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The Michigan Appropriateness Guide for Intravenous Catheters(MAGIC): Results From a Multispecialty Panel Using the RAND/UCLAAppropriateness MethodVineet Chopra, MD, MSc; Scott A. Flanders, MD; Sanjay Saint, MD, MPH; Scott C. Woller, MD; Naomi P. O’Grady, MD;Nasia Safdar, MD, PhD; Scott O. Trerotola, MD; Rajiv Saran, MD, PhD; Nancy Moureau, BSN, RN; Stephen Wiseman, PharmD;Mauro Pittiruti, MD; Elie A. Akl, MD, MPH, PhD; Agnes Y. Lee, MD, MSc; Anthony Courey, MD; Lakshmi Swaminathan, MD;Jack LeDonne, MD; Carol Becker, MHSA; Sarah L. Krein, PhD, RN; and Steven J. Bernstein, MD, MPH
Use of peripherally inserted central catheters (PICCs) has grownsubstantially in recent years. Increasing use has led to the real-ization that PICCs are associated with important complications,including thrombosis and infection. Moreover, some PICCs maynot be placed for clinically valid reasons. Defining appropriateindications for insertion, maintenance, and care of PICCs is thusimportant for patient safety.
An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use ofPICCs. After systematic reviews of the literature, scenarios re-lated to PICC use, care, and maintenance were developed ac-cording to patient population (for example, general hospitalized,critically ill, cancer, kidney disease), indication for insertion (infu-sion of peripherally compatible infusates vs. vesicants), and du-ration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days).Within each scenario, appropriateness of PICC use was com-pared with that of other venous access devices.
After review of 665 scenarios, 253 (38%) were rated as appro-priate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappro-priate. For peripherally compatible infusions, PICC use was ratedas inappropriate when the proposed duration of use was 5 orfewer days. Midline catheters and ultrasonography-guided pe-ripheral intravenous catheters were preferred to PICCs for usebetween 6 and 14 days. In critically ill patients, nontunneled cen-tral venous catheters were preferred over PICCs when 14 orfewer days of use were likely. In patients with cancer, PICCs wererated as appropriate for irritant or vesicant infusion, regardless ofduration.
The panel of experts used a validated method to develop ap-propriate indications for PICC use across patient populations.These criteria can be used to improve care, inform quality im-provement efforts, and advance the safety of medical patients.
Ann Intern Med. 2015;163:S1-S39. doi:10.7326/M15-0744 www.annals.orgFor author affiliations, see end of text.
Reliable venous access is a cornerstone of safe andeffective care of hospitalized patients. Spurred by
technological advances, several venous access devices(VADs) for use during and beyond hospitalization areavailable to meet this need. In recent years, peripher-ally inserted central catheters (PICCs) have becomepopular for venous access in hospital settings (1, 2).Compared with traditional central venous catheters(CVCs), PICCs offer several advantages, including saferinsertion in the arm, cost-effective and convenientplacement via vascular access nursing teams, and self-care compatibility that facilitates use beyond hospital-ization (3–5). It is therefore not surprising that use ofPICCs has grown considerably worldwide (6–8).
Despite these advantages, PICCs are central ve-nous catheters that may lead to important complica-tions (9). For instance, problems such as luminalocclusion, malpositioning, and dislodgement occur fre-quently with these devices (10–12). Similarly, superficialthrombophlebitis or infection at the site of PICC inser-tion may occur despite uneventful and optimal place-ment (13, 14). In addition, PICCs are associated withmorbid complications, including venous thromboem-bolism and central line–associated bloodstream infec-tion (15–17). Ensuring appropriate use of PICCs is thusvital to preventing these costly and potentially fatal ad-verse events.
A growing number of studies suggest substantialvariation and potentially inappropriate use of PICCs inhospitalized patients. For example, in a study from a
large academic medical center, many PICCs were notactively used or were inserted in patients who also hadperipheral intravenous catheters (18). In a decade-longstudy conducted in a tertiary hospital, changes in pat-terns of PICC use, including shorter dwell times andambiguous indications for insertion, were reported(19). Additional cause for concern comes from a recentstudy, which found that 1 in 5 inpatient providers didnot know that their patients had CVCs, with lack ofawareness being greatest for PICCs (20). Surveys of in-patient providers have also demonstrated knowledgegaps related to appropriate indications and care prac-tices for PICCs (21, 22). Collectively, these data havenot only led to reviews of PICC use in hospitals (23) butalso to calls by the Choosing Wisely initiative to im-prove PICC practices across the United States (24, 25).
The concepts of inappropriate overuse and under-use of medical devices are by no means unique toPICCs. Rather, such issues accompany the diffusion ofmany novel health technologies. In many such in-stances, a key barrier to achieving appropriate use is
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the fact that evidence at a level of detail needed toapply to the range of patients seen in everyday practiceis not available. Nevertheless, clinicians must makechoices regarding such innovations on a daily basis,potentially fueling inconsistent practice. In the absenceof high-quality evidence, an approach that combinesavailable data with the experience and insight of clini-cal experts is valuable as it would provide guidancewhere none is otherwise available.
Given this background, we organized and con-ducted a multidisciplinary meeting of national and in-ternational experts to develop appropriateness criteriafor use, care, and management of PICCs and relatedVADs in hospitalized patients. Our objectives were to 1)develop a list of appropriate indications for use ofPICCs in relation to other VADs, 2) define the appropri-ateness of practices associated with the insertion andcare of PICCs, 3) determine appropriate practices fortreatment and prevention of PICC complications, and4) rate the appropriateness of peripheral intravenouscatheter use in situations that prompt PICC placement.
METHODSOverview of the RAND/UCLA AppropriatenessMethod
We used the RAND Corporation/University of Cali-fornia Los Angeles (RAND/UCLA) AppropriatenessMethod to create criteria for appropriate use of PICCsand related VADs (10). Introduced in the 1980s, theRAND/UCLA method was developed to enable mea-surement of overuse of medical and surgical proce-dures. According to this methodology, a procedure isconsidered appropriate when the “expected healthbenefits (e.g., increased life expectancy, relief of pain,reduction of anxiety or pain) exceed the expected neg-ative consequences (e.g., mortality, morbidity, anxiety,pain) by a sufficiently wide margin such that the proce-dure is worth doing, exclusive of cost.” The approachhas thus been applied to an array of procedures, in-cluding coronary angiography (26), surgical proce-dures (27, 28), cataract removal (29), and transplant or-gan allocation (30). Recently, the method was also usedto develop criteria for appropriate use of urinary cath-eters in hospitalized patients (31).
The RAND/UCLA method was particularly valuablefor developing PICC appropriateness criteria for sev-eral reasons. First, the approach allowed the synthesisof the best available evidence with practice-based,domain-specific insights from experts. This uniquecombination ensured both clinical relevance and evi-dentiary support for the developed recommendations.Second, unlike other group-rating methods, the focusof the RAND/UCLA approach is not to ensure consen-sus, but minimize artifactual disagreement that mayarise from misunderstanding of scenarios being rated.This nuance is highly relevant in the case of PICCs, be-cause available evidence is derived from heteroge-neous study designs (for example, retrospective, case–control studies and randomized trials), populations (forexample, critically ill, cancer), and clinical specialties
(nursing, radiology, medical or surgical disciplines) andis thus prone to misinterpretation. Because the RAND/UCLA method pairs clear instructions and precise clin-ical definitions with a systematic, reliable, and repro-ducible rating system (27), the recommendationsgenerated will have high internal validity. Finally,should clinical scenarios lack sufficient detail to makean informed judgment regarding appropriateness, theRAND/UCLA method encourages clarification by pan-elists so as to make ratings more relevant and precise.In this fashion, generalizability and external validity ofthe developed appropriateness indications are alsoensured.
Proper conduct of the RAND/UCLA Appropriate-ness Method requires the sequential performance ofseveral steps, including information synthesis, panelistselection, creation of scenarios, rating process, andanalysis of results.
Information SynthesisThe first step of the RAND/UCLA Appropriateness
Method is to systematically review and synthesize theavailable literature. With the assistance of 2 researchlibrarians, we searched for English-language articles(between 12 November 2012 and 1 July 2013) by usingthe following databases: MEDLINE via Ovid (1950 topresent), EMBASE (1946 to present), BIOSIS (1926 topresent), and the Cochrane Central Register of Con-trolled Trials via Ovid (1960 to present). The searchstrategy incorporated Boolean logic, controlled vocab-ularies (for example, Medical Subject Heading terms)and free-text words. Because the panel was focused ondetermining the appropriateness of PICC use in hospi-talized adults, articles that included only pediatric pa-tients or devices not comparable with PICCs (for exam-ple, arterial or hemodialysis catheters) were excluded.
We also included relevant guidelines, such as theInfusion Nursing Society Standards of Practice (32),Centers for Disease Control and Prevention/HealthcareInfection Control Practices Advisory Committee centralline–associated bloodstream infection preventionguidelines (33), American Society of AnesthesiologyTask Force on Central Venous Access (34), AmericanCollege of Chest Physicians Antithrombotic Therapyand Prevention of Thrombosis Guidelines (35), and In-ternational Clinical Practice Guidelines for the Treat-ment and Prophylaxis of Thrombosis Associated WithCentral Venous Catheters in Patients With Cancer (36).
All retrieved articles were independently scannedfor eligibility by 2 of the authors. Disagreements on el-igibility were resolved by consensus, and a final list ofeligible studies and tables summarizing the evidencewere created. The search strategy is provided inAppendix Table 1 (available at www.annals.org), andTable 1 (on page S25) summarizes the included articles.
Participant and Panelist SelectionViewpoints related to PICC use are known to vary
across specialties; thus, what may be appropriate inone field may not be appropriate in another. To fosterdiscussions about these issues, specialists representingvascular access nursing, hospital-based medicine, inter-
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nal medicine, infectious disease, critical care, nephrol-ogy, hematology/oncology, pharmacy, surgery, and in-terventional radiology were considered necessary toensure representativeness of the panel. Leading na-tional and international experts from each of these pro-fessions who are eminent scholars or researchers, rep-resent relevant medical societies, or have substantialclinical experience in the field were invited to participate.
To ensure that deliberations took into accountpatient-centered viewpoints, we also invited a patientto participate on our panel. We recognized that theideal patient had to be able to speak about experi-ences with PICCs and related VADs. We recruited sucha patient from our university practice in Ann Arbor,Michigan. Owing to the scientific nature of the material,however, the patient panelist did not rate scenarios andinstead contributed to panelist discussions. Throughthis process, 15 multispecialty panelists were recruitedto develop the Michigan Appropriateness Guide for In-travenous Catheters (MAGIC) (Appendix Table 2, avail-able at www.annals.org).
Creation of ScenariosOn the basis of articles found through the system-
atic literature searches, we created clinical scenarios torate the appropriateness of insertion, maintenance, andcare of PICCs. To accurately reflect clinical decisionmaking, devices, including peripheral intravenous cath-eters, ultrasonography-guided peripheral intravenouscatheters, midline catheters, nontunneled CVCs, tun-neled CVCs, and ports, were compared with PICCs(Figure 1). Scenarios were crafted so as to allow judg-ment of real-world use of PICCs; thus, areas of consen-sus, controversy, and ambiguity were purposefully in-cluded. To further ensure validity, we asked eachexpert to provide a list of concerns related to PICC usethat were most relevant to their practice (Appendix Ta-ble 3, available at www.annals.org). If not already rep-resented, these issues were also incorporated into sce-narios of appropriateness.
