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Multifactor Analysis of Malposition of Peripherally Inserted Central Catheters in Patients With Cancer Xuying Li, RN, MSN, Honghong Wang, RN, PhD, Yongyi Chen, RN, PhD, and Zhong Yuan, RN, BSN
Background: Peripherally inserted central catheters (PICCs) are used widely in patients with cancer, but catheter malposition often occurs. Objectives: This study aimed to provide a reference for clinically safe catheterization through multifactor analysis of malposition of PICCs in patients with cancer. Methods: The occurrence of PICC malposition in patients with cancer was retrospectively re© Robert Byron/Hemera/Thinkstock viewed, and a multivariate logistic regression analysis was performed. Findings: Of 2,084 patients with PICCs, 170 cases (8%) of malposition occurred. The multivariate logistic regression analysis revealed that the risk of adverse events from malposition was higher in the right upper limb than in the left upper limb. The highest risk from malposition was cephalic vein puncture, followed by brachial vein puncture. The risk in the lower part of the elbow joint was higher than that in the upper part of the elbow joint. During PICC insertion, the left upper limb and upper part of the elbow joint should be selected for the puncture, and the basilic vein should be selected as the first-choice vein to reduce the incidence of malposition and adverse events. Xuying Li, RN, MSN, is a PhD student in the Xiangya School of Nursing at Central South University in Changsha, China, and a vice director in the Department of Nursing at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital in Changsha; Honghong Wang, RN, PhD, is a vice dean in the Xiangya School of Nursing at Central South University; Yongyi Chen, RN, PhD, is a vice president in the Department of Nursing at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital; and Zhong Yuan, RN, BSN, is a head nurse in the Department of Vascular Access Center at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital. The authors take full responsibility for the content of the article. This study was supported, in part, by the fund of the Health Department of Hunan Province (B2012-090) and the Scientific Research Platform Project of Hunan Cancer Hospital. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships have been disclosed by the independent peer reviewers or editorial staff. Wang can be reached at honghongwangcn @126.com, with copy to editor at [email protected]. (Submitted May 2014. Revision submitted September 2014. Accepted for publication October 14, 2014.) Key words: peripherally inserted central catheter; catheter malposition; multifactor analysis Digital Object Identifier: 10.1188/15.CJON.E70-E73
T
he safety and convenience of peripherally inserted central catheters (PICCs) have proven to be useful for the administration of anesthetics and toxic drugs, as well as for parenteral nutrition supply (Abedin & Kapoor, 2008; Ahn, Illum, Wang, Sharma, & Dowell, 2013). In modern nursing, PICCs have been widely used for longterm infusion in adults and children. The average retention time of a PICC line is 44–161 days (Yap, Karapetis, Lerose, Iyer, & Koczwara, 2006). A number of significant complications are related to the insertion and maintenance of PICC lines, including catheter malposition, migration, venous thrombosis, and line fracture (Amerasekera, Jones, Patel, & Cleasby, 2009). If the catheter tip is inserted into the heart, precordial discomfort, arrhythmia, cardiac tamponade, and heart valve damage may occur (Song & Li, 2013). If the catheter remains in a peripheral vein, it may induce swelling, pain, edema of the limb, discomfort, and pain at the E70
site where the catheter tip is inserted through the vessel wall. In addition, the placement of the catheter tip in the jugular vein may result in discomfort, difficulty in turning the head and neck, and soreness in the affected side (Moraza-Dulanto et al., 2012). The current study aimed to evaluate and summarize the impact of factors associated with catheter malposition by evaluating a large sample of PICC cases to inform best clinical practices.
Methods Data from 2,084 patients with cancer with PICCs inserted at vascular access centers and hospital wards were retrospectively analyzed from December 2012 to November 2013. None of the patients had a history of radiation treatment, superior vena cava (SVC) syndrome, or vascular surgery. The tumors were confirmed by pathologic diagnosis.
