Analysis of tip malposition and correction of peripherally inserted central catheters under ultrasound-guidance: 5-year outcomes from a single center

Abstract

Background:

Peripherally inserted central catheter (PICC) has become a common procedure. Although ultrasound (US)-guidance has improved success rates, a small percentage of malposition is inevitable. The purpose of our study is to evaluate malposition rates of US-guided bedside PICC catheter insertion, and the clinical factors associated with malposition.

Methods:

This is a retrospective cohort study evaluating 5981 patients who had undergone ultrasound-guided bedside PICC placement from January 2017 to December 2021 at a single tertiary center. Final tip location was confirmed on chest radiograph.

Results:

Patients were categorized into optimal, suboptimal, and malposition groups according to final tip location. 4866 cases (81.7%) showed optimal tip position, 790 (13.3%) were suboptimal, and 299 (5.0%) were malpositioned. Logistic regression analysis identified six variables associated with tip malposition; height (odds ratio (OR) 1.044; 95% confidence interval (CI), 1.028–1.061; p < 0.001), body mass index (BMI) (OR 1.051; 95% CI, 1.017–1.087; p = 0.003), prior failure at accessing peripheral intravenous (IV) access (OR 1.718; 95% CI, 1.215–2.428; p = 0.002), side of the arm (OR 3.467; 95% CI, 2.457–4.891; p < 0.001), length of the catheter (OR 0.763; 95% CI, 0.734–0.794; p < 0.001), and number of previous central catheter insertions (OR 1.069; 95% CI, 1.004–1.140; p = 0.038). Malpositioned catheters were corrected by either bedside repositioning, bedside reinsertion, fluoroscopic reinsertion, switching to jugular catheters or catheter removal. No patient related factors were significantly associated with malposition or success of reposition.

Conclusion:

US-guidance can help reduce catheter malposition during bedside PICC insertion. Patients with risk factors such as multiple previous central vein insertions, failed peripheral line insertions, left arm insertion, or high BMI should undergo thorough sonographic evaluation of the arm vessels to prevent malposition.

Keywords

Peripherally inserted central catheter line insertion vascular access devices ultrasonography

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References

Hoshal

VL.

Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch Surg 1975; 110(5): 644–646.

Pittiruti

Hamilton

Biffi

, et al.; ESPEN. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009; 28(4): 365–377.

Hong

Safety and efficacy of peripherally inserted central catheter placement by surgical intensivist-led vascular access team. Vasc Spec Int 2022; 38: 41.

Oleti

Jeeva Sankar

Thukral

, et al. Does ultrasound guidance for peripherally inserted central catheter (PICC) insertion reduce the incidence of tip malposition? – a randomized trial. J Perinatol 2019; 39(1): 95–101.

Trerotola

Thompson

Chittams

, et al. Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Interv Radiol 2007; 18(4): 513–518.

Lim

Chung

Ryu

J-A

, et al. Bedside ultrasound-guided peripherally inserted central catheter placement by critical care fellows in critically ill patients: a feasibility and safety study. J Acute Care Surg 2021; 11(1): 30–35.

Glauser

Breault

Rigamonti

, et al. Tip malposition of peripherally inserted central catheters: a prospective randomized controlled trial to compare bedside insertion to fluoroscopically guided placement. Eur Radiol 2017; 27(7): 2843–2849.

Chopra

Flanders

Saint

, et al.; Michigan App-ropriateness Guide for Intravenouse Catheters (MAGIC) Panel. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 2015; 163(6 Suppl): S1–S40.

Song

Malposition of peripherally inserted central catheter: experience from 3,012 patients with cancer. Exp Ther Med 2013; 6(4): 891–893.

10.

Kwon

Son

Lee

, et al. Outcomes of bedside peripherally inserted central catheter placement: a retrospective study at a single institution. Acute Crit Care 2020; 35(1): 31–37.

11.

Chopra

Flanders

Saint

The problem with peripherally inserted central catheters. JAMA 2012; 308(15): 1527–1528.

12.

DeChicco

Seidner

Brun

, et al. Tip position of long-term central venous access devices used for parenteral nutrition. JPEN J Parenter Enteral Nutr 2007; 31(5): 382–387.

13.

Wang

Chen

, et al. Multifactor analysis of malposition of peripherally inserted central catheters in patients with cancer. Clin J Oncol Nurs 2015; 19(4): E70–E73.

14.

Nakamuta

Nishizawa

Matsuhashi

, et al. Real-time ultrasound-guided placement of peripherally inserted central venous catheter without fluoroscopy. J Vasc Access 2018; 19(6): 609–614.

15.

Paquet

Boucher

Valenti

, et al. Impact of arm selection on the incidence of PICC complications: results of a randomized controlled trial. J Vasc Access 2017; 18(5): 408–414.

16.

Jeon

Cho

Yoon

, et al. Which arm and vein are more appropriate for single-step, non-fluoroscopic, peripherally inserted central catheter insertion? J Vasc Access 2016; 17(3): 249–255.

17.

Cho

Schlattmann

Nagel

, et al. Cephalad dislocation of PICCs under different upper limb positions: influence of age, gender, BMI, number of lumens. J Vasc Access 2018; 19(2): 141–145.

18.

Jin

Chen

Zhao

, et al. Repositioning techniques of malpositioned peripherally inserted central catheters. J Clin Nurs 2013; 22(13–14): 1791–1804.

19.

Schweickert

Herlitz

Pohlman

, et al. A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Crit Care Med 2009; 37(4): 1217–1221.

20.

Lee

Cho

Kim

, et al. The blind pushing technique for peripherally inserted central catheter placement through brachial vein puncture. J Vasc Surg 2018; 67(3): 860–867.

21.

Svendsen

Birrer

Jansen

, et al. Accurate nonfluoroscopic guidance and tip location of peripherally inserted central catheters using a conductance guidewire system. J Vasc Surg Venous Lymphat Disord 2013; 1(2): 202–208.e1.

22.

Mack

Nißler

Kasikci

, et al. Magnetic tracking and electrocardiography-guided tip confirmation system versus fluoroscopy for placement of peripherally inserted central catheters: a randomized, noninferiority comparison. Cardiovasc Intervent Radiol 2020; 43(12): 1891–1897.

23.

Johnston

Holder

Bishop

, et al. Evaluation of the Sherlock 3CG tip confirmation system on peripherally inserted central catheter malposition rates. Anaesthesia 2014; 69(12): 1322–1330.

24.

Chopra

Anand

Hickner

, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 2013; 382(9889): 311–325.