Running Head: PERIPHERALLY INSERTED CENTRAL CATHETERS VERSUS CENTRAL LINES

 Peripherally Inserted Central Catheters Versus Central Lines:

A Study Between Which One is More Likely to Cause Infection

Ashley Templeton

East Tennessee State University

Abstract

            This study is being designed to determine whether PICC line catheters or central line catheters are prone to cause more infection than the other. With the data that is collected and analyzed, the study seeks to determine which catheter is safer. All the data collected will come from patients medical records from the Johnson City Medical Center in Johnson City, Tennessee. The data will be presented in the form of tables. The first table will show on average according to age group which vein was cannulated, the size of the catheter and the location of the catheter. The second table will show the patients whether or not the patient obtained an infection. The main questions for this study are:

v  Does age/sex have any greater/lesser effect of infection?

v  Are certain veins at greater/lesser risk of infection?

v  Does catheter size deal with infection risks?

v  Does the location of the catheter impose greater risks of infection?

 List of Tables

Table 1                        Which Vein Was Cannulated, the Size of the Catheter

                                    And the Location of the Catheter                                                      p. 16

Table 2                        Whether or Not the Patient Obtained an Infection                            p.17

Chapter I Introduction

Background

            A lot of people cannot distinguish or even know the difference between a peripherally inserted central catheter (PICC line) and a central line. A PICC line is a long flexible tube inserted into a vein in the arm that is designed to reach a vein close to the heart. A central line is a special intravenous line that in inserted through the chest and threaded into one of the large veins close to the heart (Ktwlpn 2004). Because a tunnel is created at the first incision site through the exit of a line the catheter is known as a tunneled central venous catheter (tCVC) (Smith, White, 2008).

            According to the Center of Disease Control (CDC), a rate of 5.3 catheter related blood stream infection (CR-BSI)/1000 catheter days represent 80,000 patients annually who suffer from a central venous catheter (CVC) infection. Some researchers estimate a CVC infection rate at high as 35%. Studies that show control for underlying disease have mortality rates that vary from 4% to 20%; indicating that CR-BSIs annually claim 3,200 to 50,000 lives (Hadaway, 2006).

            Catheters are very common in a hospital setting so it is important to make sure that when it is placed it is done so with consideration to possible risks. This is why it is important to make sure that when the catheter is inserted it is put in a place that is less likely to cause any problems or have infections take place. In 2002 CDC guidelines stated that dense skin flora at the subclavian, internal jugular, and femoral sites pose a major risk of CR-BSI (Hadaway, 2006). These would be areas associated with a central line. Many studies have shown that using arm veins for PICC insertion poses a lower risk of CR-BSI. Normally, PICCs are used in settings other than ICUs and for longer periods than other percutaneously inserted CVCs (Hadaway, 2006).

Purpose

            The purpose of this study is to determine the best place for an intravenous catheter to be placed. Depending on location the rate of infection could vary. With the material that is collected the study seeks to point to a safer and better way to decrease the rate of catheter related infections.

Significance

            The placement of the catheter is usually determined by the doctor or certified technician. Clearly being certified in what they do shows they know what they are doing, however, they might assume that every patient that receives a central line or a PICC line are the same. They might not take the time to put into consideration that one patient that they are placing a PICC line in would do a lot better and decrease their risk of infection with a central line. Given that it might take more time to access a vein to do so, these extra considerations could be the difference of whether or not the patient is alive in 6 months. The results of this study will show if there is significant evidence to where a central line is better or worse in causing infection in relation to a PICC line. Less infection rates lead to better chances of survival of patients which in return leads to better hospital rates and procedures.

 Research Questions

            Which is less likely to cause infection, a central line catheter or a PICC line catheter? This is the focus of the study and will be the main question being asked. Other related questions that will help determine the answer to the main focus are:

v  Does age/sex have any greater/lesser effect of infection?

v  Are certain veins at greater/lesser risk of infection?

v  Does catheter size deal with infection risks?

v  Does the location of the catheter impose greater risks of infection?

