TheMichiganAppropriatenessGuideforIntravenousCatheters...

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. Conceptual 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

List

s 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 d

PICC use appropriate if proposed duration is ≥6 d; PICCs preferred to tunneled catheters fordurations 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 d

PICC use appropriate if proposed duration ≥6 d; PICC preferred to tunneled catheter fordurations 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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here

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and

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VC

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arch

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rate

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out

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late

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Con

tinue

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gp

age




Tabl

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Co

ntin

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dy,

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ence

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Des

ign

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mp

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year

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tal,

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udy

Eval

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ost

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cem

enta

ndri

skfo

rPI

CC

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Ho

spita

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ruar

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ust

2007

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qua

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sw

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and

cath

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thro

mb

osi

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2013

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Eval

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ices

inho

spita

lized

and

amb

ulat

ory

pat

ient

s

CV

C,P

ICC

,p

ort

Maj

or

reco

mm

end

atio

nsin

this

upd

ate

incl

ude

use

ofU

Sd

urin

gin

sert

ion,

use

ofC

VC

sfo

rsh

ort

-ter

mac

cess

whe

np

erip

hera

lacc

ess

isno

tpo

ssib

le,a

ndus

eo

ftun

nele

dca

thet

ers

or

po

rts

for

long

er-t

erm

acce

ss.T

hese

gui

del

ines

reco

mm

end

avo

idan

ceo

fPIC

Cs

inin

patie

ntse

tting

sb

ecau

seof

thro

mb

osis

risk

Bel

lesi

etal

,201

3(5

8)24

Pro

spec

tive

coho

rtst

udy

Eval

uate

the

effic

acy

and

safe

tyo

fPIC

Cs

aslo

ng-t

erm

VA

Ds

for

chem

oth

erap

yad

min

istr

atio

n

Patie

nts

und

erg

oin

ghe

mat

op

oie

ticst

emce

lltr

ansp

lant

atio

nw

ithPI

CC

sin

sert

edb

etw

een

May

and

No

vem

ber

2008

inIta

ly

PIC

CTh

era

teo

fCLA

BSI

with

PIC

Cs

was

sim

ilar

toth

ato

fco

nven

tiona

lCV

Cs

Bo

ncia

relli

etal

,201

1(1

11)

NA

Gui

del

ine

Defi

nere

com

men

dat

ions

for

the

corr

ecta

ndsa

feus

eo

fim

pla

ntab

leve

nous

acce

ssd

evic

esfo

rd

iag

nost

icp

roce

dur

es

Patie

nts

usin

gp

ort

sfo

rra

dio

dia

gno

stic

sPo

rtPa

tient

safe

ty,c

ost

-effe

ctiv

enes

s,an

def

ficie

ncy

are

imp

ort

anta

spec

tsin

the

use

of

po

rts

inra

dio

dia

gno

stic

s,es

pec

ially

inp

atie

nts

with

canc

erB

oni

zzo

liet

al,2

011

(112

)23

9Pr

osp

ectiv

eco

hort

stud

yA

sses

sra

tes

oft

hro

mb

osi

saf

ter

PIC

Cp

lace

men

tin

aco

hort

ofc

ritic

ally

illp

atie

nts

Patie

nts

dis

char

ged

fro

mth

eIC

Uw

itha

cent

ral

veno

usd

evic

eat

Car

egg

iTea

chin

gH

osp

ital,

Flo

renc

e,Ita

ly,f

rom

Janu

ary

toA

ugus

t200

8

CV

C,P

ICC

Hig

her

risk

for

DV

Tin

pat

ient

sw

ithPI

CC

sw

asno

ted

(27.

2%vs

.9.6

%).

Fem

ale

sex

and

the

left

bas

ilic

vein

asth

eac

cess

site

wer

eas

soci

ated

with

PIC

C-r

elat

edD

VT

Bo

ttin

oet

al,1

979

(113

)81

Pro

spec

tive

coho

rtst

udy

Ass

ess

risk

sre

late

dto

long

-ter

mus

eo

fp

erip

hera

llyin

sert

edsi

lico

neel

asto

mer

CV

Cs

inca

ncer

po

pul

atio

ns

Patie

nts

with

canc

erre

qui

ring

pro

long

edIV

ther

apy,

incl

udin

gch

emo

ther

apy

PIC

CA

ltho

ugh

6%o

fcat

hete

rsw

ere

rem

ove

dfo

rp

hleb

itis,

per

iphe

rally

inse

rted

silic

one

elas

tom

erC

VC

sm

ayb

eus

edfo

rlo

ng-t

erm

cent

ralv

eno

usac

cess

Bur

gan

dM

yles

,200

5(1

14)

79C

ross

-sec

tiona

lsu

rvey

Iden

tify

com

plic

atio

nsas

soci

ated

with

ante

par

tum

PIC

Cus

eA

ntep

artu

mp

atie

nts

with

IVth

erap

yre

cord

sat

St.

Mar

y's

Hea

lthC

ente

rfr

om

Janu

ary

2000

toM

arch

2005

PIC

CPI

CC

sha

da

low

risk

for

com

plic

atio

nsan

dw

ere

oth

erw

ise

effe

ctiv

efo

rlo

ng-t

erm

IVac

cess

.One

pat

ient

had

aD

VT,

and

6%ha

dPI

CC

sre

mo

ved

for

oth

erco

mp

licat

ions

Bur

nsan

dLa

mb

erth

,201

0(5

)N

AR

evie

wD

iscu

ssre

sour

ces,

cost

s,p

olic

ies,

and

pro

ced

ures

rela

ted

tod

evel

op

ing

vasc

ular

acce

sste

ams

Are

view

oft

hefo

rmat

ion

ofv

ascu

lar

acce

sste

ams

in2

hosp

itals

and

the

cost

san

db

enefi

tsas

soci

ated

with

thes

ep

rog

ram

s

PIC

C,

mid

line

cath

eter

,C

VC

Vas

cula

rac

cess

team

s,th

oug

has

soci

ated

with

upfr

ont

cost

s,ha

veim

po

rtan

tdo

wns

trea

mb

enefi

tsan

dco

stsa

ving

s

But

ler

etal

,201

1(1

15)

185

Ret

rosp

ectiv

eco

hort

stud

yEx

amin

eth

eas

soci

atio

nb

etw

een

PIC

Cp

lace

men

tand

sub

seq

uent

risk

for

cath

eter

-rel

ated

infe

ctio

nin

hem

od

ialy

sis

pat

ient

s

Patie

nts

req

uiri

nghe

mo

dia

lysi

sw

ithca

thet

erp

lace

men

tsan

dex

chan

ges

at1

univ

ersi

tyho

spita

lfro

mSe

pte

mb

er20

03to

Sep

tem

ber

2008

PIC

CPr

ior

PIC

Cus

ew

as2.

46tim

esm

ore

likel

yto

be

asso

ciat

edw

ithca

thet

er-r

elat

edin

fect

ion

com

par

edw

ithp

atie

nts

who

neve

rre

ceiv

edth

isd

evic

eC

apar

asan

dH

u,20

14(3

8)54

Pro

spec

tive,

cont

rolle

d,

rand

om

ized

clin

ical

tria

l

Ass

ess

whe

ther

vanc

om

ycin

can

be

safe

lyad

min

iste

red

thro

ugh

ane

wm

idlin

eca

thet

erco

mp

ared

with

PIC

Cs

Patie

nts

sche

dul

edto

rece

ive

sho

rt-t

erm

IVva

nco

myc

inat

asi

ngle

med

ical

cent

erin

Que

ens,

New

Yo

rk

Mid

line

cath

eter

,PI

CC

Sho

rt-t

erm

mid

line

cath

eter

sw

ere

safe

and

cost

-effe

ctiv

efo

rd

eliv

erin

gva

nco

myc

info

rd

urat

ions

≤6

d

Cap

eet

al,2

013

(116

)66

Ret

rosp

ectiv

eco

hort

stud

yA

naly

zePI

CC

-rel

ated

com

plic

atio

nsin

pre

gna

ntw

om

enw

hore

ceiv

edPI

CC

sfo

rva

rio

uscl

inic

alin

dic

atio

ns

Preg

nant

wo

men

with

PIC

Cs

inse

rted

bet

wee

nJa

nuar

y20

00an

dJu

ne20

06at

1m

edic

alce

nter

PIC

CPI

CC

inse

rtio

nin

pre

gna

ntw

om

enw

asas

soci

ated

with

hig

hra

tes

ofb

acte

rem

iaan

dth

rom

bo

sis.

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Cat

alan

oet

al,2

011

(117

)50

0Pr

osp

ectiv

eco

hort

stud

yA

naly

zera

tes

ofc

athe

ter-

rela

ted

tho

raci

cD

VT

inp

atie

nts

with

canc

erb

yus

ing

mul

tidet

ecto

rC

T

Can

cer

pat

ient

sw

hoha

da

CV

AD

and

und

erw

ent

CT

for

any

reas

on

CV

C,P

ICC

,p

ort

CV

C-r

elat

edth

rom

bo

sis

isco

mm

on

inp

atie

nts

with

canc

eran

dca

nb

ed

ifficu

ltto

det

ectb

ycl

inic

alm

eans

Cha

krav

arth

yet

al,

2005

(118

)31

Ran

do

miz

ed,

cont

rolle

dcl

inic

altr

ial

Eval

uate

the

inci

den

ceo

fPIC

C-r

elat

edD

VT

inIC

Up

atie

nts

Cri

tical

lyill

pat

ient

sw

hore

ceiv

eda

PIC

Cd

urin

gro

utin

ecl

inic

alca

reat

1ac

adem

icm

edic

alce

nter

PIC

CPI

CC

-rel

ated

DV

Tin

criti

cally

illp

atie

nts

isco

mm

on

(65%

)and

larg

ely

asym

pto

mat

ic;

vig

ilanc

efo

rD

VT

inth

isp

op

ulat

ion

issu

gg

este

dC

hem

aly

etal

,200

2(1

19)

2063

Ret

rosp

ectiv

eco

hort

stud

yA

sses

sth

esa

fety

ofP

ICC

sus

edfo

rlo

ng-t

erm

IVan

tibio

ticad

min

istr

atio

nPa

tient

sat

the

Cle

vela

ndC

linic

Foun

dat

ion

who

had

aPI

CC

pla

ced

for

IVan

tibio

tics

bet

wee

nJa

nuar

y19

94an

dO

cto

ber

1996

PIC

CPI

CC

use

was

asso

ciat

edw

ithU

EDV

T.Pa

tient

sw

how

ere

youn

ger

,had

pri

or

VT,

or

rece

ived

amp

hote

rici

nin

fusi

on

thro

ugh

the

PIC

Cw

ere

atg

reat

erri

skfo

rD

VT

Che

ong

etal

,200

4(1

20)