August 2015 • Volume 19, Number 4 • Clinical Journal of Oncology Nursing
All patients in the current review had their first PICC catheterization using a number 4 French catheter. The catheterization was performed by a professional PICC nurse who had PICC qualification and more than two years of clinical practice experience. The 10 PICC nurses all were trained and followed the unified PICC catheterization procedures. Of 2,084 patients with cancer, 720 cases (35%) were performed with traditional catheterization, 640 cases (31%) were performed with the modified Seldinger technique (MST), and 704 cases (34%) were performed with ultrasound-guided MST catheterization. All patients were in the supine position when the catheterization was performed and had successful first-time puncture for placement. After the successful catheterization, a chest x-ray was performed to determine the catheter tip position. When the catheter tip position was confirmed as correct, the guide wire then was pulled out. If the catheter tip position was not correct, it was adjusted, and then the guide wire was pulled out. PICC malposition was defined as a catheter tip not in the SVC but did not include situations in which the catheter was too long and entered the atrium and ventricle. The constituent ratio was used to describe PICC malposition situations. PICC malposition–related factors (age, gender, disease type, catheterization limb, puncture site, puncture vein, catheter type, and puncture method) were analyzed with descriptive statistics and logistic regression models. The independent variables were added to the model using the backward stepwise regression method, with the inclusion criterion as 0.05 and the exclusion criterion as 0.1. Statistical analysis was performed with SPSS®, version 18.0.
The sample included 2,084 patients aged 16–76 years old, with a median age of 47 years (SD = 11.23 years). Descriptive
TABLE 1. Sample Characteristics (N = 2,084) Gender Female Male Catheterization position Upper elbow joint Lower elbow joint Catheterization limb Left Right Puncture vein Basilic Brachial Cephalic Median cubital Jugular Puncture method Ultrasound-guided MST catheterization Blind method MST catheterization
Location Jugular vein Axillary vein Ipsilateral subclavian vein Contralateral subclavian vein Brachiocephalic artery Other veinsa
n
%
103 012 010 008 001 036
61 07 06 05 01 21
Could not be determined through the anatomic location of chest x-ray Note. Because of rounding, percentages may not total 100. a
information about the participants is shown in Table 1. Of the 2,084 patients with PICCs, 170 cases of malposition were seen (8%). The cases of catheter malposition are shown in Table 2. The effects of the eight factors—age, gender, disease type, catheterization limb, puncture site, puncture vein, catheter type, and puncture method—were explored. The results showed that the catheterization limb, puncture site, and puncture vein were related factors of malposition occurrence (see Table 3). Of the 170 cases of malposition, the PICC was correctly readjusted in 145 cases (85%). In 21 cases (12%), the readjustment failed and the midline catheter was kept. Of those 21 cases, one case exhibited thrombosis after chemotherapy; therefore, extubation was performed. The rest of the cases were extubated after two-cycle chemotherapy.
Discussion
Results
Characteristic
TABLE 2. Cases of Catheter Malposition (N = 170)
n
%
1,382 0,702
66 34
1,865 0,219
90 11
1,489 0,595
71 29
1,750 0,266 0,027 0,024 0,017
84 13 01 01 01
1,744 0,298 0,042
84 14 02
MST—modified Seldinger technique Note. Because of rounding, percentages may not total 100.
Acceptable catheter placement for a PICC line is the tip of the catheter being located between the middle third of the SVC and the right atrium. A catheter tip in any other position was considered malpositioned (DeChicco et al., 2007; Trerotola, Thompson, Chittams, & Vierregger, 2007). The current study used a multifactor analysis, which may avoid mutual interference among individual factors or multiple factors, overcoming the one-sidedness of unifactor analysis. The logistic regression analysis was performed to assess the impact of the eight PICC malposition factors. Two opinions exist about the impact of different puncture sites on malposition. One opinion is that the incidence of malposition when the PICC is inserted in the left upper limb is higher than when it is inserted in the right upper limb (Wrightson, 2013). The distance between the left upper limb and the SVC is longer than the distance between the right upper limb and the SVC; therefore, the right upper limb should be the preferred site for insertion. In another study, no statistical significance was seen between placement in the left and right limbs (Loewenthal et al., 2002). When advocating for PICC placement in the right upper limb, the problem of patients’ handedness also may need to be considered. For example, in right-handed patients, the left upper limb may be preferred. Therefore, selection of left or right upper limb for catheterization is still controversial. The current study compared the PICC malposition rates of 2,084 cases and found that the malposition rate was higher in right upper limb insertion than left upper limb insertion (p < 0.001). The anatomical lumen was larger in the right than in the left.
