Comparison of Complications of Peripherally Inserted Central Catheters with Ultrasound Guidance or Conventional Methods in Cancer Patients

Peripherally inserted central venous catheter (PICC) was introduced into clinical use in the United States in 1980s. The main part of PICC is to insert an infusional catheter into human superior vein cava through arm elbow, basilica, median and cephalic vein (Fearonce et al., 2010). Although PICC could set up a safe and effective intravenous infusional system for cancer patients who are exposed to long-term venous medication, several adverse factors and complications, e.g. increase in economic burden, phlebitis and venous thrombosis still influence the quality of treatment (Fletcher et al., 2011; Sperry et al., 2012). Ultrasound-guided method combined with seldinger PICC was first proposed by Royer in 2000 (cited in Schweickert et al., 2009). Our hypothesis is that adverse effects, espeically complications of conventional PICC could be avoided by ultrosound guided method. With this background, we carried out this study in 2010.


Introduction
Peripherally inserted central venous catheter (PICC) was introduced into clinical use in the United States in 1980s.The main part of PICC is to insert an infusional catheter into human superior vein cava through arm elbow, basilica, median and cephalic vein (Fearonce et al., 2010).Although PICC could set up a safe and effective intravenous infusional system for cancer patients who are exposed to long-term venous medication, several adverse factors and complications, e.g.increase in economic burden, phlebitis and venous thrombosis still influence the quality of treatment (Fletcher et al., 2011;Sperry et al., 2012).Ultrasound-guided method combined with seldinger PICC was first proposed by Royer in 2000 (cited in Schweickert et al., 2009).Our hypothesis is that adverse effects, espeically complications of conventional PICC could be avoided by ultrosound guided method.With this background, we carried out this study in 2010.

Patient Eligibility
Patients were required to be pathologically diagnosed

Comparison of Complications of Peripherally Inserted Central Catheters with Ultrasound Guidance or Conventional Methods in Cancer Patients
Ping Gong, Xin-En Huang*, Chuan-Ying Chen, Jian-Hong Liu, Ai-Feng Meng, Ji-Feng Feng* with cancer and treated in the Department of Chemotherapy of Jiangsu Cancer Hoptial from February to December of 2010; to sign the informed consent before PICC; to expose to long term chemotherapy or supportive care, hyperalimentation, repeated administration of blood or blood products or venous blood sampling; to have a score of karnofsky performance status ≥ 70, and to be followed until the end of this study.Other eligibility criteria included: adequate hematological (white blood cell count > 3.0×10 9 and platelet count > 150×10 9 ), liver (bilirubin and transaminases < 1.5 times the upper normal limit) and renal function (creatinine leval < 1.5 times the upper normal limit); patients were excluded from the study if they had active cardiac disease (LVEF < 50%), significant arrhythmia, any serious medical or psychiatric condition.

Methods
Ultrsound guided PICC catheterization (UPICC), which uses ultrasound guidance to visualize the vessels, and includes the following steps: A regular gauge hypodermic needle is inserted into a vein, then guide wire is passed several centimeters into the cannula, and cannula is removed leaving the guide wire in place.The guide wire is not advanced past the shoulder.An introducer  sheath with a dilator is introduced over the guide wire after a small incision is made on the skin near the wire; The guide wire and dilator are removed; The catheter is advanced through the introducer sheath; The introducer is then pulled back and removed.The position of the tip of the catheter is confirmed with a chest x-ray.Conventional PICC catheterization (CPICC), which is performed by feel only, steps are as follows: a cannula with a stylet is inserted into a vein near the elbow; after stylet is removed, PICC catheter is advanced through the cannula into the vein; then cannula is pulled back and peeled away from the catheter, and catheter is advanced further into the vein under ultrsound until it reaches the terminating point.The position of the tip is confirmed with a chest x-ray.
After PICC and during follow-up, information on PICC and related complications, eg., successful catheterization, abnormal tip location, bleeding, exudation, phlebitis, and discomfortability of insertion arms will be carefully recorded.
Phlebitis classification criterion is in line with U.S Institute of intravenous infusion care, the degree of phlebitis were 0 no symptoms;1 Erythema at access site with or without pain; 2 Pain at access site with erythema and/or edema; 3 Pain at access site with erythema and/or edema, Streak formation, Palpable venous cord;4 Pain at access site with erythema and/or edema, Streak formation, Palpable venous cord > 1 inch in length, Purulent drainage (Smeltzer et al., 2000;Fernandez et al., 2003).
All study data were analyzed through the STATA 8.0 software (Stata Corporation, 4905 Lakeway Drive College Station, Texas 77845 USA).P<0.05 was considered statistically significant.

