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Feasibility and Outcomes Associated With the Use of 2.6-Fr Double-Lumen PICCs in Neonates

O'Malley, Christine, MS, NNP-BC; Sriram, Sudhir, MD; White, Melissa, MS, NNP-BC; Polinski, Carol, MSN, NNP-BC; Seng, Carolyn, MSN, NNP-BC; Schreiber, Michael D., MD

Section Editor(s): Dowling, Donna PhD, RN; ; Thibeau, Shelley PhD, RNC-NIC;

doi: 10.1097/ANC.0000000000000570
Original Research
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SDC

Background: Low birth-weight infants' survival continues to improve and there is increased need to provide secure vascular access. This study examines safety of larger peripherally inserted central catheters (PICCs) that offer greater utility.

Purpose: To determine feasibility of 2.6-French (Fr) double-lumen PICCs in newborns and compare noninfectious complications such as thrombus formation, catheter breakage, infiltration, and accidental dislodgment and central line–associated bloodstream infection (CLABSI) rate with that of newborn infants treated with 1.9-Fr single- and double-lumen PICCs.

Methods: Infants requiring PICCs were admitted in our 69-bed level IV neonatal intensive care unit from September 2006 to May 2015. Two distinct groups were compared: the 1.9-Fr—(single-lumen [n = 105] and double-lumen [n = 27])—and 2.6-Fr double-lumen PICCs (n = 111). Data obtained included birth weight and weight at insertion, gestational age at birth and corrected gestation age at insertion, indication, catheter days, indication for removal, and complications: noninfectious and infectious. Univariate and multivariate statistical analysis evaluated data.

Results: There were no differences regarding gestational age at birth and insertion and indications for placement of 2.6-Fr double-lumen (n =111) and 1.9-Fr both single- and double-lumen (n = 132) PICCs. The same was noted between the groups' complications. Noninfectious complications were more common in PICCs with peripheral tip location in all groups.

Implications for Practice: Consider use of 2.6-Fr PICCs in a neonatal intensive care unit when the utility of blood administration and sampling is required.

Implications for Research: Examine line migration and CLABSI associated with sampling and blood administration.

Department of Pediatrics, University of Chicago, Illinois.

Correspondence: Christine O'Malley, MS, NNP-BC, The University of Chicago, 5841 South Maryland, MC 6060, Chicago, Illinois 60637 (Christine.O'Malley2@uchospitals.edu).

Melissa White was the original first author of the abstract that this manuscript was based upon. She conceived the project, designed the study format and inspired us to complete this work. Her vision to advance nursing practice made us all the best we could be.

She passed away suddenly on September 18, 2012.

The authors wish to acknowledge the neonatal nurse practitioners, bedside nurses, and the pharmacists at the Margaret M. and George A. Stephen Neonatal Intensive Care Nursery at the University of Chicago Comer Children's Hospital, Chicago, Illinois.

The authors declare no conflicts of interest.

Over the past several decades, the survival rate for extremely low birth-weight infants has continued to improve.1 With this improvement, the increased need to provide secure vascular access to help optimize nutritional support has become a priority.2–5 The development of smaller and safer peripherally inserted central catheters (PICCs) and improved techniques for catheter insertion and maintenance have greatly enhanced the nutritional status of this very vulnerable population.2,3,5–10 PICCs have also minimized the difficulty in treating newborn infants who require prolonged courses of medications,11 such as antibiotics, or multiple medications requiring central infusion (eg, vasoactive drugs).11–14 The use of these PICCs has also greatly reduced the number of painful procedures7,14 and need for surgically inserted intravenous catheters3 and are more cost-effective than surgically placed catheters.4 However, currently used 1.9-French (Fr) PICCs cannot be routinely utilized for blood transfusions or blood sampling.5

Recently, double-lumen PICCs (2.6 Fr) have become commercially available. Their larger size allows for both the infusion of blood products and routine blood sampling. Given these additional capabilities, such PICCs can reduce the need for surgically inserted intravenous catheters or insertion into central veins (eg, femoral, internal jugular, and subclavian). However, to date, little has been reported on inserting larger PICCs into smaller newborn infants and their long-term safety. An additional concern is that their use for routine sampling may increase the risk of a central line–associated bloodstream infection (CLABSI).3,5,7,8 In this retrospective review, we report the first large series of newborn infants treated with these 2.6-Fr double-lumen PICCs and compare the complication rate with that of newborn infants treated with 1.9-Fr single- and double-lumen PICCs.