Clinical Journal of Oncology Nursing • Volume 19, Number 4 • Multifactor Analysis of Catheter Malposition
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Malposition rates of different veins were significantly different, which could be seen from the data showing that malposi2 Factor b SD Wals x p RR RR 95% CI tion incidence was higher when Catheterization limba the cephalic vein was used than Right –0.747 0.168 19.747 < 0.001* 2.110 [1.518, 2.934] when the median cubital vein and Puncture siteb basilic vein were used as insertion Lower limb –0.781 0.232 11.339 < 0.001* 2.185 [1.386, 3.443] sites. Therefore, when selecting c Puncture vein the vessel for insertion, the basilic Brachial vein –0.667 0.215 09.607 < 0.002* 1.949 [1.278, 2.973] vein should be the first choice to Cephalic vein –1.900 0.543 12.255 < 0.001* 6.686 [2.308, 19.373] Jugular vein –1.465 0.854 02.946 < 0.086* 4.329 [0.812, 23.069] reduce the incidence of malposiMedian cubital vein –0.263 0.770 00.117 < 0.733* 0.769 [0.17, 3.477] tion, consistent with evidence from domestic and international * p < 0.05 studies (Moret, Tequi, & Loma The left limb was set as the reference. brail, 2004). However, in clinical b The upper limb was set as the reference. practice, because of the anatomic c The basilic vein was set as the reference. characteristics of the basilic vein, 2 2 b—estimated logit coefficient; CI—confidence interval; RR—risk ratio; Wals x —[b/SD] the selection of the basilic vein requires the operator to be very familiar with the strike characterIn right-side catheterization, the catheter directly touched istics of the three veins in the cubital fossa. In particular, the the left side of the jugular vein, causing malposition in some path of the median cubital vein may vary, with a division in the cases (Paulson & Miller, 2008). In another study (Trerotola et median cephalic vein and median basilic vein in the elbow area al., 2007), the jugular vein was the most common site of maland insertion into the cephalic vein and basilic vein with a “Y” position, accounting for 36% of all cases of PICC malposition. shape (Moureau, 2013). All operators need to clearly determine The current study also showed that jugular vein malposition the right path; otherwise, the catheter may easily lead to the accounted for 103 of 170 (61%) cases of PICC malposition. In cephalic vein, increasing malposition incidence. In addition, the current study, the risk ratio of the jugular vein was high at the use of the B-mode ultrasound-guided PICC catheterization 4.329, but it did not reach statistical significance. The p value technique is strongly recommended to improve the preferred was 0.086, which was near the level of statistical significance. selection of the basilic vein. In a comprehensive analysis of the evidence of malposition Interventions, such as chest x-ray confirmation of placement incidence, right upper limb insertion had a higher incidence before withdrawing the guide wire, strict disinfection and isoof malposition. Selection of the left upper limb may reduce lation measures, and establishment of specialized patient file malposition incidence, which further broke the traditional maintenance, are known to have the potential to greatly reduce concept that the right limb was the preferred catheterization the risk of PICC complications (Paulson & Miller, 2008). Since choice. the clinical introduction of PICC lines, reducing malposition has In the current study, the risk of malposition in the lower been a focus of clinical nursing practice. The incidence of malpart of the elbow joint was 2.185 times of that in the upper positioned catheters is 5%–31%, which includes malpositioned part of the elbow joint. The reason may be related to the seleccatheters, catheter slides or extrusions, and catheter drifts tion of veins in the upper and lower part of the elbow joint. (Song & Li, 2013). In the current study, the malposition rate was Nurses often choose PICC catheterization in the veins in the 8%, which is within the range proposed by other studies. The upper elbow, and they commonly use the basilic vein, median researchers believed that this was related to the recent specialcubital vein, and cephalic vein. Theoretically, the basilic vein ization and standardization of PICC technology and guidelines, should be the first choice. However, the basilic vein lies in the with many local hospitals requiring insertion by trained and cubital fossa, obliquely upward along the ulnaris. Its position qualified PICC nurses. PICC malposition has been reported is deeper, which increases puncture difficulty. The median to be related to the compression of lymph nodes or lumps in cubital vein and cephalic vein lie in the superficial position of the puncture side, as well as the patient’s emotional stress and the cubital fossa and the directions of the vessels are intuitive, incorrect posture (Baxi et al., 2013). Professional PICC nurses which makes identification and location easy. Catheterization have specialized training to assess the patient’s local and systypically is performed in the lower part of the elbow joint by temic vessels before catheterization, effectively exclude connaked eye observation or palpation. Most nurses choose the metraindicated sites, and choose the best puncture location and dian cubital vein and cephalic vein for punctures. The median vessel. Throughout the entire process, nurses include health cubital vein has many branches and vein grafts at the cubital education for the patient so the patient understands the relevant fossa, and the cephalic vein has a tortuous venous path, leading knowledge and can properly cooperate with the catheterization to higher malposition incidence. Catheterization in the upper procedure under the guidance of professional PICC nurses. part of the elbow joint is performed mostly under ultrasound Many factors may influence PICC malposition. The literature guidance. Nurses can select the basilic vein for the puncture shows that it has been related to age but not gender, puncture with ultrasound guidance. method, or lesion location (Song & Li, 2013). Wrightson (2013)
TABLE 3. Logistic Regression Analysis of Factors Related to Peripherally Inserted Central Catheter Malposition
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August 2015 • Volume 19, Number 4 • Clinical Journal of Oncology Nursing
Implications for Practice u
Use the left upper limb and upper part of the elbow joint for peripherally inserted central catheter (PICC) line insertion to reduce the incidence of malposition.
