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© 2002 American Society for Clinical Oncology Complication Rates Among Cancer Patients With Peripherally Inserted Central CathetersByFrom the Memorial Sloan-Kettering Cancer Center, New York, NY. Address reprint requests to Kent A. Sepkowitz, MD, Clinical Infectious Disease Section, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Box 288, New York, NY 10021; email: sepkowik{at}mskcc.org
PURPOSE: Peripherally inserted central catheters (PICCs) are frequently used to deliver outpatient courses of intravenous therapy. However, the rates and risks of complication for this device have not been well-studied. Our objective was to determine the incidence and risk factors of PICC-related complications with a 1-year prospective observational study. PATIENTS AND METHODS: All PICCs inserted in adult and pediatric patients at Memorial Sloan-Kettering Cancer Center (MSKCC) were followed prospectively. The device insertion team, inpatient nurses, and various home-care companies and outside institutions collected longitudinal data. RESULTS: Three hundred fifty-one PICCs were inserted during the study period and followed for a total of 10,562 catheter-days (median placement, 15 days; range, 1 to 487 days). Two hundred five PICCs (58%) were managed by home-care companies and outside institutions, and 146 PICCs (42%) were managed exclusively at MSKCC. For these 205 PICCs, 131 nurses from 74 home-care companies and institutions were contacted for follow-up clinical information. In all, 115 (32.8%) of 351 PICCs were removed as a result of a complication, for a rate of 10.9 per 1,000 catheter-days. Patients with hematologic malignancy or bone marrow transplant were more likely to develop a complication, whereas those with metastatic disease were less likely. CONCLUSION: Complications occur frequently among cancer patients with PICCs, and long-term follow-up is onerous. Despite a high complication rate, the ease of insertion and removal argues for continued PICC use in the cancer population.
OUTPATIENT THERAPY HAS become more common in recent years as hospital stays have shortened and increasing numbers of patients have required long-term treatment with intravenous antibiotics, chemotherapy, analgesia, or nutrition.1 Access is often provided by a peripherally inserted central catheter (PICC). PICCs offer an attractive alternative to other avail-able indwelling central venous catheters (CVCs) and devices. Other centrally inserted devices require tunneling or implantation via a surgical procedure and are associated with significant morbidity.2 In contrast, a PICC is peripherally placed, and is neither tunneled nor implanted. Other potential advantages of PICCs include increased dwell time compared with other peripheral catheters, fewer venous punctures for prolonged administrations,3 and decreased venous irritation from drug therapies; also, they allow for early hospital discharge.4 In previous small studies, PICCs were associated with lower infection rates compared with other nontunneled CVCs.5-7 Furthermore, PICCs were easier to insert and remove than CVCs.3 Many assume that PICCs have a lower overall complication rate compared with CVCs. Few prospective studies, though, have been performed, and fewer still have focused on patients with cancer, who frequently require long-term intravenous therapy. We therefore prospectively studied PICC outcomes to determine the rate of PICC-related complications at our hospital.
