Critical Appraisal Essay on the Use of Peripherally Inserted Central Catheter (PICC)
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This essay critically appraises the use of Peripherally Inserted Central Catheter (PICC) in relation to its maintenance and removal. It discusses the relevance of the VAD product and provides recommendations for clinicians.
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Running head: ESSAY Written Assignment: Critical Appraisal Essay Name of the Student Name of the University Author Note Word Count-
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1ESSAY Introduction- There are three common methods that are used for gaining an access into the blood namely, arteriovenous fistula, intravenous catheter, and synthetic grafts (Deshmukh & Shinde, 2014). Vascular access devices (VADs) are generallyinsertedinto the veins via central or peripheral vessels for analytic or therapeutic aims, such as central venous pressure readings, blood sampling, medication administration, fluid administration, blood transfusion, and total parenteral nutrition (TPN) (Biffi, Toro, Pozzi & Di Carlo, 2014). A peripherally inserted central catheter (PICC), also referred to as apercutaneous indwelling central catheter refers to a type of intravenous vascular access that is used for a longer time period such as, prolonged antibiotic therapy, chemotherapy and/or total parenteral nutrition (Touré et al., 2015).The selection of VAD should always be grounded on the preferences and demands of the patients, the primary reason for inserting the line, the duration it is required to remain inserted, and the skills and expertise of the operator (Argueta-Morales et al., 2014). VAD have also been found to provide a route for the onset of healthcare associated infections, in particular blood stream infection, or local infection (Bratton, Johnstone & McMullen, 2014).The current work context requires frequent administration of intravenous therapy(IV)thathelpsindeliveringliquidsubstancesintotheveinsdirectly.This intravenous route of substance administration most commonly involves injections and/or infusions. PICC can be stated as a long intravenous line, which is commonly used in contemporary practice.This essay will elaborate on a particular VAD and will critically appraise the use of the product, in relation to its maintenance and removal. VADproduct-ThePICCdeviceisacatheterthatisinsertedinthebody, percutaneously through the skin at a peripheral location (Chopra et al., 2014). The device also extends to the posterior vena cava and is found to remain in place, within the vein, for several days and weeks. This type of VAD was first described in the year 1975 and is considered as a major alternative to the use of central venous catheters in the major body veins namely,
2ESSAY internal jugular vein, femoral vein, and the subclavian vein. There is mounting evidence for the association between jugular line and subclavian line placements with pneumothorax (Chopra et al., 2014). The procedure of insertion of a PICC is typically conducted in the X- ray departments and usually takes around an hour. The healthcare staff administer local anaesthetics, with the aim of making the area numb (Itkin et al., 2014). The PICC insertion procedure is alike to insertion of a drip into the arm. The only exception lies in the fact that ultrasound is used for locating the large vein and the preparation time is lengthier, owing to the method being a sterile process. Specialised x-rays are often taken in order to check the location of the PICC. According toLiuet al. (2015) insertion of the PICC is usually conducted via the peripheral vein located in the arm, such as, the brachial vein, basilica vein, and the cephalic vein. This is followed by its proximal advancement towards the heart, through other veins that have larger diameter, until the time the tip of the line is able to rest on cavoatrial junction or the superior vena cava.The VAD is generally inserted by physician assistants, radiology assistants, physicians, nurse practitioners, respiratory therapists, and radiologic technologists. Furthermore, insertion of PICC is asterileprocess, however does not need the presence of any operating room. While being conducted at bedside, it is imperative to form and maintain an appropriate sterile field, throughout the procedure. This is achieved by typically requesting the visitors to leave the patient room until complete insertion of the PICC, concomitant withskin preparationfor cleaning the site of device insertion in the patient (Kieran et al., 2018). Relevance of the VAD product- PICC is generally considered a comfortable VAD option, in comparison to other form of needle sticks that are administered for delivering medications and drawing bloodstream from the patients. Showing similarity with standard intravenoustherapy,PICClinesalsoallowinfusionofspecificmedicationintothe