Assumptions

            The data collected during this study will be from a patient chart review. It is assumed that the charts will obtain information such as what is needed for the research questions to be answered. It is also assumed that the data in the charts are accurate and kept up to date in case any change that might occur in the patient. Also assumed is that the doctor or certified technician placed the catheter in the correct location and used the own good judgment for the best possible outcomes for the patient.

Limitations

The study has the following limitations:

1)      This study is limited to patients with intravenous catheters at the Johnson City Medical Center in Johnson City, Tennessee.

2)      There is no standardized method to show which line causes more infection. It will be based on the statistics according to the patient chart review.

Peripherally Inserted Central Catheters Versus Central Lines:

A Study Between Which One is More Likely to Cause Infection

Chapter II Literature Review

            It has been said that there is an advantage of PICC lines over central lines. Placement of a PICC line in the vein of an arm avoids the procedure-related complications associated with the placement of a central line (Gay, Woodcock, 2007). A PICC line, as well as any other central line, goes by a specific procedure when being inserted into a patient. The procedure goes as follows:

v  A vein in the upper extremity is punctured

v  A guidewire is inserted into the vein and followed centrally under fluoroscopic guidance

v  The needle is removed

v  The introducer sheath is advanced over the guidewire , and the guidewire is removed, leaving the introducer sheath behind

v  The catheter is advance until the tip lies at the superior vena cava adjacent to the right atrium, and the sheath is removed

v  The catheter is sutured in place with a nonresorbable suture

v  A semipermeable transparent dressing is placed over the site

v  A CXR is taken to document the tip position (Gay, Woodcock, 2007).

      PICC line placement has become a preferred alternative to central line placement because of favorable long-term complication rates. In patients with a paucity of obvious peripheral veins, image guidance is often required. The procedure is typically performed using an ultrasound or venography guidance to obtain access. Micropuncture needles and .018 inch wires should be utilized for initial punctures as these smaller systems are less traumatic and result in the least amount of venospasm. Tourniquets can be used to distend upper arm veins, and nitroglycerin may be injected through a peripheral intravenous line in aliquots off 100 mcg to help relieve spasm (Mosenifar, Soo Hoo, 2006).

      There are certain venipuncture techniques for different sized patients. In patients with excessive adipose tissue the veins in the extremities react in one of two ways:

v  The vessels will be buried deep in the tissue; therefore a 2 inch catheter must be used to access the vein.

v  The vasculature will be forced to the surface because the veins have been displaced by the adipose tissue. A vessel can usually be located below the antecubital site, on the lateral dorsum of the forearm.

      Multiple tourniquets can also be used to visualize veins. Place one tourniquet on the lower forearm and another tourniquet 2 minutes later at the wrist to visualize hand veins (Phillips, 1993).

      PICC lines come with a variety of potential complications. The rate of thrombolic complications associated with upper extremity PICC lines has been reported at 38%. A reported high rate of complications included sepsis, thrombosis, blockage and leakage and recommended using PICC lines in patients with solid tumors with caution (Perry, 2007). Complication of a PICC line insertion can include tendon or nerve damage, bleeding, cardiac arrhythmias, chest pain, respiratory distress, catheter embolism, and malposition of the catheter. Although with PICC lines risk of air embolism is decreased with the line being below the heart (U.S. Congress Office of Technology Assessment, 1992). An infiltration, the most common peripheral IV complications, is a significant leakage of IV fluid or blood into the extravascular tissue. It is characterized by pain and edema at the insertion site and coolness of the adjacent skin. Part or all of the limb may be swollen. An absence of blood backflow when the IV is lower than the limb or disconnected at the site is another sign of an infiltration. The gravitational flow of the IV may also be sluggish. Other PICC line infections include: thrombophlebitis, catheter embolism, hematoma, infection of the venipuncture site, systemic infection, circulatory overload, hypersensitivity, and speed shock (Nentwich, 1992).

      Complications associated with PICC lines are reported to be as high as 40%, with occlusion and infection being the most frequently reported. Complications more common with PICC lines include external breaks, shoulder pain, phlebitis without infection, exit site irritation, dislodgement, and occlusion. A study that compared PICC line function with non-central tip location showed comparable results and complication rates, with the exception that non-central PICC lines failed sooner, and few patients completed their course of therapy (Perkin, Swift, Newton, Anas, 2007).