We developed a conceptual framework to ensurethat scientific content, clinical indications, relevantVADs, and contextual factors were adequately repre-sented when drafting scenarios (Figure 2). Thus, indica-tions for PICC insertion were systematically categorizedinto 1) duration of venous access (≤5 days, 6 to 14 days,15 to 30 days, ≥31 days); 2) type of infusate (for exam-ple, irritants or vesicants, including parenteral nutritionand chemotherapy); and 3) use for specific reasons,such as frequent obtaining of blood samples, poor ordifficult venous access, and continuation of intravenoustherapies in the outpatient setting. For each of theseinstances, clinical scenarios incorporating 1) patient-specific factors (for example, critical illness, cancer di-agnosis, stage of chronic kidney disease [CKD]), 2)device-specific factors (number of lumens, gauge, typeof PICC, alternative VADs), and 3) provider-specific fac-tors (the operator inserting the PICC, technique forPICC insertion) were created. In addition, scenarios re-garding appropriate practices for care, management,and treatment of PICC complications were written. Fi-
nally, because lack of peripheral access often promptsPICC use for specific clinical needs (for example, needfor contrast-based studies or blood transfusion), sce-narios related to use of peripheral intravenous catheterin such settings were created.
We pilot-tested all scenarios with 2 hospital-medicine physicians and further edited them for con-tent and clarity on the basis of their feedback. In thismanner, 665 scenarios and 391 unique indications forPICCs and related VADs were developed.
Rating ProcessRating of scenarios and indications were con-
ducted over 2 rounds. In round 1, each panelist re-ceived the literature review, definitions of all termsused, a rating document, and instructions for rating.Panelists were asked to dedicate at least 4 hours tocomplete the rating document. In accordance with theRAND/UCLA method, panelists were instructed not toconsider cost when making judgments; rather, theywere asked to use the available scientific evidence andbest clinical judgment in rating appropriateness (Sup-plement, available at www.annals.org). To ensure thatappropriateness was rated exclusive of confoundingcircumstances (such as specialist availability), panelistswere also instructed to assume availability of all re-sources related to the scenarios.
For each indication, panel members rated appro-priateness by considering the benefit–harm ratio on ascale of 1 to 9, where 1 indicated that harms outweighbenefit and 9 signified that benefits outweigh harm;Appendix Table 4 (available at www.annals.org) pro-vides examples of this process. A middle rating of 5signified that harms or benefits were equal, or that therater could not make an informed judgment on the in-dication. For a series of indications where 2 deviceswere appropriate, we asked panelists to rate prefer-ence for use of one device compared with the other,regardless of cost. Median ratings on opposite ends ofthe scale (for example, 1 to 3 or 7 to 9) were used toindicate preference of one device over another; a rat-ing in the range of 4 to 6 suggested no preference.
Each panelist rated every scenario twice in a2-round, modified Delphi process. In the first round,ratings were made individually and no interaction be-tween panelists occurred. In the second round, panelmembers traveled to Ann Arbor, Michigan, for an in-person meeting where individualized documents show-ing their ratings along with the distribution of all first-round ratings of the panel were provided.
Over 2 days, a RAND/UCLA methodology expertand a scientific content expert moderated a panel dis-cussion of all indications and scenarios. The sessionswere structured to encourage debate and discussionspecifically about ratings where disagreement (oppo-site ratings) or neutrality/uncertainty (ratings of 4 to 6)occurred in round 1. For instance, it often became ap-parent in the second round that panelists had dis-agreed not on the indication, but on the patient or cir-cumstances being considered because of inherentassumptions, specialty-specific views, or ambiguity in
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the scenario itself. When this occurred, the scenariowas rewritten with input from the entire panel such thatclarifying language or necessary specification wasincluded.
For example, ratings for PICC insertion in patientswith CKD were found to be widely disparate in round 1.During round 2, our panel nephrologist clarified that
placement of PICCs in patients with stage 3b or greaterCKD was specifically contraindicated. Therefore, for in-dications that included CKD, 2 sets of scenarios werecreated (stage 3a or lower vs. stage 3b or higher), usingXs and Os on the rating form to distinguish these rat-ings. Panelists then rerated each of the scenarios, im-proving validity and agreement of their responses.
Figure 1. Vascular access devices reviewed to formulate appropriateness ratings.
A. Peripheral IV Catheter
B. US-Guided Peripheral IV Catheter
C. Midline Catheter
E. Tunneled Central Venous Catheter
F. Implanted Port
D. Nontunneled Central Venous Catheter
G. Peripherally InsertedCentral Catheter
IV = intravenous; US = ultrasonography. A. Peripheral IV catheter. These devices are typically 3 to 6 cm, enter and terminate in the peripheral veins(cross-section), and are often placed in the upper extremity in veins of the hand. B. US-guided peripheral IV catheter. Ultrasonography may be usedto facilitate placement of peripheral intravenous catheters in arm veins that are difficult to palpate or visualize. “Long” peripheral IV catheters(typically ≥8 cm) that are specifically designed to reach deeper veins are also available for insertion under US guidance. C. Midline catheter. Thesedevices are 7.5 to 25 cm in length and are typically inserted in veins above the antecubital fossa. The catheter tip resides in the basilic or cephalicvein, terminating just short of the subclavian vein. These devices cannot accommodate irritant or vesicant infusions. D. Nontunneled central venouscatheter. Also referred to as “acute” or “short-term” central venous catheters, these are often inserted for durations of 7 to 14 d. They are typically15 to 25 cm and are placed via direct puncture and cannulation of the internal jugular, subclavian, or femoral veins. E. Tunneled central venouscatheter. These differ from nontunneled catheters in that the insertion site on the skin and site of ultimate venipuncture are physically separated,often by several centimeters, reducing the risk for bacterial entry into the bloodstream and facilitating optimal location of the catheter for care of theexit site. Tunneled devices may be cuffed or noncuffed; the former devices have a polyethylene or silicone flange that anchors the catheter withinthe subcutaneous tissue and limits entry of bacteria along the extraluminal surface of the device. F. Implanted port. Ports are implanted in thesubcutaneous tissue of the chest and feature a reservoir for injection or aspiration (inset) and a catheter that communicates from the reservoir to adeep vein of the chest, thus providing central venous access. Ports are cosmetically more desirable than other types of central venous catheter andcan remain in place for months or years. G. Peripherally inserted central catheter. These long vascular access devices (>45 cm) are inserted intoperipheral veins of the upper arm in adults and advanced so that the tip of the catheter resides in the lower portion of the superior vena cava orupper portion of the right atrium. They are similar to central venous catheters in that they provide access to the central circulation, but they do sowithout the insertion risks associated with direct puncture of deep veins in the neck, chest, or groin.
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Data Processing and AnalysisFirst-round ratings were submitted either electron-
ically via an online survey system or through paperforms. Data obtained from paper ratings were manuallyentered into a study database (Qualtrics Research SuitePackage, Qualtrics USA) and checked in duplicate fortranscription errors. Descriptive statistics (mean, me-dian, mode) were calculated for all variables. A sum-mary result document was created that listed the fre-quency of responses, median responses, and eachindividual panelist's response for every scenario. In ac-cordance with the RAND/UCLA method, all indicationswere classified into 3 levels of appropriateness:
1. Appropriate: panel median score of 7 to 9, with-out disagreement;
2. Uncertain/neutral: panel median score of 4 to 6,or with disagreement regardless of median; and
3. Inappropriate: panel median score of 1 to 3,without disagreement.
Disagreement was said to have occurred when atleast 5 of the 15 panel members rated an indication asappropriate (median score, 7 to 9) and at least 5panelists rated the same indication as inappropriate(median score, 1 to 3). Only indications withoutdisagreement were classified as inappropriate orappropriate.
DefinitionsTo ensure consistency, standardized definitions of
devices (for example, PICC, midline), populations (ac-tive cancer, “special” populations), indications (for ex-ample, frequent obtaining of blood samples, hemody-namic monitoring), and infusates (irritant, vesicant)were provided to panelists. A complete glossary ofterms and definitions used is provided in the ratingsdocument in the Supplement (available at www.annals.org).
Figure 2. Concep ual framework used for the development of scenarios and indications of appropriateness.
AppropriatenessIndications
Proposed durationof venous access
Indication forvenous access Nature of infusate
Patientcharacteristics
Devicecharacteristics
Providercharacteristics
Systematic Review of the Literature
Clin
ical
Par
adig
ms
and
Pane
list L
ists
A
reas of Controversy, A
mbiguity, or U
ncertainty
Maintenance andcare practices
Treatment ofcomplications
Developmentof
ClinicalScenarios
To develop a conceptual framework, systematic reviews of the literature were conducted to determine the evidence base. With input from panelists,areas of controversy and ambiguity were identified and contextualized within clinical paradigms and lists of common problems associated withperipherally inserted central catheters. By methodologically pairing selection of venous access device with indication, duration, and nature ofvenous access and specific patient, device, and provider variables (center boxes), scenarios for panelists were created. These scenarios formed thebasis for the appropriateness indications.
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Role of the Funding SourceThis project was supported by a Young Researcher
Award from the Society of Hospital Medicine to Dr.Chopra. Funds were used to support panelist lodging,meals, transportation, and venue. Blue Cross BlueShield of Michigan provided salary support for 3 of theauthors through a grant to the University of Michigan.Neither funder had a role in the design, conduct, oranalysis of the project or the decision to submit themanuscript for publication.
RESULTSWithin the 665 scenarios reviewed, panel members
rated 391 unique indications for PICCs and relatedVADs. During the first round, the panel rated 237 sce-narios as appropriate (36%), 267 as inappropriate(40%), and 161 as neutral/uncertain (24%). After thesecond round of in-person interactions, 253 scenarioswere rated as appropriate (38%), 288 as inappropriate(43%), and 124 as neutral/uncertain (19%). Thus, duringthe second round of discussions, better distinction ofneutral/uncertain indications as being appropriate orinappropriate indications occurred. A substantial pro-portion of this convergence in ratings reflected resolu-tion of disagreement (30 of 37 scenarios) from round 1to round 2.
1. Appropriateness of PICC Insertion in SpecificPopulationsA. Appropriateness of PICC Insertion in HospitalizedMedical Patients
In hospitalized medical patients, panelists rated in-sertion of PICCs for infusion of peripherally compatibleinfusates as inappropriate if the expected duration ofuse was 5 or fewer days. In such scenarios, use of pe-ripheral intravenous catheters or ultrasonography-guided peripheral intravenous catheters was rated asappropriate.
If the proposed duration of infusion was 6 to 14days, panelists rated PICC use as appropriate butindicated a preference for midline catheters andultrasonography-guided peripheral intravenous cathe-ters over PICCs for this period. This rating reflected ev-idence from observational studies that suggested bothefficacy and lower risk for complications associatedwith these devices compared with PICCs for this inter-val (37–41).
When the proposed duration of infusion was 15 ormore days, PICCs were preferred to midline catheters,given the possibility of failure of the latter beyond thisperiod (42, 43). However, panelists recognized thatmidline catheters may be used for up to 4 weeks andare approved for such duration of use (32).
Use of tunneled catheters and implanted portswere rated appropriate only if the proposed duration ofinfusion was 31 or more days. Panelists noted thatthese more invasive devices should be reserved for in-stances when use of PICCs is not feasible (for example,no suitable vein or site of insertion for PICC is identi-fied), is relatively contraindicated (for example, recent
history of thrombosis), or when episodic infusions overseveral months are necessary (Figure 3).
For infusion of irritants or vesicants, such as paren-teral nutrition or chemotherapy, PICC use was rated asappropriate at any proposed duration of use. Becauseperipheral intravenous catheters, ultrasonography-guided peripheral intravenous catheters, and midlinecatheters would not provide central venous access,these VADs were rated as inappropriate for this indica-tion for all durations of use.
If skilled operators are available, panelists rateduse of nontunneled CVCs as appropriate when the ex-pected duration of use was 14 or fewer days. Panelistsalso rated use of tunneled, cuffed catheters and im-planted ports as appropriate for infusion of irritants orvesicants, but only when the proposed duration of ther-apy was 15 or more days or 31 or more days, respec-tively (Figure 4).
