placedsuccessfully by US guidance; complicationsincluded infiltration (3.4%), inadvertentremoval (2.7%), and phlebitis (0.7%). As aresult of successful PIVC placement, 40CVCs were discontinued and 34 CVCs wereavoided

Griffiths, 2007 (145) NA Review Overview of midline catheters inserted bynurses for short- and long-term IVinfusions

Narrative review Midlinecatheter

Nurse involvement in determining theappropriateness of venous access can helpimprove patient outcomes; midlinecatheters are one example of a device thatcan provide both short and long-terminfusions with low risk for complications

Grove and Pevec, 2000 (146) 678 Retrospective cohortstudy

Determine risk factors that may lead to DVTin patients who receive PICCs

Patients with PICC insertions in 1997cross-referenced with venous duplex exams at 1hospital

PICC PICC-related DVT rates were 4.5% for nursesand 2.7% for IRs; the smallest-gaugecatheter should be used to decrease risk forthrombosis

Gunst et al, 2011 (2) 121 Prospective cohortstudy

Assess whether use of PICCs results inreduced rate of BSI compared toantiseptic-coated CVCs

Patients admitted to a surgical ICU for ≥14 dbetween July 2005 and July 2006

PICC, CVC The only independent predictor of infectionwas dwell time; catheter coating and PICCuse did not predict infection, though PICCswere associated with infections lessfrequently than CVCs

Guyatt et al, 2012 (35) NA Guidelines Summary of evidence for therecommendations on antithrombotictherapy and prevention of thrombosis

Summary recommendations related to therapyand prevention of thrombosis includingcatheter-related DVT

PICC, CVC This summary is the 9th edition of theAmerican College of Chest PhysiciansAntithrombotic Guidelines; a methodsarticle with recommendations and gradingof the evidence are included

Hadaway, 2001 (147) NA Review Address the risk for catheter-related BSI andhub disinfection methods and practice

Narrative review CVC, PICC Clinicians should closely follow manufacturerinstructions regarding disinfectiontechnique and chemical composition ofdisinfectant used


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Hadaway et al, 2011 (148) 554 healthcareworkers

Survey-based study Assess the knowledge gap of health careworkers about practice with needlelessconnectors

Health care workers were invited to participate in a22-question survey

CVC, PICC Among respondents (response rate, !14%), asignificant gap of knowledge regardingneedleless connectors; cleansing practices;and flushing, clamping sequence

Hadaway, 2012 (149) NA Review Analysis of 45 studies to assess knowledgegaps and inadequate clinical practicesassociated with catheter-related BSI

Narrative review CVADs, IV Insertion techniques and other clinicalpractices differ greatly among countries;these variations may increase the risk forBSI. Catheters should be changed onlywhen clinically indicated

Hadaway, 2012 (150) NA Review Describe currently used needlelessconnectors and their potential forcomplications associated with differingmedical practices

Narrative review Needlelessconnectors

Device design, user knowledge deficits, andimproper hygiene can influence risk forinfections; such interventions as scrubbingthe connection surface, flushing, changingthe needleless connectors, and intermittentIV administration can reduce risk forinfection

Harnage, 2007 (151) 32 ICU beds Prospective cohort Assess the effect of a newly developed PICCbundle on catheter-related BSI

Patients with PICCs in 2 ICU units in 1 Californiahospital

PICC A PICC bundle that combined practice andtechnology successfully decreasedcatheter-related BSI

Harnage, 2012 (152) NR Retrospective cohortstudy

Evaluate sustainability and lessons learnedafter implementation of a PICC bundle at1 medical center

Patients in 1 California hospital PICC Catheter stabilization and zero-displacementIV connections helped reduce CLABSI

Hornsby et al, 2005 (88) NR Prospective cohortstudy

Analysis of the creation and effect of 2full-time vascular access specialtypositions at 1 medical center

500-bed facility in Saginaw, Michigan PIVC PICC More PICCs were placed proactively at thebeginning of hospital stays. Peripheralcatheter restarts were replaced with PICCsand delayed discharges related to PICCplacement were reduced

Hoshal, 1975 (86) 35 Prospective cohortstudy

Examine the feasibility of using peripherallyinserted silicone elastomer CVCs for totalIV nutrition

Patients receiving total IV nutrition at 1 medicalfacility

PICC This first-ever report of PICCs found thatperipherally inserted silicone elastomerCVCs were safe, effective, and durable fordelivery of total IV nutrition in outpatients

Hughes, 2011 (153) NA Systematic review Examine PICC-related thrombosis incidence,morbidity and effect of US guidance onoutcomes

Systematic review PICC PICC-related DVT is common, especiallyamong patients with cancer. Althoughlimited, available evidence suggests US canreduce risk for thrombosis

Hughes, 2014 (154) 31 Prospective cohortstudy

Assessing the feasibility of SecurAcath(Interrad Medical, Plymouth, Minnesota), asubcutaneous device, on inadvertent PICCmigration

Patients at 1 cancer hospital who received PICCsand the SecurAcath device during clinical care

PICC A single case of migration among 32 patientswas recorded; however, some initialproblems with infection and pain occurred

Infusion Nurses Society,2011 (32)

NA Guidelines Review of current literature for thedevelopment of standards of practice fornurses working with VADs

Standards for insertion, care, and management ofVADs for nursing professionals

PIVC, CVC,PICC,tunneledcatheter,port

Topics ranging from patient care, accessdevices, and infusion therapies to safe andeffective methods for working with VADswere included; basic requirements ineducation and competencies for insertionand management of devices are also outlined

Itkin et al, 2014 (155) 332 RCT Evaluate the risk for DVT in PICCs that arereverse-tapered vs. PICCs that are not

Patients 18–90 years of age requiring PICCinsertion at a quaternary academic medicalcenter

PICC Although tapering of PICCs did not influencerisk for PICC-related DVT, up to threequarters of patients experiencedasymptomatic thrombosis in this study,suggesting a high overall rate of thrombosis

Jin et al, 2013 (156) NA Systematic review Describe potential repositioning techniquesfor PICCs that were malpositioned duringor after insertion

Systematic review PICC Malpositioning of PICCs can occur from theright ventricle to peripheral veins.Repositioning techniques, including manualadvancement or catheter replacement, areoften necessary

Joffe and Goldhaber,2002 (157)

Review Examine the pathogenesis, signs, andsymptoms of UEDVT and the associationbetween the increasing incidence ofUEDVT and CVCs

Narrative review CVC, PICC Secondary thrombosis related to CVC use is onthe rise; thrombolysis reserved for specificinstances

Johansson et al, 2013 (6) NA Systematic review Examine the advantages and disadvantagesof PICCs vs. CVCs on the basis of availableevidence

48 studies were assessed for eligibility, of which 11were included in the qualitative analysis; 9 ofthe 11 were excluded owing to low quality

PICC, CVC,port

PICCs are commonly used in oncology;however the quality of the evidencesupporting use of these devices is limited

Johansson et al, 2013 (158) 23 oncologydepartments

Survey-based study National survey to examine use of PICCs inadult oncology departments in Sweden

Heads of 23 adult oncology departments inSweden

PICC Twenty-two of 23 sites responded (96%).Vascular nurses most often placed PICCswith US in most sites; 9 of 16 sites reportedhaving specific indications for type of deviceused; one third of departments did notplace PICCs


SU

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Vol.163

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•15

September

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ww

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Dow



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nes,

2014

(187

)N

ARe

view

Det

erm

ine

whe

ther

EKG

-gui

ded

PIC

Cp

lace

men

tis

the

pre

fera

ble

met

hod

for

PIC

Cp

ositi

onin

g

Nar

rativ

ere

view

ofth

elit

erat

ure

that

sum

mar

izes

avai

lab

leev

iden

cefo

rEKG

-gui

ded

pla

cem

ent

PIC

C,C

VCB

estp

ract

ices

and

reco

mm

end

atio

nssh

ould

be

esta

blis

hed

tous

eEK

Gas

ag

old

stan

dar

dfo

rche

ckin

gC

VCp

lace

men

tO

nget

al,2

006

(188

)31

7Re

tros

pec

tive

coho

rtst

udy

Det

erm

ine

the

freq

uenc

yan

dris

kfa

ctor

sfo

rPI

CC

-rel

ated

DVT

at1

med

ical

cent

erSy

mp

tom

atic

pat

ient

sw

itha

pos

itive

upp

er-e

xtre

mity

veno

usd

uple

xsc

anov

er3

yw

ere

revi

ewed

tod

eter

min

eris

kfa

ctor

sas

soci

ated

with

UED

VT

PIC

CPa

tient

sw

ithPI

CC

s,th

ose

rece

ivin

gch

emot

hera

py,

and

thos

ew

ithca

ncer

wer

em

ostl

ikel

yto

exp

erie

nce

DVT

Paau

wet

al,2

008

(189

)56

Pros

pec

tive

coho

rtst

udy

Det

erm

ine

the

inci

den

ceof

PIC

C-a

ssoc

iate

dD

VTw

ithan

dw

ithou

tpro

phy

lact

ican

ticoa

gul

ants

Inp

atie

nts

with

PIC

Cs

used

forp

aren

tera

lnut

ritio

nor

antib

iotic

sat

1m

edic

alce

nter

PIC

CPr

ophy

laxi

sfo

rDVT

with

hep

arin

and

LMW

Hw

asas

soci

ated

with

alo

wer

rate

ofD

VTin

pat

ient

sw

ithPI

CC

s,al

thou

gh

thes

ere

sults

wer

eno

tad

just

edfo

rcon

foun

der

sPa

riet

al,2

011

(190

)70

Pros

pec

tive

coho

rtst

udy

Initi

alap

plic

atio

nan

dre

sults

ofim

ple

men

tatio

nof

acl

inic

alp

athw

ayto

choo

seth

eb

estv

enou

sac

cess

for

ind

ivid

ualp

atie

nts

Patie

nts

with

PIC

Cs

inse

rted

thro

ugh

the

new

'Sha

red

Clin

ical

Path

way

'too

lat1

canc

erce

nter

PIC

CU

seof

the

pat

hway

imp

rove

dp

atie

ntq

ualit

yof

life,

dec

reas

edco

sts,

and

imp

rove

dw

orkfl

ow

Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Pate

leta

l,20

07(1

91)

1788

Retr

osp

ectiv

eco

hort

stud

yD

eter

min

ew

heth

erth

eus

eof

open

-end

edPI

CC

sfo

rinv

asiv

em

onito

ring

can

dec

reas

eth

eris

kfo

rCLA

BSI

Patie

nts

bef

ore

and

afte

rthe

intr

oduc

tion

ofa

hem

odyn

amic

mon

itorin

gw

ithPI

CC

sin

acl

osed

med

ical

–sur

gic

alIC

Uat

anac

adem

icm

edic

alce

nter

PIC

CO

pen

-end

edPI

CC

sm

ayb

eas

soci

ated

with

ash

orte

rcat

hete

rdw

ellt

ime,

red

uced

BSI

s,an

dan

over

alld

ecre

ase

inan

tibio

ticus

e

Pate

leta

l,20

14(1

92)

70RC

TC

omp

are

the

safe

tyan

dco

stof

PIC

Cs

vs.

por

tsus

edto

del

iver

chem

othe

rap

yPa

tient

sw

ithno

nhem

atol

ogic

canc

erre

ceiv

ing

chem

othe

rap

yei

ther

thro

ugh

aPI

CC

ora

por

tPI

CC

,por

tPo

rts

wer

eas

soci

ated

with

alo

wer

risk

for

com

plic

atio

nsin

this

pop

ulat

ion;

ther

ew

asno

diff

eren

cein

cost

usin

ga

PIC

Cvs

.por

tap

pro

ach

Paz-

Fum

agal

liet

al,

1997

(193

)11

3Pr

osp

ectiv

eco

hort

stud

yIn

vest

igat

eth

eef

fect

ofPI

CC

pla

cem

enti

np

atie

nts

with

spin

alco

rdin

jury

who

wer

eat

hig

hris

kfo

rinf

usio

np

hleb

itis

All

pat

ient

sw

itha

spin

alco

rdin

jury

and

ap

erip

hera

lIV

from

July

1993

toD

ecem

ber

1994

who

wer

eev

alua

ted

atle

asto

nce

by

the

nurs

ing

IVte

am

PIC

C,C

VCA

lthou

gh

they

wer

eas

soci

ated

with

DVT

,PIC

Cus

ew

asas

soci

ated

with

are

duc

edris

kfo

rp

hleb

itis

Penn

ey-T

imm

ons

and

Seve

dg

e,20

04(1

94)