3ESSAY bloodstream.Nonetheless,theyareconsideredmoredurableandreliablethanother intravenous options (Sharp et al., 2014). They are also used for delivering greater volumes of medications and fluids that are usually not tolerated by the tissues, when inserted through standard IV. PICC lines are administer for a range of causes, characteristically amid patients who are anticipated to require IV medication for a number of weeks. A PICC line is also found to remain in the location for several months, or as long as there is no onset of infection at the site of insertion of the line (Fallouh, McGuirk, Flanders & Chopra, 2015). Owing to the fact that the bloodstream circulates in a rapid rate inside the large veins that are leading towards the heart, the solutions and medicines hold a chance of getting mixed with the blood. Insertion of PICC line prevents the potential damage that might occur in such cases. A PICC line is often used under situations when the healthcare team fails to insert an IV, notwithstanding repeated efforts. It might also be used to guard the blood vessels from medicines that are scathing and could possibly damage the skin round an IV place, or result in impending damage to the blood vessels, like in chemotherapy.Sharp et al. (2015) conducted a research where they stated thatPICC lines are also inserted with the aim of preventing the patients from being stuck recurrently. One common example is the onset of certain types of infections that daily require IV antibiotics for more than six weeks. While most PICC are not removed hastily, if there are no signs and symptoms of infection, most healthcare facilities allow standard IV to continue at the site, 3-4 days prior to its removal and insertion of a new IV. Despite the potential advantages that PICC offers over standard IV, some of the major risk factors allied with the VAD procedure are bleeding, development of blood clot in veins (thrombosis), abnormal rhythm of the heart, puncture of adjacent arteries and veins, infection, and contrast allergic reaction (Sharp et al., 2015).
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4ESSAY Critical appraisal- A randomised controlled trial was conducted byLi et al. (2014) among 100 chemotherapy patients to determine the long term impact of PICC placement with the use of B-mode ultrasound. Results from the trial suggested that upon comparison with the control group (blind puncture), the experimental group (PICC placement by BUMST) demonstrated reduced rates of unplanned removal of catheter (4.0% vs. 18.7%;p=0.02), reduced incidence rate of venous thrombosis (0% vs. 8.3%;p=0.037),decreased incidence raterelatedtomechanicalphlebitis(0%vs.22.9%;p<0.001),andanincreaseinthe incidenceofcathetermigration(32%vs.2.1%;p<0.001).Owingtothesignificant reduction in the severity of contact dermatitis in the experimental group (p=0.038), and decreased maintenance costs (p<0.05), it can be stated that the authors were accurate in demonstrating the effectiveness of PICC line over blind puncture method (Li et al., 2014). However,moreeffectivenessofPICClineinsertionoverblindpuncturewasnotin accordance with the resultsof another study byPatel et al. (2014)that compared PICC with port-chamber catheters that were subcutaneously inserted in patients who were subjected to chemotherapyforthetreatmentofnon-haematologicalmalignancies.Uponrandomly assigning the patients to port and PICC, it was found that the port devices were associated with lower complication rates, in comparison to inserted PICC lines (HR- 0.25, CI, 0.09– 0.86,P= 0.038). This was concomitant with a decrease in the major rates of complication in the port arm, in contrast to PICC arm, where 6% and 20% patients manifested complications due to insertion (0.047 versus 0.193 major complications/100 catheter days,P= 0.034). Insertion and maintenance of PICC was also found responsible for a noteworthy increase in onset of thrombosis amid the patients (25%vs.0%,P= 0.013). Hence, the study failed to demonstrate the effectiveness of PICC as an intravenous device, which can be largely accredited to the
5ESSAY low sample size and the preferences of the patients and physicians for the type of VAD that was to be inserted amid the former (Patel et al., 2014). However,Delarbreet al. (2014) stated that it is imperative to maintain PICC line for avoiding mechanical complications, and also cited the need for providing adequate training to the healthcare staff. Accidental removal of catheter was found among two patients, which couldhavebeenavoidedwiththeappropriateadministrationofocclusivedressing. Furthermore,theauthorsalsoindicatedthatcarefulmaintenanceofthecatheterand introduction of a bidirectional valve are some of the key procedures that might prove beneficial in averting PICC line obstructions. With the aim of evaluating the nature and rates of complications that are associated with the insertion and withdrawal of Central Peripheral Access Catheter (PICC or CVCAP),Lacostena-Pérez, Buesa-Escar and Gil-Alós(2018) conducted a prospective observational study. Suspicion of infection (17.36%; 15.2 per 1000 PICC days) was the most commonly reported complication, followed by 6.25% confirmed infections (5.5 per 1000 PICC days), 1.39% infections in ICU group (1.2 per 1000 PICC days), and 4.86% infections in non-ICU groups (4.2 per 1000 PICC days). This helped in establishing the fact that insertion of PICC line, in place of standard IV is more effective in lowering the risks of implantation complications and does not require immediate removal. This was in contrast with another study that was conducted with the aim of improving the quality to reduce PICC associated complications. Upon the application of a Plan-Do-Study- Act cycle, significant reductions were observed in the complication rate, followed by an improvement in the rate of patient satisfaction. This proved operative in decreasing the complication rate of thrombosis (67%), occlusion (75%), and use of alteplase (87%), besides the absence of any infection occurrence during the study (Walters & Price, 2019). Thus, the research was able to establish the fact that it is utmost essential to take care of the inserted PICC line for preventing onset of major health complications.