Panelists disagreed on the appropriateness ofPICC placement when the indication was frequent ob-taining of blood samples (≥3 phlebotomies per day) ordifficult or poor peripheral venous access for proposeddurations of 5 or fewer days. Our patient panel mem-ber actively participated in this discussion, suggestingthat such decisions should be individualized betweenthe patient and provider after discussing risks and ben-efits related to PICC use and alternative options. Inser-tion of PICCs was rated as appropriate when the pro-posed duration of use for frequent phlebotomy ordifficult venous access was 6 or more days. In patientswith difficult venous access, ultrasonography-guidedperipheral intravenous catheters and midline catheterswere preferred over PICCs when the expected durationof use was 14 or fewer days. Panelists rated use ofCVCs for both difficult venous access and frequentphlebotomy as appropriate, provided the proposedduration of use was 14 or fewer days. Placement oftunneled catheters for patients with difficult venous ac-cess was rated as appropriate only if the proposed du-ration of use was 31 or more days. Ports were rated asinappropriate for frequent obtaining of blood samplesat all durations and appropriate for difficult venous ac-cess if use for 31 or more days was expected (Figures 5and 6).
B. Appropriateness of PICCs in Patients With CKD,Cancer, or Critical Illness
Panelists rated the appropriateness of PICC place-ment in patients with CKD according to disease stageas defined by the Kidney Disease: Improving GlobalOutcomes CKD Work Group (44). Among patients withstage 1 to 3a CKD (estimated glomerular filtration rate≥45 mL/min), rating of indications for PICC use fol-lowed those of general medical patients. However, thepanel noted that managing such patients on the basisof CKD stage alone might be imperfect because myriadfactors, including age, magnitude of albuminuria, race,and blood pressure, influence progression of renal dis-ease (45–49). The panel therefore recommended con-sultation with a nephrologist before PICC insertion if
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ambiguity regarding the severity of underlying kidneydisease exists. However, for patients with stage 3b CKDor greater (estimated glomerular filtration rate <45 mL/min), panelists acknowledged the imperative to pre-serve peripheral and central veins for possible hemodi-alysis or creation of arteriovenous fistulae and grafts(49). Thus, regardless of indication, insertion of devices(PICCs, midline catheters) into arm veins was rated asinappropriate in such patients. When venous access for5 or fewer days was necessary, panelists recommendplacement of peripheral IVs in the dorsum of the hand(avoiding the forearm veins) for infusion of peripherallycompatible infusates. If venous access for longer dura-tions or infusion of a non–peripherally compatible drugis needed, use of tunneled small-bore central catheters(for example, 4-French single-lumen or 5-Frenchdouble-lumen catheters inserted in the jugular vein andtunneled toward the chest) was rated as appropriate(50). For patients receiving any form of renal replace-ment therapy, panelists also recommended consulta-tion with a nephrologist to discuss the possibility ofdrug administration during or toward the end of thedialysis procedure.
These recommendations notwithstanding, panel-ists acknowledged that recommendations for patients
with stage 3b CKD or greater would need to be indi-vidualized, taking into account such factors as the ur-gency of the situation; rationale for venous preserva-tion; likelihood of eventual renal replacement therapy;and availability of resources, such as tunneled small-bore central catheters.
Given the risks for and consequences of infectious(51, 52) and thrombotic (53–55) complications, as wellas the unique indication of chemotherapy, ratings forPICC placement in patients with cancer differed fromthose for general medical patients. Recognizing theheterogeneity of thrombosis risk in patients with can-cer, the panel discussion focused largely on patientswith solid tumors. Panelists debated on whether ratingsfor chemotherapy should be structured by cycles oftreatment versus time; given the desire for generaliz-ability, the panel agreed on time as a more practicalscale. Therefore, for infusion of nonirritant or nonvesi-cant chemotherapy, PICCs were rated as appropriateonly if the proposed duration of such treatment was 3or fewer months.
When peripherally administrable chemotherapy forless than 3 months was necessary, panelists disagreedon PICC appropriateness, given the availability of high-
Figure 3. Venous access device recommendations for infusion of peripherally compatible infusate.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference betweenperipheral IV and US-guided
peripheral IV cathetersfor use ≤5 d
US-guided peripheral IV catheter preferred to peripheral IVcatheter if proposed duration is 6–14 d
Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d
Midline catheter preferred to PICC if proposed duration is ≤14 d
PICC preferred to midline catheter if proposed duration of infusion is ≥15 d
PICC preferred to tunneledcatheter and ports for
infusion 15–30 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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quality evidence regarding risk for thrombosis withthese devices in patients with cancer (16). However,members of the panel cited conflicting evidence re-garding nonthrombotic complications associated withPICC use (15, 56–58). Of note, a study published sincethe panel meeting (coauthored by one of our panelists)reported a low rate of PICC complications when propercare was ensured (59). Nevertheless, given the diver-gent data, panelists rated interval placement of periph-eral intravenous catheters with each chemotherapytreatment as the most appropriate strategy.
Like PICCs, tunneled, cuffed catheters were ratedas appropriate when at least 3 months of treatmentwere proposed or when PICCs were not feasible (forexample, peripheral veins were not available). Portswere rated as appropriate if the duration of treatmentwas projected to be 6 or more months, but neutral fordurations of 3 to 6 months. Panelists noted that earlieruse of ports may be appropriate but may be challeng-ing owing to coagulation abnormalities or availability ofinterventional radiology.
For infusion of irritant or vesicant chemotherapy,panelists rated PICC or tunneled, cuffed catheter use asappropriate at all time intervals; ports were rated asneutral at 3 to 6 months and appropriate at 6 or more
months. Panelists recommended tunneled, cuffed cath-eters over multilumen PICCs in settings where multipleor frequent infusions are required, citing lower risk forcomplications (60). However, panelists preferred PICCsto tunneled, cuffed catheters when managing patientswith coagulopathy and those with severe or prolongedthrombocytopenia (61). When the indication for PICCplacement was frequent phlebotomy or difficult periph-eral venous access in a hospitalized patient with cancer,panelists raised the threshold for PICC use comparedwith general medical patients. Thus, PICCs were con-sidered appropriate only if the proposed duration ofuse was 15 or more days; midline catheters were ratedas appropriate for 14 or fewer days of use.
Appropriateness of indications for PICC insertion incritically ill patients also differed from those for generalmedical patients, given the likely availability of intensiv-ists who could insert CVCs and concerns about hemo-dynamic stability, infection, and thrombosis. Panelistsconsequently rated PICC use as inappropriate for infu-sion of peripherally compatible infusates unless theproposed duration of treatment was 15 or more days.For the same indication, peripheral intravenous cathe-ters and midline catheters were rated as appropriatefor proposed durations of 5 or fewer days and 6 to 14
Figure 4. Venous access device recommendations for infusion of non–peripherally compatible infusates.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference between tunneled catheter and PICC for proposed durations ≥15 d
Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d
PICCs rated as appropriate at all proposed durations of infusion
No preference amongport, tunneled catheter, or
PICC for ≥31 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Tunneled catheter neutral for for use ≥15 d
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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days, respectively. Although limited data supportingthe recommendation for midline catheter use in criticalcare patients were available at the time of the meeting,a recent study reported favorable outcomes and costsavings with this device (62). Central venous catheterswere rated as appropriate when the proposed durationof treatment was 6 to 14 days in hemodynamically sta-ble patients; use of CVCs for proposed durations be-yond 15 days was rated as uncertain, with panelists ex-pressing concerns about infection and thrombosis.
In hemodynamically unstable patients or scenarioswhere invasive hemodynamic monitoring or central ac-cess was necessary, insertion of CVCs and PICCs wasrated as appropriate for durations of 14 or fewer daysand 15 or more days, respectively. Panelists preferredCVCs to PICCs in patients who were hemodynamicallyunstable or were actively receiving vasopressors. In thissetting, urgent requests for PICC placement were ratedas inappropriate. Given the risk for insertion complica-tions, panelists preferred use of PICCs to CVCs in criti-cally ill patients with coagulopathies (such as dissemi-nated intravascular coagulation or sepsis), especially ifuse for more than 15 days was proposed.
C. Appropriateness of PICC Insertion in SpecialPopulations
Panelists rated the appropriateness of PICCs inpopulations that need lifelong intravenous access (forexample, sickle cell anemia, short-gut syndrome, orcystic fibrosis) and populations residing in skilled nurs-ing facilities.
For populations that may require lifelong access,ratings were structured on the basis of how often pa-tients may be hospitalized within 1 year. For patientswho are infrequently hospitalized (≤5 hospitalizationsper year), PICC insertion was rated as inappropriatewhen the expected duration of use was 5 or fewer days.Insertion of a PICC was rated as uncertain when theexpected duration of use was between 6 and 14 days.The panel preferred midline catheters to PICCs for thisduration, assuming that peripherally compatible infus-ates were proposed (63). However, PICCs were rated asappropriate when the duration of use was expected tolast 15 or more days.
More permanent devices, such as tunneled, cuffedcatheters or ports, were not considered appropriate forpatients with infrequent hospitalizations, but our pa-tient panelist (reflecting on her experiences) com-
Figure 5. Venous access device recommendations for patients with difficult venous access.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference betweenperipheral IV and US-guided
peripheral IV cathetersfor use ≤5 d
US-guided peripheral IV catheters preferred to peripheral IVcatheters if proposed duration is 6–14 d
Central venous catheter preferred to PICC for use≤14 d in critically ill patients
Midline catheters preferred to PICC if proposed duration is ≤14 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Disagreement onappropriateness of PICC
for durations <5 dPICC use appropriate if proposed duration is ≥6 d; PICCs preferred to tunneled catheters for
durations of 15–30 d
No preference betweentunneled catheter or port for
use ≥31 d
Tunneled catheter neutral fordifficult IV access for
use ≥15 d
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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mented that an individualized approach would be nec-essary in such situations. In contrast, when patients inthis category are frequently hospitalized (≥6 hospital-izations per year), panelists rated use of tunneled,cuffed catheters as appropriate when the expected du-ration of venous access was 15 or more days. Portswere rated as appropriate when the proposed durationof use in frequently hospitalized patients was expectedto be 31 or more days. Panelists preferred placementof tunneled, cuffed catheters to PICCs when use for 15or more days was expected, citing the need to preserveveins to meet future, likely recurrent needs.
For patients residing in skilled nursing facilities,PICCs were rated as appropriate for infusion of nonirri-tant, nonvesicant treatments or frequent phlebotomy ifthe proposed duration of use was expected to be morethan 15 days. Appropriateness of PICC was rated asuncertain for durations of 6 to 14 days, where panelistsrated midline catheters as appropriate. For venous ac-cess of 5 or fewer days, peripheral intravenous cathe-ters were rated as being the most appropriate VAD.Given the variable resources in such facilities and chal-lenges in obtaining venous access, the appropriatenessof midline catheters was rated neutral for this period.For infusion of irritants or vesicants in this setting, pan-
elists rated PICCs as appropriate regardless of durationof use.
A summary of these ratings is provided in Table 2.
2. Appropriateness of PICC PracticesA. Appropriateness of PICC Insertion Practices
Before PICC insertion for specialty-specific indica-tions, panelists rated consultations with specialists asappropriate (for example, infectious diseases beforeplacement of a PICC for intravenous antibiotic therapy,or hematology–oncology before PICC insertion for che-motherapy). For patients who require prolonged anti-biotic infusions (for example, infections, such as osteo-myelitis), panelists rated PICC placement within 2 to 3days of hospital admission as appropriate in the ab-sence of bacteremia. In the presence of bacteremia,PICC placement was rated as uncertain owing to ambi-guities regarding pathogen, intensity of bacteremia,and clearance of infection, among other factors. Con-sultation with infectious diseases specialists was sug-gested in this setting.