NA

Retr

osp

ectiv

eco

hort

stud

yEv

alua

teou

tcom

ed

ata

forP

ICC

sp

lace

din

hosp

italiz

edp

atie

nts,

by

usin

gan

exis

ting

dat

ase

t

Hos

pita

lized

pat

ient

sw

ithPI

CC

sPI

CC

Com

plic

atio

ns,i

nclu

din

gex

it-si

tean

dB

SIs,

phl

ebiti

s,an

dth

rom

bos

is,o

ccur

red

freq

uent

lyin

this

pop

ulat

ion;

chan

ges

innu

rsin

gp

ract

ice

info

rmed

by

accu

mul

atin

gev

iden

cehe

lped

dec

reas

eth

eris

kfo

rthe

seev

ents

Peria

rdet

al,2

008

(195

)60

RCT

Com

par

eth

esa

fety

,effi

cacy

,and

cost

-effe

ctiv

enes

sof

PIC

Cs

toPI

VCs

Hos

pita

lized

pat

ient

sre

qui

ring

IVth

erap

yfo

r≥5

day

sw

ere

rand

omly

assi

gne

dto

rece

ive

eith

erPI

CC

sor

PIVC

sin

this

sing

le-c

ente

rstu

dy

PIVC

,PIC

CPI

CC

sar

eef

ficie

ntfo

rhos

pita

lized

pat

ient

sre

qui

ring

IVth

erap

yfo

r≥5

dho

wev

er,r

isk

fora

sym

pto

mat

icD

VTm

ayb

ehi

ghe

rtha

np

revi

ousl

yre

por

ted

inp

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nsw

hore

ceiv

ePI

CC

sPe

riard

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0(1

96)

NA

Revi

ewRe

view

ofth

ere

latio

nshi

pb

etw

een

inse

rtio

nsi

tean

dris

kfo

rthr

omb

osis

inp

atie

nts

with

canc

er

Patie

nts

with

leuk

emia

and

PIC

Cs

pla

ced

atd

iffer

ents

ites

PIC

CSt

udie

ssu

gg

estt

here

may

be

anas

soci

atio

nb

etw

een

PIC

Cp

lace

men

tand

thro

mb

osis

risk;

smal

lerP

ICC

sin

sert

edin

tola

rger

vein

sar

ele

astl

ikel

yto

dev

elop

thro

mb

osis

Petr

eeet

al,2

012

(197

)N

ASy

stem

atic

revi

ewD

eter

min

eef

fect

ive

met

hod

sfo

rhea

lthca

rep

rovi

der

sto

red

uce

PIC

C-r

elat

edB

SId

urin

gd

evic

ein

sert

ion

Eval

uate

and

rep

orto

np

ract

ices

atth

etim

eof

inse

rtio

nth

atm

ayre

duc

eth

eris

kfo

rCLA

BSI

inho

spita

lized

pat

ient

s

PIC

CC

ontin

uing

educ

atio

nis

less

exp

ensi

veth

anth

eco

stof

CLA

BSI

;nee

dle

less

conn

ecto

rs,

pos

itive

-pre

ssur

eva

lves

,and

pro

per

secu

rem

entw

ithan

chor

ing

dev

ices

wer

em

oste

ffect

ive

inre

duc

ing

CLA

BSI

Pikw

eret

al,2

012

(12)

NA

Syst

emat

icre

view

Exam

ine

risks

and

com

plic

atio

nsas

soci

ated

with

cent

ralv

s.p

erip

hera

lrou

tes

for

cent

ralv

enou

sca

nnul

atio

n

Com

par

eris

ksas

soci

ated

with

PIC

Cs

with

thos

eof

trad

ition

alC

VCs

PIC

C,C

VCC

athe

tert

ipm

alp

ositi

onin

g,t

hrom

bop

hleb

itis,

and

cath

eter

dys

func

tion

occu

rred

mor

efr

eque

ntly

with

PIC

Cs

than

CVC

s.N

od

iffer

ence

inra

tes

ofin

fect

ion

bet

wee

nC

VCs

and

PIC

Cs

wer

efo

und

inth

e12

incl

uded

stud

ies

Ping

leto

net

al,2

013

(80)

NA

Qua

si-e

xper

imen

tal

bef

ore–

afte

rstu

dy

Red

uctio

nof

VTE

inho

spita

lized

pat

ient

sb

yus

ing

educ

atio

nan

dsy

stem

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eop

erat

iona

lpla

ns

Hos

pita

lized

pat

ient

sat

asi

ngle

univ

ersi

ty-b

ased

med

ical

cent

erin

the

Uni

ted

Stat

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CC

Afte

rim

ple

men

tatio

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spec

ific

actio

np

lans

,us

eof

PIC

Cs

dro

pp

edfr

om36

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sert

ions

to<

200

inse

rtio

nsov

er2

year

s;ra

tes

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hosp

italiz

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atie

nts

sim

ilarly

dec

lined

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iruti

etal

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9(1

98)

NA

Gui

del

ines

Gui

del

ines

forC

VCac

cess

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e,d

iag

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s,an

dth

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com

plic

atio

nsG

uid

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est

atem

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db

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rop

ean

Soci

ety

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utrit

ion

and

Met

abol

ism

PIC

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por

tPr

ovid

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com

men

dat

ions

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e,ca

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emen

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rob

lem

sre

late

dto

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ular

dev

ices

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aren

tera

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ritio

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ttiru

tiet

al,2

012

(199

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Retr

osp

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hort

stud

yEx

amin

eou

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late

dto

use

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ctab

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CC

sin

ICU

sett

ing

sC

ritic

ally

illp

atie

nts

und

erg

oing

pow

er-in

ject

able

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Cp

lace

men

tPI

CC

PIC

Cs

that

wer

ep

ower

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able

wer

eas

soci

ated

with

mul

tiple

ther

apeu

ticad

vant

ages

and

low

risk

forc

omp

licat

ions

incr

itica

llyill

pat

ient

sPi

ttiru

tian

dLa

mp

erti,

2015

(71)

NA

Revi

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view

the

liter

atur

eon

the

inci

den

ceof

card

iac

tam

pon

ade

afte

rPIC

Cin

sert

ion

Cas

ere

por

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sese

ries

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CC

rece

ipt;

revi

ewof

sent

inel

even

tsPI

CC

Late

card

iac

tam

pon

ade

afte

rPIC

Cin

sert

ion

inad

ults

isra

rePo

ngru

ang

por

net

al,

2013

(200

)16

2N

este

dca

se–c

ontr

olst

udy

Eval

uate

the

role

ofp

atie

nt-,

pro

vid

er-,

and

dev

ice-

spec

ific

risk

fact

ors

inPI

CC

-rel

ated

BSI

Hos

pita

lized

pat

ient

sat

asi

ngle

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ersi

tyho

spita

lin

the

Uni

ted

Stat

esPI

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The

PIC

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tew

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13p

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00ca

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ays

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ilart

oth

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s);

PIC

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ated

with

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ice

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ber

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men

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atie

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ctor

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strid

ium

diffi

cile

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ctio

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nges

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l,20

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1)10

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osp

ectiv

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hort

stud

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amin

eth

esa

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CC

inse

rtio

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pat

ient

sw

ithp

rofo

und

thro

mb

ocyt

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inse

rtio

nsin

101

pat

ient

sw

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ncer

at1

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erce

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CPI

CC

pla

cem

entw

asas

soci

ated

with

ahi

gh

rate

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chni

cals

ucce

ssan

dfe

wad

vers

eev

ents

inp

atie

nts

with

seve

reth

rom

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ytop

enia

Qui

etal

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4(2

01)

551

Retr

osp

ectiv

eco

hort

stud

ySt

udy

the

inci

den

ceof

,ris

kfa

ctor

sfo

r,an

dou

tcom

esof

spon

tane

ous

PIC

Cd

islo

dg

emen

tsin

pat

ient

sw

ithca

ncer

inC

hina

551

pat

ient

sw

ithca

ncer

dia

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ses

rece

ivin

gca

reat

1ce

nter

inC

hina

PIC

CTh

ein

cid

ence

rate

ofsp

onta

neou

sd

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dg

emen

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ient

sw

hod

evel

oped

dis

lod

gem

enth

ada

sub

stan

tially

gre

ater

risk

fors

ubse

que

ntPI

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-rel

ated

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(rel

ativ

eris

k,17

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Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Raad

etal

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4(2

02)

72C

ase

serie

sA

sses

sth

efr

eque

ncy

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ican

din

fect

ious

com

plic

atio

nsof

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use

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atie

nts

with

canc

er

72ca

ncer

pat

ient

sin

a50

0-b

edte

rtia

ryca

rece

nter

wer

ein

clud

ed;p

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orte

mex

amin

atio

nsof

cath

eter

ized

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sw

ere

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form

ed

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mb

osis

resu

lting

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ular

cath

eter

sin

clud

edfib

rinsl

eeve

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clus

ive

thro

mb

osis

.Sep

ticem

iaw

asm

ore

com

mon

inp

atie

nts

with

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usiv

eth

rom

bos

isth

anin

pat

ient

sw

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nmur

alth

rom

bos

is,

sug

ges

ting

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soci

atio

nb

etw

een

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e2

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omes

Rich

ters

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4(2

03)

439

Retr

osp

ectiv

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hort

stud

yRe

por

tthe

inci

den

cean

dris

kfa

ctor

sfo

rg

ram

pos

itive

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tere

mia

and

thro

mb

osis

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atie

nts

who

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s

439

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ient

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der

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ngst

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utro

pen

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dle

ft-si

ded

pla

cem

entw

asas

soci

ated

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mia

.Pe

rsis

tent

bac

tere

mia

and

tipco

loni

zatio

nw

ere

asso

ciat

edw

ithth

rom

bos

isRi

ckar

det

al,2

012

(84)

3283

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Rout

ine

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ally

war

rant

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pla

cem

ent

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hera

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ting

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ient

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ared

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rem

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can

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rem

oved

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inic

ally

ind

icat

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tin

crea

sing

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even

ts;t

his

pra

ctic

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duc

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stsu

bst

antia

lly,a

ccor

din

gto

the

auth

ors

Rob

inso

net

al,2

005

(204

)N

APr

osp

ectiv

eco

hort

stud

yEf

fect

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edic

ated

PIC

Cte

amon

pat

ient

care

and

cost

sas

soci

ated

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sert

ion

Hos

pita

lized

pat

ient

sre

ceiv

ing

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ata

sing

lem

edic

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nter

inB

osto

n,M

assa

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etts

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trod

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ad

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ated

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ased

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ent,

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tsRo

mag

noli

etal

,201

0(2

05)

49Pr

osp

ectiv

eco

hort

stud

yRi

skfo

rPIC

C-r

elat

edD

VTin

pat

ient

sw

ithca

ncer

52PI

CC

sp

lace

din

49p

atie

nts

with

canc

erin

asi

ngle

med

ical

cent

erin

Feltr

e,Ita

lyPI

CC

3p

atie

nts

(5.7

%)d

evel

oped

PIC

C-r

elat

edD

VT;

allp

atie

nts

rece

ived

antic

oag

ulat

ion

with

LMW

Hfo

r≥3

mo;

noPE

was

rep

orte

dRo

oden

etal

,200

5(2

06)