            Flushing a catheter is essential to caring for it. The catheter must be flushed every 12 hours after each use to prevent clogging of the catheter. This is usually done with 0.9% saline and heparin, although some catheters are considered “saline only.” If flushing is difficult this indicates that the PICC line is becoming blocked and if it becomes fully blocked it may become unusable. The PICC dressing should also remain dry at all times; this helps prevent infection. The PICC line should be covered with a waterproof dressing when bathing. One way for preventing infections in a PICC line is to use a solution called Chloraprep. This solution is a new skin disinfectant which contains 2% chlorhexidine gluconate in 70% isopropyl alcohol. This solution has also been proven to eliminate bacteria like Staphylococcus and Klebsiella (Vascular Access Management, n.d.).

            Upon removal of a PICC line special precautions are taken to prevent complications related to air embolism and catheter breakage. The patient should be in the Trendelenburg position and the catheter should be removed while the patient performs the Valsalva maneuver during the beginning of the expiratory phase. Immediately after catheter removal cover the site with an occlusive dressing which consists of an ointment-based antibiotic gel, gauze, and an airtight adhesive covering.  This should remain placed for 24-72 hours (Craven, Hirnle, 2008).

            A central line involves surgical placement of a small catheter directly into a large blood vessel, often the superior vena cava; the catheter is then sutured in place. This central line allows long-term accessibility and unrestricted movement of the client when the line is not being used. There are generally two types of central lines. One is cuffed underneath the skin to protect and secure it; the other is non-cuffed and has nothing under your skin to secure it, but you may have stitches outside your body to help keep the line in (Zastocki, Rovinski-Wagner, 2000). Non-tunneled catheters are the most commonly used central lines. Available with one to four lumens, they are easily inserted into the subclavian, internal jugular vein, or external jugular vein. The right internal jugular vein is preferred because it forms a straight line with the superior vena cava. Non-tunneled catheters are also associated with the highest incidence of catheter-related infections (Rosdahl, Kowalski, 2007).

            Three common types of tunneled central venous lines and their common uses and indications are:

v  Permacath: Dual lumen, large bore line used for dialysis or pheresis

v  Hickman-type catheter: Single, double, or triple lumen catheter used for administration of IV medications, TPN, blood products, or long term chemotherapy

v  Port: Long term single or double lumen catheter designed for infrequent rather than continuous use in the administration of chemotherapy or antibiotics

            The vein most commonly used in placement of tunneled catheters is the jugular vein (Gay, Woodcock, 2007). Central lines can remain in place for extended periods of time, thus avoiding the trauma and potential for complications associated with repeated peripheral cannulation. The options for available for the type of central line are essentially the same as those for a younger person. The risks and complications associated with central lines can occur in any age group, but may be more prevalent and serious in elderly patients (Josephson, 2003).

            Infection can be caused by a number of things including: variations in the type of catheter used (tunneled, non-tunneled, cuffed, and non-cuffed), the material in which they are made of (silicone, polyethylene, polyurethane), the duration of placement (temporary, prolonged), as well as the insertion site could be some reasons. Incidence of bacteremia ranges between 1.6 and 13.5 episodes per 1,000 catheter-days using non-tunneled, non-cuffed devices. Tunneled, cuffed catheters are associated with a lower risk of infection, which ranges between 0.2 and 0.8 episodes per catheter-days (Rello, Kollef, Díaz, Rodríguez, 2007).

            Tunneled central venous catheters are indicated for repeated amounts of antibiotics, chemotherapy, and blood products. Even though CVCs are necessary for certain vascular access, they put the patient at a high risk of local and systemic infections (Smith, White, 2008). In a way having a catheter is like having an open wound. Even though it’s not directly on the skin there is a tiny opening through the catheter that can open doors to many different types of infection. Just because a person is not in the hospital does not mean they too can’t have a PICC line or central line. They are being increasingly used in the inpatient and outpatient setting to provide venous access (Smith, White, 2008).