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What This Study Adds

  • Larger bore PICCs (2.6-Fr) allow the ability to administer blood products and obtain blood samples.
  • A surgically placed central venous line may be avoided if a 2.6-Fr PICC can be placed.
  • PICCs are easily inserted by many different providers as opposed to CVLs.
  • Complications of 2.6-Fr PICCs are not increased as compared with 1.9-Fr PICCs.
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METHODS

Study Design and Population

This was a retrospective study of newborn infants admitted between September 2006 and May 2015 to the level IV Margaret M. and George A. Stephen Neonatal Intensive Care Unit at the Comer Children's Hospital at the University of Chicago. Three types of PICCs were used: 1.9-Fr single-lumen silastic catheters (Argon), 1.9-Fr double-lumen polyurethane catheters (Medtronic), and 2.6-Fr double-lumen silastic catheters (Argon). PICC insertion was performed at the bedside; radiographs were obtained after insertion to determine catheter tip location. Superior vena cava or inferior vena cava placement was considered central4,7,10,12,14; all other locations were considered peripheral. PICC insertion sites were dressed according to manufacturers' recommendations. The lines were trimmed to proper length before insertion hoping to prevent catheter migration. Insertions sites included both upper and lower extremities, external jugular veins, and temporal veins. Routine nursing assessment and dressing changes were consistent with published guidelines.2,5,7,8,14 We classified complications of PICCs into 2 categories: infectious (CLABSI) and noninfectious (thrombus formation, catheter breakage, infiltration, and accidental dislodgement). CLABSI was defined according to the Centers for Disease Control and Prevention guidelines.15 The decision to remove PICCs was made by the treating medical team. The use of 2.6-Fr double-lumen PICCs was considered in all newborn infants weighing greater than 800 g who required long-term venous access and/or multiple access ports for medication infusions, frequent blood sampling, and/or frequent infusion of blood products (packed red cells, fresh frozen plasma, and albumin). In general, infants who required multiple access ports were more medically complex, although the complexity was not specifically tracked. See Figure 1 for line size and type selection process. If the newborn infant's weight was less than 800 g, a 1.9-Fr single-lumen was inserted if intended use was for nutritional support only. If multiple access ports were required in 800 g or less, then a 1.9-Fr double-lumen catheter was inserted. Of note, the smaller bore 1.9-Fr PICCs are used by some institutions for blood sampling and blood product administration, although the manufacturer currently does not recommend this practice.11 In our cohort, 1.9-Fr single- and double-lumen catheters were not used for routine blood sampling. Appropriate sedation was given for PICC insertion. Vein suitability was determined through visual inspection performed by an experienced member of the PICC insertion team, consisting of neonatologists, neonatal nurse practitioners, and staff nurses. Ultrasound guidance was not utilized to insert catheters. PICC insertion training included completion of a didactic insertion class followed by supervised practical training. The 1.9-Fr PICCs were inserted using a 26-gauge (G) introducer needle and the larger 2.6-Fr PICCs were inserted using a 22-G introducer needle, as per manufacturer's recommendations (Argon). The 2.6-Fr double-lumen PICC houses both a 22-G and a 23-G lumen. Heparin was added to fluid infusing in all lumens. All of the 2.6-Fr double-lumen PICCs were utilized for blood sampling if indicated using the 22-G port. This port was also used for blood administration. The external jugular was utilized for all sizes and types of PICCs when other sites in an extremity were not suitable. A pediatric radiologist determined PICC tip placement radiographically. Noncentrally placed PICCs were used whenever central location could not be achieved. For noncentrally located PICCs, appropriate adjustments to intravenous fluid content and concentration were made (Table 1).

FIGURE 1

FIGURE 1

TABLE 1

TABLE 1

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PICC Care

Hourly assessments were documented in the medical record, including inspecting the insertion site, observing the catheter for kinking or leaking, verifying the hourly infusion rate and the pump occlusion alarm setting, and measuring the length of catheter external to the patient.7,8,14 Intravenous fluids were infused at a minimum rate of 0.5 mL/h via an infusion pump with adequate pressure to meet the resistance of the small-sized catheter.7,8,12,13 Heparin (0.5 Units/mL) was added per our unit guidelines.12,14,16 PICCs were not routinely flushed. Preinsertion disinfection of the skin was done with 2% chlorhexidine unless the baby was less than 28 weeks' gestation and less than 2 weeks old. Betadine was used for cleaning the skin when chlorhexidine was contraindicated. Dressing changes were performed consistent with published guidelines.5,7,14 Aseptic technique using 2% chlorhexidine was used for dressing changes in accordance with hospital and neonatal intensive care unit policies and manufacturer recommendations. PICC hub access was accomplished by scrubbing the line hub with 3% chlorhexidine solution, allowed to dry for 1 minute after application before access with nonsterile gloved hands.7,8,14 Blood gases, complete blood counts, electrolytes, blood cultures, and coagulation studies were among the samples withdrawn from 2.6-Fr PICC, only when clinically necessary. However, 1.9-Fr PICCs were not routinely used for blood draws. The manufacturer's guidelines were followed.