u
Improve the placement accuracy of PICC insertion with standardized and specialized operations and specialty training for professional nurses.
u
Select the basilic vein as the first-choice vein to avoid malposition and adverse events.
revealed that changing puncture position from supine posture to semirecumbent posture or sitting straight could reduce the incidence of malposition. In the current study, analyses of 2,084 cases revealed that age, gender, disease type, catheter type, and puncture method had no effect on incidence of malposition. In the current study, although most malpositioned PICCs could be adjusted correctly through a variety of methods, vascular anatomic differences exist that do not allow for readjustment of malpositioned PICCs. The success rate of malpositioned PICC readjustment has been reported to be 77% (Zhang, Jiang, Wei, & Yu, 2011), and another study reported a success rate of 79% (Leung, Malhotra, & Eisen, 2010). In the current study, the successful readjustment rate was 85%, which is higher than the levels reported in other studies. For the readjustment of a malpositioned PICC, an x-ray machine can measure the length and observe the anatomic position, giving real-time guidance to the operator. Under ultrasound guidance, the appropriate length of catheter to be advanced or withdrawn can be visualized to correct the malposition. All of the cases of PICC in the researchers’ hospital had guide wires for positioning, which were only pulled out when the adjustment was correctly performed and confirmed with chest x-ray. Using the guide wire may reduce PICC malposition and improve the readjustment rate. In the current study, patients were always in the supine posture during insertion, and the researchers did not compare the effect of different postures on malposition. Therefore, the relationship between malposition and punctures still needs to be validated by additional studies.
Conclusion Among the factors that influence malposition of PICCs, the main ones were catheterization position, catheterization limb, and puncture vein. To reduce the incidence of malposition, the left upper limb and upper part of the elbow joint are preferred for PICC line insertion, and the basilic vein is the preferred vein. Other factors that could improve placement accuracy are standardized and specialized operations and specialty training in PICC insertion for professional nurses.
References Abedin, S., & Kapoor, G. (2008). Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatric Blood and Cancer, 51, 251–255.
Ahn, D.H., Illum, H.B., Wang, D.H., Sharma, A., & Dowell, J.E. (2013). Upper extremity venous thrombosis in patients with cancer with peripherally inserted central venous catheters: A retrospective analysis of risk factors. Retrieved from http:// jop.ascopubs.org/content/early/2012/10/23/JOP.2012.000595 .full.pdf Amerasekera, S.S., Jones, C.M., Patel, R., & Cleasby, M.J. (2009). Imaging of the complications of peripherally inserted central venous catheters. Clinical Radiology, 64, 832–840. Baxi, S.M., Shuman, E.K., Scipione, C.A., Chen, B., Sharma, A., Rasanathan, J.J., & Chenoweth, C.E. (2013). Impact of postplacement adjustment of peripherally inserted central catheters on the risk of bloodstream infection and venous thrombus formation. Infection Control and Hospital Epidemiology, 34, 785–792. DeChicco, R., Seidner, D.L., Brun, C., Steiger, E., Stafford, J., & Lopez, R. (2007). Tip position of long-term central venous access devices used for parenteral nutrition. Journal of Parenteral and Enteral Nutrition, 31, 382–387. Leung, S., Malhotra, A.D., & Eisen, L.A. (2010). Venous access challenge on a patient with cerebral palsy and severe kyphoscoliosis. Journal of Vascular Access, 11, 66–68. Loewenthal, M.R., Dobson, P.M., Starkey, R.E., Dagg, S.A., Petersen, A., & Boyle, M.J. (2002). The peripherally inserted central catheter (PICC): A prospective study of its natural history after cubital fossa insertion. Anaesthesia and Intensive Care, 30, 21–24. Moraza-Dulanto, M.I., Garate-Echenique, L., Miranda-Serrano, E., Armenteros-Yeguas, V., Tomás-López, M.A., & Benítez-Delgado, B. (2012). Ultrasound-guided peripherally inserted central catheters (PICC) in cancer patients: Success of the insertion, survival and complications. Enfermería Clínica, 22, 135–143. Moret, L., Tequi, B., & Lombrail, P. (2004). Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital. American Journal of Infection Control, 32, 384–390. doi:10.1016/j.ajic.2004.02.004 Moureau, N. (2013). Safe patient care when using vascular access devices. British Journal of Nursing, 22, S14. doi:10.12968/bjon .2013.22.Sup1.S14 Paulson, P.R., & Miller, K.M. (2008). Neonatal peripherally inserted central catheters: Recommendations for prevention of insertion and postinsertion complications. Neonatal Network, 27, 245–257. doi:10.1891/0730-0832.27.4.245 Song, L., & Li, H. (2013). Malposition of peripherally inserted central catheter: Experience from 3,012 patients with cancer. Experimental and Therapeutic Medicine, 6, 891–893. Trerotola, S.O., Thompson, S., Chittams, J., & Vierregger, K.S. (2007). Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. Journal of Vascular and Interventional Radiology, 18, 513–518. doi:10.1016/j.jvir.2007.01.020 Wrightson, D.D. (2013). Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites. Advances in Neonatal Care, 13, 198–204. Yap, Y.S., Karapetis, C., Lerose, S., Iyer, S., & Koczwara, B. (2006). Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. European Journal of Cancer Care, 15, 342–347. Zhang, Y., Jiang, H., Wei, L., & Yu, H. (2011). Persistent hiccup caused by peripherally inserted central catheter migration. Journal of Anesthesia, 25, 625–626. doi:10.1007/s00540-011 -1146-z
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n Online Exclusive Article
Multifactor Analysis of Malposition of Peripherally Inserted Central Catheters in Patients With Cancer Xuying Li, RN, MSN, Honghong Wang, RN, PhD, Yongyi Chen, RN, PhD, and Zhong Yuan, RN, BSN
Background: Peripherally inserted central catheters (PICCs) are used widely in patients with cancer, but catheter malposition often occurs. Objectives: This study aimed to provide a reference for clinically safe catheterization through multifactor analysis of malposition of PICCs in patients with cancer. Methods: The occurrence of PICC malposition in patients with cancer was retrospectively re© Robert Byron/Hemera/Thinkstock viewed, and a multivariate logistic regression analysis was performed. Findings: Of 2,084 patients with PICCs, 170 cases (8%) of malposition occurred. The multivariate logistic regression analysis revealed that the risk of adverse events from malposition was higher in the right upper limb than in the left upper limb. The highest risk from malposition was cephalic vein puncture, followed by brachial vein puncture. The risk in the lower part of the elbow joint was higher than that in the upper part of the elbow joint. During PICC insertion, the left upper limb and upper part of the elbow joint should be selected for the puncture, and the basilic vein should be selected as the first-choice vein to reduce the incidence of malposition and adverse events. Xuying Li, RN, MSN, is a PhD student in the Xiangya School of Nursing at Central South University in Changsha, China, and a vice director in the Department of Nursing at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital in Changsha; Honghong Wang, RN, PhD, is a vice dean in the Xiangya School of Nursing at Central South University; Yongyi Chen, RN, PhD, is a vice president in the Department of Nursing at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital; and Zhong Yuan, RN, BSN, is a head nurse in the Department of Vascular Access Center at the Affiliated Cancer Hospital of Xiangya School of Medicine at Central South University/Hunan Cancer Hospital. The authors take full responsibility for the content of the article. This study was supported, in part, by the fund of the Health Department of Hunan Province (B2012-090) and the Scientific Research Platform Project of Hunan Cancer Hospital. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships have been disclosed by the independent peer reviewers or editorial staff. Wang can be reached at honghongwangcn @126.com, with copy to editor at [email protected]. (Submitted May 2014. Revision submitted September 2014. Accepted for publication October 14, 2014.) Key words: peripherally inserted central catheter; catheter malposition; multifactor analysis Digital Object Identifier: 10.1188/15.CJON.E70-E73
T
he safety and convenience of peripherally inserted central catheters (PICCs) have proven to be useful for the administration of anesthetics and toxic drugs, as well as for parenteral nutrition supply (Abedin & Kapoor, 2008; Ahn, Illum, Wang, Sharma, & Dowell, 2013). In modern nursing, PICCs have been widely used for longterm infusion in adults and children. The average retention time of a PICC line is 44–161 days (Yap, Karapetis, Lerose, Iyer, & Koczwara, 2006). A number of significant complications are related to the insertion and maintenance of PICC lines, including catheter malposition, migration, venous thrombosis, and line fracture (Amerasekera, Jones, Patel, & Cleasby, 2009). If the catheter tip is inserted into the heart, precordial discomfort, arrhythmia, cardiac tamponade, and heart valve damage may occur (Song & Li, 2013). If the catheter remains in a peripheral vein, it may induce swelling, pain, edema of the limb, discomfort, and pain at the E70
site where the catheter tip is inserted through the vessel wall. In addition, the placement of the catheter tip in the jugular vein may result in discomfort, difficulty in turning the head and neck, and soreness in the affected side (Moraza-Dulanto et al., 2012). The current study aimed to evaluate and summarize the impact of factors associated with catheter malposition by evaluating a large sample of PICC cases to inform best clinical practices.
