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Table 70Parenteral nutrition (PN) route of access: PICC vs CVC

Bibliographic referenceStudy TypeEvidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments (including source of funding)
Cowl et al 200071RCT1+102 patients

CVC n= 51
PICC n=51
Hospitalised patients who required TPN, age 18 years or older who had a visible basilic, median cubital, or cephalic vein suitable for cannulation.

Median age (range):
CVC: 59 (30–80)
PICC: 58 (21–81)

Gender, n (%)
Male:
CVC: 24 (47.1)
PICC: 32 (62.7)

Female:
CVC: 27 (52.9)
PICC: 19 (37.3)

Patients were excluded if they lacked visible venous access, possessed musculoskeletal and peripheral nervous system pathology, neutropenic (absolute neutrophil count < 500), undergone bone marrow or other organ transplantation, had suspected bacteraemia at the time catheter insertion.
PICC

Catheter insertion:

Balic vein 60.8%
Cephalic vein: 17.6%
Median antecubital basilic vein: 7.8%

Single and double lumen silicone elastomer PICCs (60 cm, 3.0 For 5.5 F, respectively) inserted over a hydrophilic guide wire.

No antibiotic-impregnated or antibiotic coated catheters were utilised.

Once catheters were inserted, each catheter lumen was heparinised with 3cc of 100 U/cc solution.

Insertion technique: Per-Q-Cath PICC catheter (Gesco International, San Antonio, TX, USA). PICC lines secured with adhesive strips placed across the wings of the catheter.

All lines were dressed with sterile gauze and covered with a transparent membrane dressing (Tegaderm, Medical products Division/3M, St Paul, MN, USA)

Dressing changes at aprox. 5 days intervals.
The catheters were flushed with 3 cc of 100 U/cc heparin solution followed by 5 to 10cc of normal saline, each time a lumen was accessed, regardless the catheter calibre. Catheters were examined daily for leakage, discomfort mechanical failure, and dislodgement.

Catheter insertions were divided randomly among senior surgical residents, specially trained intravenous nurses and study investigators.

Catheter inserted by, n (%):

Study investigators: 21 (41.2)

General surgery residents:
13 (25.5)

IV nursing team:
17 (33.0)

Insertion site, n (%):

- Basilic vein: 31 (60.8)

- Cephalic vein: 9 (17.6)

- Median antecubital basilic vein: 4 (7.8)

Site in hospital where inserted, n (%):

ICU: 2 (3.9) Inpatient ward (not monitored): 49 (96.1)

Number of catheter

ports, n (%):
- Single: 13 (29.5)
- Multiple: 31 (70.5)
CVC

Catheter insertion:

Subclavian vein:
- right: 78.4 %
- left: 15.7 %

Subclavian catheters with up to three lumens (5.0 F and 7.0 F). Insertion technique: Modified Seldinger technique. Catheters secured with a suture.

No antibiotic- impregnated or antibiotic coated catheters were utilised.

Once catheters were inserted, each catheter lumen was heparinised with 3cc of 100 U/cc solution.

All lines were dressed with sterile gauze and covered with a transparent membrane dressing (Tegaderm, Medical products Division/3M, St Paul, MN, USA)

Dressing changes every 72 hours.

The catheters were flushed with 3 cc of 100 U/cc heparin solution followed by 5 to 10cc of normal saline, each time a lumen was accessed, regardless the catheter calibre. Catheters were examined daily for leakage, discomfort mechanical failure, and dislodgement.

Catheter insertions were divided randomly among senior surgical residents, specially trained intravenous nurses and study investigators.

Catheter inserted by, n (%):

Study investigators:
15 (29.4) NS

General surgery residents:
36(60.6) p<0.01

IV nursing team:
0 (00) p<0.0001

Insertion site, n (%):

- Right subclavian: 40 (78.4)

- Left subclavian: 8 (15.7)

Site in hospital where inserted, n (%):

ICU: 4 (7.8)
Inpatient ward (not monitored): 47 (92.2)
NS

Number of catheter ports, n (%):

- Single: 8 (15.7)

- Multiple: 40 (83.3) NS
Until end of PNPICC (n=51)
CVC (n=51)
The study design was limited in that to maintain statistical power, it could only detect a 15% or greater difference between the two catheter types. A larger data set is required before the findings noted in this study can be applied to the general population of patients who receive central venous catheterisation.

33% of catheters in PICC group were inserted by IV nursing team.

CVC catheters were inserted by study investigators and general surgery residents only.

Funding: Supported in part by National Institutes of Health Grant and a Process Improvement Grant from the University of Iowa.
Difficulty in catheter insertion, n (%) (>2 and <5 attempts)PICC : 11(21.6)
CVC : 5 (9.8) [p<0.05]
Mean insertion time, min (+/− SD)PICC : 42.1 (17.2)
CVC : 36.7 (15.4) [Not significant]
Mean insertion time per catheter, min (+/−SD)Study investigators :
PICC : 39.6 (10.1)
CVC : 32.1 (9.7) [Not significant]

General surgery residents :
PICC : 54.9 (11.9)
CVC : 41.0 (8.8) [Not significant]

IV nursing team :
PICC : 42.7 (12.3)
CVC : -
Median duration of catheter dwell time days, (range)PICC : 9.6 (1–36)
CVC : 10.8 (2–27) [Not significant]
Aborted insertion attempt, n (%)PICC : 7 (13.7)
CVC : 3 (5.9) [Not significant]
Completion of therapy without line complication, n (%)
- End of prescribed coursePICC : 24 (47.1)
CVC : 35 (68.6) [p<0.05]
- Patient diedPICC : 1 (2.0)
CVC : 1 (2.0) [Not significant]
Clinically-evident thrombophlebitis:
Total, n (%)PICC : 8 (15.4)
CVC : 1 (2.0) [p<0.01]
- MildPICC : 2 (4.0)
CVC : 0 (0.0) [Not significant]
- ModeratePICC : 2 (4.0)
CVC : 1 (2.0) [Not significant]
- SeverePICC : 4 (7.8)
CVC : 0 (0.0) [p<0.05]
MalpositionPICC : 5 (9.8)
CVC : 1 (2.0) [p<0.05]
PneumotoraxPICC : 0 (0.0)
CVC : 2 (4.0) [Not significant]
Line occlusionPICC : 6 (11.7)
CVC : 2 (4.0) [Not significant]
- Requiring catheter removalPICC : 1 (2.0)
CVC : 0 (0.0) [Not significant]
Catheter infection:
- TotalPICC : 2 (4.0)
CVC : 3 (5.9) [Not significant]
- Local (purulence from site)PICC : 1 (2.0)
CVC : 1 (2.0) [Not significant]
- ProbablePICC : 1 (2.0)
CVC : 1 (2.0) [Not significant]
- DefinitePICC : 0 (0.0)
CVC : 1 (2.0) [Not significant]
Falsely suspected line infectionPICC : 1 (2.0)
CVC : 6 (11.8) [p<0.05]
Dislodge catheterPICC : 3 (5.9)
CVC : 0 (0.0) [Not significant]
Catheter failure/leakPICC : 2 (4.0)
CVC : 0 (0.0) [Not significant]

From: Appendix Four, Evidence Tables

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).
Copyright © 2006, National Collaborating Centre for Acute Care.

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