17R

etro

spec

tive

coho

rtst

udy

Do

cum

entt

hefr

eque

ncy

ofP

ICC

com

plic

atio

nsin

pat

ient

sw

ithso

lidtu

mo

rs

Patie

nts

with

solid

tum

ors

trea

ted

atFl

ind

ers

Med

ical

Cen

tre,

Sout

hA

ustr

alia

,bet

wee

nJa

nuar

y20

00an

dM

arch

2001

PIC

CC

om

par

edw

ithp

atie

nts

with

out

canc

er,a

hig

hra

teo

fco

mp

licat

ions

(sep

sis,

thro

mb

osi

s,b

lock

age,

and

leak

age)

was

foun

din

pat

ient

sw

ithca

ncer

who

rece

ived

PIC

Cs

Chi

ttic

ket

al,2

013

(121

)26

5Pr

osp

ectiv

eco

hort

stud

yC

om

par

ep

atie

nts

with

earl

y-an

dla

te-o

nset

PIC

C-r

elat

edC

LAB

SIto

asse

ssri

skfa

cto

rsPa

tient

sw

hod

evel

op

edPI

CC

-rel

ated

CLA

BSI

at1

acad

emic

cent

erPI

CC

Ther

ear

esi

gni

fican

tdiff

eren

ces

inth

em

icro

bio

log

ical

char

acte

rist

ics

ofp

atie

nts

with

earl

y-an

dla

te-o

nset

CLA

BSI

;the

sed

iffer

ence

sm

ayin

fluen

cech

oic

eo

fan

tibio

tican

dst

rate

gy

ofp

reve

ntio

nC

hop

raet

al,2

012

(17)

NA

Rev

iew

Des

crib

eev

olu

tion

ofP

ICC

san

dth

eir

ado

ptio

nin

mo

der

nm

edic

ine;

eval

uate

earl

yst

udie

so

fDV

Tan

dC

LAB

SI;p

rovi

de

focu

sfo

rar

eas

ofu

ncer

tain

tyan

dri

sk

Hum

anst

udie

sw

ithsp

ecifi

cke

ywo

rds

rela

ted

toPI

CC

s,C

LAB

SI,a

ndD

VT;

full

text

,ab

stra

cts,

and

po

ster

sw

ere

incl

uded

PIC

CIn

tro

duc

tion

ofa

conc

eptu

alm

od

el,

hig

hlig

htin

gun

cert

aint

ies

and

kno

wle

dg

eg

aps

per

tain

ing

toPI

CC

san

dsp

ecifi

cad

vers

eo

utco

mes

Cho

pra

etal

,201

2(9

)N

AR

evie

wEx

amin

eth

eri

skan

db

enefi

tofP

ICC

use

inho

spita

lized

pat

ient

sEv

alua

tion

ofP

ICC

dec

isio

nm

akin

gan

dch

ang

esin

the

epid

emio

log

yo

fCV

Cus

ein

hosp

ital

sett

ing

s

PIC

CH

ighl

ight

sth

ene

edfo

rm

ore

PIC

Cre

sear

chan

dca

utio

nin

pla

cing

PIC

Cs,

giv

enth

eri

skfo

rad

vers

eev

ents

Cho

pra

etal

,201

3(2

2)14

4C

ross

-sec

tiona

lsu

rvey

Web

-bas

edsu

rvey

des

igne

dto

und

erst

and

hosp

italis

texp

erie

nce,

pra

ctic

e,o

pin

ions

,an

dkn

ow

led

ge

rela

ted

toPI

CC

use,

care

,an

dm

anag

emen

tin

Mic

hig

an

Ho

spita

lists

fro

m10

acad

emic

and

com

mun

ityho

spita

lsin

Mic

hig

anPI

CC

Sub

stan

tialv

aria

tion

inho

spita

liste

xper

ienc

e,p

ract

ice,

op

inio

ns,a

ndkn

ow

led

ge

reg

ard

ing

PIC

Cs

was

ob

serv

ed

Cho

pra

etal

,201

3(2

1)21

12C

ross

-sec

tiona

lsu

rvey

Web

-bas

edsu

rvey

des

igne

dto

und

erst

and

hosp

italis

texp

erie

nce,

pra

ctic

e,o

pin

ions

and

kno

wle

dg

ere

late

dto

PIC

Cus

e,ca

re,

and

man

agem

enta

cro

ssth

eU

nite

dSt

ates

Ho

spita

listp

rovi

der

sw

hoar

em

emb

ers

oft

heSo

ciet

yo

fHo

spita

lMed

icin

eac

ross

the

Uni

ted

Stat

es

PIC

CH

osp

italis

tkno

wle

dg

ean

dex

per

ienc

esre

late

dto

PIC

Cs

vari

ed,w

ithkn

ow

led

ge

gap

sre

late

dto

the

ratio

nale

for

PIC

Ctip

po

sitio

ning

and

out

com

esre

late

dto

PIC

Cus

e.Tr

eatm

ento

fco

mp

licat

ions

vari

edsu

bst

antia

lly,i

nclu

din

gin

dur

atio

no

fan

tico

agul

atio

nan

dca

thet

erre

mo

vali

nth

ese

ttin

go

fPIC

C-r

elat

edD

VT

Cho

pra

etal

,201

3(1

5)57

250

Syst

emat

icre

view

and

met

a-an

alys

isR

isk

for

CLA

BSI

with

PIC

Cs

vs.C

VC

sTw

enty

-thr

eest

udie

sin

clud

ing

adul

tsw

hoha

dei

ther

aPI

CC

or

CV

Can

dre

po

rted

CLA

BSI

PIC

C,C

VC

Ho

spita

lized

pat

ient

sar

eju

stas

likel

yto

dev

elo

pC

LAB

SIw

ithPI

CC

sas

with

CV

Cs;

ino

utp

atie

nts,

PIC

Cs

wer

eas

soci

ated

with

alo

wer

risk

for

CLA

BSI

Cho

pra

etal

,201

3(1

6)29

503

Syst

emat

icre

view

and

met

a-an

alys

isR

isk

for

DV

Tw

ithPI

CC

svs

.no

ntun

nele

dC

VC

s64

stud

ies

incl

udin

gad

ultp

atie

nts

with

PIC

Cs

or

CV

Cs

CV

C,P

ICC

Patie

nts

with

canc

eran

dth

ose

with

criti

cal

illne

ssha

dth

ehi

ghe

stra

teo

fPIC

C-r

elat

edD

VT;

PIC

Cs

wer

eas

soci

ated

with

2.5

times

gre

ater

risk

for

DV

Tco

mp

ared

with

CV

Cs

Cho

pra

etal

,201

4(1

22)

747

Ret

rosp

ectiv

eco

hort

stud

yId

entif

yra

tes;

pat

tern

s;an

dp

atie

nt,

pro

vid

er,a

ndd

evic

ech

arac

teri

stic

sas

soci

ated

with

PIC

C-r

elat

edC

LAB

SI

Patie

nts

who

und

erw

entP

ICC

pla

cem

entb

etw

een

June

2009

and

July

2012

ata

VA

med

ical

cent

erin

Mic

hig

an

PIC

CPI

CC

-rel

ated

BSI

was

asso

ciat

edw

ithho

spita

lle

ngth

ofs

tay,

ICU

stat

us,a

ndnu

mb

ero

fPI

CC

lum

ens

Co

rtel

ezzi

aet

al,2

003

(123

)12

6R

etro

spec

tive

coho

rtst

udy

Ana

lyze

the

inci

den

ceo

fthr

om

bo

tican

din

fect

ious

com

plic

atio

nsin

CV

Cs

vs.P

ICC

sin

canc

erp

atie

nts

Patie

nts

with

hem

ato

log

icca

ncer

and

low

pla

tele

tco

untw

ithei

ther

aC

VC

or

aPI

CC

;pat

ient

sre

ceiv

edD

VT

pro

phy

laxi

sat

the

dis

cret

ion

of

the

pro

vid

er

CV

C,P

ICC

Thro

mb

osi

so

ccur

red

mo

refr

eque

ntly

with

PIC

Cs

than

with

CV

Cs;

pat

ient

sw

hore

ceiv

edLM

WH

wer

ele

sslik

ely

toex

per

ienc

eD

VT

than

tho

sew

hore

ceiv

edhe

par

inC

oto

gni

etal

,201

3(5

9)25

4Pr

osp

ectiv

eco

hort

stud

yEv

alua

teth

ein

cid

ence

ofV

AD

-rel

ated

com

plic

atio

nsin

canc

erp

atie

nts

who

rece

ive

hom

ep

aren

tera

lnut

ritio

n

Can

cer

pat

ient

sw

hore

ceiv

edp

aren

tera

lnut

ritio

nb

etw

een

June

2008

toN

ove

mb

er20

09at

aun

iver

sity

hosp

itali

nIta

ly

PIC

C,

tunn

eled

cath

eter

,p

ort

Ho

me

par

ente

raln

utri

tion

was

safe

and

wel

lto

lera

ted

inp

atie

nts

with

canc

er;r

isk

for

com

plic

atio

nsac

ross

dev

ices

was

low

and

acce

pta

ble

Co

uban

etal

,200

5(1

24)