Methods Data from 2,084 patients with cancer with PICCs inserted at vascular access centers and hospital wards were retrospectively analyzed from December 2012 to November 2013. None of the patients had a history of radiation treatment, superior vena cava (SVC) syndrome, or vascular surgery. The tumors were confirmed by pathologic diagnosis.
August 2015 • Volume 19, Number 4 • Clinical Journal of Oncology Nursing
All patients in the current review had their first PICC catheterization using a number 4 French catheter. The catheterization was performed by a professional PICC nurse who had PICC qualification and more than two years of clinical practice experience. The 10 PICC nurses all were trained and followed the unified PICC catheterization procedures. Of 2,084 patients with cancer, 720 cases (35%) were performed with traditional catheterization, 640 cases (31%) were performed with the modified Seldinger technique (MST), and 704 cases (34%) were performed with ultrasound-guided MST catheterization. All patients were in the supine position when the catheterization was performed and had successful first-time puncture for placement. After the successful catheterization, a chest x-ray was performed to determine the catheter tip position. When the catheter tip position was confirmed as correct, the guide wire then was pulled out. If the catheter tip position was not correct, it was adjusted, and then the guide wire was pulled out. PICC malposition was defined as a catheter tip not in the SVC but did not include situations in which the catheter was too long and entered the atrium and ventricle. The constituent ratio was used to describe PICC malposition situations. PICC malposition–related factors (age, gender, disease type, catheterization limb, puncture site, puncture vein, catheter type, and puncture method) were analyzed with descriptive statistics and logistic regression models. The independent variables were added to the model using the backward stepwise regression method, with the inclusion criterion as 0.05 and the exclusion criterion as 0.1. Statistical analysis was performed with SPSS®, version 18.0.
The sample included 2,084 patients aged 16–76 years old, with a median age of 47 years (SD = 11.23 years). Descriptive
TABLE 1. Sample Characteristics (N = 2,084) Gender Female Male Catheterization position Upper elbow joint Lower elbow joint Catheterization limb Left Right Puncture vein Basilic Brachial Cephalic Median cubital Jugular Puncture method Ultrasound-guided MST catheterization Blind method MST catheterization
Location Jugular vein Axillary vein Ipsilateral subclavian vein Contralateral subclavian vein Brachiocephalic artery Other veinsa
n
%
103 012 010 008 001 036
61 07 06 05 01 21
Could not be determined through the anatomic location of chest x-ray Note. Because of rounding, percentages may not total 100. a
information about the participants is shown in Table 1. Of the 2,084 patients with PICCs, 170 cases of malposition were seen (8%). The cases of catheter malposition are shown in Table 2. The effects of the eight factors—age, gender, disease type, catheterization limb, puncture site, puncture vein, catheter type, and puncture method—were explored. The results showed that the catheterization limb, puncture site, and puncture vein were related factors of malposition occurrence (see Table 3). Of the 170 cases of malposition, the PICC was correctly readjusted in 145 cases (85%). In 21 cases (12%), the readjustment failed and the midline catheter was kept. Of those 21 cases, one case exhibited thrombosis after chemotherapy; therefore, extubation was performed. The rest of the cases were extubated after two-cycle chemotherapy.
Discussion
Results
Characteristic
TABLE 2. Cases of Catheter Malposition (N = 170)
n
%
1,382 0,702
66 34
1,865 0,219
90 11
1,489 0,595
71 29
1,750 0,266 0,027 0,024 0,017
84 13 01 01 01
1,744 0,298 0,042
84 14 02
MST—modified Seldinger technique Note. Because of rounding, percentages may not total 100.