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Data Collection

During the study period September 2006 to May 2015, 1.9-Fr single-lumen (n = 105) and double-lumen (n = 27) infants were matched to the gestational age of 2.6-Fr double-lumen infants (n = 111). Data obtained included patient weight (birth weight and weight on day of insertion), age (day of life at insertion), PICC indication, number of days used, indication for removal and complications (ie, CLABSI, thrombus formation, catheter breakage, infiltration, and accidental dislodgment). The University of Chicago Institutional Review Board approved this study.

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Outcome Measures

Primary outcome measure of this study was the composite of all complications including CLABSI, thrombus formation, catheter breakage, infiltration, and accidental dislodgment. Secondary outcome measures were infectious (CLABSI) and noninfectious complications (thrombus formation, catheter breakage, infiltration, and accidental dislodgment).

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Statistical Analyses

For statistical analyses, we grouped PICCs lines into 2 groups: 2.6-Fr double-lumen and 1.9-Fr single- and double-lumen. Data are reported as medians and interquartile ranges, because of nonnormal distribution of the data. We compared composite of all complications: infectious (CLABSI) and non-infectious complications among 2.6-Fr double-lumen and 1.9-Fr single- and double-lumen PICC groups using χ2 and Fisher exact tests for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariate analyses are done by using logistic regression models where appropriate for comparing these 2 groups adjusting for potential confounding variables such as gestational age, weight at the time of insertion of the catheter, postnatal age, catheter days, tip location, and insertion site, which were different between these 2 groups, with P values < .2 in the univariate analysis.17 The results are expressed as odds ratios and 95% confidence intervals (CIs). A P value was set at < .05 for statistical significance.

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RESULTS

We report data from successful insertions of 2.6-Fr double-lumen PICCs (n = 111). The gestational age for newborn infants chosen for 2.6-Fr double-lumen PICC placement did not differ from the infants receiving smaller bore 1.9-Fr PICCs (n = 132) (Table 2). Median birth weight was not different between these 2 groups: 2500 g (interquartile range [IQR] 1285-3200 g) in the 2.6-Fr PICC group versus 199 5g (IQR 1030-2880) in the 1.9-Fr PICC line group. Weight on the day of insertion was higher in the 2.6-Fr group than in the 1.9-Fr group (P < .05) (Table 2). Day of life at the time of PICC placement and duration of catheter days in the 2.6-Fr double-lumen group were higher than in the 1.9-Fr lumen PICC group (P < .05) (Table 2). The primary indications for line placement were either total parental nutrition or antibiotics (Table 3). PICC characteristics included central tip location, which was achieved in 88% of all PICC insertions as well as site and blood product administration (Table 4). The CLABSI rate was 1.5/1000 catheter days and 0/1000 catheter days in 2.6-Fr double-lumen and 1.9-Fr both single- and double-lumen groups, respectively (Table 5). Each of the infected catheters had been used for frequent transfusions of fresh frozen plasma and albumin. Four catheters infected in the 2.6-Fr double-lumen PICC group, and 3 of those 4 were in a saphenous vein and 1 was in an external jugular vein. The organisms grown from the blood cultures in the four 2.6-Fr PICCs with CLABSI were Enterococcus and Serratia in 1 PICC each and E. coli in the other 2 PICCs.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

TABLE 4

TABLE 4

TABLE 5

TABLE 5

The complication rate encountered: infectious (CLABSI) and noninfectious (catheter breakage, thrombus formation, infiltration, and accidental dislodgment) in the 2.6-Fr double-lumen PICCs was not different from that encountered with the 1.9-Fr lumen PICCs 23/111 versus 19/132 (P = .19) (Table 5) (unadjusted odds ratio, 0.76; 95% CI, 0.39-1.49; adjusted odds ratio, 0.58; 95% CI, 0.26-1.31). Noninfectious complications 19/111 in the 2.6-Fr PICC line group versus 19/132 in the 1.9-Fr PICC line group (0.56) (Table 6) (unadjusted odds ratio, 0.81; 95% CI, 0.41-1.61; adjusted odds ratio, 0.67; 95% CI, 0.29-1.54) were also not different between these 2 groups. Potential confounding factors were adjusted for including gestational age, age at the time of insertion, site of insertion, central or peripheral location, and catheter days. Noninfectious complications are more common in peripherally placed PICCs in all line types: 12/31 of peripherally placed lines compared with 26/212 in centrally placed lines (P < .05) (Table 6). The reasons for line discontinuation were also examined in the 2.6-Fr double-lumen PICCs; the majority of PICCs were discontinued (76%) after they were no longer needed or the patient died (11%) (Table 7). Most of the 1.9-Fr lines were discontinued because they were no longer needed.