255

Mul

ticen

ter,

rand

om

ized

,p

lace

bo

-co

ntro

lled

clin

ical

tria

l

Ass

esse

whe

ther

low

-do

sed

aily

war

fari

nre

duc

esth

ein

cid

ence

ofs

ymp

tom

atic

CV

Cth

rom

bo

sis

inp

atie

nts

with

canc

er

Patie

nts

who

req

uire

da

CV

Cfo

rat

leas

t7d

wer

era

ndo

mly

assi

gne

dto

rece

ive

1m

gw

arfa

rin

dai

lyvs

.pla

ceb

o

CV

CSy

mp

tom

atic

CV

C-a

sso

ciat

edth

rom

bo

sis

was

less

com

mo

nth

anp

revi

ous

lyth

oug

htin

this

po

pul

atio

n;d

aily

1-m

gd

ose

so

fwar

fari

nd

idno

tred

uce

sym

pto

mat

icC

VC

-rel

ated

thro

mb

otic

even

tsC

rnic

han

dM

aki,

2002

(125

)N

AR

evie

wIn

vite

dar

ticle

that

exam

ined

use

ofn

ove

lap

pro

ache

s,su

chas

secu

rem

entd

evic

es,

dre

ssin

gs,

cath

eter

coat

ing

s,an

dlo

ckso

lutio

ns,i

np

reve

ntin

gC

LAB

SI

Exam

inin

gth

eri

skfo

rIV

D-r

elat

edin

fect

ions

,p

atho

gen

esis

,pre

vent

ion,

and

nove

ltec

hno

log

yav

aila

ble

for

cont

rolo

fBSI

asso

ciat

edw

ithlo

ng-t

erm

dev

ices

CV

C,p

ort

,PI

CC

New

erte

chno

log

ies

may

help

red

uce

CLA

BSI

.;id

entifi

catio

n,ad

apta

tion,

and

eval

uatio

no

fth

ese

nove

lap

pro

ache

sis

nece

ssar

y

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Cur

iglia

noet

al,2

007

(126

)18

8Pr

osp

ectiv

eco

hort

stud

yEv

alua

teth

eef

ficac

yan

dsa

fety

ofl

ow

-do

seas

pir

info

rp

reve

ntio

no

fVTE

Patie

nts

with

stag

eII–

IVb

reas

tcan

cer

with

CV

Cs

for

cont

inuo

usch

emo

ther

apy

fro

mA

pri

l200

0to

Mar

ch20

04in

asi

ngle

cent

er

CV

CA

ltho

ugh

noco

ntro

lor

com

par

iso

nar

mw

asin

clud

ed,l

ow

-do

seas

pir

inw

asa

reas

ona

bly

wel

lto

lera

ted

met

hod

ofD

VT

pre

vent

ion

inth

isp

op

ulat

ion

Dan

eman

etal

,201

2(1

27)

348

Ret

rosp

ectiv

eco

hort

stud

yA

sses

sth

eri

skfo

rre

curr

entb

acte

rem

iain

pat

ient

sw

ithre

cent

CLA

BSI

with

in6

wee

ks

Bac

tere

mic

pat

ient

sun

der

go

ing

PIC

Cin

sert

ion

atan

acad

emic

heal

thce

nter

wer

ere

view

edfo

rri

skfo

rre

curr

enti

nfec

tion

PIC

CR

ecur

rent

bac

tere

mia

with

in30

do

fPIC

Cin

sert

ion

occ

urre

din

33p

atie

nts

but

oft

enin

volv

eda

diff

eren

torg

anis

m(2

5p

atie

nts)

;af

ter

adju

dic

atio

n,o

nly

3o

f8re

curr

ent

infe

ctio

nsw

ere

det

erm

ined

tob

e"t

rue"

rela

pse

s(0

.9%

)D

ariu

shni

aet

al,2

010

(68)

NA

Gui

del

ines

Gui

del

ines

fro

mth

eSo

ciet

yo

fInt

erve

ntio

nal

Rad

iolo

gy

that

wer

ew

ritt

enfo

rq

ualit

yim

pro

vem

entp

rog

ram

sse

ekin

gto

asse

ssce

ntra

lven

ous

acce

ssp

roce

dur

es

Co

mp

rehe

nsiv

ere

view

ofi

ndic

atio

nsfo

rce

ntra

lve

nous

acce

ss,Q

Ieffo

rts,

and

man

agem

ento

fco

mp

licat

ions

PIC

C,C

VC

,p

ort

Thes

eg

uid

elin

esp

rovi

de

targ

etsu

cces

sra

tes

for

inse

rtio

no

fvar

ious

cath

eter

sas

wel

las

maj

or

com

plic

atio

nra

tes

and

sug

ges

ted

thre

sho

lds

for

veno

usac

cess

dev

ices

Daw

son

etal

,201

3(1

28)

NA

Rev

iew

Exam

ined

pub

lishe

dev

iden

ceo

nm

idlin

eca

thet

ers

inre

duc

ing

the

risk

for

CLA

BSI

Cal

lsfo

rg

reat

erus

eo

fmid

line

cath

eter

sas

par

tof

am

ultif

acet

edef

fort

tore

duc

eC

LAB

SIin

hosp

itals

CV

AD

,C

VC

,PI

CC

,m

idlin

eca

thet

er

Mid

line

cath

eter

sar

eef

fect

ive

too

lsfo

rin

term

edia

te-d

urat

ion

infu

sio

nsth

atar

ep

erip

hera

llyco

mp

atib

le.T

hey

can

be

used

for

blo

od

dra

ws

and

infu

sio

nan

d,a

sp

arto

fa

mul

tifac

eted

app

roac

h,ca

nre

duc

eho

spita

lrat

eso

fCLA

BSI

Deb

our

dea

uet

al,2

013

(36)

NA

Gui

del

ines

Esta

blis

hmen

tofg

oo

dcl

inic

alp

ract

ices

gui

del

ines

for

the

man

agem

ento

fCR

Tin

pat

ient

sw

ithca

ncer

Gui

del

ine

exam

ined

pro

phy

laxi

san

dtr

eatm

ento

fth

rom

bo

sis

asso

ciat

edw

ithC

VC

sin

pat

ient

sw

ithca

ncer

CV

CD

isse

min

atio

nan

dim

ple

men

tatio

no

fthe

seg

uid

elin

esis

ap

ublic

heal

thp

rio

rity

ino

rder

tore

duc

eC

RT

DeL

emo

set

al,2

011

(129

)35

Pro

spec

tive

coho

rtst

udy

Eval

uatio

no

fPIC

Cs

asan

alte

rnat

ive

toC

VC

sin

neur

osu

rgic

alcr

itica

lcar

ese

ttin

gs

Neu

rolo

gic

criti

calc

are

pat

ient

sat

1ce

nter

who

had

PIC

Cs

(as

op

po

sed

toC

VC

s)fo

rIV

acce

ssan

dm

oni

tori

ng

PIC

C,C

VC

Use

ofP

ICC

s(r

athe

rth

anC

VC

so

rp

ulm

ona

ryar

tery

cath

eter

s)re

duc

edp

roce

dur

alan

din

fect

ion

risk

Del

Prin

cip

eet

al,2

013

(56)

71R

etro

spec

tive

coho

rtA

sses

sra

tes

ofc

athe

ter-

rela

ted

thro

mb

osi

sin

rela

tion

toca

thet

erex

itsi

tein

fect

ion

Patie

nts

with

acut

em

yelo

idle

ukem

iaw

houn

der

wen

tCV

Cp

lace

men

tbef

ore

each

chem

oth

erap

ycy

cle

CV

CPa

tient

sw

ithse

psi

san

dex

it-si

tein

fect

ions

had

sig

nific

antly

hig

her

rate

so

fthr

om

bo

sis

than

tho

sew

itho

utth

ese

even

ts,i

ndep

end

ento

fo

ther

fact

ors

Dia

zet

al,2

012

(130

)50

Pro

spec

tive

coho

rtst

udy

Det

erm

ine

bas

elin

eC

LAB

SIra

tes

for

ED-in

sert

edC

VC

san

dd

escr

ibe

ind

icat

ions

,dur

atio

no

fuse

,and

natu

ral

hist

ory

oft

hese

dev

ices

Patie

nts

ata

leve

lItr

aum

a,ac

adem

icED

who

req

uire

dce

ntra

lcat

hete

rin

sert

ion

CV

CN

oC

LAB

SIev

ents

occ

urre

d;n

ota

bly

,42%

of

CV

Cs

had

nod

ate

ofr

emo

val,

sug

ges

ting

the

need

toim

pro

ved

ocu

men

tatio

nin

this

reg

ard

DiN

isio

etal

,201

0(1

31)

NA

Syst

emat

icre

view

Exam

ine

the

utili

tyo

fUS

tod

iag

nose

PIC

C-r

elat

edD

VT

17ar

ticle

sas

sess

ing

dia

gno

stic

accu

racy

oft

ests

for

clin

ical

lysu

spec

ted

UED

VT

CV

C,P

ICC

Co

mp

ress

ion

US

isan

acce

pta

ble

alte

rnat

ive

tove

nog

rap

hy,g

iven

hig

hse

nsiti

vity

and

spec

ifici

tyfo

rca

thet

erth

rom

bo

sis

Due

rkse

net

al,1

999

(132

)N

RPr

osp

ectiv

eco

hort

stud

yA

sses

sty

pe

ofC

VC

and

com

plic

atio

nsas

soci

ated

with

del

iver

yo

fpar

ente

ral

nutr

itio

n

Patie

nts

atSt

.Bo

nifa

ceG

ener

alH

osp

itali

nW

inni

peg

,Man

itob

a,C

anad

a,w

hore

ceiv

eda

CV

Cfo

rnu

triti

on

bet

wee

n19

87an

d19

97

CV

C,P

ICC

,tu

nnel

edca

thet

er

Ove

rth

e10

-yea

rst

udy,

use

ofP

ICC

sin

crea

sed

tore

pla

ceC

VC

sin

pro

vid

ing

par

ente

ral

nutr

itio

n;PI

CC

sd

idno

tinc

reas

eri

skfo

rse

psi

so

rth

rom

bo

sis

com

par

edw

ithhi

sto

rica

lco

hort

sD

urra

ni,2

009

(133

)62

3R

etro

spec

tive

coho

rtst

udy

Test

whe

ther

antic

oag

ulan

tsca

np

reve

ntV

Tin

pat

ient

sw

ithPI

CC

sPa

tient

sad

mitt

edto

asi

ngle

med

ical

cent

erb

etw

een

Janu

ary

2004

toJu

ly20

09w

hore

ceiv

eda

PIC

Can

dan

tipla

tele

tag

ents

PIC

CR

ecei

pto

fasp

irin

or

clo

pid

og

reld

urin

gho

spita

lizat

ion

did

nota

ffect

the

risk

for

PIC

C-r

elat

edD

VT

Elia

etal

,201

2(4

1)10

0R

and

om

ized

cont

rolle

dtr

ial

Co

mp

are

surv

ival

rate

sb

etw

een

stan

dar

d-le

ngth

cath

eter

svs

.lo

ngp

erip

hera

lcat

hete

rsin

sert

edb

yU

S

100

pat

ient

sin

anur

ban

hig

h-d

epen

den

cyun

itw

ere

rand

om

lyas

sig

ned

tore

ceiv

eei

ther

sho

rto

rlo

ngp

erip

hera

lcat

hete

rs

PIV

CB

oth

sho

rtan

dlo

ngp

erip

hera

lcat

hete

rsp

lace

dw

ithU

Sha

vea

hig

hsu

cces

sra

te;

cath

eter

failu

reo

ccur

red

mo

refr

eque

ntly

inth

esh

ort

cath

eter

gro

up(4

5%vs

.14%

;P

=0.