Preferential placement of PICCs by interventionalradiology professionals was rated as appropriate when1) a suitable target vein for insertion cannot be identi-
Figure 6. Venous access device recommendations for patients who require frequent phlebotomy.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Disagreement onappropriateness of PICC
for durations <5 dPICC use appropriate if proposed duration ≥6 d; PICC preferred to tunneled catheter for
durations of 15–30 d
No preference betweenperipheral IV and US-guided
peripheral IV catheterfor use ≤5 d
US-guided peripheral IVcatheter preferred if venous
access difficult
Midline catheter preferred to PICCs if proposed duration is ≤14 d
Central venous catheter preferred to PICC for use≤14 d in critically ill patients
Tunneled catheter neutral fordifficult intravenous access for
use ≥15 d
Ports inappropriate for frequent phlebotomy, regardless of proposed duration of use
Midline catheter neutral for frequent phlebotomy at
this duration
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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fied on bedside ultrasonography, 2) the guidewire orcatheter fails to advance during bedside placement, or3) the patient requests sedation that cannot be safelydelivered at the bedside. In addition, placement by aninterventional radiologist was rated as appropriate forpatients with bilateral mastectomy, altered chest anat-omy, or superior vena cava filters. For patients withpermanent pacemakers or defibrillators, preferentialplacement by an interventional radiologist rather than avascular nursing professional was rated as appropriateif the contralateral arm was not amenable to insertion.These ratings were largely driven by expert opinion.
Panelists rated the appropriateness of specificPICC insertion practices on the basis of availability ofthe contralateral arm for placement. In accordance withInfusion Nursing Society Standards of Practice (32),avoiding insertion over a bruised or corded venoussegment, near or over an open wound or burn, andinto veins below the elbow was rated as appropriate.Owing to heightened risk for thrombosis, panelistsrated avoiding PICC placement in a hemiparetic or im-mobile arm as appropriate when the opposite limb wasavailable (64). Avoiding PICC insertion in the dominantarm as a strategy to prevent complications was rated asinappropriate, given the lack of convincing data to sup-port this practice. However, our vascular nursing andpatient panelists recommended that technical aspectsand patient preferences be considered when selectingarm of insertion.
Prior to PICC use, radiographic verification of PICCtip position was rated as appropriate after blind bed-side PICC placement or admission to a hospital with anexisting PICC. Conversely, panelists rated routine ra-diographic verification of PICC tip position as inappro-priate when PICCs were placed with electrocardio-graphic guidance, provided that proficiency with thistechnology had been demonstrated and adequatetracings (such as P-wave deflections) were observed.
To limit the risk for thrombosis, the U.S. Food andDrug Administration and specialty societies recom-mend that CVCs terminate in the lower one third of thesuperior vena cava or cavoatrial junction; “higher” (suchas the upper one third of the superior vena cava) or“lower” positions (such as the right atrium) were notrecommended (32, 65, 66). Acknowledging these con-cerns, panelists rated adjustment of the PICC when thetip was in the upper or middle one third of the superiorvena cava or right ventricle as appropriate.
However, panelists deviated from existing recom-mendations in rating the right atrium as an appropriateposition for the PICC tip and one that does not warrantadjustment. This rating was made after extensive dis-cussions of clinical practice and review of contempo-rary evidence, which did not suggest that terminationof PICCs or CVCs in the right atrium was associatedwith adverse outcomes in adults (66–71). Panelists rec-ognized that supporting data were observational, and awell-conducted randomized, controlled trial would behelpful in supporting this recommendation.
The possibility of atrial tachyarrhythmia during orafter PICC insertion in this position was also debated(72). As with any CVC, placement of the PICC tip in theright atrium in the setting of an atrial arrhythmia wasnot recommended. However, in the absence ofcontraindications, repositioning the PICC tip simply be-cause it resides in the right atrium was rated asinappropriate.
Table 2. Guide for PICC Use
Appropriate indications for PICC useDelivery of peripherally compatible infusates when the proposed
duration of such use is ≥6 d*Delivery of non–peripherally compatible infusates (e.g., irritants or
vesicants), regardless of proposed duration of useDelivery of cyclical or episodic chemotherapy that can be administered
through a peripheral vein in patients with active cancer, provided thatthe proposed duration of such treatment is ≥3 mo†
Invasive hemodynamic monitoring or requirement to obtain centralvenous access in a critically ill patient, provided the proposed durationof such use is ≥15 d‡
Frequent phlebotomy (every 8 h) in a hospitalized patient, provided thatthe proposed duration of such use is ≥6 d
Intermittent infusions or infrequent phlebotomy in patients with poor/difficult peripheral venous access, provided that the proposedduration of such use is ≥6 d§
For infusions or palliative treatment during end-of-life care!!Delivery of peripherally compatible infusates for patients residing in
skilled nursing facilities or transitioning from hospital to home,provided that the proposed duration of such use is ≥15 d¶
Inappropriate indications for PICC usePlacement for any indication other than infusion of non–peripherally
compatible infusates (e.g., irritants or vesicants) when the proposedduration of use is ≤5 d
Placement in a patient with active cancer for cyclical chemotherapy thatcan be administered through a peripheral vein, when the proposedduration of such treatment is ≤3 mo and peripheral veins are available
Placement in a patient with stage 3b or greater chronic kidney disease(estimated glomerular filtration rate ≤44 mL/min) or in patientscurrently receiving renal replacement therapy via any modality
Insertion for nonfrequent phlebotomy if the proposed duration of suchuse is ≤5 d
Patient or family request in a patient who is not actively dying or inhospice, for comfort in obtaining daily blood samples for laboratoryanalysis
Medical or nursing provider request in the absence of other appropriatecriteria for PICC use
PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for infusion of peripherallycompatible infusates up to 14 d. In patients with poor peripheral ve-nous access, use of ultrasonography-guided peripheral intravenouscatheters and midlines is also preferred over use of PICCs.† In patients with cancer, the risk for thrombosis associated with PICCsmay outweigh benefits. Patients who are scheduled to receive multi-ple cycles of peripherally compatible chemotherapy for durations <3mo should do so via peripheral intravenous catheters with eachinfusion.‡ Use of nontunneled central venous catheters is preferred over use ofPICCs for central venous access or invasive hemodynamic monitoring<14 d and in patients with documented hemodynamic instabilitywhere urgent venous access is necessary.§ Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for patients with poor/difficultperipheral venous access.!! Placement of a PICC in a terminally ill patient is appropriate if itfacilitates comfort goals of care. PICCs may be left in place in suchpatients to attain similar goals.¶ Use of PICCs for home-based infusions or in skilled nursing facilities(where resources are limited) is inappropriate for short-term durations(<14 d). In such settings, use of peripheral intravenous catheters ormidlines was rated as appropriate.
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B. Appropriateness of PICC Selection, Care, andMaintenance Practices
Without a documented rationale for a multilumenPICC (for example, multiple incompatible fluids), panel-ists rated default use of single-lumen devices as an ap-propriate and potentially important way to reduce PICCcomplications (73–75). Insertion of multilumen PICCs toseparate obtaining blood samples from giving infu-sions or to ensure a “backup” lumen was available wasalso rated as inappropriate. To clarify device needs,collaboration with pharmacists or vascular access oper-ators before ordering a PICC was rated as appropriate.
Regarding dressings, panelists rated placement ofsterile gauze between the PICC entry site and adhesivedressing for the first 1 to 2 days of insertion as appro-priate; thereafter use of clear, transparent dressingsthat permit site examination and weekly or more fre-quent changes of wet, loose, or soiled dressings wasrated appropriate. Use of cyanoacrylate products (“su-per glue”) to prevent oozing or discharge from the exitsite or to secure catheters was rated as neutral by pan-elists, who noted lack of substantial evidence or expe-rience to support this recommendation (76). In accor-dance with available guidelines (33), routine use ofchlorhexidine dressings without documented adher-ence to basic infection-prevention efforts or in the ab-sence of high rates of central line–associated blood-stream infection was rated as inappropriate.
Panelists rated use of normal saline rather thanheparin to maintain catheter patency and prevent lu-men occlusion as appropriate, as reflected in recentrecommendations (77, 78). Regardless of how far outthe PICC was dislodged, panelists rated advancementof migrated PICCs as inappropriate; in this setting,guidewire exchange of the PICC was rated as appropri-ate, provided that there are no signs of local or sys-temic infection. Guidewire exchange was also rated asappropriate when changes to existing PICC character-istics (such as number of lumen or power-injectioncompatibility) were desired. Should a PICC no longerbe functional, exchange over a guidewire was rated asappropriate, provided that an indication warrantingcontinued PICC use was present. Ratings regardingguidewire exchanges were driven largely by expertrecommendation.
C. Appropriateness of Management of PICCComplications
In patients with a centrally positioned, otherwisefunctional PICC that is complicated by image-confirmed PICC-related deep venous thrombosis(DVT), panelists rated PICC removal as appropriate onlywhen 1) the PICC is clinically no longer necessary; 2)the PICC is only being used for phlebotomy, but pe-ripheral veins are available; 3) symptoms of venous oc-clusion (arm pain, swelling) persist despite therapeuticanticoagulation for 72 or more hours; and 4) bactere-mia with objective evidence of line-related infection ex-ists. Panelists rated removal of a functional PICC in thepresence of DVT as inappropriate when 1) irritants or
vesicant infusions remain necessary; 2) the patient haspoor peripheral venous access and requires frequentphlebotomy (and may thus require another PICC); and3) the patient has minimal improvement in symptoms ofvenous occlusion, but therapeutic anticoagulation hasbeen provided for 72 or fewer hours. Panelists wereneutral regarding PICC removal when 1) a patientcould not receive systemic anticoagulation, but thePICC remained clinically necessary and 2) a line-relatedinfection was suspected, but not confirmed. In general,these ratings mirrored existing evidence-based recom-mendations (35, 53, 79).
When treating PICC-related DVT, panelists ratedprovision of at least 3 months of anticoagulation at atreatment dose as appropriate. Shorter durations of an-ticoagulation or removal of the PICC as definitive ther-apy (in the absence of contraindications to anticoagu-lation) was rated as inappropriate. When treating withwarfarin, panelists recommended targeting anticoagu-lation to an international normalized ratio of 2 to 3;lower or higher international normalized ratio targetswere rated as inappropriate. Use of low-molecular-weight heparin over warfarin was preferred in patientswith cancer. Owing to insufficient evidence, preferen-tial use of target-specific oral anticoagulants over tradi-tional agents among patients with cancer was rated asinappropriate. Panelists rated urgent referral to inter-ventional radiology for catheter-directed treatment ofPICC-related DVT as appropriate when symptoms ofvenous occlusion were associated with phlegmasiacerulea dolens (swollen, enlarged, painful, and purplishdiscoloration of the affected limb).
Panelists rated the appropriateness of placementof a new PICC in patients who experienced PICC-related DVT within the past 30 days. In this scenario,panelists strongly urged against placement of a PICC,given the high risk for recurrent thrombosis. Placementof a PICC was specifically rated as inappropriate if theindication for insertion was 1) frequent phlebotomywhen peripheral access was available, or 2) patient re-quest for comfort in non–end-of-life settings. Insertionof a PICC was also considered inappropriate if the pa-tient were to require surgery lasting 1 hour or longer,owing to heightened risk for DVT in this situation (67).
In the setting of PICC-related DVT, appropriatenessof PICC insertion for parenteral antibiotics for 10 ormore days was rated as uncertain; panelists recom-mended a midline catheter in this scenario. If a PICCwas absolutely necessary in a patient with recent PICC-related DVT, panelists rated use of the smallest cathetergauge and least number of lumens as appropriate (74,75, 80). Placement in a vein in the contralateral armfollowing at least 3 months of anticoagulation for thePICC-related DVT was also rated as appropriate in thissetting.
Panelists rated the appropriateness of practices re-lated to management of PICC-related bloodstream in-fections. Regardless of clinical context and in accor-dance with recommendations (33, 81), panelists rateduse of PICCs as a strategy to reduce bloodstream infec-tion as inappropriate. In the setting of bacteremia or
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fever, PICC removal in the absence of confirmatory ev-idence of line-related infection was rated as uncertain.Panelists stated that these approaches would be dic-tated by such factors as pathogen, intensity of bacter-emia, and clinical stability, among others, and consulta-tion with infectious disease would be appropriate.