NA

Syst

emat

icre

view

Revi

ewof

the

liter

atur

eon

dia

gno

sis

of,r

isk

fact

ors

for,

and

com

plic

atio

nsof

CVC

-rel

ated

DVT

NA

CVC

,PIC

CU

Sis

reco

mm

end

edas

the

dia

gno

stic

test

ofch

oice

;var

ious

pat

ient

and

dev

ice

fact

ors

are

asso

ciat

edw

ithD

VT;a

ndro

utin

ep

rop

hyla

xis

top

reve

ntth

rom

bos

isis

not

war

rant

edon

the

bas

isof

the

avai

lab

led

ata

Ros

etal

,200

5(2

07)

36Re

tros

pec

tive

coho

rtst

udy

Eval

uate

PIC

C-r

elat

edD

VTin

pat

ient

sw

ithhe

adan

dne

ckca

ncer

36p

atie

nts

with

head

and

neck

canc

erat

1m

edic

alho

spita

lin

Spai

nPI

CC

The

rate

ofPI

CC

-rel

ated

DVT

was

11.1

%,

sug

ges

ting

ahi

gh

rate

ofth

rom

bos

isin

this

pat

ient

pop

ulat

ion

Rose

ntha

l,20

08(2

08)

NA

Revi

ewEv

alua

tead

vant

ages

,con

sid

erat

ions

,and

man

agem

ento

fmid

line

cath

eter

sco

mp

ared

with

othe

rdev

ices

,with

the

aim

ofid

entif

ying

utili

tyof

thes

ed

evic

esin

pat

ient

s

Nar

rativ

ere

view

Mid

line

cath

eter

Mid

line

cath

eter

sar

eid

ealf

oris

oton

icin

fusi

ons

that

may

last

bey

ond

5d

Rup

pet

al,2

012

(34)

NA

Gui

del

ines

Prac

tice

gui

del

ines

forc

entr

alve

nous

acce

ssp

rep

ared

by

the

Am

eric

anSo

ciet

yof

Ane

sthe

siol

ogis

ts

Prov

ides

upd

ated

reco

mm

end

atio

nson

inse

rtio

nsi

tese

lect

ion,

use

ofU

S,an

dve

rifica

tion

ofca

thet

erlo

catio

n

CVC

,PIC

CTh

eg

uid

elin

esin

dic

ate

ap

refe

renc

efo

rup

per

-ext

rem

ityin

sert

ion

site

s,us

eof

US

tog

uid

ein

sert

ion

whe

np

laci

ngC

VCs

and

PIC

Cs,

and

confi

rmat

ion

ofth

eve

nous

loca

tion

ofth

eca

thet

eran

dca

thet

ertip

loca

tion

usin

gva

rious

tech

niq

ues

Rutk

off,

2014

(209

)25

7Q

uasi

-exp

erim

enta

lb

efor

e–af

ter

des

ign

Eval

uate

the

effic

acy

ofan

timic

rob

ial

(min

ocyc

line–

rifam

pin

)–co

ated

PIC

Cs

inre

duc

ing

PIC

C-r

elat

edB

SI

Hos

pita

lized

pat

ient

sat

1m

edic

alce

nter

inC

alifo

rnia

PIC

CA

ntim

icro

bia

lPIC

Cs

resu

lted

insi

gni

fican

td

ecre

ases

inC

LAB

SIfr

om4.

10to

0.47

infe

ctio

nsp

er10

00ca

thet

er-d

ays

Sab

eret

al,2

011

(54)

NA

Patie

nt-le

vel

syst

emat

icre

view

and

met

a-an

alys

is

Exam

ine

risk

fact

ors

forC

RTin

pat

ient

sw

ithca

ncer

Patie

nts

from

5RC

Tsan

d7

pro

spec

tive

stud

ies

incl

udin

g56

36p

atie

nts

wer

ein

clud

edC

VC,P

ICC

,p

ort

Thro

mb

osis

risk

was

incr

ease

dw

ithPI

CC

s,hi

stor

yof

DVT

,sub

clav

ian

veni

pun

ctur

ein

sert

ion,

and

imp

rop

erca

thet

ertip

pos

ition

Safd

aran

dM

aki,

2005

(81)

115

Pros

pec

tive

coho

rtst

udy

Exam

ine

risk

fori

nfec

tion

with

PIC

Cs

inho

spita

lized

pat

ient

sco

mp

ared

with

that

asso

ciat

edw

ithC

VCs

115

hosp

italiz

edp

atie

nts

who

had

251

PIC

Cs

pla

ced

wer

ein

clud

ed(fr

omw

ithin

ala

rger

RCT)

PIC

CRi

skfo

rPIC

C-r

elat

edB

SIw

as2–

5p

er10

00ca

thet

er-d

ays,

anu

mb

erth

atw

asg

reat

erth

anra

tes

rep

orte

din

outp

atie

ntse

ttin

gs

and

thos

ere

late

dto

cuffe

dor

tunn

eled

CVC

sSa

nsiv

ero

etal

,201

1(2

10)

50Pr

osp

ectiv

eco

hort

stud

yEv

alua

teth

eef

ficac

yof

ano

velc

athe

ter

secu

rem

entd

evic

e50

pat

ient

sre

ferr

edfo

rPIC

Cin

sert

ion

toa

nurs

ing

vasc

ular

acce

sste

aman

dto

IRPI

CC

Ano

vels

ecur

emen

tsys

tem

resu

lted

ina

favo

rab

leco

mp

licat

ion

pro

file,

with

cost

savi

ngs

rela

ted

tore

duc

edd

ress

ing

san

dd

isp

osab

lese

cure

men

tsys

tem

sSa

ntol

imet

al,2

012

(211

)N

AQ

uasi

-exp

erim

enta

lb

efor

e–af

ter

des

ign

Und

erst

and

the

effe

ctof

ap

roto

colt

ose

lect

IVD

sin

aB

razi

lian

hosp

itali

na

QIp

roje

ctU

nive

rsity

pat

ient

sin

Bra

zila

ndva

scul

arac

cess

nurs

ing

team

PIC

C,C

VC,

por

tIm

ple

men

tatio

nof

ap

roto

colr

esul

ted

ind

ecre

ased

rate

sof

phl

ebiti

san

dim

pro

ved

nurs

ing

satis

fact

ion

Sasa

due

szet

al,1

999

(50)

34Pr

osp

ectiv

eco

hort

stud

yEv

alua

teth

eef

fect

ofsm

all-b

ore

tunn

eled

cath

eter

sas

am

eans

top

rese

rve

vein

sco

mp

ared

with

PIC

Cs

34p

atie

nts

with

end

-sta

ge

rena

ldis

ease

at1

sing

leac

adem

icm

edic

alce

nter

PIC

C,

smal

l-b

ore

cath

eter

Two

min

orin

sert

ion

com

plic

atio

ns(a

rter

ial

pun

ctur

ean

dca

thet

erd

amag

ed

urin

gsu

turin

g)o

ccur

red

.Thi

sap

pro

ach

resu

lted

ina

nove

lfor

mof

acce

ss,p

rese

rvin

gp

erip

hera

lvei

nsan

dlim

iting

risk

forc

entr

alve

inst

enos

isin

this

pat

ient

pop

ulat

ion

Schi

mp

etal

,200

3(2

12)

264

Retr

osp

ectiv

eco

hort

stud

yEv

alua

tein

cid

ence

and

outc

omes

rela

ted

toU

EDVT

inp

atie

nts

with

gyn

ecol

ogic

canc

er

264

wom

enw

hore

ceiv

ed32

5to

talc

athe

ters

ata

univ

ersi

tyho

spita

lPI

CC

,por

t13

pat

ient

sd

evel

oped

cath

eter

-rel

ated

DVT

;11

ofth

ep

atie

nts

had

por

tsan

d2

had

PIC

Cs.

No

pat

ient

sd

evel

oped

PE

Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Seel

eyet

al,2

007

(213

)23

3Re

tros

pec

tive

coho

rtst

udy

Dev

elop

aris

k-p

red

ictio

nm

odel

and

iden

tify

fact

ors

asso

ciat

edw

ithPI

CC

-rel

ated

DVT

Hos

pita

lized

pat

ient

sre

ceiv

ing

care

ata

Mid

wes

tco

mm

unity

hosp

ital

PIC

C17

pat

ient

sd

evel

oped

DVT

;log

istic

reg

ress

ion

mod

els

foun

dth

atb

edre

st,l

ocal

ized

tend

erne

ss,s

mok

ing

,ant

icoa

gul

antu

se,

and

oste

omye

litis

wer

eas

soci

ated

with

PIC

C-r

elat

edD

VTSh

arp

etal

,201

4(6

3)64

Retr

osp

ectiv

eco

hort

stud

yEv

alua

tesa

fety

and

effic

acy

ofm

idlin

eca

thet

ers

com

par

edw

ithPI

CC

sin

adul

tsw

ithcy

stic

fibro

sis

231

mid

line

cath

eter

san

d97

PIC

Cs

wer

ep

lace

din

64p

atie

nts

PIC

C,

mid

line

cath

eter

Rate

sof

adve

rse

even

tsw

ithPI

CC

san

dm

idlin

eca

thet

ers

wer

esi

mila

r,b

utre

mov

alra

tes

form

idlin

eca

thet

ers

wer

etw

ice

that

ofPI

CC

sSh

eaet

al,2

006

(214

)57

5Re

tros

pec

tive

coho

rtst

udy

Eval

uate

risk

forP

ICC

-rel

ated

DVT

inp

atie

nts

with

infla

mm

ator

yb

owel

dis

ease

15p

atie

nts

met

incl

usio

nan

dex

clus

ion

crite

ria,

and

3ha

dPI

CC

-rel

ated

DVT

PIC

CA

20%

inci

den

ceof

PIC

C-r

elat

edD

VTin

hosp

italiz

edp

atie

nts

with

infla

mm

ator

yb

owel

dis

ease

and

PIC

Cs

was

note

d.T

hein

cid

ence

rate

ofPI

CC

-rel

ated

DVT

was

2.17

%p

erd

aySi

mco

ck,2

008

(215

)19

1Q

uasi

-exp

erim

enta

ld

esig

nU

nder

stan

dth

eef

fect

ofus

eof

US

onra

teof

PIC

Cco

mp

licat

ions

Patie

nts

adm

itted

toa

UK

hosp

italw

hore

ceiv

edPI

CC

sat

vario

ustim

ep

oint

sPI

CC

Rate

sof

DVT

,inf

ectio

ns,a

ndot

her

com

plic

atio

nsd

eclin

edaf

teru

seof

US

Sim

onov

aet

al,2

012

(76)

NA

Invi

tro

stud

yEv

alua

teth

eab

ility

oftis

sue

adhe

sive

san

dcy

anoa

cryl

ate

glu

eto

secu

rein

trav

enou

sca

thet

ers

com

par

edw

ithSt

atLo

ckd

evic

es(B

ard

Med

ical

,Cov

ing

ton,

Geo

rgia

)in

anim

alm

odel

s

NA

PIC

C,C

VCTi

ssue

adhe

sive

sco

mp

ared

favo

rab

lyw

ithSt

atLo

ckd

evic

esan

dtr

ansp

aren

tp

olyu

reth

ane

dre

ssin

gs

toin

crea

seth

e"p

ull-o

ut"

forc

eof

cath

eter

s

Skaf

feta

l,20

12(2

16)

147

Retr

osp

ectiv

eco

hort

stud

yC

omp

are

and

cont

rast

the

use

ofH

ickm

an(tu

nnel

ed)c

athe

ters

and

PIC

Cs

inp

atie

nts

with

acut

ele

ukem

iare

ceiv

ing

ind

uctio

nch

emot

hera

py

147

pat

ient

sw

ithne

wly

dia

gno

sed

acut

ele

ukem

iaw

hore

ceiv

edei

ther

aH

ickm

anca

thet

eror

aPI

CC

(with

orw

ithou

tUS

gui

dan

ce)

PIC

C,

tunn

eled

cath

eter

Hic

kman

cath

eter

sin

sert

edaf

ter2

007

by

IRw

ere

asso

ciat

edw

ithfe

wer

com

plic

atio

ns(b

acte

rem

iaan

dex

it-si

tein

fect

ion)

;PIC

Cs

wer

eas

soci

ated

with

less

loca

linfl

amm

atio

nb

uthi

ghe

rrat

esof

phl

ebiti

san

db

lock

age

req

uirin

gly

tictr

eatm

ents

.Sk

iest

etal

,200

0(2

17)

66Pr

osp

ectiv

eco

hort

stud

yD

eter

min

eris

kfo

rcom

plic

atio

nsin

pat

ient

sw

ithH

IVin

fect

ion

who

req

uire

dlo

ng-t

erm

veno

usac

cess

ortr

eatm

ents

and

rece

ived

PIC

Cs

97PI

CC

sw

ere

inse

rted

in66

pat

ient

sfo

rvar

ious

clin

ical

ind

icat

ions

PIC

C53

%(5

1of

97)o

fPIC

Cs

wer

eas

soci

ated

with

aco

mp

licat

ion,

fora

nov

eral

lcom

plic

atio

nra

teof

6.1

per

1000

cath

eter

-day

s;m

edia

ntim

eto

aca

thet

er-r

elat

edco

mp

licat

ion

was

115

d.E

leve

nca

thet

ers

wer

ein

fect

ed,7

ofw

hich

wer

eas

soci

ated

with

ab

acte

rem

ia.