001)

ElTe

rset

al,2

012

(49)

282

Cas

e–co

ntro

lstu

dy

Ass

ess

the

asso

ciat

ion

bet

wee

nhi

sto

ryo

fPI

CC

use

and

sub

seq

uent

mal

func

tioni

ngo

rno

nfun

ctio

ning

arte

rio

veno

usfis

tula

Hem

od

ialy

sis

out

pat

ient

sin

7M

ayo

Clin

icun

itsin

Ro

ches

ter,

Min

neso

taPI

CC

Ast

rong

and

ind

epen

den

tass

oci

atio

n(3

.2tim

esg

reat

ero

dd

so

fano

nfun

ctio

ning

fistu

la)w

asno

ted

inp

atie

nts

who

had

rece

ived

pri

or

PIC

Cs

Evan

set

al,2

010

(73)

1728

Pro

spec

tive

coho

rtst

udy

Ass

ess

the

pre

vale

nce

and

risk

fact

ors

asso

ciat

edw

ithsy

mp

tom

atic

PIC

C-r

elat

edD

VT

inho

spita

lized

pat

ient

s

Patie

nts

with

PIC

Cin

sert

ions

ata

larg

eun

iver

sity

-bas

edhe

alth

syst

emPI

CC

PIC

Cin

sert

ion

inp

atie

nts

who

have

canc

er,

und

erg

osu

rger

yla

stin

gg

reat

erth

an1

h,o

rha

veex

per

ienc

edp

rio

rth

rom

bo

sis

isas

soci

ated

with

gre

ater

risk

for

DV

T;C

athe

ter

gau

ge

isa

stro

ngan

dm

od

ifiab

lefa

cto

ras

soci

ated

with

PIC

CD

VT

Evan

set

al,2

013

(74)

5018

Pro

spec

tive

coho

rtst

udy

Ass

ess

whe

ther

smal

l-dia

met

erPI

CC

sm

ayre

duc

eth

eri

skfo

rD

VT

inho

spita

lized

pat

ient

s

All

pat

ient

sw

ithPI

CC

inse

rtio

nsat

1ho

spita

lfro

mJa

nuar

y20

08to

Dec

emb

er20

10PI

CC

Use

ofs

mal

ler-

gau

ge

PIC

Cs

was

asso

ciat

edw

ithsu

bst

antia

llylo

wer

rate

so

fDV

T

Fag

anan

ieta

l,20

07(1

34)

1410

Pro

spec

tive

coho

rtst

udy

Eval

uate

the

asso

ciat

ion

bet

wee

nan

tipla

tele

tthe

rap

yan

dri

sko

fsu

bse

que

ntca

thet

er-r

elat

edth

rom

bo

sis

Patie

nts

atte

ndin

g1

of1

8p

artic

ipat

ing

hosp

itals

who

had

solid

or

hem

ato

log

ical

tum

ors

and

aC

VC

,PIC

C,o

rp

ort

CV

C,P

ICC

,p

ort

Ant

ithro

mb

otic

pro

phy

laxi

sd

idno

tpre

vent

cath

eter

-rel

ated

VT

inth

ishi

gh-

risk

coho

rt

Fear

onc

eet

al,2

010

(135

)31

Ret

rosp

ectiv

eco

hort

stud

yC

om

par

eth

eus

ean

dsa

fety

ofP

ICC

svs

.C

VC

sin

aco

hort

ofp

atie

nts

adm

itted

toa

bur

nIC

U

Bur

np

atie

nts

ata

sing

lece

nter

who

rece

ived

one

or

mo

rePI

CC

sb

etw

een

July

2005

and

June

2007

PIC

C,C

VC

Co

mp

ared

with

PIC

Cs,

CV

Cs

had

ahi

ghe

rra

teo

fcat

hete

r-re

late

dB

SI;P

ICC

sw

ere

asso

ciat

edw

ithg

reat

erri

skfo

rD

VT

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Flet

cher

and

Bo

den

ham

,20

00(7

0)50

1R

etro

spec

tive

coho

rtst

udy

Ass

ess

the

inci

den

cera

tean

dcl

inic

alsi

gni

fican

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Ret

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ane

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bru

ary

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PIC

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are

asso

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clud

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mb

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oth

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itted

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and

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ted

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nts

with

canc

er.A

ltho

ugh

limite

d,a

vaila

ble

evid

ence

sug

ges

tsU

Sca

nre

duc

eri

skfo

rth

rom

bo

sis

Hug

hes,

2014

(154

)31

Pro

spec

tive

coho

rtst

udy

Ass

essi

ngth

efe

asib

ility

ofS

ecur

Aca

th(In

terr

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edic

al,P

lym

out

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),a

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neo

usd

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adve

rten

tPIC

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igra

tion

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nts

at1

canc

erho

spita

lwho

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ived

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Cs

and

the

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rAca

thd

evic

ed

urin

gcl

inic

alca

rePI

CC

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ngle

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igra

tion

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pat

ient

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ow

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,so

me

initi

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lem

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ithin

fect

ion

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urse

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atur

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men

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ds

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emen

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eter

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ort

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cces

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and

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ctiv

em

etho

ds

for

wo

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ere

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uded

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icre

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ents

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ucat

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agem

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ned

Itkin

etal

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332

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eri

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vers

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ove

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mb

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net

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ibe

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ter

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n

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view

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om

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cle

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osi

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ing

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ual

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erre

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enne

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and

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ldha

ber

,20

02(1

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iew

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pto

ms

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ualit

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lace

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tinue

don

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gp

age




Tabl

e1—

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ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

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ign

Focu

so

rO

verv

iew

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dy

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ple

and

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arac

teri

stic

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evic

eFi

nd

ing

san

dC

om

men

ts

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sto

net

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012

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and

om

ized

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CC

valv

ete

chno

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ces

rate

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sio

n10

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atie

nts

who

rece

ived

PIC

Cs

wer

era

ndo

mly

assi

gne

dto

rece

ive

to1

of3

diff

eren

tPI

CC

sin

asi

ngle

hosp

ital

PIC

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est

udy

was

term

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edea

rly

bec

ause

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od

eso

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oly

sis

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loo

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mp

les

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om

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ngle

typ

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fPIC

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alve

dPI

CC

sd

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mto

influ

ence

rate

so

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CC

occ

lusi

on

on

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bas

iso

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ilab

led

ata

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set

al,2

010

(160

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1Pr

osp

ectiv

eco

hort

stud

yD

eter

min

efa

cto

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ated

with

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rate

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olu

tion

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pto

mat

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atie

nts

po

sitiv

efo

rU

EDV

Taf

ter

und

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oin

gd

uple

xU

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om

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ary

2001

toJu

ne20

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1m

edic

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nter

CV

CC

athe

ter-

asso

ciat

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EDV

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solv

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cath

eter

isre

mo

ved

with

in48

hour

so

fd

iag

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s;C

VC

rein

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ion

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ated

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ahi

gh

rate

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gar

dle

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tico

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atio

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alle

net

al,2

010

(161

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AR

evie

wEm

pha

size

the

imp

ort

ance

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reve

ntio

nan

dre

duc

tion

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utsi

de

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ICU

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alth

care

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litie

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Shed

slig

hto

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ang

ing

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log

yo

fC

VC

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ithm

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bei

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und

out

sid

eth

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tent

ion

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de

the

ICU

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VC

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rove

men

tofe

pid

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log

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ract

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clud

eno

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tes

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eded

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oni

tor

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red

uce

rate

so

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ly,2

013

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sert

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cess

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ram

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atar

ed

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ned

tom

inim

ize

risk

and

imp

rove

pat

ient

safe

ty;k

now

led

ge

of

anat

om

yan

dp

hysi

olo

gy

can

help

red

uce

PIC

C-r

elat

edco

mp

licat

ions

Kin

get

al,2

006

(163

)12

96C

ase–

cont

rols

tud

yEv

alua

tecl

inic

alco

nditi

ons

and

ther

apie

sas

soci

ated

with

incr

ease

dri

skfo

rPI

CC

-rel

ated

DV

T

Patie

nts

who

und

erw

entP

ICC

pla

cem

enta

t1ho

spita

love

r3

year

sPI

CC

The

ove

rall

inci

den

ceo

fPIC

C-r

elat

edD

VT

was

2%.P

atie

nts

with

canc

erw

ere

2.5

times

mo

relik

ely

tod

evel

op

PIC

C-r

elat

edD

VT;

pro

phy

lact

ican

tico

agul

atio

nd

idno

tlo

wer

this

risk

Lam

per

tiet

al,2

012

(164

)N

ASy

stem

atic

revi

ewIn

tern

atio

nalp

anel

reco

mm

end

atio

nso

nU

S-g

uid

edva

scul

arac

cess

Stud

ies

pub

lishe

db

etw

een

1985

and

2010

wer

ein

clud

ed;t

heG

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DE

and

GR

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AN

Dm

etho

ds

wer

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men

dat

ions

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ffect

ive,

and

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ssar

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hen

inse

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san

dar

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ers

Lath

amet

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Invi

tro

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eth

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yo

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od

ynam

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ress

ure

mea

sure

men

tsfr

om

PIC

Cs

vs.

