1. This observational study found that compared with midline catheters, peripheral insertion of the central catheter and the risk of major complications (the most common obstruction) doubled, and the probability of bloodstream infection increased four times.
Research outline: Peripherally inserted central venous catheter (PICC) is a central venous catheter that is inserted into a peripheral vein and terminates at the junction of the vena cava near the right atrium. Because of their location, they are associated with a variety of complications, including centerline associated bloodstream infection (CLABSI) and deep vein thrombosis (DVT). In contrast, catheter-related bloodstream infections (CRBSI) and DVT are less likely to use midline catheters, which terminate at or below the axillary veins in the brachial vein, the expensive vein, or the cephalic vein. This study investigated the results of patients receiving PICC and midline treatment at many US centers in multiple states. The 48 hospitals affiliated with the Hospital Medical Safety Alliance collected data on PICC and midline complications that were inserted due to difficult venous access or antibiotic use. Complications include CLABSI or CRBSI, symptomatic upper extremity DVT, pulmonary embolism (PE), and catheter blockage within 30 days of insertion. PICC is used more for antibiotics and longer duration, while the midline is more used when patients with difficult-to-access and study samples have a history of thromboembolism. Compared with the midline (N = 5105), more PICC (N = 5758) was associated with complications (9.9% vs. 3.9%), including catheter obstruction and CLABSI (compared to CRBSI). DVT and PE also occur in both types of circuits. The most common complication is catheter blockage. Due to complications, the midline is more likely to be removed. When considering other factors, compared with the midline, PICC is twice as likely to have major complications, twice as likely to develop occlusion, and four times as likely to cause bloodstream infections. The advantage of this study is its sample size, as a large-scale multicenter comparison between PICC and midline, which provides generality for the results. One of the limitations of this study is its observational design, which allows for confusion and inability to draw causal conclusions. In addition, there is no tracking of the PICC and midline equipment specific features, manufacturers, and coatings involved, which may vary in quality, leading to the risk of complications.
Click to read the research of JAMA Internal Medicine
Related reading: Comparison of complication and incidence of different peripheral puncture central venous catheters (PICC) in patients with hematological malignancies: a retrospective cohort study
In-depth [Prospective Cohort]: This multicenter observational study collected PICC and midline complications in a representative sample of adult inpatients in general medical wards or intensive care units. The included patients received PICC or midline therapy for less than 30 days due to difficult intravenous access or indications for intravenous (IV) antibiotics. Follow up patient results for up to 30 days. Pregnant patients or patients under observation were excluded. This study analyzed 5758 PICCs and 5105 midlines (mean age = 64.8 years, 52.8% were women). Compared with PICC, more midline is used for venous access or difficult to draw blood (72.4% vs. 40.1%), and PICC is used for antibiotics more than midline (72.4% vs. 40.1%). PICC stays longer, the average stay time (stay time) is 14 days, and the median stay time is 6 days. Patients receiving midline therapy were more likely to have a history of thromboembolism than patients receiving PICC (6.7% vs. 3.3%). Compared with midline patients, PICC patients had more major complications (9.9% vs. 3.9%, standard mean deviation [SMD] = -0.237). Catheter occlusion is the most common complication, with a higher incidence in PICC than in the midline (7.0% vs. 2.1%, SMD = -0.240). CLABSI is more common in PICC than CRBSI in the midline (1.6% vs. 0.4%, SMD = -0.126). The frequency of DVT in PICC and midline is almost the same (1.5% vs. 1.4%, SMD = -0.003). Among patients receiving PICC or midline, 0.2% had PE (SMD = -0.018). Interestingly, compared with PICC, the midline is more likely to be removed due to its complications (7.3% vs. 5.2%). In an analysis adjusted for demographic characteristics and medical history, compared with the midline, patients who received PICC were twice as likely to have major complications (OR = 1.99, 95% CI = 1.61-2.47). Twice the likelihood of occlusion (OR = 2.24, 95% CI = 1.70-2.96) and bloodstream infection (OR = 4.44, 95% CI = 2.52-7.82) is the same as the likelihood of DVT (OR = 0.93) , 95% CI = 0.63-1.37) or PE (OR = 1.29, 95% CI = 0.46-3.61). These findings are consistent with the risk in the first 10 days of catheterization.
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