TABLE 6

TABLE 6

TABLE 7

TABLE 7

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DISCUSSION

We report the successful use of 2.6-Fr double-lumen PICCs in over 100 newborn infants, as small as 800 g. We found that newborn infants tolerated PICC placement well with no apparent increase in overall complication risk. Although PICC availability has contributed to improved survival and decreased morbidity in this high-risk population,3 traditional size 1.9-Fr PICCs are generally thought to be too small to allow blood sampling18 or blood product administration.19 To the best of our knowledge, our report is the first to discuss the feasibility of 2.6-Fr double-lumen PICCs in neonates. The alternative to a PICC is a surgically placed central venous line (CVL) or percutaneous insertion into a central vein (ie, internal jugular, subclavian or femoral).18,20 There are several benefits of placing larger sized PICCs compared with CVLs. Many providers can be trained to place PICCs whereas only pediatric surgeons typically insert CVLs in our setting. In our cohort, qualified neonatologists, neonatal nurse practitioners, and staff nurses skilled in routine 1.9-Fr PICC insertion were all able to place the larger PICCs. PICC insertion is less expensive than a surgical procedure and carries less risk.10,14 At our institution, CVL insertion costs $5300.00 (2016) compared with PICC bedside insertion, which costs $2300.00 (2016). A bedside PICC insertion does not require a pediatric surgeon, anesthesiologist, operating room time, pre- and postoperative nursing, care or endotracheal intubation.18,20,21 Medical caretakers at our institution did not require additional training to place 2.6-Fr double-lumen PICC insertion.9

Weaknesses of this chart review include its retrospective nature and also the unequal distribution of gestational age, postnatal age, catheter days, tip location, and insertion site (central or peripheral) between different PICC groups (Tables 2 and 4). We addressed this unequal distribution using multivariate regression. Unadjusted and adjusted odds ratios were not statistically different when we compared the complications of the 2.6-Fr double-lumen PICC group with the 1.9-Fr lumen PICC group. Incidental finding in this study was CLABSI rate: with 1.5/1000 catheter days in the 2.6-Fr double-lumen PICC group compared with 0/1000 catheter days in the 1.9-Fr PICC group. Lower or no CLABSI rate in the 1.9-Fr group may be due to selection bias, which might have occurred during our matching process. This CLABSI prevalence in the 2.6-Fr double-lumen group of 1.5/1000 catheter days is comparable to the CLABSI rate in other studies, with single-lumen PICCs 1.66 to 2.01/1000 catheter days.22,23 The higher rate of CLABSI in the 2.6-Fr PICC group could also be explained by dwell time of the catheters or the presence of multiple access ports multiplying risk. In our study, dwell time of 2.6-Fr PICCs double-lumen is more than 2 weeks (21 days, IQR 11-30 days) compared to less than 2 weeks in the 1.9-Fr PICC group (12 days, IQR 7-23 days; P < .05) (Table 2). Alternatively, the CLABSI rate in the 2.6-Fr PICC group in our study could have been due to entering the lines for blood withdrawals and blood product transfusion. We did not have the data regarding how many times the infected lines were accessed compared with noninfected lines for blood draws or blood sampling. The overall complications and noninfectious complications were not different between these 2 groups of PICCs (Table 5). Another serendipitous finding was neck veins were used more in 2.6-Fr PICCs compared with 1.9-Fr PICCs, and we speculate that this was due to site availability in a particular patient. We did not examine catheter migration or difficulty with catheter removal as possible complications. The latter did not occur in our sample, but migration was occasionally noted in all groups but was not measured. In addition, the success rate and the number of needle sticks required were not compared and need to be addressed in future studies.

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CONCLUSIONS

We describe the feasibility of inserting 2.6-Fr double-lumen PICCs into our patient population including infants weighing more than 800 g. Utilizing these larger PICCs in small premature infants allowed for both administration of blood products and blood draws without subjecting them to additional painful procedures.

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References

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Keywords:

1.9-French single lumen; 2.6-French double lumen; CLABSI; neonates; PICC complications; PICCs

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