This cohort study examines the differential risks of an unplanned removal of a peripherally inserted central catheter (PICC) triggered by distinct complication types, including infection, thrombosis, mechanical complications, and catheter-associated skin injury.

AIMS AND OBJECTIVES:(i) To estimate the national incidence of unplanned removal of peripherally inserted central catheters (PICCs) in China. (ii) To explore the associated risk factors to provide evidence for the prevention.DESIGN:A multi-centre prospective cohort study.METHODS:A representative sample of 3222 Chinese adult patients with successful PICC insertion was recruited for the PICC Safety Management Research (PATH) using a two-stage cluster sampling method from December 2020 to June 2022. Sixty hospitals from seven Chinese provinces representing all geographical regions were selected. Demographic information and PICC characteristics were collected using a standard online case report form. Risk factors for the unplanned removal of PICCs were assessed using a cause-specific hazard model and verified using a sub-distribution hazard model. STROBE guidelines were followed in reporting this study.RESULTS:Three thousand one hundred and sixty-six patients were included in the final analysis with a mean age of 59 years and a total of 344,247 catheter days. The incidence of unplanned removal was 10.04%. Female, with thrombosis history, PICC insertion due to infusion failure, valved catheter and double-lumen catheter were risk factors, whereas longer insertion and exposure length were protective factors in the cause-specific hazard model. Higher BMI became an independent risk factor in the sub-distribution hazard model.CONCLUSIONS:Unplanned removal of PICCs is a serious clinical challenge in China. Our findings call for prevention strategies targeting the identified risk factors.RELEVANCE TO CLINICAL PRACTICE:Our study characterised the epidemiology of unplanned removal of PICCs among Chinese adult inpatients, highlighting the need for prevention among this population and providing a basis for the formulation of relevant prevention strategies.PATIENT OR PUBLIC CONTRIBUTION:Patients contributed through sharing their information required for the case report form. Healthcare professionals who provide direct care to the patient at each medical centre contributed by completing the online case report form.

RATIONALE:The spontaneous migration of the peripherally inserted central catheter (PICC) is the displacement of the PICC tip from a satisfactory documented position in the superior vena cava (SVC) into its adjacent veins after several days or months of PICC insertion, and most frequently occurs in the ipsilateral internal jugular vein. However, it is rarely reported to detect migration of PICC tip into the azygos vein in patients who suffered from gastrointestinal dysmotility after abdominal surgery. We report 2 cases of spontaneous malposition of PICC into the azygos vein here and discuss the predisposing factors and processing procedures of this condition. PATIENT CONCERNS:Two female patients with pancreatic disease were inserted PICCs on the left limbs before the abdominal surgery. After the surgery, 1 patient suffered from gastroparesis, and the other suffered from constipation. The nurses found that blood could not be aspirated from the PICCs while normal saline could be injected through the PICCs smoothly. DIAGNOSES:We identified the position of the PICC tip step-by-step, using ultrasound, intracavitary electrocardiogram, and chest X-ray, and confirmed that the tip of the PICC migrated into the azygos vein. INTERVENTIONS:The patients were placed in the semi-reclining position from the supine position, and blood could be easily aspirated from the PICC after flushing with the push-pause flush technique. Intracavitary electrocardiogram displayed the elevated P, indicating that the PICC tip reentered the SVC and was at the lower 1/3 of SVC. OUTCOMES:The PICCs of the 2 patients functioned well afterward and were removed after the parenteral nutrition support was completed. LESSONS:It is critical to assess the function of the PICC before every time of infusion. For patients who undergo abdominal surgery with PICC on the left side, when they had gastrointestinal dysmotility combined with PICC dysfunction, the possibility of spontaneous migration of PICC tip into the azygos vein should be considered.

Background: Intracavity electrocardiogram (IC-ECG) guidance is an effective technology for monitoring the tip locations of centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs). However, for patients with an indwelling CICC, there has been no study on whether the CICC affects PICC tip positioning with IC-ECG guidance. Methods: Thirty people with a CICC requiring PICC insertion, matched with age to controls without a CICC. The stability of IC-ECG waveforms, the amplitude of P-waves, and the accuracy of PICC tip location were compared. Results: There was no significant difference in the stability of the IC-ECG waveforms (chi(2) = 0.22, p = 0.64). The amplitudes of baseline P-waves and ideal P-waves also showed no significant difference (t1 = 0.06, p1 = 0.96, t2 = 0.80, p2 = 0.43). Neither the accuracy of tip location (chi(2) = 1.40, p = 0.50) nor the distance of PICC tip (t = -0.03, p = 0.98) were significantly different. Conclusion: For patients with an indwelling CICC, the position of PICC tip can be accurately determined by the dynamic changes in the P-wave amplitude.