6ESSAY This was in accordance with anothersystematic review and meta-analysis byMa, Cheng, Ding, Li and Wang (2018) that illustrated the efficacy of the WeChat smartphone application in self-management of PICC, following discharge of patients from hospitals. Patient group receiving WeChat follow-up demonstrated reduced risks of complications related to PICC (OR- 0.23, 95% CI- 0.19-0.27, P < 0.00001),enhanced ability of self-care (meandifference:36.41,95%CI-34.68-38.14,P<0.00001),greatermaintenance dependency of PICC(OR: 4.27, 95% CI: 3.35-5.44, P < 0.00001), and a substantial improvement in patient satisfaction (OR: 6.20, 95% CI: 4.32-8.90, P < 0.00001).Thus, an analysis of the evidences discussed helps in establishing the fact that PICC can lead to infections in the patients, if not maintained in an appropriate manner and should be immediately withdrawn for averting further complications. Hence, proper PICC insertion and maintenanceisbeneficialforpatients,andanyfailureindoingsoresultsinhealth complications. Recommendations- It is imperative for the clinicians to select a suitableintravascular device (IVD), and take into consideration the type of the catheter, number of lumen, catheter length, site of insertion, type of therapy, risk of difficulties together with infection, and other patient factors. The insertion of this VAD must always be performed bycompetent staff and/ortrainingstaff, underthesupervisionof experiencedworkforce,forminimising infection and other healthcare complications (Sheth et al., 2014). Efforts must be taken by the clinician for explaining to the patient, and their parent/guardian, the process and necessity for catheterisation. Adequate control measures such as, closed door and pulled curtains must also be taken, with the aim of eliminating several environmental risk factors that might worsen the health condition of the patients (Bouaziz et al., 2015).Sterile occlusive dressings must be put, during removal of PICC line, as a method of air embolism aversion protocol.Further recommendations also involve setting up of sterile fields, proximately before any insertion
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7ESSAY procedure is carried out by the suitably trained juniors or clinicians.Performing ultrasound will reduce the frequency of cannulation attempts.During PICC insertion, there trolleys and/or carts having necessary medical supplies must be at close proximity. There is also a need for the precise certification and record keeping by the clinician, in order to guarantee patient safety, permit for audits, and trail occurrences of infection.The physicians must also administer thrombolytic agents like Alteplase for declotting the PICC lines (Dougherty, 2014).The credentials should take account of the time and date of insertion, together with category of VAD, name of operator, length of the line on addition and elimination, skin preparationsolutionused,gauge,anatomicallocation,observationatsiteanddevice replacement or elimination details (Yagnik, Graves & Thong, 2017). All clinicians who are responsible for the addition and maintenance of VADs must guarantee that this is contained by their scope of medical practice, governed by the individual’s authorisations, tutoring, training, capability and maintenance of enactment at a predictable level of care and quality (Department of Health, 2018). The scope of practice of the healthcare professionals is largely reliant on the ability and aptitude of the health facility in which they are employed. Conclusion- To conclude, defining fitting suggestions for the insertion, care, and maintenance of PICCs is significant for patient protection. Vascular access refers to the direct and rapid procedure of insertion or removal of chemicals and devices from the bloodstream of patients.Vascular access is typically used in haemodialysis for removing blood of the patient, for its filtration through a dialyser. PICC is a type of VAD that is inserted through the veins located in the upper arm and helps in conducting essential medicines and nutrients inside the body. Flushing the catheter at regular intervals, and changing the dressings form an essentialaspectofPICCinsertionanditsmaintenance.Hence,adherencetothe recommendationsand considerationof thescholarlyevidenceswilldeliver clarityfor supervision of composite situations before, during and after PICC insertion.