In patients with confirmed PICC-related blood-stream infection, continued treatment using the af-fected PICC, guidewire exchange, or placement of anew device in the contralateral arm without docu-mented clearance of infection was rated as inappropri-ate. After a line-free interval (typically 48 to 72 hours)and negative blood cultures, panelists rated placementof a PICC or other acute CVC as appropriate only if anindication warranting central catheter use was present.Panelists preferred use of peripheral IVs in such pa-tients wherever possible.
D. Appropriateness of PICC RemovalIn contradistinction to indwelling urinary catheters
(82), panelists rated PICC removal without physiciannotification as inappropriate. After physician notifica-tion, panelists rated PICC removal as appropriate when1) the PICC has not been used for any clinical purposefor 48 hours or longer; 2) the patient no longer has aclinical indication for a PICC, or the original indicationfor use has been met (for example, an antibiotic coursehas been completed); or 3) the PICC is only used forroutine obtaining of blood samples in a hemodynami-cally stable patient and peripheral veins are available.Panelists rated routine removal of a PICC in a hemody-namically stable patient with poor venous access or he-modynamically unstable patients as uncertain. Removalof a PICC by clinicians who have received training toremove CVCs, but not PICCs, was rated as inappropri-ate (32).
A summary of these ratings is provided in Table 3.
3. Appropriateness of Peripheral IntravenousCatheter Use in Specific Scenarios
Because PICC use is often driven by difficult pe-ripheral venous access, we asked panelists to rate ap-propriateness of peripheral intravenous catheter use invarious clinical scenarios that often prompt PICC use. Inthe absence of other indications for central venous ac-cess, panelists rated use of ultrasonography-guidedperipheral intravenous catheters as appropriate beforeinsertion of a PICC in general medical, critically ill, andcancer populations with difficult venous access (39, 68).However, use of ultrasonography-guided peripheral in-travenous catheters in patients with stage 3b or greaterCKD was rated as inappropriate. If a suitable arm veincould not be found, panelists rated placement of a pe-ripheral intravenous catheter catheter in the externaljugular vein of the neck as appropriate only if the pro-posed duration of use was 96 hours or less or in anemergency situation. Panelists rated placement of a pe-ripheral intravenous catheter in the lower extremity asappropriate only in emergencies.
Citing the results of a Cochrane systematic review(83) and a randomized trial (84), panelists rated re-
placement of peripheral intravenous catheters as ap-propriate when prompted by clinical signs and symp-toms rather than prespecified durations. Panelistsnoted that such practice might extend availability of pe-ripheral venous access (83), reduce cost (85), and limituse of PICCs, but recognized that these data were lim-ited to 1 randomized trial and low event rates in theliterature. When PICC placement was requested forblood transfusions, panelists rated 16-, 18-, and 20-
Table 3. Guide for PICC Insertion, Care, and MaintenancePractices
Appropriate PICC practicesBefore ordering a PICC, consult relevant specialists (e.g., infectious
diseases, oncology), operators (vascular access professional), and/orhospital pharmacists to determine optimal device choice andcharacteristics*
After non-EKG or non–fluoroscopically guided PICC insertion, verify PICCtip position via chest radiography
Only adjust PICCs that terminate in the upper or middle one third of thesuperior vena cava or right ventricle
In the absence of indications for a multilumen PICC, use a single-lumenPICC of the smallest gauge
Use normal saline rather than heparin to flush PICCs after infusion orphlebotomy
Exchange PICCs to change device features (e.g., number of lumens) ortreat dislodgement over a guidewire
Provide ≥3 mo of uninterrupted systemic anticoagulation for treatmentof PICC-related DVT in the absence of contraindications to suchtherapy†
Use the smallest sized catheter and vein on the contralateral arm after≥3 mo of therapeutic anticoagulation when placing a PICC in a patientwith history of PICC-related DVT‡
Provide a "line-free" interval to ensure clearance of bacteremia whenmanaging PICC-related bloodstream infections
Inappropriate PICC practicesUrgent requests for PICC placement in a hemodynamically unstable
patient in the wards or ICUPreferential placement of a PICC on the basis of arm dominanceChest radiography verification of the PICC tip after placement via verified
EKG guidance or fluoroscopy§Adjustment of PICC tips that reside in the lower one third of the superior
vena cava, cavoatrial junction, or right atriumAdvancement of a partially dislodged PICC in the setting of external
migration of the catheter of any lengthRemoval of PICCs that are clinically necessary, centrally positioned, and
otherwise functional in the setting of PICC-related DVTRoutine removal or replacement of PICCs that are clinically necessary
without objective evidence of catheter-associated bloodstreaminfection in febrile patients
Removal of a PICC by a health care team member not trained to removethis device
DVT = deep venous thrombosis; EKG = electrocardiography; ICU =intensive care unit; PICC = peripherally inserted central catheter.* Consultations with nephrologists for patients with stage 1 to 3achronic kidney disease was rated as neutral owing to challenges re-lated to determining stage of kidney disease in hospitalized patients.In such patients, consultation is recommended especially if hospital-ized with acute kidney injury or fluctuating renal function.† In patients with cancer, use of low-molecular-weight heparin overwarfarin for systemic anticoagulation was rated as preferred. Extend-ing the duration of anticoagulation beyond such periods if the PICCremained in place was rated as appropriate.‡ If the contralateral arm is not available, selection of a vein not in-volved with the original PICC-DVT in the ipsilateral arm was rated asappropriate.§ When forgoing chest radiographs for PICC tip position, technicalproficiency in the placement of PICCs via EKG guidance is assumed.Additionally, verification of tip-positioning via EKG (adequate P-wavedeflection/mapping) is assumed. If concerns regarding positioning ex-ist, obtaining a chest radiograph is appropriate.
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gauge peripheral intravenous catheters as appropriateand preferable to PICC use. For administering intrave-nous contrast through radiographic injectors, panelistsrated use of 16- to 20-gauge peripheral intravenouscatheters as appropriate and preferred over PICCs;use of 22-gauge devices or larger was rated asinappropriate.
A summary of these ratings is provided in Table 4.
DISCUSSIONOur 15-member multidisciplinary panel success-
fully applied the RAND/UCLA Appropriateness Methodto generate novel criteria for use, care, and manage-ment of PICCs in hospitalized patients. In addition, pan-elists rated the comparative utility of other VADs in re-lation to PICCs, providing new insights for decisionmaking in venous access. The implication of this work issubstantial, because it provides a potential means to
quantify appropriateness, qualify existing use, and im-prove care of PICCs and related devices in hospitalizedpatients. Given an international team of experts thatrepresented multiple subspecialties and the inclusionof a patient to formulate panelist ratings, these criteriaare well-positioned to broadly improve the quality andsafety of venous access in hospitalized adults.
As with many health care innovations, PICCs wereintroduced to solve an important clinical problem in adefined population (86). However, over time, the use ofPICCs has evolved to span diverse indications and pa-tient populations. In hospital settings, accumulating ev-idence suggests that placement of PICCs may occur forpotentially inappropriate reasons (18, 87). Notwith-standing such benefits as convenience, comfort, andeconomic efficiency (4, 88), PICC insertion may intro-duce unnecessary risk and potential for preventableharm (15, 16, 73). Despite this fact, no framework toinform use of these devices has been developed todate.
These observations were the motivation underlyingthis project, which sought to incorporate existing evi-dence with the knowledge of clinicians and content ex-perts to define criteria for appropriate PICC use. Unlikeexisting recommendations, our appropriateness criteriarepresent a departure from the status quo in severalways.
First, they offer clinical granularity for clinicians. Forexample, existing guidelines recommend “use of mid-line catheters or PICCs instead of a short peripheralintravenous catheter when the duration of IV [inter-venous] therapy will likely exceed six days” (33). Ourcriteria build on this advice by adding such details aswhat patient-specific considerations should be incorpo-rated in this decision, which other devices may be ap-propriate, and when PICC use for shorter durationsmight be reasonable.
Second, whereas existing recommendations targetproceduralists or specialties that most often insert de-vices, our criteria are the first to provide direction toclinicians, such as internists or hospitalists, who orderPICCs. Thus, these criteria fill a critical gap, bringingrecommendations to those that drive the decision toplace such devices.
Finally, by tackling some of the most controversialtopics of venous access—including when to adjust thePICC position, appropriate indications for removal, andindications for reinsertion of PICCs after complications—our criteria advance the science of vascular access inimportant and innovative ways.
Some aspects of panelist deliberations and ratingsmerit further discussion. First, patterns of recommenda-tions for PICC appropriateness often hinged on 2 vari-ables: the nature of the infusate and duration ofvenous access. Thus, non–peripherally compatible infu-sions or scenarios where venous access was necessaryfor 6 days or longer often led panelists to rate PICC useas appropriate; conversely, shorter duration of use withperipherally compatible infusions led to a recommen-dation for use of a peripheral intravenous catheter,ultrasonography-guided catheter, or midline catheter.
Table 4. Guide for Peripheral Intravenous CatheterPractices
Appropriate peripheral intravenous catheter practicesInsert a peripheral intravenous catheter in the external jugular vein if the
proposed duration of use is ≤4 d or an emergent/life-threateningsituation exists
Place a peripheral intravenous catheter in the foot only in the setting ofan emergent, life-threatening situation
Use ultrasonographic guidance to place short or long peripheralintravenous catheters in patients with difficult venous access whorequire treatment for ≤5 d*
Remove peripheral intravenous catheters in the setting of redness,swelling, or phlebitis over the vein of insertion
In hospitalized patients who are likely to require ≥15 d of intravenousantibiotics, transition from a peripheral intravenous catheter to a PICCor midline catheter as soon as possible†
Use a 16-, 18-, or 20-gauge peripheral intravenous catheters in anupper-extremity vein rather than a PICC when venous access isneeded for blood transfusion or performance of a contrast-basedradiographic study
Inappropriate peripheral intravenous catheter practicesRemoval of peripheral intravenous catheters on the basis of a routine
schedule or in the absence of redness, swelling, or other signs ofinflammation is inappropriate; site rotation should be driven byclinically warranted change‡
Removal of a functioning peripheral intravenous catheter that has beeninserted in the field (e.g., ambulance or nonhospital site) in theabsence of redness, tenderness, or swelling over the insertion site isinappropriate
Placement of peripheral intravenous catheters on the same side as priorbreast surgery, axillary node dissection, or arteriovenous fistulae(regardless of whether the fistula is functional or not) is inappropriate
In the absence of a clinical indication warranting insertion, routineplacement of a peripheral intravenous catheter at the time ofadmission to the hospital is inappropriate
In the absence of a clinical indication warranting continued use, routinereplacement of a peripheral intravenous catheter is inappropriate
PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters isinappropriate in patients with advanced (stage 3b or greater) chronickidney disease. In such patients, consultation with a nephrologist anduse of a small-bore tunneled central catheter are appropriate.† Delaying transition from a peripheral intravenous catheter to a PICCbefore discharge may deplete available venous access sites and is notappropriate when intravenous antibiotic treatment beyond 15 d isclinically necessary.‡ Routine changes of peripheral intravenous catheters may result inloss of potentially available peripheral veins for infusion or therapy,inadvertently leading to greater use of PICCs in hospitalized patients.
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Unlike existing standards, however, variation in risk forcomplications according to patient population influ-enced this pattern. This is well-illustrated in ratings forcritically ill patients and those with cancer, where atheme of limiting PICCs to durations of use of 15 daysor longer is evident.
Second, throughout deliberations, panelists notedthat it is often challenging for clinicians to estimate anexpected duration of venous access. Relatedly, a “max-imal” window within which PICCs may be safely used isnot known and depends on myriad factors, includingadequacy of care and differential risk for complications.Finally, panelists acknowledged that separation of indi-cations for PICC placement into individual categoriesand defining VADs by finite duration was artificial, be-cause venous access is rarely driven by a single clinicalpurpose or limited by duration.