The

over

alln

onin

fect

ious

com

plic

atio

nra

tew

as4.

6p

er10

00ca

thet

er-d

ays

Smith

etal

,199

8(2

18)

441

Retr

osp

ectiv

eco

hort

stud

yC

omp

are

ind

icat

ions

fori

nser

tion,

com

plic

atio

ns,a

ndec

onom

icef

fect

ofC

VCs

vs.P

ICC

s

441

men

who

rece

ived

838

(283

CVC

,555

PIC

C)

cons

ecut

ivel

yp

lace

dve

nous

cath

eter

sre

flect

ing

4936

5C

VC-d

ays

and

1181

4PI

CC

-day

s

PIC

C,C

VCA

tota

lof5

7(1

9%)c

omp

licat

ions

wer

eid

entifi

edin

the

CVC

gro

upan

d19

7(3

5%)

com

plic

atio

nsin

the

PIC

Cg

roup

.The

rew

ere

sig

nific

antly

few

erto

talc

omp

licat

ions

,ca

thet

erm

alfu

nctio

ns,e

pis

odes

ofp

hleb

itis,

and

"oth

er"

com

plic

atio

nsin

the

CVC

gro

upth

anin

the

PIC

Cg

roup

Smith

and

Nol

an,2

013

(219

)N

ASy

stem

atic

revi

ewPr

ovid

ean

over

view

ofC

VCs

and

inse

rtio

nte

chni

que

s,an

dco

nsid

erth

ep

reve

ntio

nan

dm

anag

emen

tofc

omm

onco

mp

licat

ions

NA

PIC

C,C

VCTo

red

uce

rate

sof

thro

mb

osis

rela

ted

tolo

ng-t

erm

cath

eter

sin

pat

ient

sw

ithca

ncer

,th

eca

thet

ertip

shou

ldlie

atth

eju

nctio

nof

the

SVC

and

right

atriu

m.M

ultil

umen

cath

eter

sm

ayb

eas

soci

ated

with

asl

ight

lyhi

ghe

rris

kfo

rinf

ectio

nth

ansi

ngle

-lum

enon

es.P

rop

hyla

ctic

antib

iotic

sb

efor

elin

ein

sert

ion,

antib

iotic

lock

solu

tions

,or

antib

iotic

oint

men

tsap

plie

dto

the

inse

rtio

nsi

tear

eno

trec

omm

end

edSn

ellin

get

al,2

001

(220

)28

Retr

osp

ectiv

eco

hort

stud

yC

omp

are

trea

tmen

tsuc

cess

with

tunn

eled

cath

eter

svs

.PIC

Cs

and

exam

ine

rate

ofan

dris

kfo

rcom

plic

atio

nsw

ithb

oth

dev

ices

inp

atie

nts

with

gas

troi

ntes

tinal

canc

er

16tu

nnel

edca

thet

ers

and

18PI

CC

sw

ere

inse

rted

in28

pat

ient

sun

der

goi

ngp

rotr

acte

dIV

infu

sion

ther

apy

PIC

C,

tunn

eled

cath

eter

Afte

r120

d,t

unne

led

cath

eter

surv

ival

was

bet

tert

han

that

ofPI

CC

s(P

=0.

051)

.C

omp

licat

ions

occu

rred

in61

%of

pat

ient

sw

ithtu

nnel

edca

thet

ers

and

67%

ofp

atie

nts

with

PIC

Cs

Song

and

Li,2

013

(11)

3012

Retr

osp

ectiv

eco

hort

stud

yO

bse

rve

and

anal

yze

the

caus

esof

mis

pla

cem

ento

fPIC

Ctip

sin

pat

ient

sw

ithca

ncer

3012

pat

ient

sw

ithca

ncer

who

rece

ived

aPI

CC

(159

0m

en,1

121

wom

en,a

nd30

1ch

ildre

n;ag

era

nge,

1–94

y[m

edia

nag

e,52

y])f

orch

emot

hera

py

ornu

triti

onal

sup

por

t

PIC

CM

alp

ositi

onw

asob

serv

edin

237

case

s(7

.87%

),w

ithth

em

ostf

req

uent

site

bei

ngth

ein

tern

alju

gul

ar,f

ollo

wed

by

the

axill

ary

vein

;PIC

Cs

wer

ere

loca

ted

bac

kto

the

SVC

orsu

bcl

avia

nve

inus

ing

vario

uste

chni

que

sSp

erry

etal

,201

2(2

21)

798

Retr

osp

ectiv

eco

hort

stud

yEv

alua

teth

ein

fluen

ceof

late

ralit

yof

PIC

Cin

sert

ion

(rig

htar

mvs

.lef

tarm

)on

the

risk

fors

ubse

que

ntPI

CC

-rel

ated

DVT

798

seq

uent

ialP

ICC

pla

cem

ents

at1

med

ical

cent

erin

Was

hing

ton,

DC

PIC

CA

rmof

PIC

Cp

lace

men

twas

nota

ssoc

iate

dw

ithsy

mp

tom

atic

VTE

Stok

owsk

ieta

l,20

09(2

22)

538

Retr

osp

ectiv

eco

hort

stud

yEv

alua

tion

ofth

eef

fect

ofU

Son

risk

forP

ICC

com

plic

atio

ns53

8p

atie

nts

(bot

hin

pat

ient

and

outp

atie

nt)w

hore

ceiv

edPI

CC

sat

aC

anad

ian

med

ical

cent

erPI

CC

Com

par

edw

ithp

alp

atio

n,PI

CC

sp

lace

dvi

aU

Sha

dlo

wer

sub

seq

uent

rate

sof

thro

mb

osis

Stra

hile

vitz

etal

,200

1(2

23)

40Re

tros

pec

tive

coho

rtst

udy

Exam

ine

outc

omes

rela

ted

toPI

CC

use

inp

atie

nts

with

acut

em

yelo

idle

ukem

iaFo

rty

pat

ient

sw

hore

ceiv

ed52

PIC

Cs

dur

ing

the

stud

yp

erio

dPI

CC

PIC

Cs

wer

eas

soci

ated

with

early

mec

hani

cal

com

plic

atio

nsan

din

fect

ions

;how

ever

,the

com

plic

atio

nra

tew

asd

eem

ed"a

ccep

tab

le"

inth

isp

atie

ntp

opul

atio

n

Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Teje

dor

etal

,201

2(1

8)89

Retr

osp

ectiv

eco

hort

stud

yD

escr

ibe

pat

tern

sof

use

ofte

mp

orar

yC

VCs

and

PIC

Cs

inno

n-IC

Uw

ard

s89

pat

ient

sw

ith14

6C

VCs

(56%

ofw

hich

wer

ePI

CC

s)at

1ac

adem

icm

edic

alce

nter

PIVC

,CVC

,PI

CC

An

aver

age

of4.

1id

led

ays

with

aC

VCan

da

mea

nof

3.4

idle

day

sw

ithb

oth

aC

VCan

da

PIVC

wer

eno

ted

;pat

ient

sw

itha

PIC

Cha

d5.

4d

inw

hich

they

also

had

aPI

VC,

com

par

edw

ith10

din

pat

ient

sw

itha

CVC

Thak

arar

etal

,201

4(2

24)

3273

Retr

osp

ectiv

eco

hort

stud

yEv

alua

tion

oftP

Aus

eas

am

arke

rfor

insi

tuth

rom

bos

isan

dris

kfo

rsub

seq

uent

PIC

C-r

elat

edC

LAB

SI

3273

pat

ient

sat

ate

rtia

ryca

rece

nter

,40%

ofw

hom

rece

ived

tPA

PIC

CU

seof

tPA

was

asso

ciat

edw

ith3.

59tim

esg

reat

erris

kfo

rCLA

BSI

com

par

edw

ithp

atie

nts

who

did

notr

ecei

veth

istr

eatm

ent

Tim

site

tal,

1998

(225

)26

5Pr

osp

ectiv

eco

hort

stud

yA

ssoc

iatio

nb

etw

een

cath

eter

thro

mb

osis

and

cath

eter

infe

ctio

n26

5p

atie

nts

rece

ivin

gIC

Uca

rein

aFr

ench

hosp

ital

CVC

Cat

hete

rthr

omb

osis

was

asso

ciat

edw

ith2.

62-fo

ldg

reat

erris

kfo

rcat

hete

r-re

late

dse

psi

sTi

war

ieta

l,20

11(2

26)

436

Pros

pec

tive

coho

rtst

udy

Ap

pro

pria

tene

ssof

vasc

ular

dev

ice

use

inho

spita

lized

pat

ient

s43

6ho

spita

lized

pat

ient

sw

hore

ceiv

ed87

6IV

Ds

over

2909

hosp

ital-d

ays

PIVC

,CVC

31%

ofto

talc

athe

ter-

day

sw

ere

adju

dic

ated

asin

app

rop

riate

(usi

ngth

eau

thor

s'cr

iteria

for

app

rop

riate

vs.i

nap

pro

pria

teus

e)To

uré

etal

,201

5(2

27)

196

Pros

pec

tive

coho

rtst

udy

Com

par

eth

era

tes

ofco

mp

licat

ions

asso

ciat

edw

ithtu

nnel

edca

thet

ers

(Bro

viac

)and

PIC

Cin

pat

ient

sre

ceiv

ing

hom

ep

aren

tera

lnut

ritio

n

204

cath

eter

sw

ere

inse

rted

in19

6p

atie

nts

who

rece

ived

care

ina

hom

ep

aren

tera

lnut

ritio

np

rog

ram

PIC

C,

tunn

eled

cath

eter

Com

plic

atio

nsw

ere

sim

ilarb

etw

een

bot

hca

thet

erg

roup

s;ho

wev

er,c

athe

teri

nfec

tion

rate

sw

ere

low

erin

the

PIC

Cg

roup

Tran

etal

,201

0(6

0)47

8Re

tros

pec

tive

coho

rtst

udy

Det

erm

ine

the

inci

den

cean

dou

tcom

esas

soci

ated

with

PIC

C-r

elat

edD

VTSi

ngle

-cen

tera

naly

sis

ofp

atie

nts

with

hem

atol

ogic

canc

er,P

ICC

s,an

dsy

mp

tom

atic

UED

VTPI

CC

Hig

hin

cid

ence

ofD

VTas

soci

ated

with

PIC

Cs

inp

atie

nts

rece

ivin

gm

yelo

sup

pre

ssiv

ech

emot

hera

py;

cent

rally

pos

ition

edPI

CC

stu

nnel

edin

toth

ein

tern

alju

gul

arve

inw

ere

asso

ciat

edw

ithlo

win

cid

ence

ofth

rom

bos

isTr

erot

ola

etal

,200

7(2

28)