Background: Peripherally inserted central catheters are widely used in clinical practice. Despite the many advantages of peripherally inserted central catheters, unplanned removals can occur owing to irreversible complications and may have adverse consequences for patients. However, the relationship between peripherally inserted central catheter type and the incidence of unplanned removal is unclear.Objective: To investigate the association between the type of peripherally inserted central catheter and unplanned catheter removal.Design: A multicenter prospective cohort study.Settings: Sixty hospitals located in 30 cities across seven provinces in China.Participants: Three thousand two hundred and twenty-two patients aged 18 years or older with one peripherally inserted central catheter inserted for treatment were enrolled, and 3166 (98.3 %) patients with follow-up data were included in the final analysis.Methods: The included participants had peripherally inserted central catheters that either had a proximal valve (n = 2436) or were open-ended (n = 730). A competing risk Cox regression model was used, and both univariate and multivariate analyses were conducted. A sub-distribution hazard model was applied to test the validity of the results.Results: Of the 2436 peripherally inserted central catheters with a proximal valve and 730 that were open-ended, 272 (11.2 %) and 46 (6.3 %) were removed unplanned, respectively. The whole incidence of unplanned removal was 10.04 %; multivariate Cox regression was conducted and it was determined that unplanned removal was statistically significantly associated with the proximal valve peripherally inserted central catheter type (hazard ratio: 1.86, 95 % confidence interval: 1.28 to 2.70, p = 0.001). In patients without cancer, the risk of unplanned removal of peripherally inserted central catheters with a proximal valve was 8.14 times higher than that of openended peripherally inserted central catheters (p < 0.001). Conclusions: In this study, peripherally inserted central catheters with a proximal valve had a higher risk of unplanned removals, especially in patients without cancer. The peripherally inserted central catheter type should be considered in advance, and clinical staff should take appropriate measures to prevent unplanned removals after insertion.(c) 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Peripherally inserted central venous catheter (PICC)-related upper extremity venous thrombosis (UEVT) is defined as upper extremity venous thrombosis within the veins where PICCs were placed or adjacent to and may result in pulmonary embolism. Malignancies, previous history of venous thrombosis and malposition are common risk factors for PICC-UEVT. Once patients demonstrate clinical manifestations of phlebitis and thrombosis, such as swelling, pain and tenderness at the PICC site, venous duplex ultrasonography is the first choice for diagnosing PICC-UEVT. According to American College of Chest Physicians guidelines, it's not recommended to remove PICCs upon detection of PICC-UEVT. The first-line treatment is to administer systemic anticoagulants while keeping the catheter in place, unless any contraindications. PICCs could continue to be used during anticoagulation therapy, suppose that catheter tip remains well placed and functions as normal. With early diagnosis and standard anticoagulant treatment, a better clinical outcome could be achieved. Prophylactic anticoagulation is not routinely recommended per guidelines. Recommendation for asymptomatic PICC-related thrombosis is still absent and warrants further prospective studies with large sample size.

准确的导管尖端位置是PICC安全使用的前提,2021年中华护理学会发布《PICC尖端心腔内电图定位技术》团体标准,对PICC尖端心腔内电图定位技术的核心流程及要点进行规范.本文结合已发表的临床实践证据,对该标准中的核心要点进行简要解读.

Objective:To study the effects of cold spray on pain after non-coring needle insertion.Methods:This was a randomized controlled study. Patients with totally implantable access port (TIAP) were randomly divided into the experimental group and the control group. The experimental group were given cold spray, while the control group were given eutectic mixture of local anesthetics cream (EMLA). The severity of pain, comfort and satisfaction, right-first-time insertion rate and skin reaction incidence were compared between groups.Results:29 patients were included in each of the two groups. The pain assessed with numeric rating scale in the experimental group was less severe than the control group ([1.52±1.02] vs [2.24±1.62]). However, there was no significant difference (d=-0.02 [95% CI:-0.55~0.51], P=0.109). The right-first-time insertion rate was 100% for both groups. The incidence of skin reactions in experimental group was lower (ARR=27.6% [95% CI: 11.32%~43.86%], P=0.008), and comfort scores ( d=-0.97 [95% CI: -0.42~-1.52], P<0.01) and satisfaction scores(ARR=13.8% [95% CI: 1.24%~26.34%], P=0.013) were significantly higher compared with control group. Conclusions:There was no statistically significant difference in the analgesic effect of cold spray and EMLA on pain from non-coring needle insertion. Cold spray acted quickly, comfortably and safely, resulting in better patient satisfaction.