8ESSAY
9ESSAY References Argueta-Morales, I. R., Tran, R., Ceballos, A., Clark, W., Osorio, R., Divo, E. A., ... & DeCampli, W. M. (2014). Mathematical modeling of patient-specific ventricular assistdeviceimplantationtoreduceparticulateembolizationratetocerebral vessels.Journalofbiomechanicalengineering,136(7),071008.doi: 10.1115/1.4026498 Biffi, R., Toro, A., Pozzi, S., & Di Carlo, I. (2014). Totally implantable vascular access devices 30 years after the first procedure. What has changed and what is still unsolved?.SupportiveCareinCancer,22(6),1705-1714. https://doi.org/10.1007/s00520-014-2208-1 Bouaziz, H., Zetlaoui, P. J., Pierre, S., Desruennes, E., Fritsch, N., Jochum, D., ... & Villiers, S.(2015).Guidelinesontheuseofultrasoundguidanceforvascular access.AnaesthesiaCriticalCare&PainMedicine,34(1),65-69. https://doi.org/10.1016/j.accpm.2015.01.004 Bratton, J., Johnstone, P. A., & McMullen, K. P. (2014). Outpatient management of vascular accessdevicesinchildrenreceivingradiotherapy:complicationsand morbidity.Pediatricblood&cancer,61(3),499-501. https://doi.org/10.1002/pbc.24642 Chopra, V., Ratz, D., Kuhn, L., Lopus, T., Chenoweth, C., & Krein, S. (2014). PICC- associated bloodstream infections: prevalence, patterns, and predictors.The American journal of medicine,127(4), 319-328.https://doi.org/10.1016/j.amjmed.2014.01.001 Chopra, V., Ratz, D., Kuhn, L., Lopus, T., Lee, A., & Krein, S. (2014). Peripherally inserted centralcatheter‐relateddeepveinthrombosis:contemporarypatternsand predictors.JournalofThrombosisandHaemostasis,12(6),847-854.
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10ESSAY https://doi.org/10.1111/jth.12549 Delarbre, B., Dabadie, A., Stremler-Lebel, N., Jolibert, M., Cassagneau, P., Lebel, S., ... & Petit, P. (2014). Introduction of the use of a pediatric PICC line in a French University Hospital:reviewofthefirst91procedures.Diagnosticandinterventional imaging,95(3), 277-281.https://doi.org/10.1016/j.diii.2013.05.004 Department of Health. (2018). Guideline-Peripherally inserted central venous catheters (PICC).Retrievedfrom https://www.health.qld.gov.au/__data/assets/pdf_file/0032/444497/icare-picc- guideline.pdf Deshmukh, M., & Shinde, M. (2014). Impact of structured education on knowledge and practice regarding venous access device care among nurses.Int J Sci Res,3(1), 895- 901.Retrievedfromhttps://www.semanticscholar.org/paper/Impact-of-Structured- Education-on-Knowledge-and-Deshmukh-Shinde/ f12c1ad0d8b57132f702285b10d0fa6383cd6ed0 Dougherty, L. (2014). Frequency, diagnosis, and management of occlusive and mechanical PICC complications. InPeripherally inserted central venous catheters(pp. 85-94). Springer, Milano.https://doi.org/10.1007/978-88-470-5665-7_8 Fallouh, N., McGuirk, H. M., Flanders, S. A., & Chopra, V. (2015). Peripherally inserted central catheter-associated deep vein thrombosis: a narrative review.The American journal of medicine,128(7), 722-738.https://doi.org/10.1016/j.amjmed.2015.01.027 Itkin, M., Mondshein, J. I., Stavropoulos, S. W., Shlansky-Goldberg, R. D., Soulen, M. C., & Trerotola, S. O. (2014). Peripherally inserted central catheter thrombosis—reverse taperedversusnontaperedcatheters:arandomizedcontrolledstudy.Journalof VascularandInterventionalRadiology,25(1),85-91.