1654

PIC

Cs

Retr

osp

ectiv

eco

hort

stud

yD

eter

min

eth

ein

cid

ence

and

loca

tion

ofPI

CC

tipm

alp

ositi

onSi

ngle

-cen

tera

naly

sis

of23

67b

edsi

de

atte

mp

tsat

inse

rtio

nPI

CC

Tip

mal

pos

ition

occu

rred

in16

3ca

ses

afte

rb

edsi

de

inse

rtio

n;m

ostm

alp

ositi

onin

gs

wer

eco

rrec

ted

by

cath

eter

exch

ang

e(5

8%)

and

rep

ositi

onin

g(3

6%)

Trer

otol

aet

al,2

010

(229

)50

Pros

pec

tive

coho

rtst

udy

Eval

uate

outc

omes

asso

ciat

edw

ithus

eof

atr

iple

-lum

enPI

CC

inth

eIC

Use

ttin

gC

ritic

ally

illp

atie

nts

who

rece

ived

trip

le-lu

men

PIC

Cs

PIC

CTh

est

udy

was

stop

ped

afte

ran

inte

riman

alys

isd

emon

stra

ted

extr

emel

yhi

gh

rate

sof

sym

pto

mat

icD

VTin

20%

ofp

atie

nts

Tric

ket

al,2

004

(230

)32

0C

ross

-sec

tiona

lsu

rvey

Eval

uate

how

ofte

nC

VCs

wer

ep

lace

dw

ithou

tclin

ical

just

ifica

tion

inth

em

edic

alre

cord

Hos

pita

lized

adul

tpat

ient

sin

a60

0-b

edp

ublic

hosp

ital

CVC

Unj

ustifi

edus

eof

CVC

sw

asm

ore

com

mon

inp

atie

nts

rece

ivin

gca

reou

tsid

eth

eIC

U;

how

ever

,mos

tpat

ient

sre

ceiv

edC

VCs

whi

lein

anIC

Use

ttin

gTu

ffaha

etal

,201

4(8

5)N

AC

ost-

effe

ctiv

enes

san

alys

isA

sses

sth

eco

st-e

ffect

iven

ess

ofcl

inic

ally

ind

icat

edvs

.rou

tine

rep

lace

men

tofP

IVC

sD

ata

from

anRC

Tw

ere

used

tod

eter

min

eco

st-e

ffect

iven

ess

PIVC

Clin

ical

lyin

dic

ated

rep

lace

men

tstr

ateg

yw

asas

soci

ated

with

cost

-sav

ing

sp

erp

atie

ntof

AU

$7.6

0(9

5%C

I,A

U$4

.96–

AU

$10.

62)

Turc

otte

etal

,200

6(2

31)

NA

Syst

emat

icre

view

Eval

uate

infe

ctio

us,t

hrom

bot

ic,p

hleb

itic,

and

othe

rcom

mon

com

plic

atio

nsof

PIC

Cs

com

par

edw

ithC

VC

48ar

ticle

sw

ere

incl

uded

;com

plic

atio

nsfr

omPI

CC

sw

ere

com

par

edw

ithth

ose

from

CVC

sac

ross

seve

rals

tud

yp

opul

atio

ns

PIC

C,C

VCPI

CC

sw

ere

asso

ciat

edw

itha

com

plic

atio

np

rofil

eth

atw

assi

mila

rto

orex

ceed

edth

atof

CVC

s.PI

CC

sw

ere

mor

eco

mm

only

asso

ciat

edw

ithp

hleb

itis

and

mal

pos

ition

ing

than

CVC

sU

gas

etal

,201

2(2

32)

NA

Syst

emat

icre

view

Revi

ewth

eev

iden

ceon

the

inci

den

ceof

cent

rala

ndp

erip

hera

lven

ous

CRB

SIs

incr

itica

llyill

surg

ical

pat

ient

s,an

dou

tline

pat

hway

sfo

rpre

vent

ion

and

inte

rven

tion

Crit

ical

lyill

ICU

pat

ient

sin

surg

ical

ICU

sett

ing

sPI

CC

,CVC

Div

erse

defi

nitio

nsof

the

dia

gno

sis

ofce

ntra

lan

dp

erip

hera

lven

ous

CRB

SIs

and

asm

all

pop

ulat

ion

ofp

atie

nts

with

PIC

Cs

led

toin

cons

iste

ntco

nclu

sion

san

dfin

din

gs

Vese

ly,2

003

(66)

NA

Revi

ewSu

mm

ariz

eth

eev

iden

cere

late

dto

optim

altip

pos

ition

ofa

CVC

Nar

rativ

ere

view

PIC

C,C

VCTh

esc

ient

ific

evid

ence

atth

etim

ed

idno

tp

rovi

de

suffi

cien

tevi

den

ceto

sup

por

tor

cond

emn

the

pla

cem

ento

faca

thet

ertip

inth

erig

htat

rium

Vid

alet

al,2

008

(233

)11

5Pr

osp

ectiv

eco

hort

stud

yEv

alua

teco

mp

licat

ions

inp

atie

nts

who

rece

ived

PIC

Cs

forp

aren

tera

lnut

ritio

n,an

tibio

tics,

blo

odtr

ansf

usio

ns,a

ndot

her

infu

sion

s

115

hosp

italiz

edp

atie

nts

who

rece

ived

127

PIC

Cs

fora

varie

tyof

clin

ical

ind

icat

ions

;PIC

Cs

wer

ein

sert

edin

the

nond

omin

anta

rmin

94of

the

115

pat

ient

s

PIC

CO

cclu

sion

(17%

),ru

ptu

re(1

.6%

),ac

cid

enta

lw

ithd

raw

al(2

.4%

),in

fect

ion

(3.1

%),

and

VT(2

.4%

)wer

eth

em

ostc

omm

onco

mp

licat

ions

Vizc

arra

etal

,201

4(2

34)

NA

Infu

sion

Nur

ses

Soci

ety

gui

del

ine/

pos

ition

pap

er

Iden

tify,

pro

mot

e,an

dd

evel

opre

com

men

dat

ions

and

tool

sto

imp

rove

pat

ient

safe

typ

ract

ices

rela

ted

toth

eus

eof

shor

tPIV

Cs

NA

;pos

ition

stat

emen

trev

iew

ing

the

liter

atur

ean

dre

com

men

din

gb

estp

ract

ices

PIVC

Hea

lthca

rep

rovi

der

know

led

ge,

educ

atio

n,an

dtr

aini

ng,a

long

with

org

aniz

atio

nal

pol

icie

san

dp

roce

dur

es,s

houl

db

ed

evel

oped

toen

sure

PIVC

safe

ty;i

nad

diti

on,s

urve

illan

cep

rog

ram

sto

ensu

resa

fety

with

aud

itsan

dfe

edb

ack

are

nece

ssar

yto

imp

rove

dev

ice

safe

tyW

alke

rand

Tod

d,2

013

(4)

Surv

ey-b

ased

stud

yC

omp

are

inse

rtio

nco

st,p

atie

ntsa

tisfa

ctio

n,an

din

fect

ion

rate

sof

PIC

Cs

inse

rted

by

trai

ned

nurs

esan

dra

dio

log

ists

Hos

pita

lized

pat

ient

sun

der

goi

ngPI

CC

inse

rtio

nin

ad

istr

ictg

ener

alho

spita

lin

the

Uni

ted

King

dom

PIC

CPI

CC

sp

lace

db

yIR

wer

eas

soci

ated

with

gre

ater

cost

than

nurs

e-le

dPI

CC

inse

rtio

ns.

Patie

ntsa

tisfa

ctio

nre

gar

din

gex

pla

natio

nof

trea

tmen

twas

hig

heri

nth

enu

rse

gro

up

Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Wal

liset

al,2

014

(235

)32

83RC

TSe

cond

ary

anal

ysis

ofan

exis

ting

RCT

dat

ase

tto

eval

uate

risk

fact

ors

forP

IVC

failu

re32

83ad

ultm

edic

alan

dsu

rgic

alp

atie

nts

(590

7ca

thet

ers)

with

aPI

VCw

ith≥

4d

ofex

pec

ted

use

PIVC

PIVC

surv

ival

isim

pro

ved

by

pre

fere

ntia

lfo

rear

min

sert

ion,

sele

ctio

nof

app

rop

riate

PIVC

dia

met

er,a

ndin

sert

ion

by

IVte

ams

orot

hers

pec

ialis

tsW

alsh

eet

al,2

002

(51)

335

Pros

pec

tive

coho

rtst

udy

Eval

uate

com

plic

atio

nsaf

terP

ICC

inse

rtio

nin

aco

hort

ofad

ulta

ndp

edia

tric

canc

erp

atie

nts

335

pat

ient

sw

hore

ceiv

ed35

1PI

CC

sd

urin

gho

spita

lizat

ion;

pat

ient

sw

ere

care

dfo

reith

erb

ya

hom

ein

fusi

onag

ency

(205

)orb

yth

eho

spita

lst

aff(

146)

PIC

C11

5(3

2.8%

)of3

51PI

CC

sw

ere

rem

oved

asa

resu

ltof

aco

mp

licat

ion,

fora

rate

of10

.9p

er10

00ca

thet

er-d

ays;

pat

ient

sw

ithhe

mat

olog

icca

ncer

orb

one

mar

row

tran

spla

ntw

ere

mor

elik

ely

tod

evel

opa

com

plic

atio

nW

ebst

eret

al,2

013

(83)

NA

Syst

emat

icre

view

Eval

uate

whe

ther

rout

ine

chan

ges

ofPI

Vca

thet

ers

ever

y72

–96

hw

assu

pp

orte

db

yev

iden

ceof

effic

acy

orsa

fety

7tr

ials

with

ato

talo

f489

5p

atie

nts

wer

ein

clud

edin

the

revi

ewPI

VCN

oev

iden

cew

asfo

und

tosu

pp

ortr

outin

ePI

VCch

ang

esev

ery

72–9

6h;

cons

eque

ntly

,he

alth

care

org

aniz

atio

nsm

ayco

nsid

erp

olic

ies

whe

reb

yca

thet

ers

are

chan

ged

only

ifcl

inic

ally

ind

icat

edW

ilson

etal

,201

2(6

4)43

1Re

tros

pec

tive

coho

rtst

udy

Ana

lyze

and

iden

tify

risk

fact

ors

asso

ciat

edw

ithla

rge

vein

thro

mb

osis

inp

atie

nts

with

PIC

Cs

Neu

rosu

rgic

alIC

Up

atie

nts

PIC

CSu

rger

yfo

r>1

h,hi

stor

yof

VTE,

rece

ipto

fm

anni

tol,

and

und

erg

oing

pla

cem

enti

na

par

etic

arm

wer

eid

entifi

edas

risk

fact

ors

for

DVT

Wils

onet

al,2

013

(236

)43

1Re

tros

pec

tive

coho

rtst

udy

Com

par

eris

kfo

rcom

plic

atio

nsw

ithPI

CC

sw

ithth

ose

asso

ciat

edw

ithC

VCs

incr

itica

llyill

pat

ient

s

Neu

rosu

rgic

alIC

Up

atie

nts

PIC

C,C

VCD

urin

gth

est

udy

per

iod

,431

uniq

uePI

CC

sw

ere

pla

ced

,with

acu

mul

ativ

ein

cid

ence

ofsy

mp

tom

atic

thro

mb

osis

of8.

4%,C

LAB

SIof

2.8%

,and

line

inse

rtio

n–re

late

dco

mp

licat

ions

of0.