Memorial Sloan-Kettering Cancer Center (MSKCC) is a 434-bed tertiary care cancer center in Manhattan, New York. We prospectively identified and followed all patients who had a PICC successfully inserted during a 1-year period, from November 22, 1998, to November 21, 1999, until the catheter was removed or through November 21, 2000. The project was approved by the MSKCC Institutional Review Board as part of a grant for Excellence in Infection Control from the Centers for Disease Control and Prevention. Twenty-six patients had more than one PICC placed during the study period. For the analysis, we counted each PICC placement as a new event. Therefore, all presented calculations, including the demographic description of the patient group, use PICC placements rather than individual patients as the unit for counting. Personnel responsible for the insertion and care of PICCs included eight nurses certified in PICC insertion from the intravenous (IV) insertion team, three physicians and the nurse manager from interventional radiology, a nurse practitioner certified in PICC placement, and nurses from various home-care companies. With their input, a three-part data collection form was developed that focused on insertion, inpatient care, and outpatient care. Appropriate health care personnel completed these forms. The insertion team was responsible for the insertion portion; the treating inpatient nurse completed the inpatient care form at each shift. Outpatient care forms were completed by the home-care companies responsible for the outpatient care. Information on patients discharged to another hospital was obtained by contacting treating personnel at the receiving hospital. Home-care companies and hospital personnel were contacted frequently to determine the status of the patient’s PICC. The Bard Groshong PICC (Bard Access Systems, Salt Lake City, UT) is used at MSKCC and is available as a single-lumen 18-gauge (4-F) or a dual-lumen 16-gauge (5-F) catheter. These silicone catheters have a rounded, closed tip. A three-way valve at the catheter tip is designed to prevent reflux of blood into the catheter.8 This valve opens during infusion when positive pressure exceeds 80 mmHg and during aspiration when the negative pressure is less than -7 mmHg, and is closed when the pressure is equalized.8 The manufacturer suggests that these catheters be flushed with 10 to 20 mL of 0.9% saline solution once a week or after intermittent use.8
Insertion and Maintenance PICCs were placed at the bedside on all inpatient floors and were not inserted if a patient’s platelet count was below 20,000. The nurse used mask, hat, sterile gloves, and sterile drape. Some but not all members of the PICC nurse IV insertion team have met competency criteria for suturing, and secure the catheter by suturing; others use Proxi-Strip (Ethicon, Inc, Somerville, NJ). Tip placement was confirmed by chest radiograph. Interventional radiology personnel placed PICCs in an angiography suite using sterile technique, including mask, hat, sterile gown and gloves, and large sterile drape. The catheter was secured by suturing. Ultrasound- or fluoroscopy-guided placement was performed with or without venography. Tip placement was confirmed by fluoroscopy. Personnel from both the nurse IV insertion team and interventional radiology insert catheters in either the basilic, median cubital, brachial, or cephalic veins. The catheter is positioned in either the superior vena cava or the right atrium. The PICCs are used for all types of infusions and for phlebotomy. The primary care inpatient nurse is responsible for catheter care, changes both dressing and IV tubing three times weekly and as needed, and performs the weekly saline flush. The IV insertion team is responsible for repair of torn catheters and unblocking of catheters. Urokinase (Abbokinase Open-Cath; Abbott Pharmaceuticals, Abbott, IL) was initially used to unblock catheters, but was changed to alteplase (Activase; Genentech, Inc, San Francisco, CA) after the Food and Drug Administration’s warning regarding urokinase and potential for transmission of infectious agents (January 1999). The policy of the receiving home-care company or other institution is followed when caring for discharged patients with a PICC. PICC disposition was assigned as follows: PICC removal after completing therapy or removal with no evidence of a complication; death of patient; removal because of changing IV therapy requirements; patient request for removal; or removal due to PICC-related complication. All PICCs still in place at completion of follow-up (November 21, 2000) were considered not to have a complication. A single reason was determined for any PICC that was removed prematurely. Reasons included primary or secondary catheter-related bloodstream infection (CR-BSI), phlebitis, thrombosis, catheter occlusion, leakage or broken catheter, or accidental removal. The decision to remove a PICC line was made by the patient’s primary physician. Primary and secondary CR-BSIs were defined according to Centers for Disease Control and Prevention guidelines.9 Phlebitis-related complications were defined according to Maki et al.10 Data from the three data extraction sheets regarding patient characteristics, PICC characteristics, and PICC follow-up were analyzed. The categorical predictor variables included diagnosis, hematology data, primary indication for PICC use, handedness, person inserting PICC, catheter size and number of lumens, arm and site of insertion, and method of PICC attachment. Data were collected on whether the patient at the time of catheter insertion had had recent radiation therapy, chemotherapy, or corticosteroid use, or had received antibiotics.