            Coagulase-negative staphylococci are most commonly implicated in catheter-related infections, followed by S. aureus yeasts. The type of catheter (central vs. peripheral) influences the type of infection. Candida species are found most often in infections in central venous catheters, whereas S. aureus and coagulase-negative staphylococci cause infection in both central and peripheral venous catheters (Irwin, Rippe, 2007).

            Malpositioning is another complication of central lines. Numerous complications described both during placement of the catheter and later in the long-term maintenance, are both hazardous to the patients and expensive to treat. Malposition of the catheter tip usually involves placement of the catheter in various large tributaries of superior vena cava. Malpositioning of central venous catheters was reported to be between 1 to 33 percent by different investigators. Though characteristic chest pain often provides clue to the erroneous catheter position, catheter malposition is more often identified by a post-procedure chest radiograph. After placement of all central venous catheters, a chest radiograph should be obtained. A posteroanterior or anteroposterior film is usually adequate; if not, a lateral view may be taken. If uncertainty still exists, a venogram through the catheter should be performed for precise localization (Ghosh, Dewan, Bhattacharyya, 2008).

            Central line placement performed under ultrasound and fluoroscopy guidance offers significant advantages over blind placement because the chance for successful placement is increased. Venous systems that are inaccessible to blind puncture due to anatomic variation or obesity can be easily accessed, and the safety profile is increased with decreased incidence of pneumothorax or arterial puncture. Once the vessel is accessed, fluoroscopy is generally used for proper catheter position. A steerable wire or contrast injection may be required (Mosenifar, Soo Hoo, 2006). 

Chapter III Research Method

Research Design

            The idea behind this study is to determine whether peripherally inserted catheter or central line catheters tend to cause more infection than the other. In order to accomplish this particular goal with the material that is collected the study seeks to point to a safer and better way to decrease the rate of catheter related infections. Every effort has been made to diminish the number of variables that will hinder the validity and reliability of the data collected. Data will be collected using medical records from the Johnson City Medical Center and be recorded in a table for comparison. It is believed that the data from these records will be accurate and up to date. Data will be collected from different variations of patients for a broader spectrum and to make the results more accurate. To ensure an adequate sample the data will be collected to meet the criteria of each variable such as sex and age.

Research Questions

            The table has been designed to show the differences between variables and the two types of catheters. The questions include:

v  Does age/sex have any greater/lesser effect of infection?

v  Are certain veins at greater/lesser risk of infection?

v  Does catheter size deal with infection risks?

v  Does the location of the catheter impose greater risks of infection?

Participants

            During this study there will be one distinct group of participants, the patients who have inquired infection with a peripherally inserted central catheter or a central line catheter. All the information will be gathered from the patients’ medical records at the Johnson City Medical Center. Obtaining some background information about the patients will help determine if there are particular causes such as age or sex for infection or if it is just by chance. Throughout this study it is important to consider that some of the medical records might not be up to date, therefore resulting in information that is not accurate. Because of this the table will be made out to show multiple patients with the same variables and symptoms to show any resemblance.

Data Collection Methods

            The following data collection instruments are examples of tables that will be collected from the medical records. The first table will show on average according to age group which vein was cannulated, the size of the catheter and the location of the catheter. This is intended to show the differences between the variables. The second table will show the patients whether or not the patient obtained an infection. This is intended to compare the results of PICC line and central line infections. Together the information obtained from these tables should answer the questions being asked by this study.

Table #1: Patient Catheterization

            Avg. Vein    Avg. Size of    Avg.                  Avg. Vein     Avg. Size of     Avg.

PICC line

Infant-12

13-21

22-44

45-59

Central Line

            Infant-12

            13-21

            22-44

            45-59

Table #2: Patient Catheterization

PICC Lines

Infant-12

13-21

22-44

45-59

Central Lines

Infant-12

13-21

22-44

45-59

 Data Analysis

      After reviewing the completed table, it will be possible to determine the following:

v  Average Vein Cannulated in Each Age Group

v  Average Size Catheter in Each Age Group

v  Average Location in Each Age Group

v  Number of Infections Occurring from PICC Lines

v  Number of Infections Occurring from Central Lines

v  Age Group That is Most Prone to Infection Between PICC and Central Lines

With this information it will be possible to answer the critical questions that have been asked by this study.

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