0%W

ojna

rand

Bea

man

,20

13(2

3)26

0Re

tros

pec

tive

coho

rtst

udy

Eval

uate

clin

ical

app

rop

riate

ness

ofPI

CC

use

com

par

edw

ithav

aila

ble

reco

mm

end

atio

ns

PIC

Cin

sert

ion

dur

ing

hosp

italiz

atio

nfo

rany

clin

ical

ind

icat

ion;

pat

ient

sw

ere

rand

omly

sele

cted

from

ala

rger

coho

rt

PIC

CRe

sults

sug

ges

ttha

teac

hp

atie

ntha

d≥

3in

dic

atio

nsfo

rPIC

Cp

lace

men

t.H

owev

er,i

n7

pat

ient

s,us

eof

PIC

Cs

did

notm

eet

curr

entC

DC

and

Infu

sion

Nur

ses

Soci

ety

reco

mm

end

atio

nsin

that

the

dur

atio

nof

use

was

<7

day

sW

orle

yet

al,2

007

(237

)46

8Re

tros

pec

tive

coho

rtst

udy

Eval

uate

outc

omes

rela

ted

tous

eof

PIC

Cs

ina

spec

ializ

edhe

adac

hetr

eatm

entu

nit

468

hosp

italiz

edad

ultp

atie

nts

ina

spec

ializ

edhe

adac

hetr

eatm

entu

nit

PIC

CO

nly

2p

atie

nts

(0.8

0%)e

xper

ienc

edPI

CC

-rel

ated

DVT

;the

inve

stig

ator

sco

nclu

ded

that

pat

ient

sw

ithPI

CC

sar

eno

tat

incr

ease

dris

kfo

rUED

VTco

mp

ared

with

othe

rhos

pita

lized

pat

ient

sW

orth

etal

,200

9(2

38)

66Pr

osp

ectiv

eco

hort

stud

yD

eter

min

eth

ena

tura

lhis

tory

and

rate

of,

and

risk

fact

ors

for,

CVC

-rel

ated

com

plic

atio

nsof

CLA

BSI

ina

hem

atol

ogy

pop

ulat

ion

106

CVC

s(7

5PI

CC

s,31

CVC

s)w

ere

eval

uate

din

66p

atie

nts,

over

2399

CVC

-day

sin

anam

bul

ator

yco

hort

PIC

C,C

VCD

VToc

curr

edin

16ca

ses

(15.

1%),

exit-

site

infe

ctio

nin

2ca

ses

(1.9

%),

and

CLA

BSI

in18

case

s(7

.5p

er10

00C

VC-d

ays)

.No

sig

nific

antd

iffer

ence

sw

ere

foun

dw

hen

com

plic

atio

nra

tes

bet

wee

nPI

CC

and

CVC

sw

ere

com

par

edX

ing

etal

,201

2(2

39)

187

Retr

osp

ectiv

eco

hort

stud

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udy

the

inci

den

ce,d

iag

nosi

s,p

reve

ntio

n,an

dtr

eatm

ento

fPIC

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elat

edU

EDVT

inp

atie

nts

with

bre

astc

ance

r

187

pat

ient

sw

ithb

reas

tcan

cerw

hore

ceiv

eda

PIC

Cfo

rche

mot

hera

py

PIC

CFo

ur(2

.1%

)of1

88PI

CC

sw

ere

rem

oved

asa

resu

ltof

PIC

C-r

elat

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EDVT

in14

–112

cath

eter

-day

s,at

ara

teof

0.28

per

1000

cath

eter

-day

sYa

mad

aet

al,2

010

(240

)21

9Pr

osp

ectiv

eco

hort

stud

yC

larif

yth

ed

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eof

pat

ient

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ceiv

edco

mfo

rtan

dco

nven

ienc

e,in

add

ition

top

roce

dur

e-re

late

dd

istr

ess,

resu

lting

from

use

ofPI

CC

sin

term

inal

lyill

pat

ient

sw

ithca

ncer

Am

ong

219

pat

ient

sad

mitt

edto

ap

allia

tive

care

unit,

39(1

8%)u

nder

wen

tPIC

Cp

lace

men

t(a

tota

lof4

4p

roce

dur

esw

ere

per

form

edb

ecau

se5

pat

ient

sun

der

wen

tPIC

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sert

ion

twic

e)

PIC

CPI

CC

sw

ere

safe

lyin

sert

edin

90%

ofte

rmin

ally

illp

atie

nts

with

canc

erw

ithin

20m

inut

es;

alth

oug

h30

%of

the

pat

ient

sex

per

ienc

edtr

ansi

entp

roce

dur

e-re

late

dd

istr

ess,

>90

%fe

ltth

atth

ep

aren

tera

lrou

tew

asm

ore

com

fort

able

and

conv

enie

ntYa

pet

al,2

006

(241

)88

Pros

pec

tive

coho

rtst

udy

Eval

uate

PIC

Cco

mp

licat

ion

rate

sin

2003

afte

rint

rod

uctio

nof

safe

tym

easu

res

and

com

par

eth

emw

ithth

ose

rep

orte

din

the

sam

ece

nter

in20

01(a

hist

oric

alco

hort

)

88PI

CC

lines

wer

ein

sert

edin

73p

atie

nts

und

erra

dio

log

icg

uid

ance

PIC

CTh

eov

eral

lcom

plic

atio

nra

tew

as15

.9%

.In

fect

ions

dev

elop

edin

5.7%

and

thro

mb

otic

even

tsoc

curr

edin

4.5%

ofPI

CC

s.Th

eco

mp

licat

ion

rate

for2

003

was

sig

nific

antly

low

erth

anth

era

tefo

r200

1(P

=0.

006)

,sug

ges

ting

that

stra

teg

ies

tore

duc

ePI

CC

com

plic

atio

nsw

ere

succ

essf

ulYi

etal

,201

4(2

42)

81Pr

osp

ectiv

eco

hort

stud

yIn

vest

igat

eris

kfa

ctor

sfo

rPIC

C-r

elat

edD

VTin

pat

ient

sw

ithca

ncer

Hos

pita

lized

pat

ient

sw

ithca

ncer

sche

dul

edto

rece

ive

PIC

Cs

bet

wee

nSe

pte

mb

er20

09an

dM

ay20

12at

1ce

nter

PIC

CD

iab

etes

incr

ease

dth

eris

kfo

rPIC

C-r

elat

edD

VTin

pat

ient

sre

ceiv

ing

chem

othe

rap

y

Con

tinue

don

follo

win

gpa

ge




Tabl

e1—

Con

tinue

d

Stud

y,Y

ear

(Ref

eren

ce)

Par

tici

pan

ts,

nD

esig

nFo

cus

orO

verv

iew

Stud

ySa

mp

lean

dC

hara

cter

isti

csD

evic

eFi

ndin

gs

and

Com

men

ts

Yue

etal

,201

0(2

43)

400

Pros

pec

tive

coho

rtst

udy

Exam

ine

inse

rtio

n,in

fect

ious

,and

noni

nfec

tious

com

plic

atio

nsre

late

dto

PIC

Cus

ein

pat

ient

sw

ithca

ncer

at1

med

ical

cent

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ap

rovi

nce

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hina

400

amb

ulat

ory

pat

ient

sw

ithva

rious

typ

esof

canc

erw

hore

ceiv

edPI

CC

sfo

rche

mot

hera

py

PIC

CD

urin

gin

sert

ion,

arrh

ythm

iaoc

curr

edin

1.5%

(6of

400)

ofp

atie

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diffi

cult

cath

eter

thre

adin

gin

3.75

%(1

5of

400)

,and

exce

ssiv

eoo

zing

ofb

lood

in0.

3%(1

of40

0).

Dur

ing

the

cath

eter

dw

ell-i

np

erio

d,

sens

itizi

ngd

erm

atiti

soc

curr

edin

8%(3

8of

400)

,mec

hani

calp

hleb

itis

in7.

5%(3

0of

400)

,cat

hete

rocc

lusi

onin

9.5%

(38

of40

0),

cath

eter

-ass

ocia

ted

hem

atog

enou

sin

fect

ion

in3%

(12

of40

0),a

ndVT

in2%

(8of

400)

Zhu

etal

,200

8(2

44)

2170

Retr

osp

ectiv

eco

hort

stud

yEx

amin

ead

vers

eev

ents

and

risk

fact

ors

asso

ciat

edw

ithsu

chou

tcom

esSi

ngle

-cen

ters

tud

yof

pat

ient

sun

der

goi

ngPI

CC

pla

cem

entf

orva

rious

ind

icat

ions

PIC

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case

sof

DVT

and

2ca

ses

ofb

acte

rem

iaoc

curr

ed;D

VTse

emed

tob

ere

late

dto

adva

nced

canc

er,n

once

ntra

lPIC

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pos

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onar

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tery

dis

ease

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bet

es,

and

hyp

erlip

idem

iaZi

ngg

etal

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1(8

7)29

2Pr

osp

ectiv

eco

hort

stud

yQ

uant

ifyth

ein

dic

atio

nsfo

rcat

hete

rp

lace

men

tove

rdw

ellt

ime

and

inve

stig

ate

agre

emen

tbet

wee

nhe

alth

care

wor

kers

onC

VCus

e

378

CVC

sin

292

pat

ient

s,ac

coun

ting

for2

704

cath

eter

-day

sC

VCTh

em

ostf

req

uent

reas

on(4

9%)f

orca

thet

erus

ew

asp

rolo

nged

(>7

d)a

ntib

iotic

ther

apy,

follo

wed

by

par

ente

raln

utrit

ion

(22.

3%).

Ato

talo

f130

cath

eter

-day

s(4

.8%

)wer

eun

nece

ssar

y,w

itha

hig

herp

rop

ortio

nin

non-

ICU

sett

ing

s(6

.6%

).In

35on

-site

visi

ts(8

.3%

)in

non-

ICU

sett

ing

s,ne

ither

the

nurs

eno

rthe

trea

ting

phy

sici

ankn

eww

hyth

eca

thet

erw

asin

pla

ceZo

chio

set

al,2

014

(245

)N

ASy

stem

atic

revi

ewRe

view

the

liter

atur

esu

rrou

ndin

gPI

CC

san

dhi

ghl

ight

the

epid

emio

log

y,p

atho

phy

siol

ogy,

dia

gno

sis,

and

man

agem

ento

fPIC

C-r

elat

edth

rom

bos

isin

criti

cally

illp

atie

nts

Syst

emat

icre

view

exam

inin

gris

kfa

ctor

sfo

rand

dia

gno

sis

and

trea

tmen

tofP

ICC

-rel

ated

DVT

incr

itica

llyill

pop

ulat

ions

PIC

CTh

ein

cid

ence

ofPI

CC

-rel

ated

thro

mb

osis

incr

itica

llyill

pat

ient

sis

uncl

ear.