On balance, panelists rationalized that clinicians of-ten do not reflect carefully enough on the nature ofvenous access or weigh its inherent risks and benefits.Panel members added that in many hospitals, the deci-sion to place a PICC is often dichotomous, with consid-eration of other devices lacking. Thus, an unforeseenadvantage of these criteria is the introduction of aphysician-directed “time-out” in vascular access deci-sion making. During this pause, reflection on the ap-propriate device, patient risk factors, and discussionswith specialists could conceivably improve outcomes inhospital settings.
Our approach has several limitations. First, we ex-cluded neonatal and pediatric studies when formulat-ing these recommendations, because considerable dif-ferences in PICC use exist between these patients andadults. However, because these populations often re-ceive PICCs, future panels should choose to focus onthese subsets.
Second, although our panel was multidisciplinary,we did not include bedside nurses, who often requestPICCs in hospitalized settings. However, vascularnurses and hospitalists are attuned to considerationsregarding PICC use from this group of providers andwere well-represented on our panel.
Third, the applicability of these recommendationswill vary on the basis of provider scope of practice, ed-ucation, and training. As echoed in other standards(89), provider availability, competence, and technicalexpertise should guide insertion and selection of ap-propriate VADs.
Finally, our panel was focused on appropriatenessof PICCs in relation to other devices. We acknowledgethat certain devices may be used for longer durations(for example, midline catheters for up to 28 days) orindications of different durations (for example, intrave-nous antibiotics for 6 weeks). These limitations werenecessary to ensure comparability among various de-vices and generalizability of these recommendations.
Despite these limitations, our appropriateness cri-teria represent a major multidisciplinary effort towardimproving decision making related to PICCs and re-lated VADs. Avoiding PICC use for inappropriate indi-cations, considering alternative devices, ensuring ap-
propriate consultations, and outlining instances wherePICC removal is appropriate are but a few examples ofhow these recommendations may be implemented toimprove practice. In addition, by including a patientwhose opinion influenced panel deliberations, we tookinto account the implications of provider decisionsfrom “the other side of the needle.” Finally, the criteriawe propose span not just indications for PICC insertionbut also best practices for use, care, and maintenance.Thus, we hope that our recommendations will provideclarity for management of complex situations not onlybefore, but also during and after, PICC placement.
Although optimal strategies to implement our cri-teria remain to be defined, an expansive range of op-tions is possible. For example, routine benchmarkingand feedback of metrics, such as PICC dwell time, indi-cations for insertion, and practices related to manage-ment of complications, may serve to inform hospital-specific “PICC dashboards” and quality-improvementefforts. Alternatively, more sophisticated paradigms,such as decision aids and computerized physicianorder-entry taking into account proposed duration ofuse, indication, and patient characteristics, are alsoplausible.
Because many of our recommendations are algo-rithmic, Web sites or smartphone applications to deter-mine the appropriateness of PICCs before insertionseem to be feasible. We are beginning to explore theseoptions through 2 strategic partners. First, through theongoing Blue Cross Blue Shield/Blue Care Network–funded Hospital Medicine Safety collaborative qualityimprovement project, we will use our appropriatenesscriteria to evaluate and improve PICC utilization in 47Michigan hospitals (90). Because the Hospital MedicineSafety project is composed of diverse hospitals and isbuilt on a robust data platform, we will also seek tounderstand contextual barriers, facilitators, and unin-tended consequences related to use of our criteria.
Second, through work recently funded by the Vet-erans Affairs National Center for Patient Safety and theNo Preventable Harms Campaign, we will test ways inwhich to operationalize our criteria within the highly in-tegrated Veterans Affairs health system. Given the ad-vanced electronic medical record systems in thissetting, our experiences will shed new light on imple-mentation strategies that could inform our work withinand beyond this setting. Such research may take sev-eral forms. For instance, quasi-experimental designs,such as pre–post or interrupted time series that exam-ine the influence of specific appropriateness recom-mendations (for example, avoid use of PICCs for pe-ripherally compatible infusions lasting 5 days or less)within and between hospitals, could be tested in par-ticipating Michigan and Veterans Affairs sites. Alterna-tively, a “bundle” of best practices related to PICCs,including appropriateness criteria for insertion, care,and management, may be deployed, leveraging a step-wedge or cluster randomized approach to account forsecular trends.
More robust research designs, such as randomizedclinical trials, that utilize our criteria are also feasible.
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For example, randomly assigning patients who requireless than 2 weeks of peripherally compatible infusionsto receive a midline catheter or PICC is not only feasi-ble but also relevant, because many PICCs are placedto deliver antibiotics for such intervals after hospital dis-charge. Such a study may be powered to ascertain thenoninferiority of midline catheters, rates of therapycompletion, or complications with either device. There-fore, several research designs that span one or morehospitals, and one or more of our recommendations,may be used as interventions to target clinical out-comes, overall utilization, adverse events, and costs.
In conclusion, we used the RAND/UCLA Appropri-ateness Method to define best practices for PICC inser-tion, care, and management. Although a key first step,these criteria offer but a blueprint of best practices. Tomake MAGIC truly happen, diffusion, uptake, and re-finement from the providers and stakeholders engagedin vascular access is necessary. Through use of a sys-tematic rating process, a multidisciplinary internationalpanel, and patient representation, we hope to achievethis goal. Our patients deserve nothing less.
From University of Michigan Medical School, Patient SafetyEnhancement Program of the Veterans Affairs Ann ArborHealthcare System, and the Institute for Healthcare Policy andInnovation, University of Michigan Ann Arbor, and OakwoodHospital, Dearborn, Michigan; Intermountain Medical Center,Murray, and the University of Utah School of Medicine, SaltLake City, Utah; Clinical Center, National Institutes of Health,Bethesda, and Greater Baltimore Medical Center, Baltimore,Maryland; William S. Middleton Memorial Veterans AffairsHospital and Division of Infectious Diseases, University of Wis-consin Medical School, Madison, Wisconsin; Perelman Schoolof Medicine, University of Pennsylvania, Philadelphia, Pennsyl-vania; PICC Excellence, Hartwell, Georgia; Catholic University,Rome, Italy; American University of Beirut, Lebanon; and Uni-versity of British Columbia, Vancouver, British Columbia,Canada.
Portions of this work were presented at the 2015 Annual So-ciety of Hospital Medicine Meeting, Washington, DC, and the2015 Society for Healthcare Epidemiology of America Meet-ing, Orlando, Florida.
Acknowledgment: The authors thank Tanya Boldenow, MD,and Aaron Berg, MD, for reviewing early drafts of the appro-priateness document; Andy Hickner, MSI, and Marisa Conte,MSI, for assistance with literature searches; and GeorgiannZiegler, their patient panelist, whose views greatly influencedpanel discussions.
Disclosures: Dr. Chopra reports grants from the Society ofHospital Medicine and Agency for Healthcare Research andQuality during the conduct of the study. Dr. Flanders reportsgrants from Blue Cross Blue Shield of Michigan during theconduct of the study and consultancy for the Institute forHealthcare Improvement and the Society of Hospital Medi-cine; employment by the University of Michigan; one expertreview per year as expert testimony; grants or grants pendingfrom the CDC Foundation, Blue Cross Blue Shield of Michi-
gan, Michigan Hospital Association, and Agency for Health-care Research and Quality; honoraria for various talks at hos-pitals as a visiting professor; and royalties from WileyPublishing outside the submitted work. Dr. Saint reports serv-ing on the medical advisory board of Doximity (a social net-working site for physicians) and receiving an honorarium forbeing a member of this medical advisory board, and servingon the scientific advisory board of Jvion (a health care tech-nology company) outside the submitted work. Dr. Woller re-ports a grant paid by Bristol Myers-Squibb to IntermountainHealthcare, with no financial support to Dr. Woller, outsidethe submitted work. Dr. Trerotola reports personal fees fromUniversity of Michigan during the conduct of the study andgrants from Vascular Pathways; personal fees from Bard Pe-ripheral Vascular, B. Braun, Orbimed, Teleflex, Cook, W.L.Gore, and Lutonix outside the submitted work. Dr. Moureaureports PICC Appropriateness Panel reimbursement duringthe conduct of the study and serving as chief executive officerof PICC Excellence, Inc.; vascular access specialist and teammember at Greenville Hospital System, Greenville, South Car-olina; and associate adjunct professor and member of Alli-ance for Vascular Access Device Training and Research (AVA-TAR), Griffith University, Brisbane, Australia, outside thesubmitted work. Dr. LeDonne reports personal fees from Tele-flex, Ethicon, Bard International, SonoSite, and 3M outside thesubmitted work. Ms. Becker reports grants from the Society ofHospital Medicine and Blue Cross Blue Shield of Michiganduring the conduct of the study. Dr. Bernstein reports grantsfrom Department of Veterans Affairs National Center for Pa-tient Safety and Blue Cross Blue Shield of Michigan during theconduct of the study; in addition, he is a member of the BlueCare Network Clinical Quality Committee, which reviews is-sues related to quality of care, and although peripherally in-serted central venous catheters have not been considered inthe past, their use may be reviewed in the future. Dr. Bern-stein is also director of quality for the University of MichiganMedical Group; if the appropriateness of peripherally insertedcentral venous catheter criteria developed as part of this pro-cess are widely adopted, they could be applied to the Univer-sity of Michigan by outside agencies. Authors not named herehave disclosed no conflicts of interest. Disclosures can alsobe viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0744.
Grant Support: By a Young Researcher Award from the Soci-ety of Hospital Medicine and a career development award(1-K08-HS022835-01) from the Agency for Healthcare Re-search and Quality to Dr. Chopra and by Blue Cross BlueShield and Blue Care Network of Michigan, which providedsalary support for Drs. Flanders and Bernstein and Ms. Beckerthrough the Michigan Hospital Medicine Safety Consortium.
Requests for Single Reprints: Vineet Chopra, MD, MSc, Insti-tute for Healthcare Policy and Innovation, University of Michi-gan, North Campus Research Complex, 2800 Plymouth Road,Building 16, Room 432W, Ann Arbor, MI 48109; [email protected].
Current Author Addresses: Dr. Chopra: Institute for Health-care Policy and Innovation, University of Michigan, NorthCampus Research Complex, 2800 Plymouth Road, Building16, Room 432W, Ann Arbor, MI 48109.
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Dr. Flanders: Taubman Medical Center, University of Michi-gan, 1500 East Medical Center Drive, SPC 5376, Ann Arbor,MI 48109.Dr. Saint: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 432W, Ann Arbor, MI48109.Dr. Woller: Intermountain Medical Center, PO Box 57700,5169 South Cottonwood Street, Suite 307, Murray, UT 84107.Dr. O’Grady: Critical Care Medicine Department, Clinical Cen-ter, National Institutes of Health, 10 Center Drive, Building 10,Room 2C145, Bethesda, MD 20892.Dr. Safdar: University of Wisconsin Medical School, MFCB5221, 1685 Highland Avenue, Madison WI 53705.Dr. Trerotola: Department of Radiology, University of Pennsyl-vania Medical Center, 1 Silverstein, 3400 Spruce Street, Phil-adelphia, PA 19104.Dr. Saran: Division of Nephrology, Department of InternalMedicine, University of Michigan Medical School, 1415 Wash-ington Heights, SPH I, Suite 3645, Ann Arbor, MI 48109-2029.Ms. Moureau: PICC Excellence, Inc., 1905 Whippoorwill Trail,Hartwell, GA 30643.Dr. Wiseman: Veterans Affairs Ann Arbor Healthcare System,VISN 11, 2215 Fuller Road, Department of Pharmacy (119),Ann Arbor, MI 48105.Dr. Pittiruti: Catholic University, Via Malcesine 65, 00135Rome, Italy.Dr. Akl: American University of Beirut Medical Center, PO Box11-0236 Riad-El-Solh 1107 2020, Beirut, Lebanon.Dr. Lee: Division of Hematology, University of British Colum-bia, 2775 Laurel Street, 10th Floor, Vancouver, British Colum-bia V5Z 1M9, Canada.Dr. Courey: Taubman Medical Center, University of Michigan,1500 East Medical Center Drive, SPC 3918, Ann Arbor, MI48109-3918.Dr. Swaminathan: Division of Hospital Medicine, OakwoodHospital, 18101 Oakwood Boulevard, Dearborn, MI 48124.Dr. LeDonne: Department of Surgery, Greater Baltimore Med-ical Center, 10210 Breconshire Road, Ellicott City, MD 21041.Ms. Becker: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 476C, Ann Arbor, MI48109.Dr. Krein: Department of Veterans Affairs, 2800 PlymouthRoad, Building 16, Room 33W, Ann Arbor, MI 48109-2800.Dr. Bernstein: Institute for Healthcare Policy and Innovation,University of Michigan, North Campus Research Complex,2800 Plymouth Road, Building 16, Room 446E, Ann Arbor, MI48109.