Background: The Michigan Risk Score (MRS) was the only predicted score for peripherally inserted central venous catheters (PICC) associated upper extremity venous thrombosis (UEVT). Age-adjusted D-dimer increased the efficiency for UEVT. There were no external validations in an independent cohort. Method: A retrospective study of adult patients with PICC insertion was performed. The primary objective was to evaluate the performance of the MRS and age-adjusted D-dimer in estimating risk of PICC-related symptomatic UEVT. The sensitivity, specificity and areas under the receiver operating characteristics (ROC) of MRS and age-adjusted D-dimer were calculated. Results: Two thousand one hundred sixty-three patients were included for a total of 206,132 catheter days. Fifty-six (2.6%) developed PICC-UEVT. The incidences of PICC-UEVT were 4.9% for class I, 7.5% for class II, 2.2% for class III, 0% for class IV of MRS (p = 0.011). The incidences of PICC-UEVT were 4.5% for D-dimer above the age-adjusted threshold and 1.5% for below the threshold (p = 0.001). The areas under ROC of MRS and age-adjusted D-dimer were 0.405 (95% confidence interval (CI) 0.303-0.508) and 0.639 (95% CI 0.547-0.731). The sensitivity and specificity of MRS were 0.82 (95% CI, 0.69-0.91), 0.09 (95% CI, 0.08-0.11), respectively. The sensitivity and specificity of age-adjusted D-dimer were 0.64 (95% CI, 0.46-0.79) and 0.64 (95% CI, 0.61-0.66), respectively. Conclusions: MRS and age-adjusted D-dimer have low accuracy to predict PICC-UEVT. Further studies are needed.

To prevent coronavirus disease 2019 (COVID-19) and enhance the nutrition management for patients, the Beijing Quality Control and Improvement Center for Clinical Nutrition Therapy organized relevant experts to formulate Nutrition Management of Patients with Coronavirus Disease 2019 in the Hospital: An Expert Opinion (2020). It clearly stated that food safety, food hygiene, and nutrition management should be incorporated into the whole process of prevention, control, treatment, and rehabilitation of COVID-19. The reasonable and standardized pathway of nutrition management, which includes nutrition-risk screening, malnutrition diagnosis, nutritional support therapy and nutrition monitoring, should be established to improve the immune status, clinical outcome, and quality of life of patients with COVID-19.

Objective:To explore the application effect of time-sharing appointment in the peripherally inserted central catheter(PICC) maintenance clinic.Methods:Patients with medical appointments within two months before and after the application of time-sharing appointment practice in the PICC maintenance clinic were selected. Patients with appointment before application were control group and took paper appointment sheet manually while those after application were study group and took time-sharing appointment. Waiting time, average number of patients waiting per pre-specified time period, patient satisfaction and nurse satisfaction were compared between the two groups.Results:The median waiting time of the study group was 15 min, significantly shorter than that of the control group of 46 min ( P<0.01). The numbers of patients waiting in the waiting area for the study group remained relatively stable across each time period, showing low people density. In the contrast, numbers of patients waiting varied significantly for the control group and the peak of patient flow occurred in periods of 8∶00—10∶00 and 13∶30—14∶30. Patient satisfaction and nurse satisfaction of the study group were both significantly higher than those of the control group (4.99±0.05 vs. 2.15±0.17, P=0.009; 4.67±1.92 vs. 1.90±0.37, P<0.01, respectively). Conclusion:The application of time-sharing appointment in PICC maintenance clinics effectively reduces the waiting time for patients, achieves reasonable patient triage, improves the clinic environment, improves nurse and patient satisfaction, and improves the level of hospital management.