US

isth

ep

refe

rred

dia

gno

stic

imag

ing

mod

ality

.No

RCTs

onb

estt

reat

men

tofP

ICC

-rel

ated

thro

mb

osis

inth

eIC

Use

ttin

gto

info

rmp

ract

ice

are

avai

lab

leZw

icke

reta

l,20

14(5

3)N

ASy

stem

atic

revi

ewan

dg

uid

elin

ePr

ovid

ere

com

men

dat

ions

ford

iag

nosi

san

dm

anag

emen

tofC

VC-a

ssoc

iate

dD

VTin

pat

ient

sw

ithca

ncer

Syst

emat

icre

view

ofth

elit

erat

ure

and

exp

ert

opin

ion

from

ag

uid

elin

ew

ritin

gp

anel

ofth

eIn

tern

atio

nalS

ocie

tyon

Thro

mb

osis

and

Hae

mos

tasi

s

PIC

C,C

VCU

Sis

reco

mm

end

edas

the

initi

alte

stof

choi

ce.R

outin

ead

min

istr

atio

nof

pha

rmac

olog

icp

rop

hyla

xis

top

reve

ntD

VTis

notr

ecom

men

ded

.Ant

icoa

gul

atio

nw

ithLM

WH

with

outr

emov

alof

the

cath

eter

ifcl

inic

ally

nece

ssar

yis

reco

mm

end

ed

BSI

=b

lood

stre

amin

fect

ion;

CD

C=

Cen

ters

for

Dis

ease

Con

trol

and

Prev

entio

n;C

KD=

chro

nic

kid

ney

dis

ease

;CLA

BSI

=ce

ntra

llin

e–as

soci

ated

blo

odst

ream

infe

ctio

n;C

RBSI

=ca

thet

er-r

elat

edb

lood

stre

amin

fect

ion;

CRT

=ca

thet

er-r

elat

edth

rom

bos

is;C

T=

com

put

edto

mog

rap

hy;C

VAD

=ce

ntra

lven

ous

acce

ssd

evic

e;C

VC=

cent

ralv

enou

sca

thet

er;D

VT=

dee

pve

nous

thro

mb

osis

;ED

=em

erg

ency

dep

artm

ent;

EKG

=el

ectr

ocar

dio

gra

phy

;ES

A=

eryt

hrop

oies

is-s

timul

atin

gag

ent;

GRA

DE

=G

rad

ing

ofRe

com

men

dat

ions

Ass

essm

ent,

Dev

elop

men

tan

dEv

alua

tion;

ICU

=in

tens

ive

care

unit;

IR=

inte

rven

tiona

lrad

iolo

gy;

IV=

intr

aven

ous;

IVD

=in

trav

enou

sd

evic

e;LM

WH

=lo

w-m

olec

ular

-wei

ght

hep

arin

;N

A=

not

app

licab

le;

NR

=no

tre

por

ted

;PE

=p

ulm

onar

yem

bol

ism

;PIC

C=

per

iphe

rally

inse

rted

cent

ralc

athe

ter;

PIVC

=p

erip

hera

lIV

cath

eter

;QI=

qua

lity

imp

rove

men

t;RC

T=

rand

omiz

ed,c

ontr

olle

dtr

ial;

SVC

=su

per

ior

vena

cava

;TC

VC=

tunn

eled

cent

ralv

enou

sca

thet

er;t

PA=

tissu

ep

lasm

inog

enac

tivat

or;T

PN=

tota

lpar

ente

raln

utrit

ion;

UC

LA=

Uni

vers

ityC

alifo

rnia

,Los

Ang

eles

;UED

VT=

upp

er-e

xtre

mity

dee

pve

nous

thro

mb

osis

;US

=ul

tras

onog

rap

hy;V

A=

Vete

rans

Affa

irs;V

AD

=ve

nous

acce

ssd

evic

e;VT

=ve

nous

thro

mb

osis

;VTE

=ve

nous

thro

mb

oem

bol

ism

.




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Appendix Table 1. Literature Search Strategy

Search Query Items Found, n

PubMed (searched9 March 2013)

#23 (#8 not (#12 or #21 or #22)) 1109#22 (("Case Reports"[pt] or "case report"[Title])) 1 664 821#21 (#19 not #20) 455 878#8 ((#3 OR #4) AND #7) 1542#20 (#16 or #17) 769 402#19 (#13 or #18) 507 993#17 ((#3 OR #4) AND #7) Filters: Adult: 19+ years 577#16 adult*[Title/Abstract] 768 894#13 ((#3 OR #4) AND #7) Filters: Child: birth-18 years 417#18 (pediatric or neonat*[Title]) 507 773#12 (#9 NOT (#10 or 11)) 56#10 ((#3 OR #4) AND #7) Filters: Humans 1435#9 ((#3 OR #4) AND #7) Filters: Other Animals 82#11 (human* or patient*[Title/Abstract]) 6 257 942#7 ("Guideline" [Publication Type] OR "Guidelines as Topic"[Mesh] OR "Practice Guideline" [Publication

Type] OR "Unnecessary Procedures" [MeSH] or (appropriate* or inappropriate* or indicat* orguideline* or unnecessary[Title/Abstract]))

2 824 018

#4 "peripherally inserted central catheter*" OR "peripherally inserted" or picc*[Title/Abstract] 1474#3 "Catheterization, Central Venous"[Majr] 8919

CINAHL 325S24 S20 not S23S23 S21 NOT S22S22 S20 Limiters–Age Groups: All AdultS21 S18 AND S19 Limiters–Age Groups: All ChildS20 S18 AND S19S19 S16 OR S17S18 TI (appropriate* or inappropriate* or indicat* or guideline* or unnecessary) OR AB ( appropriate* or

inappropriate* or indicat* or guideline* or unnecessary)S17 TI ("peripherally inserted central catheter*" OR "peripherally inserted" or picc*) OR AB (

"peripherally inserted central catheter*" OR "peripherally inserted" or picc*)S16 (MH "Catheter Care, Vascular+") OR (MH "Central Venous Catheters+")

Google Scholar "peripherally inserted central catheter*" AND (appropriate* or inappropriate* or indicat* orguideline* or unnecessary)

134 (only 131 imported)

ClinicalTrials.gov(searched 9 April2013)

peripherally inserted central catheter* or picc* 40

www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015


Appendix Table 2. Characteristics of MAGIC Panel Members

Panelist Title Affiliation Clinical Specialty Area of Technical Expertise

Agnes Y. Lee, MD, PhD Medical Director, ThrombosisProgram; AssociateProfessor of Medicine

University of British Columbia;Vancouver Coastal Health;British Columbia CancerAgency; Vancouver, BritishColumbia, Canada

Hematology andoncology

Thrombosis in cancer patients

Anthony Courey, MD Assistant Professor ofMedicine

University of Michigan, AnnArbor, MI

Critical care Vascular access and use ofultrasound in critically illpatients

Elie Akl, MD, MPH, PhD Director, ClincialEpidemiology Unit;Co-director, Center forSystematic Reviews inHealth Policy and SystemsResearch (SPARK)

American University, Beirut,Lebanon; Department ofClinical Epidemiology andBiostatistics, McMasterUniversity, Hamilton, Ontario,Canada

Internal medicine;hospitalmedicine

Guideline development,thrombosis,evidence-based medicine

Jack LeDonne, MD Director of Vascular AccessPrograms; Past President,Association of VascularAcccess

Greater Baltimore MedicalCenter, Baltimore, MD

General surgery Vascular access in generalmedical and surgicalpatients

Mauro Pittiruti, MD Director of Vascular AccessDirector, GAVeCeLT

Catholic University, Rome, Italy General surgery Vascular access

Nancy Moureau, RN Chief Executive Office;Director of VascularEducation

PICC Excellence, Inc., Hartwell,GA

Vascular accessnursingeducation

Vascular access

Naomi O'Grady, MD,PhD

Director of Procedures,Vascular Access andConcious Sedation

National Institutes of HealthClinical Center, Bethesda,MD

Critical care Guideline development,central line–associatedbloodstream infection,critical care

Nasia Safdar, MD, PhD Associate Professor ofMedicine; Medical Director,Infection Control; AssociateChief of Staff for Research

University of Wisconsin; WilliamS. Middleton MemorialVeterans Hospital; Madison,WI

Infectiousdiseases

Central line-associatedbloodstream infection

Rajiv Saran, MD, MRCP,MS

Professor of Medicine andEpidemiology; Director, USRenal Data SystemCoordinating Center;Associate Director, KidneyEpidemiology and CostCenter, University ofMichigan

University of MichiganAnn Arbor, MI

Nephrology Chronic kidney disease;vascular access in patientswith end-stage renaldisease

Lakshmi Swaminathan,MD

Staff Hospitalist; PhysicianChampion, HMS PICCQuality ImprovementProject*

Oakwood Health System,Dearborn, MI

Internal medicine Hospital medicine; patientsafety; quality improvementin hospitalized medicalpatients

Scott O. Trerotola, MD Professor of Radiology;Associate Chair and Chief ofInterventional Radiology

University of Pennsylvania,Philadelphia, PA

Interventionalradiology

Guideline development;vascular access

Dana Wanschneider, RN Vascular Access Nurse St. Josephs Mercy HealthSystem, Ann Arbor, MI

Vascular access Vascular access; nursing

Scott C. Woller, MD Associate Professor ofMedicine

Intermountain Medical Center;University of Utah School ofMedicine, Salt Lake City, UT

Internal medicine Venous thromboembolism;anticoagulationmanagement

Stephen Wiseman,PharmD

Clinical Pharmacy Specialist;Assistant Professor ofPharmacy

University of Michigan; VA AnnArbor Healthcare SystemAnn Arbor, MI

Pharmacology Infectious diseases; homeintravenous therapy;management of parenteraltherapy

Georgiann Ziegler Patient Representative University of Michigan HealthSystem

– Personally experiencedmultiple vascular accessdevices; insights into thepatient experience

GAVeCeLT = Gruppo Aperto di Studio 'Gli Accessi Venosi Centrali a Lungo Termine; HMS = Hospital Medicine Safety Consortium; MAGIC =Michigan Appropriateness Guide for Intravenous Catheters; PICC = peripherally inserted central catheter; VA = Veterans Affairs.* A Blue Cross Blue Shield–funded collaborative quality initative focused on improving PICC use in hospitalized medical patients in 47 particiatinghositals in the State of Michigan.

Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org


Appendix Table 3. Sample Lists of Thematic Concerns Raised by Panelists*

Theme or Area Question or Top Concern

Appropriateness of PICC placementand concerns regarding deviceselection

Is the request for a PICC appropriate for what is needed (i.e., does the entity to be infused require a PICC, orwill a midline or peripheral catheter suffice?

Overuse of PICC for long-term care when tunneled, cuffed catheters (Hickman, cuffed Groshong, Broviac, etc.)or port would be more appropriate

PICCs ordered or maintained for blood draws—is this appropriate?PICCs ordered without trying other devicesPICCs ordered when all else fails for 1–3 doses of an infusion—is insertion appropriate?

Issues related to device insertionand selection of PICCcharacteristics

Is location of the tip of the catheter in the right atrium acceptable?Are dedicated lumens for parenteral nutrition still needed?How many lumens are appropriate for a given use?

Process concerns regardingutilization

Increasing use of PICCs when peripheral catheters may work? How can we drive this down?Unnecessary number/size of PICC lumensImplications of ordering chest radiographs for "PICC placement only" that are otherwise abnormalPatient “requested” PICC line appropriatenessHow do we resolve disagreement with radiology on where a PICC is located on chest radiograph?Strategies to minimize idle PICC-daysWhen should PICC tips be adjusted for optimal positioning?

Identifying best practices fortreatment and prevention ofPICC-related DVT

Optimal treatment is undefined. That covers everything from line removal? Anticoagulation? Duration andintensity of anticoagulation

Prophylaxis: Is primary prophylaxis indicated in those with "high-risk" factors? What are these factors, and if theyare present, how do we provide primary prophylaxis?

Prophylaxis: Is secondary prophylaxis indicated? I've had many patients who had a CRT as the index thromboticevent but then re-present with a DVT/PE. Is the risk for recurrence high enough to warrant secondaryprophylaxis? If a patient develops DVT and still requires central venous access, should we leave the catheterin situ?

If a symptomatic DVT is not improving clinically with a PICC in situ, how long should we wait before removingthe PICC or calling IR?

Management of specificcomplications

If a PICC is pulled out from original position, how far can it migrate out before it has to be pulled/replaced?Is it appropriate to empirically pull a PICC without other evidence of line infection?PICC in place when bacteremia occurs but no evidence of CLABSI—remove or treat through?Optimal timing of placement in bacteremia for long-term antibiotic treatment?

CLABSI = central line–associated bloodstream infection; CRT = catheter-related thrombosis; DVT = deep venous thrombosis; IR = interventionalradiology; PE = pulmonary embolism; PICC = peripherally inserted central catheter.* Edited by the authors for readability. Questions were selected at random from several panelists to illustrate the depth and breadth of focus.