Author Contributions: Conception and design: E.A. Akl, C.Becker, S.J. Bernstein, V. Chopra, S.A. Flanders, S.L. Krein, J.LeDonne, S. Saint, L. Swaminathan, S. Wiseman, S. WollerAnalysis and interpretation of the data: C. Becker, S.J. Bern-stein, V. Chopra, J. LeDonne, A.Y. Lee, M. Pittiruti, S. TrerotolaDrafting of the article: S.J. Bernstein, V. Chopra, A.J. Courey,N. O’Grady, S. Trerotola.Critical revision for important intellectual content: E.A. Akl, C.Becker, S.J. Bernstein, V. Chopra, A.J. Courey, S.A. Flanders,S.L. Krein, J. LeDonne, A.Y. Lee, N.L. Moureau, N. O'Grady, M.Pittiruti, N. Safdar, S. Saint, R. Saran, L. Swaminathan, S. Trero-tola, S. Wiseman, S. Woller.
Final approval of the article: E.A. Akl, C. Becker, S.J. Bernstein,V. Chopra, A.J. Courey, S.A. Flanders, S.L. Krein, J. LeDonne,A.Y. Lee, N.L. Moureau, N. O'Grady, M. Pittiruti, N. Safdar, S.Saint, R. Saran, L. Swaminathan, S. Trerotola, S. Wiseman, S.Woller.Provision of study materials or patients: V. Chopra, S.A. Flan-ders, A.Y. Lee.Statistical expertise: S.J. Bernstein, V. Chopra.Obtaining of funding: V. Chopra, A.J. Courey, S.A. Flanders,S. Saint.Administrative, technical, or logistic support: C. Becker, S.J.Bernstein, V. Chopra, S.A. Flanders, R. Saran.Collection and assembly of data: E.A. Akl, C. Becker, V. Cho-pra, S.A. Flanders, N.L. Moureau, N. O'Grady, L. Swaminathan,S. Trerotola, S. Wiseman, S. Woller.
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peripheral venous catheters in gynecology oncology patients. Gyne-col Oncol. 2003;89:301-5. [PMID: 12713995]213. Seeley MA, Santiago M, Shott S. Prediction tool for thrombiassociated with peripherally inserted central catheters. J Infus Nurs.2007;30:280-6. [PMID: 17895807]214. Shea CD, Chang GL, Rahimi R, Mahdavian M. The incidence ofsymptomatic, PICC-related venous thrombosis in hospitalized pa-tients with inflammatory bowel disease [Abstract]. Am J Gastroen-terol. 2006;101:S460.215. Simcock L. No going back: advantages of ultrasound-guidedupper arm PICC placement. Journal of the Association for VascularAccess. 2008;13:191-7.216. Skaff ER, Doucette S, McDiarmid S, Huebsch L, Sabloff M. Vas-cular access devices in leukemia: a retrospective review amongstpatients treated at the Ottawa Hospital with induction chemotherapyfor acute leukemia. Leuk Lymphoma. 2012;53:1090-5. [PMID:22080756] doi:10.3109/10428194.2011.639879217. Skiest DJ, Abbott M, Keiser P. Peripherally inserted central cath-eters in patients with AIDS are associated with a low infection rate.Clin Infect Dis. 2000;30:949-52. [PMID: 10880311]218. Smith JR, Friedell ML, Cheatham ML, Martin SP, Cohen MJ,Horowitz JD. Peripherally inserted central catheters revisited. Am JSurg. 1998;176:208-11. [PMID: 9737634]219. Smith RN, Nolan JP. Central venous catheters. BMJ. 2013;347:f6570. [PMID: 24217269] doi:10.1136/bmj.f6570220. Snelling R, Jones G, Figueredo A, Major P. Central venous cath-eters for infusion therapy in gastrointestinal cancer. A comparativestudy of tunnelled centrally placed catheters and peripherally in-serted central catheters. J Intraven Nurs. 2001;24:38-47. [PMID:11836843]221. Sperry BW, Roskos M, Oskoui R. The effect of laterality on ve-nous thromboembolism formation after peripherally inserted centralcatheter placement. J Vasc Access. 2012;13:91-5. [PMID: 21948128]doi:10.5301/jva.5000014222. Stokowski G, Steele D, Wilson D. The use of ultrasound to im-prove practice and reduce complication rates in peripherally in-serted central catheter insertions: final report of investigation.J Infus Nurs. 2009;32:145-55. [PMID: 19444022] doi:10.1097/NAN.0b013e3181a1a98f223. Strahilevitz J, Lossos IS, Verstandig A, Sasson T, Kori Y, Gillis S.Vascular access via peripherally inserted central venous catheters(PICCs): experience in 40 patients with acute myeloid leukemia at asingle institute. Leuk Lymphoma. 2001;40:365-71. [PMID: 11426559]224. Thakarar K, Collins M, Kwong L, Sulis C, Korn C, Bhadelia N.The role of tissue plasminogen activator use and systemic hyperco-agulability in central line-associated bloodstream infections. Am JInfect Control. 2014;42:417-20. [PMID: 24559598] doi:10.1016/j.ajic.2013.11.016225. Timsit JF, Farkas JC, Boyer JM, Martin JB, Misset B, Renaud B,et al. Central vein catheter-related thrombosis in intensive care pa-tients: incidence, risks factors, and relationship with catheter-relatedsepsis. Chest. 1998;114:207-13. [PMID: 9674471]226. Tiwari MM, Hermsen ED, Charlton ME, Anderson JR, Rupp ME.Inappropriate intravascular device use: a prospective study. J HospInfect. 2011;78:128-32. [PMID: 21507524] doi:10.1016/j.jhin.2011.03.004227. Toure A, Duchamp A, Peraldi C, Barnoud D, Lauverjat M, GelasP, et al. A comparative study of peripherally-inserted and Broviaccatheter complications in home parenteral nutrition patients. ClinNutr. 2015;34:49-52. [PMID: 24439240] doi:10.1016/j.clnu.2013.12.017228. Trerotola SO, Thompson S, Chittams J, Vierregger KS. Analysisof tip malposition and correction in peripherally inserted centralcatheters placed at bedside by a dedicated nursing team. J VascInterv Radiol. 2007;18:513-8. [PMID: 17446542]229. Trerotola SO, Stavropoulos SW, Mondschein JI, Patel AA, Fish-man N, Fuchs B, et al. Triple-lumen peripherally inserted centralcatheter in patients in the critical care unit: prospective evaluation.
Radiology. 2010;256:312-20. [PMID: 20574104] doi:10.1148/radiol.10091860230. Trick WE, Vernon MO, Welbel SF, Wisniewski MF, Jernigan JA,Weinstein RA. Unnecessary use of central venous catheters: theneed to look outside the intensive care unit. Infect Control HospEpidemiol. 2004;25:266-8. [PMID: 15061422]231. Turcotte S, Dube S, Beauchamp G. Peripherally inserted centralvenous catheters are not superior to central venous catheters in theacute care of surgical patients on the ward. World J Surg. 2006;30:1605-19. [PMID: 16865322]232. Ugas MA, Cho H, Trilling GM, Tahir Z, Raja HF, Ramadan S,et al. Central and peripheral venous lines-associated blood streaminfections in the critically ill surgical patients. Ann Surg Innov Res.2012;6:8. [PMID: 22947496] doi:10.1186/1750-1164-6-8233. Vidal V, Muller C, Jacquier A, Giorgi R, Le Corroller T, GaubertJ, et al. [Prospective evaluation of PICC line related complications].J Radiol. 2008;89:495-8. [PMID: 18477956]234. Vizcarra C, Cassutt C, Corbitt N, Richardson D, Runde D, Staf-ford K. Recommendations for improving safety practices with shortperipheral catheters. J Infus Nurs. 2014;37:121-4. [PMID: 24583942]doi:10.1097/NAN.0000000000000028235. Wallis MC, McGrail M, Webster J, Marsh N, Gowardman J, Play-ford EG, et al. Risk factors for peripheral intravenous catheter failure:a multivariate analysis of data from a randomized controlled trial.Infect Control Hosp Epidemiol. 2014;35:63-8. [PMID: 24334800] doi:10.1086/674398236. Wilson TJ, Stetler WR Jr, Fletcher JJ. Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherallyinserted central venous lines in the neurological intensive care unit.Clin Neurol Neurosurg. 2013;115:879-82. [PMID: 22948189] doi:10.1016/j.clineuro.2012.08.025237. Worley TA, Revesz E, Clark ET, Podbielkski FJ. Peripherally in-serted central catheters do not increase the risk of upper extremitydeep vein thrombosis. Chest. 2007;132:492a.238. Worth LJ, Seymour JF, Slavin MA. Infective and thromboticcomplications of central venous catheters in patients with hemato-logical malignancy: prospective evaluation of nontunneled devices.Support Care Cancer. 2009;17:811-8. [PMID: 19096883] doi:10.1007/s00520-008-0561-7239. Xing L, Adhikari VP, Liu H, Kong LQ, Liu SC, Li HY, et al. Diag-nosis prevention and treatment for PICC-related upper extremitydeep vein thrombosis in breast cancer patients. Asia Pac J Clin On-col. 2012;8:e12-6. [PMID: 22897494] doi:10.1111/j.1743-7563.2011.01508.x240. Yamada R, Morita T, Yashiro E, Otani H, Amano K, Tei Y, et al.Patient-reported usefulness of peripherally inserted central venouscatheters in terminally ill cancer patients. J Pain Symptom Manage.2010;40:60-6.[PMID:20638981]doi:10.1016/j.jpainsymman.2009.11.327241. Yap YS, Karapetis C, Lerose S, Iyer S, Koczwara B. Reducing therisk of peripherally inserted central catheter line complications in theoncology setting. Eur J Cancer Care (Engl). 2006;15:342-7. [PMID:16968315]242. Yi XL, Chen J, Li J, Feng L, Wang Y, Zhu JA, et al. Risk factorsassociated with PICC-related upper extremity venous thrombosis incancer patients. J Clin Nurs. 2014;23:837-43. [PMID: 23710585] doi:10.1111/jocn.12227243. Yue ZY, Li JY, Yu CH, Zhao SZ, Fu Y. [Complications with pe-ripherally inserted central catheters—observations and nursing expe-riences at one medical center in Chengdu]. Hu Li Za Zhi. 2010;57:79-85. [PMID: 20535681]244. Zhu M, Cui H, Xi H, Ye G, Li D, Wei J. Prevention and treatmentof deep vein thrombosis induced by peripherally inserted enteralcatheter. Chinese Journal of Clinical Nutrition. 2008;16:160-3.245. Zochios V, Umar I, Simpson N, Jones N. Peripherally insertedcentral catheter (PICC)-related thrombosis in critically ill patients.J Vasc Access. 2014;15:329-37. [PMID: 24811591] doi:10.5301/jva.5000239
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
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Table 1. Summary of Studies Included in the Literature Review
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Abdullah et al, 2005 (91) 26 Prospective cohortstudy
Determine the incidence of DVT in patientswith PICCs as diagnosed with anupper-limb venogram at the time of PICCremoval
Patients aged 15–70 y with PICCs at the Universityof Malaya Medical Centre
PICC PICCs were associated with a significant rate ofDVT by venography; no correlation betweensize and insertion site of catheter and UEVTEwere noted.