Acceptable catheter placement for a PICC line is the tip of the catheter being located between the middle third of the SVC and the right atrium. A catheter tip in any other position was considered malpositioned (DeChicco et al., 2007; Trerotola, Thompson, Chittams, & Vierregger, 2007). The current study used a multifactor analysis, which may avoid mutual interference among individual factors or multiple factors, overcoming the one-sidedness of unifactor analysis. The logistic regression analysis was performed to assess the impact of the eight PICC malposition factors. Two opinions exist about the impact of different puncture sites on malposition. One opinion is that the incidence of malposition when the PICC is inserted in the left upper limb is higher than when it is inserted in the right upper limb (Wrightson, 2013). The distance between the left upper limb and the SVC is longer than the distance between the right upper limb and the SVC; therefore, the right upper limb should be the preferred site for insertion. In another study, no statistical significance was seen between placement in the left and right limbs (Loewenthal et al., 2002). When advocating for PICC placement in the right upper limb, the problem of patients’ handedness also may need to be considered. For example, in right-handed patients, the left upper limb may be preferred. Therefore, selection of left or right upper limb for catheterization is still controversial. The current study compared the PICC malposition rates of 2,084 cases and found that the malposition rate was higher in right upper limb insertion than left upper limb insertion (p < 0.001). The anatomical lumen was larger in the right than in the left.
Clinical Journal of Oncology Nursing • Volume 19, Number 4 • Multifactor Analysis of Catheter Malposition
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Malposition rates of different veins were significantly different, which could be seen from the data showing that malposi2 Factor b SD Wals x p RR RR 95% CI tion incidence was higher when Catheterization limba the cephalic vein was used than Right –0.747 0.168 19.747 < 0.001* 2.110 [1.518, 2.934] when the median cubital vein and Puncture siteb basilic vein were used as insertion Lower limb –0.781 0.232 11.339 < 0.001* 2.185 [1.386, 3.443] sites. Therefore, when selecting c Puncture vein the vessel for insertion, the basilic Brachial vein –0.667 0.215 09.607 < 0.002* 1.949 [1.278, 2.973] vein should be the first choice to Cephalic vein –1.900 0.543 12.255 < 0.001* 6.686 [2.308, 19.373] Jugular vein –1.465 0.854 02.946 < 0.086* 4.329 [0.812, 23.069] reduce the incidence of malposiMedian cubital vein –0.263 0.770 00.117 < 0.733* 0.769 [0.17, 3.477] tion, consistent with evidence from domestic and international * p < 0.05 studies (Moret, Tequi, & Loma The left limb was set as the reference. brail, 2004). However, in clinical b The upper limb was set as the reference. practice, because of the anatomic c The basilic vein was set as the reference. characteristics of the basilic vein, 2 2 b—estimated logit coefficient; CI—confidence interval; RR—risk ratio; Wals x —[b/SD] the selection of the basilic vein requires the operator to be very familiar with the strike characterIn right-side catheterization, the catheter directly touched istics of the three veins in the cubital fossa. In particular, the the left side of the jugular vein, causing malposition in some path of the median cubital vein may vary, with a division in the cases (Paulson & Miller, 2008). In another study (Trerotola et median cephalic vein and median basilic vein in the elbow area al., 2007), the jugular vein was the most common site of maland insertion into the cephalic vein and basilic vein with a “Y” position, accounting for 36% of all cases of PICC malposition. shape (Moureau, 2013). All operators need to clearly determine The current study also showed that jugular vein malposition the right path; otherwise, the catheter may easily lead to the accounted for 103 of 170 (61%) cases of PICC malposition. In cephalic vein, increasing malposition incidence. In addition, the current study, the risk ratio of the jugular vein was high at the use of the B-mode ultrasound-guided PICC catheterization 4.329, but it did not reach statistical significance. The p value technique is strongly recommended to improve the preferred was 0.086, which was near the level of statistical significance. selection of the basilic vein. In a comprehensive analysis of the evidence of malposition Interventions, such as chest x-ray confirmation of placement incidence, right upper limb insertion had a higher incidence before withdrawing the guide wire, strict disinfection and isoof malposition. Selection of the left upper limb may reduce lation measures, and establishment of specialized patient file malposition incidence, which further broke the traditional maintenance, are known to have the potential to greatly reduce concept that the right limb was the preferred catheterization the risk of PICC complications (Paulson & Miller, 2008). Since choice. the clinical introduction of PICC lines, reducing malposition has In the current study, the risk of malposition in the lower been a focus of clinical nursing practice. The incidence of malpart of the elbow joint was 2.185 times of that in the upper positioned catheters is 5%–31%, which