Statistical comparisons between nursing personnel and interventional radiology were established using Pearson
A total of 366 PICCs were inserted into 335 patients during the 1-year period. Twenty-three patients had two PICCs inserted, two patients had three PICCs inserted, and one patient had five PICCs inserted. Fifteen patients and their 15 PICCs who were lost to follow-up are excluded from the analysis. The demographic profile of 351 patients and the primary indications for PICC placement are listed in Table 1. Overall, the patient population included 180 (51.3%) men and 171 (48.7%) women, with a mean age 56.3 years (range, 9 to 91 years). Two hundred eighty-two patients had a solid tumor. Of patients with cancer, 169 (51.4%) of 329 had metastatic disease. A single-lumen catheter was inserted in 311 (88.6%) of 351 placements. The basilic vein was used most commonly (49.1%). The majority of PICCs (65%) were secured by suture.
Two hundred five patients (58%) were discharged from MSKCC with a PICC still in place. Follow-up for these patients was coordinated with 74 unrelated home-care companies and outside institutions. Because many companies had multiple branches, in all, a total of 131 representatives were contacted to follow these 205 patients. The remaining 150 patients (42%) remained at MSKCC for the entire duration of PICC use. The 351 PICCs were in place for a total of 10,562 catheter-days (median time, 15 days; range, 1 to 487 days; mean, 30 days). PICCs inserted by interventional radiology remained in place a median of 21 days (range, 1 to 487 days; mean, 36.2 days) compared with those inserted by the IV insertion team (median, 12.5 days; range, 2 to 275 days; mean, 22.6 days; P = .005). Reasons for PICC removal are listed in Table 2. One hundred fifteen (32.8%) of 351 PICCs were removed because of complication, for a rate of 10.9 per 1,000 catheter-days. Complications occurred in 56 (29%) of 193 PICCs inserted by interventional radiology compared with 59 (37.3%) of 158 placed by the IV insertion team (P = .098). Phlebitis rates accounted for most of the difference: five (2.6%) inserted by interventional radiology versus 18 (11.4%) placed by the IV insertion team.
The temporal distribution of complications is summarized in Fig 1. Of the 115 PICCs removed for complications, 44 (38%) were removed within a week of placement. Catheters removed because of phlebitis or thrombosis were particularly likely to be removed early: 71% were taken out in the first week. Infection leading to catheter removal was more evenly distributed across the weeks. Few complications occurred after week 5.
The influence of demographic and disease characteristics on risk of infection is summarized in Table 3. Patients with hematologic malignancy (P = .03) and bone marrow transplant (P = .05) were at increased risk for CR-BSIs and those with metastatic disease were at reduced risk (P = .03). Radiation therapy, chemotherapy, corticosteroid use, and antibiotic therapy did not influence risk.
Thirty-nine isolates were identified from 25 patients. Staphylococcus species predominated, accounting for 34%, and 24% were attributable to Gram-negative rods. Three candidal infections were seen.
PICCs have become a mainstay for patients requiring long-term IV access. Many practitioners prefer PICCs because of their durability and ease of insertion and removal, yet few studies have examined the complication rate of this popular device. We therefore performed a prospective study of all PICCs inserted at our hospital, a tertiary care cancer center. We coordinated the gathering of information with various outpatient providers, and were therefore able to determine a true incidence of complications. Our investigation, the largest prospective study defining the outcome of PICCs placed in cancer patients, demonstrated a surprisingly high complication rate for these devices. We found that 115 (33%) of 351 PICCs were removed because of a complication (10.9 per 1,000 catheter-days). Infection resulted in PICC removal in 7.4% (2.5 per 1,000 catheter-days), exceeding rates reported in most other series (0.46 to 1.3 per 1,000 catheter-days).2,11-16 This may be because of substantial differences in patient populations studied. Our cohort consisted overwhelmingly of cancer patients, many of whom were neutropenic and/or thrombocytopenic. Many earlier studies included large numbers of normal hosts, such as orthopedic patients, who might be expected to have fewer complications. The only other previous prospective study of PICCs in patients with cancer was conducted 20 years ago on 81 patients.17 The investigators found an infection rate of 2.3 per 1,000 catheter-days, similar to the rate in our study (2.5 per 1,000 catheter-days). Interestingly, these rates approximate that defined in cancer patients with tunneled central venous catheters (2.8 infections per 1,000 catheter-days).18 The rate of catheter removal because of phlebitis has ranged from 2.2% to 3.3% in previous reports.1,2,11,15,19 In contrast, 6.6% of PICCs were removed because of phlebitis in our study, a rate comparable with that defined in a previous study of cancer patients (7%).17 Of note, both