Substantial Variation in Peripherally Inserted Central Catheter Use and Outcomes in Patients with Hematologic Malignancies: A Multi-Center Study

Background: Use of peripherally inserted central catheters (PICCs) has grown rapidly in patients with hematologic malignancies. Studies demonstrating the safety of PICCs in hematologic malignancies, however, are largely single-center, retrospective designs focused on the outpatient setting. Little is known about inpatient PICC use in patients with hematologic malignancies and how such use varies across hospitals. Methods: Data was prospectively collected between November 2013 and December 2019 from a cohort of patients admitted at one of 42 Michigan hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Patients had a diagnosis of a hematologic malignancy and had a PICC placed during their hospital stay. Adult medical patients admitted to a general ward or intensive care unit were eligible for data collection and data were collected from the medical record using a standardized template. The indications for PICC placement, catheter characteristics, and associated complications from 17 hospitals with more than 25 discrete patients with hematologic malignancy were included in a comparative analysis. Major complications were defined as central line associated bloodstream infection (CLABSI), catheter occlusion, and venous thromboembolism (VTE). Differences across hospitals were tested using the Kruskal-Wallis test for continuous variables and Pearson chi-square test for categorical variables. Results: A total of 2092 PICCs placed in 1798 patients were included in the analysis with a median (IQR) dwell time of 15 (6-30) days. Most patients were male (n=1242, 59.4%), white (n=1720, 82.2%), and 50 to 69 years old (n=950, 45.4%). Patients were primarily admitted to large hospitals (≥375 beds: n=1429, 68.8%) that were teaching centers (n=1600, 76.5%) in metropolitan locations (n=2000, 95.6%). Leukemia (n=752, 36.0%) and non-Hodgkin's lymphoma (n=409, 19.6%) were the most represented malignancies. The most common primary indication for PICC placement was administration of chemotherapy (n=1180, 56.4%). The majority of PICCs were double lumen (n=1457, 69.6%), most often placed by vascular access nurses (n=1520, 72.7%). A concurrent central venous catheter was present at the time of PICC placement in 12.2% (n=264) of patients. A major complication event occurred in over 1 in 4 PICCs placed (n=562, 26.9%). Catheter occlusion occurred in 17.8% (n=372), CLABSI in 8.2% (n=171), and VTE in 3.8% (n=80) of PICCs respectively. There was wide variation in PICC indications, characteristics, and outcomes across hospitals. Placement of PICCs for chemotherapy varied from 33.3% to 85.3% (p<0.001). Similarly, there was a wide range of placement for antibiotics (2.8% to 32.4%, p<0.001), transfusion of blood products (0.0% to 9.7%, p<0.001), medications requiring central access (0% to 26.7%, p<0.001), difficult access and blood draws (1.8% to 33.3%, p<0.001), and administration of total parenteral nutrition (0.0% to 14.3%, p=0.002). There was significant variation in the number of lumens used: single (5.6% to 37.9%, p<0.001), double (51.9% to 93.0%, p<0.001), or triple (0.0% to 30.8%, p<0.001). The incidence of major complications spanned from 9.7% to 40.8% (p=0.001). Rate of catheter occlusion had the widest range (0.0% to 36.7%, p<0.001). The differences between rates of VTE (0.0% to 8.7%, p=0.29) and CLABSI (1.4% to 15.9%, p< 0.20) were not statistically significant. Patient mortality ranged from 2.8% to 19.4% (p<0.001). Conclusion: Appropriate venous access is critical to the care of patients with hematologic malignancy. This study demonstrates wide variation in the practice patterns and outcomes for PICCs in patients with hematologic malignancies across hospitals in Michigan. Further work is necessary to further understand and improve decision making around choosing vascular access in this vulnerable population. Figure 1 Figure 1. Disclosures Zhang: SIMR, Inc: Ended employment in the past 24 months, Research Funding; AmerisourceBergen: Current Employment. Sood: Bayer: Consultancy.

