VOL: 97, ISSUE: 38, PAGE NO: 32
Ruth Hendy, BSc, DipANC, CertCouns, RGN, is chemotherapy clinical nurse specialist, Bristol Haematology and Oncology Centre
Peripherally inserted central catheters are inserted into the antecubital veins, creating reliable central venous access for patients who need drugs, blood products or parenteral nutrition (MacRae, 1998).
Delivering therapies via PICCs prevents the peripheral veins from being damaged by exposure to irritant drugs. The PICC acts as a vein lining, enabling the drug to be delivered at a central point and sparing the smaller peripheral veins. Because of their long life they can also benefit patients with needle phobias, who would otherwise require multiple venepuncture over a course of treatment.
Groshong PICCs are made up of a soft silicone tubing with a closed, rounded tip. Unlike open-ended catheters, the closed end has a valve that can allow fluids in or out, but remains shut when not in use. This increases patient safety as the valve restricts bleed-back and air embolism. There is also less need for flushing (only every seven days with normal saline, when not in use).
Setting up a PICC service
Before the establishment of the PICC service at Bristol Haematology and Oncology Centre in April 1999, Groshong skin-tunnelled central venous catheters (CVCs) were the device of choice for central delivery. But a literature review indicated that many oncology and some haematology patients would be suitable for the insertion of a PICC - a less invasive procedure with fewer associated complications.
Two nurses were initially trained to insert PICCs, followed by another six as the service expanded. A PICC clinic is now held once a week. The aim is to ensure that all PICCs are managed appropriately in accordance with existing evidence-based criteria (Todd, 1998; Gabriel, 1995; Timmis, 1998).
Assessing standards of PICC management
To judge the success of this change in practice, a retrospective audit was conducted after a year to establish whether the most suitable patients were being selected. Data collected from patient casenotes and records was analysed. The audit period was the year to April 2000, with patients followed up for six months. Final data was collected in October 2000, with the last audited line placed in April 2000. Data from 66 patients was analysed and a total of 75 PICCs were audited.
The percentage of PICCs placed successfully at the first attempt (91%) was high, considering they were the first PICCs ever placed at the centre. Insertion information was documented in the medical notes and included details on flushing, bleed-back and X-ray confirmation of tip position.
The priority is to select a suitable vein rather than automatically opting for the non-dominant arm. If such a vein is in the non-dominant arm, it is the best choice. However, discussions with colleagues have suggested that PICCs inserted in the left arm may cause more complications. Research is needed to confirm or disprove this.
The referring doctor completed an assessment form giving reasons why the patient was likely to be suitable for a PICC. These were:
- Continuous five-fluorouracil (5FU) chemotherapy regimens (87%);
- Poor peripheral veins (9%);
- Thrombophlebitic drugs (3%);
- Needle-phobic patients (1%).
Reasons for referral
Of these patients, 56% received regimens containing continuous 5FU and 44% received intermittent chemotherapy regimens. The reduction from the initial 87% referred for continuous regimens resulted from a change in the therapy regime to intermittent treatment. Some regimens were also continuous for 48 hours every fortnight and were therefore categorised as intermittent.
Counting the complications
The audit showed that 61% of PICCs had at least one complication and 39% had no complications. This sounds high, but 71% of complications were resolved easily while 29% involved the line being removed (see Table 1). The average PICC placement was 100 days, which supports the use of PICCs for medium-term therapy.
The most common reason for PICC removal was completion of therapy (59%). They were also removed because of progressive disease (9%), thrombosis (7%), infection (7%), migration (5%), patients pulling the line out (5%), chemotherapy being stopped because of toxicity (4%) and occlusion (3%).
Splits can occur if the PICC becomes twisted and leaks may be noted around the exit site of the catheter. It may be necessary to pull the catheter back slightly to locate and repair the damaged area. If this happens, a repeat X-ray is performed to ensure that the catheter tip is still in the correct position. Out of 14 split catheters encountered during the study, 13 were repaired.
Only five infections were confirmed, even though 13 patients were initially suspected of having one. Four had Staphylococcus aureus and one had methicillin-resistant S. aureus, which had been acquired at another hospital. Suspected infections should always be investigated and confirmed by bacteriological culture so they can be treated with appropriate antibiotics. Signs of potential infection include pyrexia and redness, discomfort or a discharge around the insertion site.
Although mechanical phlebitis did not lead to the removal of any lines in this study, it is usually caused by damage to the intima during insertion of the line and tends to present as pain, swelling and redness in the arm within a week of placement.
All patients were advised to apply moist heat packs prophylactically for 20 minutes, three to four times a day for the first five days after insertion. But there were 10 episodes of phlebitis, with an average onset of 7.6 days after insertion and seven days’ duration. Patients took oral analgesics and continued heat-pack treatment until it subsided.
Occlusions can occur if the fine lumina of PICCs are not flushed correctly after use, but may also result from the formation of a fibrin sheath around the line. Platelets and fibrin stick to the catheter and can eventually occlude the tip. Of six occluded catheters, two were cleared with normal saline and two with urokinase. The rest were replaced. One had been blocked by 5FU crystallising in the line.
Thrombosis is a well-documented complication of CVCs. It has been suggested that a prophylactic minidose of 1mg warfarin a day can protect against thrombosis in selected cancer patients with CVCs, but its effectiveness in routine clinical practice for oncology and haematology patients with PICCs is yet to be proven. Six patients had a proven thrombosis, confirmed by venogram, resulting in the line being removed in five cases. On average, thrombosis occurred 65 days after insertion, at a stage when patients were nearing the end of treatment. Of the five lines removed, four patients finished their therapy with a peripheral cannula and one line was replaced.
Further analysis of the audit results showed that of the 33 patients receiving continuous infusion 5FU, 19% developed thrombosis, resulting in removal of the line. Sixty-one per cent received anticoagulation therapy and only one of these developed thrombosis. Of the 11 patients not receiving an anticoagulant, four developed thrombosis. This appears to indicate that warfarin should be considered for continuous infusion 5FU patients, but larger trials need to be concluded to accurately assess its role and dosage.
Migration, which is indicated when the external part of the line appears to be longer than usual or the dressing no longer covers the site, may mean that the line is no longer centrally placed. Of six line migrations, two were resolved without removing the line. In the others, a chest X-ray indicated that it had migrated too far and had to be replaced.
The following recommendations are being implemented as PICC placement policy:
- Continue initial patient vein assessment by PICC placer;
- Warfarin 1mg/day for patients receiving continuous infusion 5FU therapy, unless previous medical history (PMH) indicates otherwise;
- No warfarin for patients receiving intermittent infusion therapy, unless indicated by PMH.
Based on the audit outcomes, protocols for the management of PICC complications are being produced. We hope to publish them later this year.
The appropriate referral and assessment of patients before PICC placement has been instrumental in the high rate of lines remaining in place for the duration of treatment. The simple insertion technique and low incidence of serious complications make PICCs a reliable, cost-effective and generally safe option for the delivery of certain oncology regimens.
We would like to extend the service to more oncology patients, particularly those receiving vesicant chemotherapy. These drugs are often given via a peripheral cannula, but should be delivered through a central line. This would ensure safe central venous delivery, reducing the risk of extravasation and the likelihood of thrombophlebitis.
Single-lumen PICCs are used at the centre, but dual-lumen lines may be considered for continuous infusion 5FU regimens, allowing for blood sampling and cisplatin regimens to enable continuous 5FU while cisplatin is administered.