interventional radiology and nursing personnel at MSKCC used powdered gloves. Neither team performed glove rinsing, which may lower the rate of phlebitis.1 The difference also may be related to insertion technique17 or to various abnormalities common to the cancer population, such as abnormal clotting. Finally, the definition of phlebitis, although standardized,10 requires a clinical determination; we therefore may have classified some cases as phlebitis that other researchers would have categorized differently. We found a significant difference in median PICC duration according to who placed the catheter. Possible explanations for this include the experience of the person inserting the PICC and differences in setting of insertion. Catheters inserted in interventional radiology are placed under strict sterile conditions, whereas the nurse IV insertion team places catheters at the bedside under aseptic conditions. This difference has been previously described. Cardella et al20 compared bedside insertion performed by nursing personnel (n = 459) with radiology suite insertion performed by cardiovascular and interventional radiology physicians (n = 349). They too found a significant difference: 21 days of PICC duration for nursing personnel versus 32 days for cardiovascular and interventional radiology (P = .002). The authors ascribed the difference to indication for PICC: nurses were more likely to insert PICCs for IV therapy, whereas the cardiovascular and interventional radiology group placed PICCs for parenteral nutrition and immunosuppressive therapy.20 Such a distinction did not apply to our study. Although we are confident of our findings, there are several limitations to our study. First, our rate of those lost to follow-up was 4.1% of all PICCs. This may have resulted in undetected adverse outcomes. Second, some PICCs were removed because of apparently noninfectious complications, and thus cultures were not sent. This may therefore have underestimated the infection rate; it would not, however, have changed the overall complication rate. In addition, because patients were evaluated in a wide variety of inpatient and outpatient settings, interpretation of PICC outcomes may have differed between health care workers providing the information. To minimize such variability, frequent follow-up calls were made to providers and home-care agencies. However, this might have been insufficient. This would not have affected the overall complication rate (because catheter removal was a clear definitional end point) but rather the specific causes of the complication. Our decision to define the unit of measure as the PICC placement (n = 351) and not the unique patient (n = 335) might have led to a misrepresentation of a certain risk or demographic feature. However, we felt that the better approach was to consider each PICC insertion episode as an event for which risk for complication was equally present. Finally, most of our patients had cancer as the underlying diagnosis. Because we focused on this relatively ill group, our complication rates may be higher than those in patients treated at general hospitals. Despite this potential limitation in generalizability, we feel that, because PICCs are used so frequently in patients with cancer, the presented data could prove useful for programs caring for large numbers of persons with cancer or other serious medical illnesses. We were not able to quantify perhaps the largest perceived advantage of a PICC: its affect on daily quality of life when compared with other CVCs. Certainly, patients and providers seem to favor the device, despite the fact that no controlled clinical trials have been performed to endorse its use.16 The lack of the need for a surgical procedure, the pain some experience with insertion of a centrally placed device, and the ease of removal are all attractive reasons for use, especially in a patient group such as those with cancer, who require months and years of intensive therapy, often through central venous access. Specific PICC recommendations were not included in the recently published guidelines for the management of intravascular infections.21 Such guidelines should be developed, given the frequency of use of this device. The device is potentially quite durable, especially compared with other peripherally inserted catheters: they have been successfully used for periods as long as 432 days,20 and up to 487 days at MSKCC (median, 20 to 53 days) among inpatient and outpatients,2,11-14,19 thus guidelines for optimal care might improve overall PICC survival. We conclude that PICCs placed into patients with cancer have a high overall complication and infection rate, approximating that seen in patients with tunneled central venous devices. Despite this, we feel that the convenience and simple management of complications when they do occur argue for continued widespread PICC use in the cancer population.
Supported by Centers for Disease Control and Prevention grant no. U50 CCU 215090. We thank the nursing staff of Memorial Sloan-Kettering Cancer Center and the staff of the home-care companies and outside institutions for assistance with data collection.