CV

Cs

Med

ical

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pat

ient

sin

anac

adem

icho

spita

lwith

bo

tha

PIC

Can

dC

VC

inp

lace

PIC

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VC

PIC

Cs

are

equi

vale

ntto

CV

Cs

whe

nst

atic

and

dyn

amic

pre

ssur

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vitr

ow

ere

mea

sure

din

ase

lect

edco

hort

ofI

CU

pat

ient

sLe

eet

al,2

006

(55)

444

Pro

spec

tive

coho

rtst

udy

Exam

ine

the

inci

den

ce,r

isk

fact

ors

,and

long

-ter

mco

mp

licat

ions

asso

ciat

edw

ithC

VC

use

inp

atie

nts

with

canc

er

Co

nsec

utiv

ep

atie

nts

with

canc

erw

houn

der

wen

tC

VC

inse

rtio

nat

1m

edic

alce

nter

inC

anad

aC

VC

His

tory

ofp

rio

rC

VC

inse

rtio

nw

asas

soci

ated

with

gre

ater

risk

for

sub

seq

uent

thro

mb

osi

s

Lee,

2008

(79)

NA

Rev

iew

Cur

rent

stan

dar

ds

ofp

ract

ice

for

dia

gno

sis,

pre

vent

ion,

and

trea

tmen

tofV

TEin

canc

erp

atie

nts

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rativ

ere

view

CV

C,P

ICC

,p

ort

Patie

nts

with

canc

erar

ea

uniq

uesu

bse

twith

reg

ard

toth

rom

bo

sis;

cons

ider

atio

no

fthe

risk

for

DV

Tin

rela

tion

tod

evic

ety

pe

isne

cess

ary

Lelk

eset

al,2

013

(166

)38

4R

etro

spec

tive

coho

rtst

udy

Eval

uate

the

effic

acy

ofe

lect

rom

agne

ticd

etec

tion

via

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Sher

lock

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stem

for

op

timal

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osi

tioni

ng

384

pat

ient

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houn

der

wen

tbed

sid

ePI

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pla

cem

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sing

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Sher

lock

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loca

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em

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atie

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lace

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tha

da

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phy

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yer

etal

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3(1

67)

222

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spec

tive

coho

rtst

udy

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ort

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plic

atio

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ter

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lace

men

tin

aFr

ench

teac

hing

hosp

ital

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nts

havi

ngun

der

go

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CC

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cem

enti

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ata

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hing

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itali

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ord

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nce

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ruct

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din

fect

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sw

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ove

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gto

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plic

atio

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ung

etal

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120

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rosp

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hort

stud

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win

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atio

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rtio

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ltim

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ents

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eter

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rosc

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uid

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ior

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ante

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ozi

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hleb

itis,

and

occ

lusi

on

oft

eno

ccur

red

inp

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nts

with

thro

mb

ocy

top

enia

and

leuk

emia

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ices

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vent

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tele

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ptio

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ayb

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lein

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pes

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vent

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ung

etal

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1(1

4)27

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etro

spec

tive

coho

rtst

udy

Eval

uate

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ors

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ciat

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ithPI

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reb

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mp

arin

gp

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ds

afte

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ero

llout

of

nurs

ing

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imp

rove

men

ts

Patie

nts

with

med

ical

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rds

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ent

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chsi

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sin

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fter

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ased

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mp

licat

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itis

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duc

edLi

etal

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3)10

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CT

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mp

are

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cts

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ent

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de

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din

sert

ion

100

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ient

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uere

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mp

licat

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pat

ient

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ared

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ach

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etal

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atic

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utin

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ance

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gy

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uld

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rese

rved

for

pro

vid

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uate

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aine

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rop

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nditi

ons

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

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div

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oft

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eren

cein

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ga

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ach

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All

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alsu

cces

san

dfe

wad

vers

eev

ents

inp

atie

nts

with

seve

reth

rom

bo

cyto

pen

iaQ

uiet

al,2

014

(201

)55

1R

etro

spec

tive

coho

rtst

udy

Stud

yth

ein

cid

ence

of,

risk

fact

ors

for,

and

out

com

eso

fsp

ont

aneo

usPI

CC

dis

lod

gem

ents

inp

atie

nts

with

canc

erin

Chi

na

551

pat

ient

sw

ithca

ncer

dia

gno

ses

rece

ivin

gca

reat

1ce

nter

inC

hina

PIC

CTh

ein

cid

ence

rate

ofs

po

ntan

eous

dis

lod

gem

entw

as4.

1%;p

atie

nts

who

dev

elo

ped

dis

lod

gem

enth

ada

sub

stan

tially

gre

ater

risk

for

sub

seq

uent

PIC

C-r

elat

edD

VT

(rel

ativ

eri

sk,1

7.46

)

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Raa

det

al,1

994

(202

)72

Cas

ese

ries

Ass

ess

the

freq

uenc

yo

fthr

om

bo

tican

din

fect

ious

com

plic

atio

nso

fCV

Cus

ein

pat

ient

sw

ithca

ncer

72ca

ncer

pat

ient

sin

a50

0-b

edte

rtia

ryca

rece

nter

wer

ein

clud

ed;p

ost

mo

rtem

exam

inat

ions

of

cath

eter

ized

vein

sw

ere

per

form

ed

CV

CTh

rom

bo

sis

resu

lting

fro

mva

scul

arca

thet

ers

incl

uded

fibri

nsl

eeve

too

cclu

sive

thro

mb

osi

s.Se

ptic

emia

was

mo

reco

mm

on

inp

atie

nts

with

occ

lusi

veth

rom

bo

sis

than

inp

atie

nts

with

nonm

ural

thro

mb

osi

s,su

gg

estin

gan

asso

ciat

ion

bet

wee

nth

ese

2o

utco

mes

Ric

hter

set

al,2

014

(203

)43

9R

etro

spec

tive

coho

rtst

udy

Rep

ort

the

inci

den

cean

dri

skfa

cto

rsfo

rg

ram

po

sitiv

eb

acte

rem

iaan

dth

rom

bo

sis

inp

atie

nts

who

rece

ived

CV

Cs

439

pat

ient

sun

der

go

ing

stem

cell

tran

spla

ntat

ion

CV

CD

urat

ion

ofn

eutr

op

enia

and

left

-sid

edp

lace

men

twas

asso

ciat

edw

ithb

acte

rem

ia.

Pers

iste

ntb

acte

rem

iaan

dtip

colo

niza

tion

wer

eas

soci

ated

with

thro

mb

osi

sR

icka

rdet

al,2

012

(84)

3283

RC

TR

out

ine

vs.c

linic

ally

war

rant

edre

pla

cem

ent

ofp

erip

hera

lIV

sin

hosp

itals

ettin

gH

osp

italiz

edp

atie

nts

at3

hosp

itals

inA

ustr

alia

PIV

CC

om

par

edw

ithro

utin

ere

mo

val,

PIV

Cs

can

be

rem

ove

das

clin

ical

lyin

dic

ated

with

out

incr

easi

ngad

vers

eev

ents

;thi

sp

ract

ice

can

red

uce

cost

sub

stan

tially

,acc

ord

ing

toth

eau

tho

rsR

ob

inso

net

al,2

005

(204

)N

APr

osp

ectiv

eco

hort

stud

yEf

fect

ofd

edic

ated

PIC

Cte

amo

np

atie

ntca

rean

dco

sts

asso

ciat

edw

ithPI

CC

inse

rtio

n

Ho

spita

lized

pat

ient

sre

ceiv

ing

care

ata

sing

lem

edic

alce

nter

inB

ost

on,

Mas

sach

uset

tsPI

CC

Intr

od

uctio

no

fad

edic

ated

PIC

Cte

amd

ecre

ased

inap

pro

pri

ate

PIC

Cp

lace

men

t,w

aitt

imes

toin

sert

ion,

and

ove

rall

cost

sR

om

agno

liet

al,2

010

(205

)49

Pro

spec

tive

coho

rtst

udy

Ris

kfo

rPI

CC

-rel

ated

DV

Tin

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

op

edPI

CC

-rel

ated

DV

T;al

lpat

ient

sre

ceiv

edan

tico

agul

atio

nw

ithLM

WH

for

≥3

mo

;no

PEw

asre

po

rted

Ro

od

enet

al,2

005

(206

)N

ASy

stem

atic

revi

ewR

evie

wo

fthe

liter

atur

eo

nd

iag

nosi

so

f,ri

skfa

cto

rsfo

r,an

dco

mp

licat

ions

of

CV

C-r

elat

edD

VT

NA

CV

C,P

ICC

US

isre

com

men

ded

asth

ed

iag

nost

icte

sto

fch

oic

e;va

rio

usp

atie

ntan

dd

evic

efa

cto

rsar

eas

soci

ated

with

DV

T;an

dro

utin

ep

rop

hyla

xis

top

reve

ntth

rom

bo

sis

isno

tw

arra

nted

on

the

bas

iso

fthe

avai

lab

led

ata

Ro

set

al,2

005

(207

)36

Ret

rosp

ectiv

eco

hort

stud

yEv

alua

tePI

CC

-rel

ated

DV

Tin

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

ofP

ICC

-rel

ated

DV

Tw

as11

.1%

,su

gg

estin

ga

hig

hra

teo

fthr

om

bo

sis

inth

isp

atie

ntp

op

ulat

ion

Ro

sent

hal,

2008

(208

)N

AR

evie

wEv

alua

tead

vant

ages

,co

nsid

erat

ions

,and

man

agem

ento

fmid

line

cath

eter

sco

mp

ared

with

oth

erd

evic

es,w

ithth

eai

mo

fid

entif

ying

utili

tyo

fthe

sed

evic

esin

pat

ient

s

Nar

rativ

ere

view

Mid

line

cath

eter

Mid

line

cath

eter

sar

eid

ealf

or

iso

toni

cin

fusi

ons

that

may

last

bey

ond

5d

Rup

pet

al,2

012

(34)

NA

Gui

del

ines

Prac

tice

gui

del

ines

for

cent

ralv

eno

usac

cess

pre

par

edb

yth

eA

mer

ican

Soci

ety

of

Ane

sthe

sio

log

ists

Pro

vid

esup

dat

edre

com

men

dat

ions

on

inse

rtio

nsi

tese

lect

ion,

use

ofU

S,an

dve

rific

atio

no

fca

thet

erlo

catio

n

CV

C,P

ICC

The

gui

del

ines

ind

icat

ea

pre

fere

nce

for

upp

er-e

xtre

mity

inse

rtio

nsi

tes,

use

ofU

Sto

gui

de

inse

rtio

nw

hen

pla

cing

CV

Cs

and

PIC

Cs,

and

confi

rmat

ion

oft

heve

nous

loca

tion

oft

heca

thet

eran

dca

thet

ertip

loca

tion

usin

gva

rio

uste

chni

que

sR

utko

ff,20

14(2

09)

257

Qua

si-e

xper

imen

tal

bef

ore

–aft

erd

esig

n

Eval

uate

the

effic

acy

ofa

ntim

icro

bia

l(m

ino

cycl

ine–

rifa

mp

in)–

coat

edPI

CC

sin

red

ucin

gPI

CC

-rel

ated

BSI

Ho

spita

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

om

4.10

to0.