Appendix Table 4. Example Scenarios From Ratings Material

How appropriate is theuse of each of thefollowing vascularaccess devices toobtain venous accessfor infusion oftherapeutics and/orlab draws in a patientwho is likely tobe hospitalized for apotential duration of:*

PeripheralIV Catheter

US-GuidedPeripheralIV Catheter

MidlineCatheter

PICC NontunneledCVC

Tunneled,CuffedCatheter

Port

≤5 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

Compared with PICCs, how preferable is the use of a midline in a hospitalized medical patient who requiresvenous access for infusion of a nonirritant, nonvesicant therapy for a proposed duration of:

Preference ofMidline Catheter vs.PICC†

≤5 d? 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9

CVC = central venous catheter; IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.* Rating scale: 1 = highly inappropriate; 5 = neutral or uncertain; 9 = highly appropriate.† Prefer midline catheter = 1; prefer PICC = 9.



Continuing Medical Education/Maintenance of Certification ActivityIn addition to CME credit, physicians enrolled in the American Board of Internal Medicine’s (ABIM) Maintenance

of Certification (MOC) program can earn 8 medical knowledge self-assessment points for successful completing thefollowing module online. To earn 5 CME credits, please take this quiz at www.annals.org/article.aspx?doi=10.7326/M15-0744. To earn MOC points, you must take the MOC quiz at www.acponline.org/magicmoc; successful com-pletion qualifies for 8 MOC points, and this information will be transferred to the ABIM.

These CME and MOC activities are free to ACP members and individual subscribers to Annals of InternalMedicine. Others who are interested in completing this MOC activity can learn more about ACP membership andindividual subscriptions to Annals of Internal Medicine at www.acponline.org.

Question 1: The RAND/UCLA Appropriateness Method was developed to:A. Examine risks and benefits of medical and surgical procedures, regardless of their cost to estimate the over-

or underuse of specific medical and surgical proceduresB. To determine whether specific medical interventions are cost-effective.C. Develop consensus regarding appropriate medical and surgical procedures from a multidisciplinary panel.D. To determine whether insurers should cover the cost of an intervention

Question 2: According to the RAND/UCLA Appropriateness Method, which of the following is the hallmark of an“appropriate” rating?

A. When all participating panelists agree on the appropriateness of a clinical scenario.B. When the expected health benefits exceed the expected negative consequences and the panel median rating

is 7 to 9 without disagreement.C. When the majority of the panel rates the clinical scenario as highly appropriate.D. When no panel member rates the clinical scenario as inappropriate.

Question 3: According to the RAND/UCLA Appropriateness Method, which of the following indicates an “uncertain”rating?

A. When the panel median ranges from 4 to 6, or there is disagreement regardless of the median.B. When the panel median ranges from 1 to 3.C. When the panel median ranges from 7 to 9.D. When the panel median ranges from 5 to 7.

Question 4: Which of the following information sources was not used to develop the clinical scenarios for rating theappropriateness of various intravenous devices in this document?

A. Systematic reviews of the literatureB. List of controversial topics/key problems generated by expertsC. Clinical areas of ambiguity, controversy, or uncertaintyD. Medicare coverage of the procedure

Question 5: For this project, which of the following elements was NOT used to develop the clinical scenarios orindications that were rated by panelists?

A. Proposed duration of venous accessB. Device characteristicsC. Patient preferenceD. Maintenance and care practices

Question 6: In this project, a multidisciplinary panel of experts rated the appropriateness of a number of vascularaccess devices. Which of the following indications were rated as appropriate for use of peripherally inserted centralcatheters?



A. Placement in a patient with active cancer for cyclical chemotherapy that can be administered through aperipheral vein, when the proposed duration of such treatment is 3 months or less and peripheral veins areavailable.

B. Delivery of non–peripherally compatible infusates (e.g., irritants/vesicants) regardless of proposed duration ofuse.

C. Patient or family requests for a patient who is not actively dying/on hospice for comfort from daily lab draws.D. Medical or nursing provider request in the absence of other appropriate criteria for peripherally inserted

central catheter use.

Question 7: In this project, a multidisciplinary panel of experts rated the appropriateness of practices associated witha number of venous access devices. Which of the following practices were rated as appropriate for peripherallyinserted central catheter insertion?

A. Urgent requests for peripherally inserted central catheter placement in a hemodynamically unstable patient inthe wards or intensive care unit setting.

B. Routine use of chest radiographs to verify peripherally inserted central catheter tip positioning followinguneventful placement via EKG guidance or fluoroscopy by staff who are technically proficient in this technology.

C. Preferential placement of a peripherally inserted central catheter based on the patient’s arm dominance.D. Consult with a relevant specialist (e.g., infectious disease, heme-oncology), operator (vascular access profes-

sional), and/or hospital pharmacist prior to ordering a peripherally inserted central catheter to determineoptimal device choice and characteristics.

Question 8: Which of the following were rated as an appropriate practice for peripherally inserted central cathetercare or maintenance by this multidisciplinary panel?

A. Removal of a peripherally inserted central catheter by a health care team member trained to remove centralvenous catheters, but not specifically trained to remove a peripherally inserted central catheter.

B. Removal of a peripherally inserted central catheter that is clinically necessary, centrally positioned, andotherwise functional in the setting of arm deep venous thrombosis.

C. Use of normal saline rather than heparin to flush a peripherally inserted central catheter following infusion orphlebotomy.

D. Routine removal and/or replacement of a peripherally inserted central catheter that remains clinically neces-sary without objective evidence of catheter-associated bloodstream infection in febrile patients.

Question 9: Which of the following was rated as an appropriate practice when caring for peripheral intravenouscatheters?

A. Routine replacement or continuation of a peripheral intravenous catheter in the absence of a clinical indica-tion warranting continued use.

B. Removal of a peripheral intravenous catheter in the setting of redness, swelling, pain, or phlebitis over thevein of insertion.

C. Replacement of a peripheral intravenous catheter on the basis of a routine schedule in the absence ofredness, swelling, or other signs of inflammation.

D. Removal of a functioning peripheral intravenous catheter because it was inserted in the field (e.g., ambulanceor nonhospital site) in the absence of redness, tenderness, or swelling over the insertion site.

Question 10: For the indication of infusion of peripherally compatible fluids, which of the following vascular accessdevices was rated as neutral for a proposed infusion for 6 to 14 days?

A. Ultrasound-guided peripheral intravenous cathetersB. MidlinesC. Peripherally inserted central cathetersD. Peripheral intravenous catheters

Question 11: For the infusion of peripherally compatible fluids, which of the following vascular access devices wererated as inappropriate for a proposed duration of 31 days or more?



A. Peripherally inserted central cathetersB. Ultrasound-guided peripheral IVsC. Implanted portsD. Tunneled catheters

Question 12: According to the Fistula First Breakthrough Initiative, in what stages of chronic kidney disease may useof peripherally inserted central catheters be considered appropriate following expert consultation with nephrology?

A. Stage 1 onlyB. Stage 3b or greaterC. Stage 2 onlyD. Stage 1 to 3a

Question 13: For the infusion of peripherally noncompatible fluids in critically ill patients, which of the followingvascular access devices were rated as appropriate and preferred for a proposed duration of 5 days or less?

A. Nontunneled central venous cathetersB. Tunneled cathetersC. Peripheral intravenous cathetersD. Midlines

Question 14: For patients with difficult peripheral venous access, which of the following pairs of vascular accessdevices were rated as appropriate and preferred to peripherally inserted central catheters when the proposedduration of use is 14 days or less?

A. Midlines and portsB. Nontunneled central venous catheters and portsC. Midlines and central venous cathetersD. Tunneled-cuffed catheters and peripherally intravenous catheters

Question 15: According to our panel, which of the following was rated as appropriate for the treatment of periph-erally inserted central catheter-related deep venous thrombosis?

A. Provide at least 1 month of uninterrupted systemic anticoagulation.B. Low-molecular-weight heparin over warfarin in patients with cancer.C. Remove the peripherally inserted central catheter and replace this with another device to prevent clot

propagation.D. Refer all patients with peripherally inserted central catheter-related deep venous thrombosis to interventional

radiology for evaluation.

Question 16: Among scenarios examining use of vascular access devices in patients that require frequent phlebot-omy, which of the following statements are true?

A. Central venous catheters were rated as appropriate and preferred to peripherally inserted central catheterswhen the expected duration of venous access was 14 days or less in critically ill patients.

B. Ports were rated as appropriate to use in this population, regardless of duration of use.C. Peripheral intravenous catheters and ultrasound-guided peripheral intravenous catheters were rated as ap-

propriate for use for 5 days or less in patients that require frequent phlebotomy.D. The most appropriate vascular access device should be determined by patient preference in this setting.

Question 17: Among patients who require frequent phlebotomy for less than 5 days, which of the following resultedin panelist disagreement regarding appropriateness of device use?

A. MidlinesB. Central venous cathetersC. Peripherally inserted central cathetersD. Ports



Question 18: Among patients receiving peripherally compatible infusions in home-based or skilled nursing facilities,which of the following expected durations of use was rated as being appropriate for peripherally inserted centralcatheter placement?

A. 6 to 14 daysB. Only 15 to 30 daysC. Only more than 30 daysD. More than 15 days

Question 19: Among patients who are likely to require lifelong venous access but are infrequently hospitalized (<5times per year), when is use of peripherally inserted central catheters considered appropriate according to thispanel?

A. When expected duration of venous access is 5 days or less.B. When the expected duration of venous access is 6 to 14 days.C. When the expected duration of venous access is 15 or more days.D. When the expected duration of access is not well-known.

Question 20: In critically ill populations, which of the following expected durations of venous access were rated asappropriate for midline insertion and use?

A. 5 days or lessB. 6 to 14 daysC. 15 to 30 daysD. More than 30 days

Question 21: A patient is diagnosed with active cancer and is recommended multiple cycles of nonvesicant, inter-mittent chemotherapy that can be administered into a peripheral vein for a total duration of 1 month. Based on therecommendations of this panel, which of the following vascular access devices is considered appropriate for this patient?

A. Peripherally inserted central cathetersB. Intermittent use of peripheral intravenous cathetersC. PortsD. Tunneled-cuffed catheters

Question 22: A patient with an unknown stage of chronic kidney disease is admitted to the hospital with pneumoniaand is likely to require venous access for 5 days or less. However, the patient is a “difficult stick” and nurses arehaving trouble establishing reliable peripheral access. According to this panel, which of the following are appropri-ate in this particular setting?

A. Because of the ambiguity regarding the stage of CKD, consultation with nephrology is appropriate prior toperipherally inserted central catheter insertion for any reason.

B. Should the patient be determined to have stage 3b or greater CKD or is possibly a candidate for hemodialysis(with estimated GFR < 45 mL/min), insertion of a peripherally inserted central catheter is appropriate.

C. If peripheral venous access for 5 days or less is likely, placement of a peripheral intravenous catheter in thedorsum of the hand is considered inappropriate.

D. Should longer-term intravenous antibiotics be necessary, placement of a small-bore central catheter forinfusion of 14 days of intravenous antibiotics is inappropriate in patients with stage 3b or greater CKD.

Question 23: A patient is being discharged from the hospital to a local skilled nursing facility for continuation of aplanned 6 weeks of intravenous antibiotics. According this panel, which of the following vascular access devices areconsidered appropriate for this patient in this scenario?

A. Nontunneled central venous catheterB. Peripheral intravenous catheterC. MidlineD. Peripherally inserted central catheter



Question 24: A patient with an existing peripherally inserted central catheter is admitted to the hospital. A portablechest radiograph performed to ascertain the catheter tip position shows this to be located approximately 1 cm withinthe right atrium. Based on the recommendations of this panel, which of the following is the most appropriate nextcourse of action?

A. Adjust peripherally inserted central catheter so as to localize the catheter tip in the cavoatrial junction; repeatchest radiography to confirm.

B. No further action is needed; the catheter is well-positioned and okay to use.C. Withdraw tip so as to localize the catheter tip in the lower third of the superior vena cava.D. Perform computed tomography to confirm catheter placement.



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