1. Abi-Nader JA: Peripherally inserted central venous catheters in critical care patients. Heart Lung 22: 428-434, 1993[Medline] 2. Skiest DJ, Abbott M, Keiser P: Peripherally inserted central catheters in patients with AIDS are associated with a low infection rate. Clin Infect Dis 30: 949-952, 2000[CrossRef][Medline]
3. Dubois J, Garel L, Tapiero B, Dube J, Laframboise S, David M: Peripherally inserted central catheters in infants and children. Radiology 204: 622-626, 1997 4. Legha SS, Haq M, Rabinowits M, Lawson M, McCredie K: Evaluation of silicone elastomer catheters for long-term intravenous chemotherapy. Arch Intern Med 145: 1208-1211, 1985[Abstract] 5. Raad I, Davis S, Becker M, et al: Low infection rate and long durability of nontunneled silastic catheters: A safe and cost-effective alternative for long-term venous access. Arch Intern Med 153: 1791-1796, 1993[Abstract] 6. Ryder MA: Peripheral access options. Surg Oncol Clin North Am 4: 395-427, 1995[Medline] 7. Smith JR, Friedell ML, Cheatham ML, Martin SP, Cohen MJ, Horowitz JD: Peripherally inserted central catheters revisited. Am J Surg 176: 208-211, 1998[CrossRef][Medline] 8. Bard Access Systems: Peripherally inserted central catheters: selection, insertion and management (pamphlet). Salt Lake City UT, 9. Centers for Disease Control and Prevention: Guideline for prevention of intravascular device-related infections. Am J Infect Control 24: 262-293, 1996[CrossRef][Medline] 10. Maki DG, Botticelli JT, LeRoy ML, Thielke TS: Prospective study of replacing administration sets for intravenous therapy at 48- vs 72-hour intervals. JAMA 258: 1777-1781, 1987[Abstract] 11. Merrell SW, Peatross BG, Grossman MD, Sullivan JJ, Harker WG: Peripherally inserted central venous catheters: Low-risk alternatives for ongoing venous access. West J Med 160: 25-30, 1994[Medline]
12. Tokars JI, Cookson ST, McArthur MA, Boyer CL, McGeer AJ, Jarvis WR: Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Ann Intern Med 131: 340-347, 1999 13. Graham DR, Keldermans MM, Klemm LW, Semenza NJ, Shafer ML: Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med 91: 95-100, 1991 (suppl 3b) 14. Ng PK, Ault MJ, Ellrodt AG, Maldonado L: Peripherally inserted central catheters in general medicine. Mayo Clin Proc 72: 225-233, 1997[Medline] 15. Loughran SC, Borzatta M: Peripherally inserted central catheters: A report of 2506 catheter days. JPEN J Parenter Enteral Nutr 19: 133-136, 1995[Abstract] 16. Duerksen DR, Papineau N, Siemens J, Yaffe C: Peripherally inserted central catheters for parenteral nutrition: A comparison with centrally inserted catheters. JPEN J Parenter Enteral Nutr 23: 85-89, 1999[Abstract] 17. Bottino J, McCredie KB, Groschel DHM, Lawson M: Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 43: 1937-1943, 1979[CrossRef][Medline]
18. Groeger JS, Lucas AB, Thaler HT, et al: Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 119: 1168-1174, 1993 19. Lam S, Scannell R, Roessler D, Smith MA: Peripherally inserted central catheters in an acute-care hospital. Arch Intern Med 154: 1833-18337, 1994[Abstract] 20. Cardella JF, Cardella K, Bacci N, Preston SF, Post JH: Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. J Vasc Interv Radiol 7: 5-13, 1996[Medline] 21. Mermel LA, Farr BM, Sherertz RJ, et al: Guidelines for the management of intravascular catheter-related infections. Infect Control Hosp Epidemiol 22: 222-242, 2001[CrossRef][Medline] Submitted November 27, 2001; accepted April 30, 2002. This article has been cited by other articles:
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 for larger sample sizes and Fisher’s exact test for small sample sizes (whenever a cell contained less than five observations). Findings were considered statistically significant at a value of P < .05. 