47in

fect

ions

per

1000

cath

eter

-day

sSa

ber

etal

,201

1(5

4)N

APa

tient

-leve

lsy

stem

atic

revi

ewan

dm

eta-

anal

ysis

Exam

ine

risk

fact

ors

for

CR

Tin

pat

ient

sw

ithca

ncer

Patie

nts

fro

m5

RC

Tsan

d7

pro

spec

tive

stud

ies

incl

udin

g56

36p

atie

nts

wer

ein

clud

edC

VC

,PIC

C,

po

rtTh

rom

bo

sis

risk

was

incr

ease

dw

ithPI

CC

s,hi

sto

ryo

fDV

T,su

bcl

avia

nve

nip

unct

ure

inse

rtio

n,an

dim

pro

per

cath

eter

tipp

osi

tion

Safd

aran

dM

aki,

2005

(81)

115

Pro

spec

tive

coho

rtst

udy

Exam

ine

risk

for

infe

ctio

nw

ithPI

CC

sin

hosp

italiz

edp

atie

nts

com

par

edw

ithth

atas

soci

ated

with

CV

Cs

115

hosp

italiz

edp

atie

nts

who

had

251

PIC

Cs

pla

ced

wer

ein

clud

ed(fr

om

with

ina

larg

erR

CT)

PIC

CR

isk

for

PIC

C-r

elat

edB

SIw

as2–

5p

er10

00ca

thet

er-d

ays,

anu

mb

erth

atw

asg

reat

erth

anra

tes

rep

ort

edin

out

pat

ient

sett

ing

san

dth

ose

rela

ted

tocu

ffed

or

tunn

eled

CV

Cs

Sans

iver

oet

al,2

011

(210

)50

Pro

spec

tive

coho

rtst

udy

Eval

uate

the

effic

acy

ofa

nove

lcat

hete

rse

cure

men

tdev

ice

50p

atie

nts

refe

rred

for

PIC

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

osa

ble

secu

rem

ents

yste

ms

Sant

olim

etal

,201

2(2

11)

NA

Qua

si-e

xper

imen

tal

bef

ore

–aft

erd

esig

n

Und

erst

and

the

effe

cto

fap

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

,p

ort

Imp

lem

enta

tion

ofa

pro

toco

lres

ulte

din

dec

reas

edra

tes

ofp

hleb

itis

and

imp

rove

dnu

rsin

gsa

tisfa

ctio

nSa

sad

uesz

etal

,199

9(5

0)34

Pro

spec

tive

coho

rtst

udy

Eval

uate

the

effe

cto

fsm

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

or

inse

rtio

nco

mp

licat

ions

(art

eria

lp

unct

ure

and

cath

eter

dam

age

dur

ing

sutu

ring

)occ

urre

d.T

his

app

roac

hre

sulte

din

ano

velf

orm

ofa

cces

s,p

rese

rvin

gp

erip

hera

lvei

nsan

dlim

iting

risk

for

cent

ral

vein

sten

osi

sin

this

pat

ient

po

pul

atio

nSc

him

pet

al,2

003

(212

)26

4R

etro

spec

tive

coho

rtst

udy

Eval

uate

inci

den

cean

do

utco

mes

rela

ted

toU

EDV

Tin

pat

ient

sw

ithg

ynec

olo

gic

canc

er

264

wo

men

who

rece

ived

325

tota

lcat

hete

rsat

aun

iver

sity

hosp

ital

PIC

C,p

ort

13p

atie

nts

dev

elo

ped

cath

eter

-rel

ated

DV

T;11

oft

hep

atie

nts

had

po

rts

and

2ha

dPI

CC

s.N

op

atie

nts

dev

elo

ped

PE

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Seel

eyet

al,2

007

(213

)23

3R

etro

spec

tive

coho

rtst

udy

Dev

elo

pa

risk

-pre

dic

tion

mo

del

and

iden

tify

fact

ors

asso

ciat

edw

ithPI

CC

-rel

ated

DV

TH

osp

italiz

edp

atie

nts

rece

ivin

gca

reat

aM

idw

est

com

mun

ityho

spita

lPI

CC

17p

atie

nts

dev

elo

ped

DV

T;lo

gis

ticre

gre

ssio

nm

od

els

foun

dth

atb

edre

st,l

oca

lized

tend

erne

ss,s

mo

king

,ant

ico

agul

antu

se,

and

ost

eom

yelit

isw

ere

asso

ciat

edw

ithPI

CC

-rel

ated

DV

TSh

arp

etal

,201

4(6

3)64

Ret

rosp

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

Rat

eso

fad

vers

eev

ents

with

PIC

Cs

and

mid

line

cath

eter

sw

ere

sim

ilar,

but

rem

ova

lra

tes

for

mid

line

cath

eter

sw

ere

twic

eth

ato

fPI

CC

sSh

eaet

al,2

006

(214

)57

5R

etro

spec

tive

coho

rtst

udy

Eval

uate

risk

for

PIC

C-r

elat

edD

VT

inp

atie

nts

with

infla

mm

ato

ryb

ow

eld

isea

se15

pat

ient

sm

etin

clus

ion

and

excl

usio

ncr

iteri

a,an

d3

had

PIC

C-r

elat

edD

VT

PIC

CA

20%

inci

den

ceo

fPIC

C-r

elat

edD

VT

inho

spita

lized

pat

ient

sw

ithin

flam

mat

ory

bo

wel

dis

ease

and

PIC

Cs

was

note

d.T

hein

cid

ence

rate

ofP

ICC

-rel

ated

DV

Tw

as2.

17%

per

day

Sim

cock

,200

8(2

15)

191

Qua

si-e

xper

imen

tal

des

ign

Und

erst

and

the

effe

cto

fuse

ofU

So

nra

teo

fPI

CC

com

plic

atio

nsPa

tient

sad

mitt

edto

aU

Kho

spita

lwho

rece

ived

PIC

Cs

atva

rio

ustim

ep

oin

tsPI

CC

Rat

eso

fDV

T,in

fect

ions

,and

oth

erco

mp

licat

ions

dec

lined

afte

rus

eo

fUS

Sim

ono

vaet

al,2

012

(76)

NA

Invi

tro

stud

yEv

alua

teth

eab

ility

oft

issu

ead

hesi

ves

and

cyan

oac

ryla

teg

lue

tose

cure

intr

aven

ous

cath

eter

sco

mp

ared

with

Stat

Lock

dev

ices

(Bar

dM

edic

al,C

ovi

ngto

n,G

eorg

ia)i

nan

imal

mo

del

s

NA

PIC

C,C

VC

Tiss

uead

hesi

ves

com

par

edfa

vora

bly

with

Stat

Lock

dev

ices

and

tran

spar

ent

po

lyur

etha

ned

ress

ing

sto

incr

ease

the

"pul

l-out

"fo

rce

ofc

athe

ters

Skaf

feta

l,20

12(2

16)

147

Ret

rosp

ectiv

eco

hort

stud

yC

om

par

ean

dco

ntra

stth

eus

eo

fHic

kman

(tun

nele

d)c

athe

ters

and

PIC

Cs

inp

atie

nts

with

acut

ele

ukem

iare

ceiv

ing

ind

uctio

nch

emo

ther

apy

147

pat

ient

sw

ithne

wly

dia

gno

sed

acut

ele

ukem

iaw

hore

ceiv

edei

ther

aH

ickm

anca

thet

ero

ra

PIC

C(w

itho

rw

itho

utU

Sg

uid

ance

)

PIC

C,

tunn

eled

cath

eter

Hic

kman

cath

eter

sin

sert

edaf

ter

2007

by

IRw

ere

asso

ciat

edw

ithfe

wer

com

plic

atio

ns(b

acte

rem

iaan

dex

it-si

tein

fect

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wer

eas

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with

less

loca

linfl

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nb

uthi

ghe

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tes

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and

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ckag

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qui

ring

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ts.

Skie

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Pro

spec

tive

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rtst

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risk

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plic

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pat

ient

sw

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fect

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who

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uire

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97PI

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ere

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rted

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ient

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atio

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53%

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of9

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fPIC

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wer

eas

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aco

mp

licat

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for

ano

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ian

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ven

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cted

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ated

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acte

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tious

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plic

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etal

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Ret

rosp

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atio

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ndec

ono

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effe

cto

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441

men

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ived

838

(283

CV

C,5

55PI

CC

)co

nsec

utiv

ely

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ced

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usca

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ctin

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1181

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-day

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PIC

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(19%

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mp

licat

ions

wer

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entifi

edin

the

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Cg

roup

and

197

(35%

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mp

licat

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inth

ePI

CC

gro

up.T

here

wer

esi

gni

fican

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wer

tota

lco

mp

licat

ions

,ca

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erm

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nctio

ns,e

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od

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s,an

d"o

ther

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mp

licat

ions

inth

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VC

gro

upth

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PIC

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roup

Smith

and

No

lan,

2013

(219

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ASy

stem

atic

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ovi

de

ano

verv

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ofC

VC

san

din

sert

ion

tech

niq

ues,

and

cons

ider

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pre

vent

ion

and

man

agem

ento

fco

mm

on

com

plic

atio

ns

NA

PIC

C,C

VC

Tore

duc

era

tes

oft

hro

mb

osi

sre

late

dto

long

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mca

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atie

nts

with

canc

er,

the

cath

eter

tipsh

oul

dlie

atth

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um.M

ultil

umen

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eter

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ayb

eas

soci

ated

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asl

ight

lyhi

ghe

rri

skfo

rin

fect

ion

than

sing

le-lu

men

one

s.Pr

op

hyla

ctic

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efo

relin

ein

sert

ion,

antib

iotic

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solu

tions

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antib

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rtio

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om

men

ded

Snel

ling

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,200

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etro

spec

tive

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mp

are

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tmen

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eter

svs

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rate

of

and

risk

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atio

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oth

dev

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atie

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gas

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sw

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on

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etro

spec

tive

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rtst

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Ob

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sin

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pat

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ived

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en,1

121

wo

men

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301

child

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age,

52y]

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tion

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ob

serv

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s(7

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ithth

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uent

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ere

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ted

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798

Ret

rosp

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stud

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fluen

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flat

eral

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sert

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(rig

htar

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risk

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seq

uent

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VT

798

seq

uent

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ICC

pla

cem

ents

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ical

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Was

hing

ton,

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CA

rmo

fPIC

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lace

men

twas

nota

sso

ciat

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ithsy

mp

tom

atic

VTE

Sto

kow

skie

tal,

2009

(222

)53

8R

etro

spec

tive

coho

rtst

udy

Eval

uatio

no

fthe

effe

cto

fUS

on

risk

for

PIC

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mp

licat

ions

538

pat

ient

s(b

oth

inp

atie

ntan

do

utp

atie

nt)w

hore

ceiv

edPI

CC

sat

aC

anad

ian

med

ical

cent

erPI

CC

Co

mp

ared

with

pal

pat

ion,

PIC

Cs

pla

ced

via

US

had

low

ersu

bse

que

ntra

tes

oft

hro

mb

osi

sSt

rahi

levi

tzet

al,2

001

(223

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Ret

rosp

ectiv

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hort

stud

yEx

amin

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mes

rela

ted

toPI

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use

inp

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with

acut

em

yelo

idle

ukem

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rty

pat

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sw

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ed52

PIC

Cs

dur

ing

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stud

yp

erio

dPI

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PIC

Cs

wer

eas

soci

ated

with

earl

ym

echa

nica

lco

mp

licat

ions

and

infe

ctio

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ow

ever

,the

com

plic

atio

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ed"a

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op

ulat

ion

Con

tinue

don

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win

gp

age




Tabl

e1—

Co

ntin

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Stu

dy,

Yea

r(R

efer

ence

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arti

cip

ants

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Des

ign

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so

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verv

iew

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dy

Sam

ple

and

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arac

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stic

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men

ts

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ret

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89R

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spec

tive

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Des

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seo

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rary

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ard

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pat

ient

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s(5

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ere

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at1

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emic

med

ical

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Can

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sw

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oth

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VC

and

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VC

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eno

ted

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ient

sw

itha

PIC

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d5.

