This study reported the experience of a nurse-inserted PICC program in a pediatric sub-specialty outside intensive care unit in a tertiary children’s hospital from China. Of all cases, 83.4%(141/169) were from the department of gastroenterology with inflammatory bowel disease as the most common diagnosis while 16.6%(28/169) were from pulmonology with pneumonia as the most common diagnosis. The age range of cases was from 1 month to 16 years old. PICCs inserted during the study had catheter diameters ranging from 1.9Fr to 4.0Fr. Regarding the age range of patients, PICC insertion in such a pediatric sub-specialty seems more challenging than that in neonatal intensive care units, where age and weight were more uniform. PICC in pediatric sub-specialties apart from intensive care units has been reported in other studies. Piper et al. reported that, for infants with intestinal failure, PICCs offer an advantage over central venous catheters; PICCs can often be inserted without general anesthesia and have a low rate of catheter-related bloodstream infection and venous thrombosis. The study recommended PICCs for infants with intestinal failure requiring parenteral nutrition12. Gibson et al. from Canada reported PICC use at a tertiary care pediatric center. The number of PICCs used outside intensive care units, including general pediatrics, oncology, cardiology, general surgery, gastrointestinal medicine, and neurosurgery, increased from 2001 to 201213. In China, PICC use in pediatric sub-specialties other than oncology and intensive care units is underdeveloped. Since interventional pediatric radiologists inserting PICCs under fluoroscopic guidance, which is common in developed countries, is not available yet in China. The nurse-inserted PICC program reported in this study is a feasible alternative model meriting introduction to other pediatric subspecialties.
The complication rate in our study was 16.4 per 1000 catheter days. The result is consistent with other reports. In a review, Westergaard et al reported the overall rates of complications in pediatric populations ranging from 1.11 to 19.3 per 1000 catheter days14. Of all complications in our cases, only 19.1%(9/47) required removal or replacement of the PICC, the rate was much lower than one-third as reported in previous publications15. Therefore, only a small proportion of complications in cases included in this study could be classified as severe. Malposition was the leading complication in our cases, however, 93.8%(15/16) of cases were primary malposition occurred just after insertion; only one incident of secondary malposition occurred as a result of patient behavior (severe cough). 60%(9/15) of primary malposition occurred in 1.9Fr cases, ultrasound not being used for guiding PICC procedure in such low age group potentially delayed the detection of malposition. PICC obstruction, with a rate of 4.9 per 1000 catheter days was the second most common complication, all of which occurred in cases where a 1.9Fr lumen PICC was inserted. Obstruction was significantly greater in PICCs with smaller lumina. The result is consistent with Thiagarajan et al.'s study16. There was one catheter-related bloodstream infection that occurred in our study, the rate was 0.3 per 1000 catheter days which was relatively low compared with the rates reported in previous studies in pediatrics ranging from 1.4 to 2.0 per 1000 catheter days16,17. We ascertained that the risk factors for PICC complications were low age and small PICC lumina. The result was consistent with Flores Moreno M's report18. Of all 28 1.9Fr complications, 50%(14/28) was obstruction. In a review, Westergaard recommended daily flushing of the catheter with saline or a heparin solution(50-100U/ml) to reduce the risk of catheter obstruction14. The approach potentially could be introduced to 1.9Fr cases.
Of 16 malposition, 9 were corrected by arm movement. Correct PICC tip position by arm manipulation has been reported previously. Nadroo et al. reported that arm movements significantly affect the position of the tip of the PICCs in neonatal cases. For catheters that were placed in the basilic vein, simultaneous shoulder adduction and elbow flexion caused the greatest movement toward the heart(15.11 ± 1.22mm)9. Another adult study reported that there was a large amplitude of PICC tip position change with the depth of inspiration and arm position19. Since arm movement significantly alters PICC tip position, there were studies using arm movement for correcting malposition. Nadroo et al. described the maneuver for correcting PICC malposition and approved the effectiveness9. The maneuver was used in this study. Besides arm movement, a high-flow flush technique was another approach to malposition correction studied in previously published studies with a success rate of approximately 70%20. Of note, arm movement and high-flow flush are only alternative approaches for PICC malposition correction while radiologic intervention is the first or only choice in certain complicated cases21.
Our study comprehensively reported the experience of PICC practice in infants and children outside intensive care units from a single tertiary pediatric center. All clinical data were collected prospectively, therefore, the data accuracy was high. Risk factor analyses for complications and malposition correction techniques provided a valuable reference for counterparts. Our study has limitations as well. Firstly, in analyzing risk factors for complications, some risk factors reported in previous studies22,23, such as dual lumen catheters, non-central position of the catheter tip, were not identified due to small sample size (only 2 non-central cases) and only single lumina catheters used in our practice. Secondly, Rastogi et al. reported that a malapportioned PICC potentially could be corrected spontaneously24. Arm movement was approved effective in malposition correction in our descriptive study, however, without non-intervention control, the necessity of proactive correction by arm movement warrants further comparison studies.
Even though the complication rate in overall cases was not remarkably high, there is still large room for improvement. The following approaches could be carefully reviewed in future cases: ultrasound for guiding PICC insertion, routine daily heparin flushing in 1.9Fr cases, novel approaches for guiding PICC insertion, such as intracavitary electrocardiogram etc.25.