Results
The number of patients who fulfil the study eligibility was 180, and they were divided into UPICC or CPICC group.The number of UPICC group which adopted ultrasound-guided combined with improved Seldinger PICC catheterization was 90, including 54 male patients and 36 female patients, the age arranging from 22 to 79.The number of CPICC which adopted traditional PICC method was 90, including 58 male patients and 32 female patients, with age arranging from 26 to 74.
No statistically significant difference was detectede between two group of patients in age, gender, cancer site,and clotting time (Table 1).
In Table 2, it suggested that rates of successful PICC placement and abnormal tip location of catheter were significantly different (both p < 0.05) between two groups, that is 98.9% and 2.2% in UPICC, better than what observed in CPICC group.There were significant differences in phlebitis (1.1% in UPICC vs. 11.1% in CPICC) and finger swelling (2.2% in UPICC vs. 10% in CPICC) between two groups (P < 0.05).During the sixth day to removal of catheter, statistically significant difference was revealed between two groups in terms of venous thrombosis and comfortability of insertion arms (Table 3).More thrombosis (7.5%) and discomfortability (20%) were recorded in CPICC than in UPICC group (0% and 2.4% , respectively).

Discussion
PICC has been performed for more than 10 years in Jiangsu Cancer Hospital and Resarch Institute.Some information regarding research and clinical work of this hospital has been introduced elsewhere (Huang et al., 2004;Zhou et al., 2009;Jiang et al., 2010;Yan et al., 2010;Huang et al., 2011;Li et al., 2011;Li et al., 2011).Practitioners with good trainning and experience were arranged to conduct CPICC in Jiangsu Cancer Hospital and Resarch Institute.Before catheterization, they have to distinguish the location of a vein in the capital fosse or elbow by their naked eyes.This has been attributed to be a risk factor of imprecision and of unsuccessful venous puncture rate of CPICC that is reported around 65% to   (Yaghmai et al., 1998).Compared with CPICC, our study suggested that UPICC could clearly identify the vascular structure, therefore, increase the successful rate of venous puncture to 98.9%.Results of this study also revealed that the possibility of bleeding was reduced during UPICC.One reason is that needle of CPICC could impose more damage to vascular endothelium and induce more hemorrhage.This is different compared with UPICC, during which a tiny needle is employed to puncture the tissue and a blade to expand the operation field, thus reduced hemorrhage and exudation.The same reason could also explain our results that the occurrence of phlebitis during UPICC is less common than that observed during CPICC.Phlebitis was one of the most common complications in the PICC catheter, with the incidence reported around 2.6% to 9.7% (Zheng et al., 2004), and usually occurred within 5 days after catheterization (Du et al., 2005).For CPICC, catheter line is usually placed along the median or cephalic vein that is relatively superficial, and easy to be fixed.However these two veins, are thought to hold more venous valves and branches, making catheterization unsuccessful.In our study, rate of phlebitis in CPICC was 11.1%, that is in line with previous study, with another main risk considered to be repeat venous puncture (Nicholson et al., 2010).In addition to above reasons, other risk factors including weather condition in Nanjing that is hot and humid from June to October and makes patients sweat more, easy to be bacteria infected, also contributed to the high rate of phlebitis.On the other hand, during UPICC, practitioner could clearly view the structure of basilica vein that is ususlly straight, so that the length of catheter is shortened, thus reduce phlebitis (Wu et al., 2008).In our study, only one patient in UPICC group, with large body mass index and excessive sweating, was dectected to suffer from phlebitis.In terms of venous thrombosis, which is the most dangerous complication caused by PICC, and generally occurs in 14 to 53 days after catheterization (Zhou et al., 2008), our results suggested that it was less common in UPICC than in CPICC group.We considered the reason could be in line with what observed in phlebitis.
In conclusion, considering low complications of UPICC when compared with CPICC, UPICC should be strongly recommended in clinical practice especially to cancer patients, who need long-term intravenous medications.

Table 3 . Complication Comparison Between Cancer Patients Who Received Ultrsound Guided Peripherally Inserted Central Venous Catheterization (UPICC) or Conventional PICC (CPICC)
*According to follow-up analysis, five days after catheter removal, sample size was 85 in UPICC