4d

inw

hich

they

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3273

Ret

rosp

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stud

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mb

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que

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-rel

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3273

pat

ient

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ate

rtia

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nter

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Use

oft

PAw

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soci

ated

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gre

ater

risk

for

CLA

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com

par

edw

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atie

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who

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ecei

veth

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Tim

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tal,

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(225

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5Pr

osp

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rom

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sis

and

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eter

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ctio

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5p

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nts

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ivin

gIC

Uca

rein

aFr

ench

hosp

ital

CV

CC

athe

ter

thro

mb

osi

sw

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soci

ated

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2.62

-fo

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Pro

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Ap

pro

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pat

ient

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6ho

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pat

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sw

hore

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ed87

6IV

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ove

r29

09ho

spita

l-day

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C31

%o

fto

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athe

ter-

day

sw

ere

adju

dic

ated

asin

app

rop

riat

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sing

the

auth

ors

'cri

teri

afo

rap

pro

pri

ate

vs.i

nap

pro

pri

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use)

Tour

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me

par

ente

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utri

tion

204

cath

eter

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rted

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6p

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who

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ived

care

ina

hom

ep

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tera

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eled

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eter

Co

mp

licat

ions

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esi

mila

rb

etw

een

bo

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thet

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roup

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athe

ter

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tes

wer

elo

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inth

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gro

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0(6

0)47

8R

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spec

tive

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rtst

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Det

erm

ine

the

inci

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mes

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ithPI

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DV

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ngle

-cen

ter

anal

ysis

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atie

nts

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hem

ato

log

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and

sym

pto

mat

icU

EDV

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CC

Hig

hin

cid

ence

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VT

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CC

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pat

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ceiv

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ntra

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tione

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CC

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nnel

edin

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tern

alju

gul

arve

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ere

asso

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win

cid

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oft

hro

mb

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ero

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etal

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28)

1654

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Ret

rosp

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hort

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eter

min

eth

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ence

and

loca

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PIC

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po

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ter

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367

bed

sid

eat

tem

pts

atin

sert

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PIC

CTi

pm

alp

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tion

occ

urre

din

163

case

saf

ter

bed

sid

ein

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ion;

mo

stm

alp

osi

tioni

ngs

wer

eco

rrec

ted

by

cath

eter

exch

ang

e(5

8%)

and

rep

osi

tioni

ng(3

6%)

Trer

oto

laet

al,2

010

(229

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Pro

spec

tive

coho

rtst

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Eval

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out

com

esas

soci

ated

with

use

ofa

trip

le-lu

men

PIC

Cin

the

ICU

sett

ing

Cri

tical

lyill

pat

ient

sw

hore

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iple

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enPI

CC

sPI

CC

The

stud

yw

asst

op

ped

afte

ran

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ons

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ick

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30)

320

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surv

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wo

ften

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wer

ep

lace

dw

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utcl

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alju

stifi

catio

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med

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rd

Ho

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hosp

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CV

CU

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use

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sw

asm

ore

com

mo

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pat

ient

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ived

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U$7

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6–A

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31)

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Syst

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hro

mb

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do

ther

com

mo

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mp

licat

ions

of

PIC

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com

par

edw

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VC

48ar

ticle

sw

ere

incl

uded

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mp

licat

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fro

mPI

CC

sw

ere

com

par

edw

ithth

ose

fro

mC

VC

sac

ross

seve

rals

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yp

op

ulat

ions

PIC

C,C

VC

PIC

Cs

wer

eas

soci

ated

with

aco

mp

licat

ion

pro

file

that

was

sim

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rex

ceed

edth

ato

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Cs.

PIC

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wer

em

ore

com

mo

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ciat

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and

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po

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012

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stem

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ous

CR

BSI

sin

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rgic

alp

atie

nts,

and

out

line

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reve

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din

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tical

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tions

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and

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and

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po

pul

atio

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cath

eter

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rig

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rium

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5Pr

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ions

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atie

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rece

ived

PIC

Cs

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par

ente

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utri

tion,

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iotic

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loo

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ansf

usio

ns,a

ndo

ther

infu

sio

ns

115

hosp

italiz

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atie

nts

who

rece

ived

127

PIC

Cs

for

ava

riet

yo

fclin

ical

ind

icat

ions

;PIC

Cs

wer

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sert

edin

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nond

om

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oft

he11

5p

atie

nts

PIC

CO

cclu

sio

n(1

7%),

rup

ture

(1.6

%),

acci

den

tal

with

dra

wal

(2.4

%),

infe

ctio

n(3

.1%

),an

dV

T(2

.4%

)wer

eth

em

ost

com

mo

nco

mp

licat

ions

Viz

carr

aet

al,2

014

(234

)N

AIn

fusi

on

Nur

ses

Soci

ety

gui

del

ine/

po

sitio

np

aper

Iden

tify,

pro

mo

te,a

ndd

evel

op

reco

mm

end

atio

nsan

dto

ols

toim

pro

vep

atie

ntsa

fety

pra

ctic

esre

late

dto

the

use

ofs

hort

PIV

Cs

NA

;po

sitio

nst

atem

entr

evie

win

gth

elit

erat

ure

and

reco

mm

end

ing

bes

tpra

ctic

esPI

VC

Hea

lthca

rep

rovi

der

kno

wle

dg

e,ed

ucat

ion,

and

trai

ning

,alo

ngw

itho

rgan

izat

iona

lp

olic

ies

and

pro

ced

ures

,sho

uld

be

dev

elo

ped

toen

sure

PIV

Csa

fety

;in

add

itio

n,su

rvei

llanc

ep

rog

ram

sto

ensu

resa

fety

with

aud

itsan

dfe

edb

ack

are

nece

ssar

yto

imp

rove

dev

ice

safe

tyW

alke

ran

dTo

dd

,201

3(4

)Su

rvey

-bas

edst

udy

Co

mp

are

inse

rtio

nco

st,p

atie

ntsa

tisfa

ctio

n,an

din

fect

ion

rate

so

fPIC

Cs

inse

rted

by

trai

ned

nurs

esan

dra

dio

log

ists

Ho

spita

lized

pat

ient

sun

der

go

ing

PIC

Cin

sert

ion

ina

dis

tric

tgen

eral

hosp

itali

nth

eU

nite

dK

ing

do

m

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

no

ftr

eatm

entw

ashi

ghe

rin

the

nurs

eg

roup

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Wal

liset

al,2

014

(235

)32

83R

CT

Seco

ndar

yan

alys

iso

fan

exis

ting

RC

Td

ata

sett

oev

alua

teri

skfa

cto

rsfo

rPI

VC

failu

re32

83ad

ultm

edic

alan

dsu

rgic

alp

atie

nts

(590

7ca

thet

ers)

with

aPI

VC

with

≥4

do

fexp

ecte

dus

ePI

VC

PIV

Csu

rviv

alis

imp

rove

db

yp

refe

rent

ial

fore

arm

inse

rtio

n,se

lect

ion

ofa

pp

rop

riat

ePI

VC

dia

met

er,a

ndin

sert

ion

by

IVte

ams

or

oth

ersp

ecia

lists

Wal

she

etal

,200

2(5

1)33

5Pr

osp

ectiv

eco

hort

stud

yEv

alua

teco

mp

licat

ions

afte

rPI

CC

inse

rtio

nin

aco

hort

ofa

dul

tand

ped

iatr

icca

ncer

pat

ient

s

335

pat

ient

sw

hore

ceiv

ed35

1PI

CC

sd

urin

gho

spita

lizat

ion;

pat

ient

sw

ere

care

dfo

rei

ther

by

aho

me

infu

sio

nag

ency

(205

)or

by

the

hosp

ital

staf

f(14

6)

PIC

C11

5(3

2.8%

)of3

51PI

CC

sw

ere

rem

ove

das

are

sult

ofa

com

plic

atio

n,fo

ra

rate

of1

0.9

per

1000

cath

eter

-day

s;p

atie

nts

with

hem

ato

log

icca

ncer

or

bo

nem

arro

wtr

ansp

lant

wer

em

ore

likel

yto

dev

elo

pa

com

plic

atio

nW

ebst

eret

al,2

013

(83)

NA

Syst

emat

icre

view

Eval

uate

whe

ther

rout

ine

chan

ges

ofP

IVca

thet

ers

ever

y72

–96

hw

assu

pp

ort

edb

yev

iden

ceo

feffi

cacy

or

safe

ty

7tr

ials

with

ato

talo

f489

5p

atie

nts

wer

ein

clud

edin

the

revi

ewPI

VC

No

evid

ence

was

foun

dto

sup

po

rtro

utin

ePI

VC

chan

ges

ever

y72

–96

h;co

nseq

uent

ly,

heal

thca

reo

rgan

izat

ions

may

cons

ider

po

licie

sw

here

by

cath

eter

sar

ech

ang

edo

nly

ifcl

inic

ally

ind

icat

edW

ilso

net

al,2

012

(64)

431

Ret

rosp

ectiv

eco

hort

stud

yA

naly

zean

did

entif

yri

skfa

cto

rsas

soci

ated

with

larg

eve

inth

rom

bo

sis

inp

atie

nts

with

PIC

Cs

Neu

rosu

rgic

alIC

Up

atie

nts

PIC

CSu

rger

yfo

r>

1h,

hist

ory

ofV

TE,r

ecei

pto

fm

anni

tol,

and

und

erg

oin

gp

lace

men

tin

ap

aret

icar

mw

ere

iden

tified

asri

skfa

cto

rsfo

rD

VT

Wils

on

etal

,201

3(2

36)

431

Ret

rosp

ectiv

eco

hort

stud

yC

om

par

eri

skfo

rco

mp

licat

ions

with

PIC

Cs

with

tho

seas

soci

ated

with

CV

Cs

incr

itica

llyill

pat

ient

s

Neu

rosu

rgic

alIC

Up

atie

nts

PIC

C,C

VC

Dur

ing

the

stud

yp

erio

d,4

31un

ique

PIC

Cs

wer

ep

lace

d,w

itha

cum

ulat

ive

inci

den

ceo

fsy

mp

tom

atic

thro

mb

osi

so

f8.4

%,C

LAB

SIo

f2.

