The research findings, described online March 18 in JAMA Pediatrics, show that catheters in children inserted in a vessel in the arm or leg and not threaded into a large vein near the heart are nearly four times as likely to dislodge, cause vein inflammation or dangerous blood clots as are catheters advanced into major vessels near the heart.
A peripherally inserted central venous catheter, or PICC line, is a tube placed into a small blood vessel, usually in the arm, and threaded toward a major blood vessel near the lungs and heart to serve as a temporary portal for medications, nutrients or fluids. However, clinicians sometimes forego threading close to the heart and leave the PICC line in a peripheral vein in the arm or leg instead — a choice dictated by the ease and speed of placement or a child’s overall condition or anatomy.
The study findings, however, suggest that leaving the device in a non-central vein should only be done as last resort, the researchers say.
“Clinicians should carefully weigh the ease and speed of non-central vein placement against the higher complication risk that our study found goes with it,” says senior investigator and pediatric infectious disease specialist Aaron Milstone, M.D., M.H.S.
Non-central, smaller veins, especially those in the arm, are narrower, thinner and more prone to injury than major vessels near the heart, the researchers say. Thus, a catheter can easily damage the protective coating on the walls of such veins and encourage the formation of blood clots that, in the worst-case scenario, can dislodge and travel to the lungs or heart, causing a pulmonary embolism or heart damage.
Conducted among more than 1,800 pediatric patients hospitalized at Johns Hopkins over six years, the study found that such non-centrally positioned catheters accounted for a mere 16 percent of the central lines, but for 44 percent of all complications that led to catheter removal.
Children in the study cumulatively underwent more than 2,500 catheter insertions, of which more than 500 — one in five — had to be removed due to complications. Three-quarters of problems stemmed from mechanical malfunction such as device breakage or dislodgement, clot formation or blood vessel inflammation. The rest were due to infection, which traditionally has been the greatest worry with central lines. Vein location, however, played no role in infection risk, the research showed.
Despite the higher risks seen with non-centrally position catheters, overall complications rates dropped significantly over the six-year study period, a trend that should get a further boost by emerging technologies, the investigators say.
“We are already adopting new technologies that render PICC placement near the heart easier, safer and faster, and which will drive complications rates further down,” says Leslie Gosey, R.N., M.S., leader of the pediatric catheter-insertion team at Johns Hopkins.
The study was funded by the National Institutes of Health under grant numbers K23 AI081752 and R03 NR012558.
Co-investigators included Ketan Jumani, B.D.S., M.P.H.; Sonali Advani, M.B.B.S., M.P.H.; and Nicholas Reich, Ph.D., all of Johns Hopkins.
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Founded in 1912 as the children’s hospital of the Johns Hopkins Medical Institutions, the Johns Hopkins Children’s Center offers one of the most comprehensive pediatric medical programs in the country, with nearly 95,000 patient visits and some 9,000 admissions each year. Hopkins Children’s is consistently ranked among the top children’s hospitals in the nation. Hopkins Children’s is Maryland’s largest children’s hospital and the only state-designated Trauma Service and Burn Unit for pediatric patients. It has recognized Centers of Excellence in dozens of pediatric subspecialties, including allergy, cardiology, cystic fibrosis, gastroenterology, nephrology, neurology, neurosurgery, oncology, pulmonary, and transplant. For more information, visit www.hopkinschildrens.org.
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