In this study, we sought to explore the risk factors associated with MARSI at the PICC insertion site of patients with cancer and develop a nomogram for risk prediction.Study showed that MARSI is the second largest complication related to PICC in cancer patients, with an incidence rate of 11.6%[13]. Previous studies have shown that the incidence of MARSI at the placement site of peripheral venous catheters in adults hospitalized in the intensive care unit (ICU) was 31.0%,[14] while the incidence of MARSI in hospitalized patients in the cardiac intensive care unit was 22.7%[15]. Our research results show that the incidence of MARSI at the PICC site is about 17.61%, There are differences in the incidence rate of MARSI between different studies.The varying incidence rates of MARSI across different studies may be attributed to several factors, including patient demographics, underlying medical conditions, the type and duration of catheterization, and the care and maintenance protocols for PICC lines[16, 17].Our findings indicate that several factors contribute to the risk of PICC-related skin injury in cancer patients. Notably, delayed catheter maintenance, catheter duration, adhesive characteristics emerged, and APTT as significant predictors in the multivariate analysis.The results of this study indicate that delayed catheter maintenance is a risk factor for MARSI at the PICC insertion site of patients with cancer,which may involve multiple factors, including the patient's specific medical environment, physiological changes in the skin, and the interaction between catheter fixation materials and the patient's skin[18].The prolonged catheter maintenance period may result in the extended contact time of medical adhesive with the patient's skin, increasing the risk of friction and shear and thereby elevating the likelihood of skin injuries[19].Additionally, prolonged catheter fixation may impede blood circulation, affecting oxygen and nutrient supply to the skin and subsequently impacting its overall health[20].Factors such as inadequate awareness of the importance of PICC maintenance post-insertion, weakened physical condition post-chemotherapy, and residing far from the hospital contribute to reduced patient compliance with timely catheter maintenance, thereby increasing the probability of MARSI occurrence.Currently, there is no evidence indicating the optimal frequency of PICC fixation device replacement. Apart from immediate replacements necessitated by damaged dressings, drug or blood seepage, the possibility of extending the PICC maintenance period considering patient-specific physiological and economic conditions requires further investigation.
Cancer patients with wet PICC indwelling site are prone to MARSI.When the skin surface is exposed to substances such as exudate, sweat, and disinfectants, the increased permeability of the skin's stratum corneum and decreased skin resistance may lead to inflammatory reactions, thereby augmenting the risk of MARSI[21, 22]. Studies[23] have been conducted to carry out continuing education activities for physicians, physician assistants, nurse practitioners and nurses interested in skin and wound care, providing information on superficial skin problems related to moisture related skin injuries, medical adhesive related skin injuries and skin tears, so as to reduce the incidence of MARSI.Future studies should delve into the specific mechanisms through which a humid environment affects the permeability and resistance of the skin's stratum corneum, facilitating the development of more effective protective measures.Cancer patients with a history of skin allergies are at a higher risk of developing MARSI. Patients with a history of skin allergies possess heightened sensitivity and specificity in immune reactions, making them prone to hypersensitivity responses upon exposure to disinfectants and dressing materials, aligning with the findings of this study[24]. Such patients should be advised to avoid contact with substances that may trigger allergic reactions, especially common disinfectants and dressing components.
This study extensively explores the potential association between APTT and MARSI and identifies various risk factors. The analysis reveals that factors such as anticoagulant therapy, coagulation factor deficiencies, platelet dysfunction, vascular diseases, and drug usage may influence the coagulation status of patients during medical adhesive application, thereby increasing the risk of skin injuries. Particularly in anticoagulant therapy patients, an observed prolongation of APTT may be linked to an elevated risk of bleeding during medical adhesive procedures. Individuals with coagulation factor deficiencies may be more prone to bleeding during medical adhesive application due to the lack of normal coagulation factors[25]. Additionally, platelet dysfunction and vascular diseases may render the skin more fragile, increasing the likelihood of injury during medical adhesive procedures[26]. Therefore, it is recommended that healthcare professionals pay close attention to the coagulation status of patients during medical adhesive application, especially in those with potential risk factors, to implement personalized preventive measures and reduce the risk of medical adhesive-related skin injuries. Future research should further refine the risk factors in different patient groups and develop more precise preventive strategies to enhance the safety and efficacy of medical adhesive applications.
Strengths and Limitations
We created a model to predict MARSI at the PICC insertion site of patients with cancer using selected risk factors. The model is presented in the form of nomogram. The C index of the nomogram model in the training group was 0.917, (95%CI:0.872 ~ 0.963), and the C index in the validation group was 0.864, (95%CI:0.769 ~ 0.959), indicating that the nomogram has good predictive value. Good prediction efficiency is helpful to find high-risk patients, so as to give corresponding support and nursing immediately, so as to minimize the incidence of adverse prognosis. In addition,the selected variables were common and easy to obtain from clinical practice, helping nurses to manage cancer patients with PICC placement. The scoring system of nomogram was simple and comprehensible which achieved good predictive accuracy and favorable stability. By producing an accurate prognosis, this nomogram could help nurses to stratify patients and make individual clinical treatment strategies under variable conditions. For patients identified as high-risk, preventive strategies such as alternative adhesive options, frequent skin assessments, and specialized care protocols can be implemented to mitigate the risk of skin injuries. This personalized approach aligns with the principles of patient-centered care and may contribute to improved patient outcomes and satisfaction.
However, there were still some limitations in the present study. First, this analysis was based on data from a single institution, it is necessary to validate the results from other centers. Second, the risk factors of MARSI are complex and there are far more factors to be investigated and used to predict the prognosis of MARSI. Third, the retrospective nature of some data collection elements may introduce bias, and a large prospective study with a long-term follow-up should be performed in the future. Thus, the accuracy of this prediction model will be improved to a certain extent.