Objective:To investigate nurses' knowledge, attitude and behavior status about the safety management of enteral nutrition tube in a tertiary Class A hospital in Beijing.Methods:A self-designed questionnaire based on reliability and validity was used. Besides, a convenient sampling method was used to select 309 nurses working on enteral nutrition from the hospital.Results:Nurses scored (28.58±6.09)for knowledge, (37.65±5.03)for attitude and (70.01±5.45)for behavior. The percentage of average scores in the three indicators were 57.16%, 94.13% and 93.35%. According to the single factor analysis, the score of behavior differed among nurses with different working years( F=23.61, P=0.032). The score of knowledge differed among nurses with different titles( F=4.48, P=0.012). Besides, the frequency of tube feeding operations had great effects on nurses′ knowledge and behavior ( F=9.64, P<0.001; F=34.59, P=0.018). But there was no statistical difference in the knowledge, attitude, and behavior scores among nurses trained at different frequencies( F=0.85, P=0.497; F=12.56, P=0.231; F=18.97, P=3.479). Conclusions:Nurses have a positive attitude towards the safety management of enteral nutrition tube, but their knowledge level is poor and their behavior needs to be further regulated. It is necessary to carry out relevant training to standardize clinical operations and ensure the safety management of enteral feeding tube.

Global leading scholars in the field of parenteral and enteral nutrition have been seeking for the criteria of diagnosis of malnutrition. In determining the diagnostic criteria for malnutrition, it is also necessary to take into account the normal values and clinically obtained cut-off points of different countries and races. The Global Leadership (nutrition field) Initiative on Malnutrition, GLIM) diagnostic criteria published online on Sep. 2 & Sep.3 2018. In January & February 2019, the [American Society for Parenteral and Enteral Nutrition, ASPEN] and the [European Society for Clinical Nutrition and Metabolism, ESPEN] published in print. The GLIM criteria has also been recorded in [National terminology of parenteral and enteral nutrition of China-2019]. In 2016 "Disease Classification and Code (Chinese expanding version of ICD-10)" having "nutritional risk" and "malnutrition" items officially listed. In 2019 " Notice on National Tertiary Public Hospitals" and in the "National Medical Insurance Administration-coding standard" also include the items of "nutritional risks " and "malnutrition" as diseases name.Although promoting individualized medical therapy in China now, but the actual situation of each clinical department is different. As far as parenteral and enteral nutrition is concerned, it was far from "precision medicine" or "targeted therapy " in clinical practice nowadays. The current aim is to identify which patients need nutrition support therapy for reasonable application - benefit to patient. China's DRG being developed by "big data survey system" . Therefore, it is necessary for "this system" can find nutritional risk and malnutrition as diseases name with the codes from Chinese expanding version of ICD-10. So, nutritional risk and malnutrition need to be filled in the cover page of discharged medical record.

Patients with hematological malignancies and peripherally inserted central venous catheters (PICCs) tend to develop catheter-associated upper extremity venous thromboses (UEVTs) and pulmonary emboli (PE) [ [1] Sanfilippo K.M. Wang T.F. Gage B.F. et al. Incidence of venous thromboembolism in patients with non-Hodgkin lymphoma. Thromb Res. 2016; 143: 86-90 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar , [2] Kang J.R. Long L.H. Yan S.W. et al. Peripherally inserted central catheter-related vein thrombosis in patients with lung cancer. Clin Appl Thromb Hemost. 2017; 23: 181-186 Crossref PubMed Scopus (25) Google Scholar ]. Active cancer, malposition and PICC gauge are common risk factors for PICC-UEVTs [ [2] Kang J.R. Long L.H. Yan S.W. et al. Peripherally inserted central catheter-related vein thrombosis in patients with lung cancer. Clin Appl Thromb Hemost. 2017; 23: 181-186 Crossref PubMed Scopus (25) Google Scholar , [3] Chopra V. Kaatz S. Conlon A. et al. The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis. J Thromb Haemost. 2017; 15: 1951-1962 Crossref PubMed Scopus (58) Google Scholar ]. The association between D-dimer thresholds before catheter insertion and the development of PICC-UEVT in cancer patients remains unknown. D-dimers have been widely used in clinical practice as a high-sensitivity diagnostic approach for suspected venous thromboembolisms (VTEs) [ [4] Cohen A.T. Spiro T.E. Spyropoulos A.C. et al. D-dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial. J Thromb Haemost. 2014; 12: 479-487 Crossref PubMed Scopus (77) Google Scholar ]. Higher D-dimer levels have been associated with an increased risk of lower limb deep venous thromboses (DVTs) or PEs [ [5] van der Hulle T. den Exter P.L. Erkens P.G. et al. Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism. J Thromb Haemost. 2013; 11: 1986-1992 Crossref PubMed Scopus (23) Google Scholar ]. Age-adjusted D-dimers increased the efficiency of excluding clinically suspected DVTs [ [6] van Es N. Bleker S.M. Di Nisio M. et al. Improving the diagnostic management of upper extremity deep vein thrombosis. J Thromb Haemost. 2017; 15: 66-73 Crossref PubMed Scopus (15) Google Scholar ]. Nonetheless, little work has focused on patients with hematological malignancies receiving a PICC.