11ESSAY https://doi.org/10.1016/j.jvir.2013.10.009 Kieran, E. A., O’sullivan, A., Miletin, J., Twomey, A. R., Knowles, S. J., & O’donnell, C. P. F. (2018). 2% chlorhexidine–70% isopropyl alcohol versus 10% povidone–iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial.Archives of Disease in Childhood-Fetal and Neonatal Edition,103(2), F101- F106.http://dx.doi.org/10.1136/archdischild-2016-312193 Lacostena-Pérez, M. E., Buesa-Escar, A. M., & Gil-Alós, A. M. (2018). Complications related to the insertion and maintenance of peripheral venous access central venous catheter.Enfermeriaintensiva.Retrievedfromhttp://www.elsevier.es/es-revista- enfermeria-intensiva-142-linkresolver-complicaciones-relacionadas-con-insercion-el- S1130239918300804 Li, J., Fan, Y. Y., Xin, M. Z., Yan, J., Hu, W., Huang, W. H., ... & Qin, H. Y. (2014). A randomised, controlled trial comparing the long-term effects of peripherally inserted central catheter placement in chemotherapy patients using B-mode ultrasound with modified Seldinger technique versus blind puncture.European Journal of Oncology Nursing,18(1), 94-103.https://doi.org/10.1016/j.ejon.2013.08.003 Liu, Y., Gao, Y., Wei, L., Chen, W., Ma, X., & Song, L. (2015). Peripherally inserted central catheter thrombosis incidence and risk factors in cancer patients: a double-center prospectiveinvestigation.Therapeuticsandclinicalriskmanagement,11,153. doi:10.2147/TCRM.S73379 Ma, D., Cheng, K., Ding, P., Li, H., & Wang, P. (2018). Self-management of peripherally insertedcentralcathetersafterpatientdischargeviatheWeChatsmartphone application: A systematic review and meta-analysis.PloS one,13(8), e0202326. doi: 10.1371/journal.pone.0202326
12ESSAY Patel, G. S., Jain, K., Kumar, R., Strickland, A. H., Pellegrini, L., Slavotinek, J., ... & Ullah, S. (2014). Comparison of peripherally inserted central venous catheters (PICC) versus subcutaneouslyimplantedport-chambercathetersbycomplicationandcostfor patients receiving chemotherapy for non-haematological malignancies.Supportive Care in Cancer,22(1), 121-128.https://doi.org/10.1007/s00520-013-1941-1 Sharp, R., Cummings, M., Fielder, A., Mikocka-Walus, A., Grech, C., & Esterman, A. (2015). The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study.Internationaljournalofnursingstudies,52(3),677-685. https://doi.org/10.1016/j.ijnurstu.2014.12.002 Sharp, R., Grech, C., Fielder, A., Mikocka-Walus, A., Cummings, M., & Esterman, A. (2014). The patient experience of a peripherally inserted central catheter (PICC): a qualitativedescriptivestudy.Contemporarynurse,48(1),26-35. https://doi.org/10.1080/10376178.2014.11081923 Sheth, R. A., Walker, T. G., Saad, W. E., Dariushnia, S. R., Ganguli, S., Hogan, M. J., ... & Zuckerman, D. A. (2014). Quality improvement guidelines for vascular access and closuredeviceuse.JVascIntervRadiol,25(1),73-84.Retrievedfrom http://rentgenhirurg.ru/sites/default/files/rekomendacii_po_vcd.pdf Touré, A., Duchamp, A., Peraldi, C., Barnoud, D., Lauverjat, M., Gelas, P., & Chambrier, C. (2015).Acomparativestudyofperipherally-insertedandBroviaccatheter complications in home parenteral nutrition patients.Clinical Nutrition,34(1), 49-52. https://doi.org/10.1016/j.clnu.2013.12.017 Walters, B., & Price, C. (2019).Quality Improvement Initiative Reduces the Occurrence of Complications in Peripherally Inserted Central Catheters.Journal of Infusion Nursing,
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13ESSAY 42(1), 29-36. DOI: 10.1097/NAN.0000000000000310 Yagnik, L., Graves, A., & Thong, K. (2017). Plastic in patient study: Prospective audit of adherencetoperipheralintravenouscannulamonitoringanddocumentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications.Americanjournalofinfectioncontrol,45(1),34-38. https://doi.org/10.1016/j.ajic.2016.09.008