Intermediate and Long-Term Outcome of Percutaneous Trans-catheter Device Closure of Ventricular Septal Defects

Background Ventricular septal defect (VSD) is the most common congenital heart defect in children and adults. Until recently, open-heart surgical closure has traditionally been considered the mainstay of intervention for the majority of VSDs. The development of a trans-catheter occlusion technique with the advancement of the newer percutaneous occluding VSD closure devices that can safely and effectively close these defects was welcomed by cardiologists, patients, and their families making trans-catheter device closure an attractive and feasible alternative. Objective We aim to evaluate the intermediate and long-term follow-up outcome of patients who underwent percutaneous trans-catheter closure of isolated ventricular septal defects. Patients and Methods This study is an exploratory pilot single-tertiary center study. The study included 25 patients who have successfully undergone percutaneous ventricular septal closure in the cardiac catheterization unit of the cardiology department at Ain Shams university Hospitals in the period from June 2015 till June 2018. The follow up protocol includes detailed history taking, clinical examination, and full 2D echocardiography with additional circumferential and radial strain imaging by speckle tracking technique (STE), resting and Holter electrocardiograms. Results A significant increase in growth parameters were noticed during 6.3 month mean follow up time, with an overall mean weight increase by 10% and an overall mean height increase by 6.2%. Sequential echocardiographic follow-up showed highly significant decrease in LV dimensions and volumes, circumferential LV strain values, pulmonary to systemic circulation (Qp:Qs) ratio, RVSP and mPAP. Significant complications occurred in (12%) of patients: symptomatic/significant Brady-arrhythmia (Complete heart block) that required permanent pacemaker implantation (4%), significant residual shunt causing hemolytic anemia requiring re-intervention (4%) and significant valvular regurgitation (Severe Tricuspid Regurgitation) (4%) Conclusion The development of a VSD trans-catheter occlusion technique with the advancement of the newer percutaneous occluding VSD closure devices is an attractive and feasible procedure with high success rates

Should PICCs be avoided in patients with certain solid organ cancers?

6572 Background: Peripherally inserted central catheters (PICCs) are widely utilized in oncology. Previous studies have shown a high risk of catheter-related thrombosis and bloodstream infection in the uniquely susceptible oncologic population; however, most studies are limited by single center, outpatient, retrospective designs. Therefore, we performed a multi-center study to further describe PICC use and complications in the solid tumor population within the inpatient setting. Methods: Data was collected on PICC lines inserted across 50 hospitals in Michigan from November 2013 to December 2019. Patients with a solid tumor diagnosis at time of PICC insertion were selected (n = 3,956). Indications for PICC placement, catheter characteristics, and associated complications were compared by metastatic (n = 1,488) and non-metastatic (n = 2,468) disease. Complications were also compared by cancer type. Major complications were defined as central line associated blood stream infection (CLABSI), catheter occlusion, deep vein thrombosis (DVT), and pulmonary embolism (PE). Paired t-test and Pearson Chi-square test were used for analyses. Results: PICCs were most commonly placed for antibiotics (n = 1232, 31%) and chemotherapy (n = 907, 23%). The majority of catheters were multi-lumen with 61% (n = 2362) double lumen and 8% (n = 326) triple lumen. Median dwell time was 13 days. Notably, 17% of patients had another central venous catheter (CVC) at time of placement. Metastatic patients were more likely to have a PICC placed for difficult venous access (24.7% vs 17.7%, p < 0.001) and total parenteral nutrition (20.2% vs 12.3%, p < 0.001) as well as to have a current CVC in place (22% vs 14%, p <.001). Non-metastatic patients were more likely to have a PICC placed for chemotherapy (24.1% vs 20.9%, p = 0.02) and have a longer median dwell time (13.0d vs 11.0d, p = 0.04). Of all solid tumor patients, 15.5% (n = 612) experienced a major complication. Catheter occlusion occurred most frequently (n = 402, 10.2%) followed by DVT (n = 138, 3.5%), CLABSI (n = 107, 2.7%), and PE (n = 22, 0.6%). Catheter occlusion was more likely to occur in non-metastatic patients (11% vs 8.8%, p = 0.03). Rates of CLABSI, DVT, and PE did not differ significantly by presence of metastases. Certain cancers had a higher frequency of major complications when compared to the average solid tumor cohort rate of 15.5%; these were malignant brain (17.2%), pancreatic (18.4%), uterine (18.5%), and ovarian tumors (24.2%). Conclusions: PICCs are associated with significant complications in 16% of patients with solid organ cancers. Alternate access such as an implanted port should be considered; alternatively, limiting PICC placement in the presence of concurrent CVC or minimizing use of multiple lumen PICCs may limit complications and resultant morbidity. Specifically, these considerations may apply preferentially to patients with certain solid organ cancers with higher rates of PICC associated morbidity.