8%,a

ndlin

ein

sert

ion–

rela

ted

com

plic

atio

nso

f0.0

%W

ojn

aran

dB

eam

an,

2013

(23)

260

Ret

rosp

ectiv

eco

hort

stud

yEv

alua

tecl

inic

alap

pro

pri

aten

ess

ofP

ICC

use

com

par

edw

ithav

aila

ble

reco

mm

end

atio

ns

PIC

Cin

sert

ion

dur

ing

hosp

italiz

atio

nfo

ran

ycl

inic

alin

dic

atio

n;p

atie

nts

wer

era

ndo

mly

sele

cted

fro

ma

larg

erco

hort

PIC

CR

esul

tssu

gg

estt

hate

ach

pat

ient

had

≥3

ind

icat

ions

for

PIC

Cp

lace

men

t.H

ow

ever

,in

7p

atie

nts,

use

ofP

ICC

sd

idno

tmee

tcu

rren

tCD

Can

dIn

fusi

on

Nur

ses

Soci

ety

reco

mm

end

atio

nsin

that

the

dur

atio

no

fuse

was

<7

day

sW

orl

eyet

al,2

007

(237

)46

8R

etro

spec

tive

coho

rtst

udy

Eval

uate

out

com

esre

late

dto

use

ofP

ICC

sin

asp

ecia

lized

head

ache

trea

tmen

tuni

t46

8ho

spita

lized

adul

tpat

ient

sin

asp

ecia

lized

head

ache

trea

tmen

tuni

tPI

CC

Onl

y2

pat

ient

s(0

.80%

)exp

erie

nced

PIC

C-r

elat

edD

VT;

the

inve

stig

ato

rsco

nclu

ded

that

pat

ient

sw

ithPI

CC

sar

eno

tat

incr

ease

dri

skfo

rU

EDV

Tco

mp

ared

with

oth

erho

spita

lized

pat

ient

sW

ort

het

al,2

009

(238

)66

Pro

spec

tive

coho

rtst

udy

Det

erm

ine

the

natu

ralh

isto

ryan

dra

teo

f,an

dri

skfa

cto

rsfo

r,C

VC

-rel

ated

com

plic

atio

nso

fCLA

BSI

ina

hem

ato

log

yp

op

ulat

ion

106

CV

Cs

(75

PIC

Cs,

31C

VC

s)w

ere

eval

uate

din

66p

atie

nts,

ove

r23

99C

VC

-day

sin

anam

bul

ato

ryco

hort

PIC

C,C

VC

DV

To

ccur

red

in16

case

s(1

5.1%

),ex

it-si

tein

fect

ion

in2

case

s(1

.9%

),an

dC

LAB

SIin

18ca

ses

(7.5

per

1000

CV

C-d

ays)

.No

sig

nific

antd

iffer

ence

sw

ere

foun

dw

hen

com

plic

atio

nra

tes

bet

wee

nPI

CC

and

CV

Cs

wer

eco

mp

ared

Xin

get

al,2

012

(239

)18

7R

etro

spec

tive

coho

rtst

udy

Stud

yth

ein

cid

ence

,dia

gno

sis,

pre

vent

ion,

and

trea

tmen

tofP

ICC

-rel

ated

UED

VT

inp

atie

nts

with

bre

astc

ance

r

187

pat

ient

sw

ithb

reas

tcan

cer

who

rece

ived

aPI

CC

for

chem

oth

erap

yPI

CC

Four

(2.1

%)o

f188

PIC

Cs

wer

ere

mo

ved

asa

resu

lto

fPIC

C-r

elat

edU

EDV

Tin

14–1

12ca

thet

er-d

ays,

ata

rate

of0

.28

per

1000

cath

eter

-day

sY

amad

aet

al,2

010

(240

)21

9Pr

osp

ectiv

eco

hort

stud

yC

lari

fyth

ed

egre

eo

fpat

ient

-per

ceiv

edco

mfo

rtan

dco

nven

ienc

e,in

add

itio

nto

pro

ced

ure-

rela

ted

dis

tres

s,re

sulti

ngfr

om

use

ofP

ICC

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

Cin

sert

ion

twic

e)

PIC

CPI

CC

sw

ere

safe

lyin

sert

edin

90%

oft

erm

inal

lyill

pat

ient

sw

ithca

ncer

with

in20

min

utes

;al

tho

ugh

30%

oft

hep

atie

nts

exp

erie

nced

tran

sien

tpro

ced

ure-

rela

ted

dis

tres

s,>

90%

felt

that

the

par

ente

ralr

out

ew

asm

ore

com

fort

able

and

conv

enie

ntY

apet

al,2

006

(241

)88

Pro

spec

tive

coho

rtst

udy

Eval

uate

PIC

Cco

mp

licat

ion

rate

sin

2003

afte

rin

tro

duc

tion

ofs

afet

ym

easu

res

and

com

par

eth

emw

ithth

ose

rep

ort

edin

the

sam

ece

nter

in20

01(a

hist

ori

calc

oho

rt)

88PI

CC

lines

wer

ein

sert

edin

73p

atie

nts

und

erra

dio

log

icg

uid

ance

PIC

CTh

eo

vera

llco

mp

licat

ion

rate

was

15.9

%.

Infe

ctio

nsd

evel

op

edin

5.7%

and

thro

mb

otic

even

tso

ccur

red

in4.

5%o

fPI

CC

s.Th

eco

mp

licat

ion

rate

for

2003

was

sig

nific

antly

low

erth

anth

era

tefo

r20

01(P

=0.

006)

,sug

ges

ting

that

stra

teg

ies

tore

duc

ePI

CC

com

plic

atio

nsw

ere

succ

essf

ulY

ieta

l,20

14(2

42)

81Pr

osp

ectiv

eco

hort

stud

yIn

vest

igat

eri

skfa

cto

rsfo

rPI

CC

-rel

ated

DV

Tin

pat

ient

sw

ithca

ncer

Ho

spita

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

eri

skfo

rPI

CC

-rel

ated

DV

Tin

pat

ient

sre

ceiv

ing

chem

oth

erap

y

Con

tinue

don

follo

win

gp

age




Tabl

e1—

Co

ntin

ued

Stu

dy,

Yea

r(R

efer

ence

)P

arti

cip

ants

,n

Des

ign

Focu

so

rO

verv

iew

Stu

dy

Sam

ple

and

Ch

arac

teri

stic

sD

evic

eFi

nd

ing

san

dC

om

men

ts

Yue

etal

,201

0(2

43)

400

Pro

spec

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

erin

ap

rovi

nce

ofC

hina

400

amb

ulat

ory

pat

ient

sw

ithva

rio

usty

pes

of

canc

erw

hore

ceiv

edPI

CC

sfo

rch

emo

ther

apy

PIC

CD

urin

gin

sert

ion,

arrh

ythm

iao

ccur

red

in1.

5%(6

of4

00)o

fpat

ient

s,d

ifficu

ltca

thet

erth

read

ing

in3.

75%

(15

of4

00),

and

exce

ssiv

eo

ozi

ngo

fblo

od

in0.

3%(1

of4

00).

Dur

ing

the

cath

eter

dw

ell-i

np

erio

d,

sens

itizi

ngd

erm

atiti

so

ccur

red

in8%

(38

of

400)

,mec

hani

calp

hleb

itis

in7.

5%(3

0o

f40

0),c

athe

ter

occ

lusi

on

in9.

5%(3

8o

f400

),ca

thet

er-a

sso

ciat

edhe

mat

og

eno

usin

fect

ion

in3%

(12

of4

00),

and

VT

in2%

(8o

f400

)Zh

uet

al,2

008

(244

)21

70R

etro

spec

tive

coho

rtst

udy

Exam

ine

adve

rse

even

tsan

dri

skfa

cto

rsas

soci

ated

with

such

out

com

esSi

ngle

-cen

ter

stud

yo

fpat

ient

sun

der

go

ing

PIC

Cp

lace

men

tfo

rva

rio

usin

dic

atio

nsPI

CC

6ca

ses

ofD

VT

and

2ca

ses

ofb

acte

rem

iao

ccur

red

;DV

Tse

emed

tob

ere

late

dto

adva

nced

canc

er,n

onc

entr

alPI

CC

tipp

osi

tion,

coro

nary

arte

ryd

isea

se,d

iab

etes

,an

dhy

per

lipid

emia

Zing

get

al,2

011

(87)

292

Pro

spec

tive

coho

rtst

udy

Qua

ntify

the

ind

icat

ions

for

cath

eter

pla

cem

ento

ver

dw

ellt

ime

and

inve

stig

ate

agre

emen

tbet

wee

nhe

alth

care

wo

rker

so

nC

VC

use

378

CV

Cs

in29

2p

atie

nts,

acco

untin

gfo

r27

04ca

thet

er-d

ays

CV

CTh

em

ost

freq

uent

reas

on

(49%

)fo

rca

thet

erus

ew

asp

rolo

nged

(>7

d)a

ntib

iotic

ther

apy,

follo

wed

by

par

ente

raln

utri

tion

(22.

3%).

Ato

talo

f130

cath

eter

-day

s(4

.8%

)wer

eun

nece

ssar

y,w

itha

hig

her

pro

po

rtio

nin

non-

ICU

sett

ing

s(6

.6%

).In

35o

n-si

tevi

sits

(8.3

%)i

nno

n-IC

Use

ttin

gs,

neith

erth

enu

rse

nor

the

trea

ting

phy

sici

ankn

eww

hyth

eca

thet

erw

asin

pla

ceZo

chio

set

al,2

014

(245

)N

ASy

stem

atic

revi

ewR

evie

wth

elit

erat

ure

surr

oun

din

gPI

CC

san

dhi

ghl

ight

the

epid

emio

log

y,p

atho

phy

sio

log

y,d

iag

nosi

s,an

dm

anag

emen

tofP

ICC

-rel

ated

thro

mb

osi

sin

criti

cally

illp

atie

nts

Syst

emat

icre

view

exam

inin

gri

skfa

cto

rsfo

ran

dd

iag

nosi

san

dtr

eatm

ento

fPIC

C-r

elat

edD

VT

incr

itica

llyill

po

pul

atio

ns

PIC

CTh

ein

cid

ence

ofP

ICC

-rel

ated

thro

mb

osi

sin

criti

cally

illp

atie

nts

isun

clea

r.U

Sis

the

pre

ferr

edd

iag

nost

icim

agin

gm

od

ality

.No

RC

Tso

nb

estt

reat

men

tofP

ICC

-rel

ated

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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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