目的 探讨经外周静脉置入中心静脉导管(peripherally inserted central venous catheter,PICC)并发症多媒体教学病例库在专科护师临床教学中的应用效果.方法 选择参加北京协和医院2013年1月至2014年12月PICC培训班的244例PICC专科执业护师为研究对象,以首次接受PICC并发症多媒体教学病例库教学的执业护师为研究组(139例),选择前期接受传统方式教学的执业护师为对照组(105例),比较两组培训后的考核成绩.结果 两组在年龄和职称等方面比较,差异无显著性.研究组平均考核成绩[(73.1±6.0)分]高于对照组[(70.1±6.0)分],差异有显著性(P=0.000).结论 PICC并发症多媒体教学病例库的建立和教学应用利于提高专科护师识别和处理PICC并发症的能力.

营养风险筛查是临床营养支持治疗的基础.护理人员在营养风险筛查中应扮演重要角色.应建立护士主导的多学科营养支持小组,实现住院患者营养筛查与干预的常规化.对存在营养风险的患者,通过营养支持治疗可改善患者临床结局和成本效果比.

目的:分析改良心电图专用转换夹在PICC置管中辅助导管尖端定位的可行性及安全性.方法:采用前瞻性对照研究.实验组(n=551)使用无菌套膜包裹非无菌心电图专用转换夹引导腔内心电图,对照组(n=551)使用无菌心电图专用转换夹引导腔内心电图.比较两组导管相关性血流感染发生率、心电图波形稳定性、导管尖端位置的准确性.结果:两组均未发生导管相关性血流感染,心电图波形稳定性相近(P=0.376)、导管尖端位置准确性相近(P=0.367).结论:应用改良心电图专用转换夹引导腔内心电图既保证了患者的安全,又使操作过程无菌和便捷.

RATIONALE:Peripherally inserted central catheters (PICC), normally located at the lower 1/3rd of the superior vena cava (SVC) and cavo-atrial junction, are commonly used in cancer patients. Persistent left superior vena cava (PLSVC) is a vascular anomaly, in patients with which seldom research was reported about PICC implanted. After obtaining written informed consent, we present a case where two successful insertions of PICC were performed in a 50-year-old female patient with PLSVC and right SVC.PATIENTS CONCERNS:The patient had ovarian cancer and was admitted for chemotherapy using PICC.DIAGNOSES:Ovarian cancer and PLSVC.INTERVENTIONS AND OUTCOMES:Following insertion of PICC in PLSVC, thrombosis developed. PICC was removed after routine anticoagulation therapy. Owing to tumor recurrence, a second PICC was inserted in the right SVC without any complications.LESSONS:PICC insertion in PLSVC for chemotherapy may be associated with an increased risk of deep venous thrombosis of the upper extremity. A right catheter insertion in patient with PLSVC was preferred.

Objective: To explore the practice of peripherally inserted central catheter (PICC) in patients with severe diseases. Methods: 2580 patients with severe diseases were performed PICC from January 2015 to June 2016. New vascular grading standards were established. Blind insertion technology, ultrasound guidance technology, ultrasound catheter position preliminary judgment method and electrocardiogram (EKG) positioning special conversion clamp were applied during PICC. Results: For the 980 patients with severe vascular injury (38.0%), the successful rate of the blind insertiontechnology and the ultrasound guidance technology was 99.1 and 99.9% respectively. For the 851 patients with severe systemic edema (33.0%), the successful rate of the blind insertiontechnology and ultrasound guidance technology was 99.0% and 99.7% respectively. For the 439 patients with skin laxity (17.0%), the successful rate of the ultrasound guidance technology was 99.7%. For the 310 patients with severe limb contracture (12.0%), the successfulrate of the ultrasound guidance technology was 99.7%. Conclusion: The improved PICC technology can enhance the successful rate of catheterization in patients with severe diseases.