Do antimicrobial and antithrombogenic peripherally inserted central catheter (PICC) materials prevent catheter complications? An analysis of 42,562 hospitalized medical patients

Objective: To examine the effectiveness of antimicrobial and antithrombogenic materials incorporated into peripherally inserted central catheters (PICCs) to prevent bloodstream infection, thrombosis, and catheter occlusion. Methods: Prospective cohort study involving 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Sample included adult hospitalized medical patients who received a PICC between January 2013 and October 2019. Coated and impregnated catheters were identified by name, brand, and device marketing or regulatory materials. Multivariable Cox proportional hazards models with robust sandwich standard error estimates accounting for the clustered nature of data were used to identify factors associated with PICC complications in coated versus noncoated devices across general care, intensive care unit (ICU), and oncology patients. Results were expressed as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Results: Of 42,562 patients with a PICC, 39,806 (93.5%) were plain polyurethane, 2,263 (5.3%) incorporated antimicrobial materials, and 921 (2.2%) incorporated antithrombogenic materials. Most were inserted in general ward settings (n = 28,111, 66.0%), with 12, 078 (28.4%) and 1,407 (3.3%) placed in ICU and oncological settings, respectively. Within the entire cohort, 540 (1.3%) developed thrombosis, 745 (1.8%) developed bloodstream infection, and 4,090 (9.6%) developed catheter occlusion. Adjusting for known risk factors, antimicrobial PICCs were not associated with infection reduction (HR, 1.16; 95% CI, 0.82–1.64), and antithrombogenic PICCs were not associated with reduction in thrombosis and occlusion (HR, 1.15; 95% CI, 0.92–1.44). Results were consistent across populations and care settings. Conclusions: Antimicrobial and antithrombogenic PICCs were not associated with a reduction in major catheter complications. Guidance aimed at informing use of these devices, balancing benefits against cost, appear necessary.

Safety of Red Blood Cell Transfusion Using Small Central Lines in Neonates: An in vitro Non-inferiority Study

Aim: This study aimed to investigate the safety of transfusing red blood cell concentrates (RBCCs) through small [24 gauge (24G)] and extra-small [28 gauge [28G)] peripherally inserted central catheters (PICCs), according to guidelines of transfusion practice in Switzerland.Methods: We performed a non-inferiority in vitro study to assess the safety of transfusing RBCC for 4 h at a 4 ml/h speed through 24G silicone and 28G polyurethane PICC lines, compared with a peripheral 24G short catheter. The primary endpoint was hemolysis percentage. Secondary endpoints were catheter occlusion, inline pressure, and potassium and lactate values.Results: For the primary outcome, hemolysis values were not statistically different among catheter groups (0.06% variation, p = 0.95) or over time (2.75% variation, p = 0.72). The highest hemolysis values in both 24G and 28G PICCs were below the non-inferiority predefined margin. We did not observe catheter occlusion. Inline pressure varied between catheters but followed the same pattern of rapid increase followed by stabilization. Potassium and lactate measurements were not statistically different among tested catheters (0.139% variation, p = 0.98 for potassium and 0.062%, p = 0.96 for lactates).Conclusions: This study shows that RBCC transfusion performed in vitro through 24G silicone and 28G polyurethane PICC lines is feasible without detectable hemolysis or pressure concerns. Also, it adds that, concerning hemolysis, transfusion of RBCC in small and extra-small PICC lines is non-inferior to peripheral short 24G catheters. Clinical prospective assessment in preterm infants is needed to confirm these data further.