includes malpositioned part of the elbow joint. The reason may be related to the seleccatheters, catheter slides or extrusions, and catheter drifts tion of veins in the upper and lower part of the elbow joint. (Song & Li, 2013). In the current study, the malposition rate was Nurses often choose PICC catheterization in the veins in the 8%, which is within the range proposed by other studies. The upper elbow, and they commonly use the basilic vein, median researchers believed that this was related to the recent specialcubital vein, and cephalic vein. Theoretically, the basilic vein ization and standardization of PICC technology and guidelines, should be the first choice. However, the basilic vein lies in the with many local hospitals requiring insertion by trained and cubital fossa, obliquely upward along the ulnaris. Its position qualified PICC nurses. PICC malposition has been reported is deeper, which increases puncture difficulty. The median to be related to the compression of lymph nodes or lumps in cubital vein and cephalic vein lie in the superficial position of the puncture side, as well as the patient’s emotional stress and the cubital fossa and the directions of the vessels are intuitive, incorrect posture (Baxi et al., 2013). Professional PICC nurses which makes identification and location easy. Catheterization have specialized training to assess the patient’s local and systypically is performed in the lower part of the elbow joint by temic vessels before catheterization, effectively exclude connaked eye observation or palpation. Most nurses choose the metraindicated sites, and choose the best puncture location and dian cubital vein and cephalic vein for punctures. The median vessel. Throughout the entire process, nurses include health cubital vein has many branches and vein grafts at the cubital education for the patient so the patient understands the relevant fossa, and the cephalic vein has a tortuous venous path, leading knowledge and can properly cooperate with the catheterization to higher malposition incidence. Catheterization in the upper procedure under the guidance of professional PICC nurses. part of the elbow joint is performed mostly under ultrasound Many factors may influence PICC malposition. The literature guidance. Nurses can select the basilic vein for the puncture shows that it has been related to age but not gender, puncture with ultrasound guidance. method, or lesion location (Song & Li, 2013). Wrightson (2013)
TABLE 3. Logistic Regression Analysis of Factors Related to Peripherally Inserted Central Catheter Malposition
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August 2015 • Volume 19, Number 4 • Clinical Journal of Oncology Nursing
Implications for Practice u
Use the left upper limb and upper part of the elbow joint for peripherally inserted central catheter (PICC) line insertion to reduce the incidence of malposition.
u
Improve the placement accuracy of PICC insertion with standardized and specialized operations and specialty training for professional nurses.
u
Select the basilic vein as the first-choice vein to avoid malposition and adverse events.
revealed that changing puncture position from supine posture to semirecumbent posture or sitting straight could reduce the incidence of malposition. In the current study, analyses of 2,084 cases revealed that age, gender, disease type, catheter type, and puncture method had no effect on incidence of malposition. In the current study, although most malpositioned PICCs could be adjusted correctly through a variety of methods, vascular anatomic differences exist that do not allow for readjustment of malpositioned PICCs. The success rate of malpositioned PICC readjustment has been reported to be 77% (Zhang, Jiang, Wei, & Yu, 2011), and another study reported a success rate of 79% (Leung, Malhotra, & Eisen, 2010). In the current study, the successful readjustment rate was 85%, which is higher than the levels reported in other studies. For the readjustment of a malpositioned PICC, an x-ray machine can measure the length and observe the anatomic position, giving real-time guidance to the operator. Under ultrasound guidance, the appropriate length of catheter to be advanced or withdrawn can be visualized to correct the malposition. All of the cases of PICC in the researchers’ hospital had guide wires for positioning, which were only pulled out when the adjustment was correctly performed and confirmed with chest x-ray. Using the guide wire may reduce PICC malposition and improve the readjustment rate. In the current study, patients were always in the supine posture during insertion, and the researchers did not compare the effect of different postures on malposition. Therefore, the relationship between malposition and punctures still needs to be validated by additional studies.
Conclusion Among the factors that influence malposition of PICCs, the main ones were catheterization position, catheterization limb, and puncture vein. To reduce the incidence of malposition, the left upper limb and upper part of the elbow joint are preferred for PICC line insertion, and the basilic vein is the preferred vein. Other factors that could improve placement accuracy are standardized and specialized operations and specialty training in PICC insertion for professional nurses.
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