Ahn et al, 2013 (57) 237 Retrospective cohortstudy
Ascertain risk factors associated withPICC-related DVT in cancer patients
Patients with cancer and PICCs at the Dallas VAmedical center from 2006 to 2009
PICC Antiplatelet agents were protective againstDVT whereas use of ESAs, hospitalization,and treatment dose anticoagulation wereassociated with DVT
Akers and Chelluri, 2009 (92) 5 Retrospective cohortstudy
Analysis of CVC use 18 mo before and aftera hospitalist training program to placePICCs
3 hospitalists were trained to place PICCs inpatients at 1 university-affiliated communityhospital
PICC After training, use of CVCs doubled, withPICCs representing over 80% of all devices
Akl et al, 2011 (93) 3611 Cochrane systematicreview
Evaluate the efficacy and safety ofanticoagulation in patients with cancer
Patients with cancer and CVCs from 12 RCTs CVC A clear rationale supporting use ofanticoagulants to prevent CRT could not bedefined
Alexandrou et al, 2014 (94) 3447 Prospective cohortstudy
Report characteristics and outcomes from aCVC insertion service offered by trainednurses
Adult patients with a CVC, PICC, high-flow dialysiscatheter, or midlines in one tertiary careuniversity hospital in Sydney, Australia, betweenNovember 1996 and December 2009
CVADs Trained vascular access nurses using US andbest practice can lower complication ratesduring insertion and may improve patientsafety
Alhimyary et al, 1996 (95) 231 Prospective cohortstudy
Report complications using PICCs for TPN innon-ICU patients compared to placementof CVCs in the subclavian vein
Non-ICU patients who needed TPN received PICCsinserted in the antecubital vein or CVCs at 1institution from July 1991 to March 1994
CVC, PICC Complication rates did not differ significantlybetween the 2 groups; PICCs can be usedsafely for exclusive TPN administration
Alkindi et al, 2012 (96) 16 Retrospective cohortstudy
Review outcomes related to implanted portplacement in patients with sickle celldisease who required red cellexchange/transfusion
Patients with sickle cell disease who werefrequently hospitalized at a single academicmedical center
Port Of 24 devices placed, 17 required removalowing to infection or thrombosis. Themedian working life of the ports was 688.5 d(range, 39–3925 d). The number ofinfections was significantly correlated withthe number of ports (Pearson r = 0.66;P < 0.01)
Allan et al, 2012 (97) 10 In vivo comparisonstudy
Rabbit model used to evaluate theperformance of antimicrobial(chlorhexidine)–coated PICCs in a clinicalsetting, compared with uncoatedcatheters
Healthy, 15-week-old New Zealand white femalerabbits
PICC Chlorhexidine-coated catheters significantlyreduced microbial colonization andprevented microbial migration comparedwith uncoated devices
Allen et al, 2000 (98) 119 Retrospective cohortstudy
Evaluate the rate of DVT in patients who hadvenography before and after PICCplacement
354 PICCs were placed in 119 patients betweenApril 1992 and August 1998 at a single center;all patients underwent venography before andafter PICC placement
PICC Overall rate of DVT associated with PICCs was38%; incidence was highest for PICCsplaced in the cephalic vein (57%)
Al Raiy et al, 2010 (1) 1260 Prospective cohortstudy
Compare PICC-related CLABSI rates withthose associated with CVCs inhospitalized patients
Patients with CVCs in non-ICUs and patients withPICCs hospital-wide at 1 institution
CVC, PICC CVCs and PICCs had similar rates of CLABSI;with surveillance and intervention, high-riskCVCs were removed; PICCs may be safer forlonger IV access
Al-Tawfiq et al, 2012 (99) 92 PICCs Prospective cohortstudy
Describe PICC-related BSI incidence in 1hospital setting
Hospitalized patients with PICCs at Dhahran HealthCare Center, Saudi Arabia, from January toDecember 2009
PICC Rates of PICC-related CLABSI varied accordingto patient factors, such as cancer and criticalillness
Amerasekera et al,2009 (100)
NA Review Overview of venous anatomy andcomplications related to PICC use withradiographic images
NA PICC To help diagnose PICC complications,radiologists should have good knowledgeof venous anatomy and imaging techniquesrelated to PICC insertion
Anderson, 2004 (42) 6004 midlinecatheters;337 PICCs
Review article andretrospectivecohort study
Examine midline catheter use as a bridgebetween peripheral and central cathetersover a 6-year period
Patients at Evangelical Community Hospital inLewisburg, PA
PIVC,midlinecatheter,PICCIV
Substituting a midline for a short peripheralcatheter led to improved outcomes,including reduced rates of venipuncture,decreased length of stay, and improved staffand patient satisfaction
Armstrong et al, 2013 (101) 49 Case–control study Compare bacteremia rates in patients withantibiotic (minocycline–rifampin)impregnated PICCs vs. those whoreceived conventional PICCs
Patients admitted to a regional burn center whorequired a PICC as part of clinical care
PICC Antibiotic-impregnated PICCs substantiallydecreased the rate of bacteremia in burnpatients (0% vs. 50%)
Association for VascularAccess, 2011 (102)
NA Guideline Position statement and recommendationsfor the insertion of CVADs by registerednurses using US guidance
NA CVC,midlinecatheter,PICC
US guidance for placement of CVADs bytrained nurses is safe and cost-effective andshould become part of routine practice
Aw et al, 2012 (103) 340 Retrospective cohortstudy
Determine the incidence of symptomaticPICC-related DVT in cancer patients
Patients with cancer who had PICCs placed by USguidance for delivery of chemotherapy
PICC Symptomatic PICC-related DVT is frequent inthis population; diabetes and chronicobstructive pulmonary disease are riskfactors for PICC-related DVT
Bai and Hou, 2010 (104) 37 Prospective cohortstudy
Explore feasibility of US-guided PICCinsertion in elderly adults using modifiedSeldinger technique
Elderly adults with PICCs inserted by US guidancein a Chinese medical center
PICC US-guided insertion of PICCs is safe andeffective for elderly adults with nonpalpableveins
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Table 1—Continued
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Bai et al, 2013 (105) 128 Prospective cohortstudy
Determine clinical outcomes in patients whoreceived chemotherapy via an indwellingIVs compared to PICCs
Patients with lung cancer in 1 radiation oncologydepartment in Shenyang, China
IV, PICC Patients undergoing combined radiationtherapy and chemotherapy prefer a PIVCover a PICC for intermittent chemotherapy
Barr et al, 2012 (106) 2766 Retrospective cohortstudy
Examine rates of complications andoutcomes in patients receiving outpatientantibiotic therapy by device type
Patients in the ambulatory care setting using theGlasgow outpatient antibiotic therapy service
Midlinecatheter,PICC,TCVC
Line infections were associated with durationof line use, female sex, and TCVCs; dwelltime was significantly associated with risk forline infection
Bates et al, 2012 (107) NA Guidelines fordiagnosis of DVT
Identify and recommend strategies fordiagnosis of DVT in ambulatory adults
Eligible studies included those that addresseddiagnostic accuracy and clinical outcomes
PICC, CVC For diagnosis of UEDVT, initial evaluation withcombined modality US over other tests,including venography and D-dimer, isrecommended
Baumgarten et al, 2013 (108) NR Prospective cohortstudy
Evaluate a training and implementationprogram to reduce CLABSI in the homehealth care environment
Ochsner home infusion outpatients who receivedPICC lines were included; a checklist for bestdressing practices and order sets wereevaluated
PICC After institution of a checklist and an order setto standardize care in home infusionpatients, PICC infection rates decreased by46% compared with prior years
Baxi et al, 2008 (109) 1350 PICCs Retrospective cohortstudy
Evaluate the association betweenpost-placement and risk for PICC-relatedBSI and DVT
Hospitalized patients from February to August2007 at a quaternary medical center in Michigan
PICC Post-placement adjustment of PICCs was notassociated with CLABSI or DVT. Factorsassociated with CLABSI were diabetes,immune suppression, and number oflumens; lumens were associated with risk forDVT and catheter thrombosis
Baxi et al, 2013 (110) 1652 Retrospective cohortstudy
Evaluate the association betweenpost-placement and risk for PICC-relatedBSI and DVT
Hospitalized patients from February to August2007 at a quaternary medical center in Michigan
PICC Post-placement adjustment of PICCs was notassociated with CLABSI or DVT. Factorsassociated with CLABSI were power-capablePICCs, diabetes, immune-suppression andnumber of lumens; lumens were alsoassociated with risk for DVT and thrombosis
British Committee forStandards in Haematology,1997 (69)
NA Guidelines British Committee for Standards inHaematology guidelines that review basicprinciples of the care of patients withCVCs
2007 update to the 1997 guidelines that providemajor recommendations for use of severaldevices in hospitalized and ambulatory patients
CVC, PICC,port
Major recommendations in this update includeuse of US during insertion, use of CVCs forshort-term access when peripheral access isnot possible, and use of tunneled cathetersor ports for longer-term access. Theseguidelines recommend avoidance of PICCsin inpatient settings because of thrombosis risk
Bellesi et al, 2013 (58) 24 Prospective cohortstudy
Evaluate the efficacy and safety of PICCs aslong-term VADs for chemotherapyadministration
Patients undergoing hematopoietic stem celltransplantation with PICCs inserted betweenMay and November 2008 in Italy
PICC The rate of CLABSI with PICCs was similar tothat of conventional CVCs
Bonciarelli et al, 2011 (111) NA Guideline Define recommendations for the correct andsafe use of implantable venous accessdevices for diagnostic procedures
Patients using ports for radiodiagnostics Port Patient safety, cost-effectiveness, andefficiency are important aspects in the use ofports in radiodiagnostics, especially inpatients with cancer
Bonizzoli et al, 2011 (112) 239 Prospective cohortstudy
Assess rates of thrombosis after PICCplacement in a cohort of critically illpatients
Patients discharged from the ICU with a centralvenous device at Careggi Teaching Hospital,Florence, Italy, from January to August 2008
CVC, PICC Higher risk for DVT in patients with PICCs wasnoted (27.2% vs. 9.6%). Female sex and theleft basilic vein as the access site wereassociated with PICC-related DVT
Bottino et al, 1979 (113) 81 Prospective cohortstudy
Assess risks related to long-term use ofperipherally inserted silicone elastomerCVCs in cancer populations
Patients with cancer requiring prolonged IVtherapy, including chemotherapy
PICC Although 6% of catheters were removed forphlebitis, peripherally inserted siliconeelastomer CVCs may be used for long-termcentral venous access
Burg and Myles, 2005 (114) 79 Cross-sectionalsurvey
Identify complications associated withantepartum PICC use
Antepartum patients with IV therapy records at St.Mary's Health Center from January 2000 toMarch 2005
PICC PICCs had a low risk for complications andwere otherwise effective for long-term IVaccess. One patient had a DVT, and 6% hadPICCs removed for other complications
Burns and Lamberth, 2010 (5) NA Review Discuss resources, costs, policies, andprocedures related to developingvascular access teams
A review of the formation of vascular access teamsin 2 hospitals and the costs and benefitsassociated with these programs
PICC,midlinecatheter,CVC
Vascular access teams, though associated withupfront costs, have important downstreambenefits and cost savings
Butler et al, 2011 (115) 185 Retrospective cohortstudy
Examine the association between PICCplacement and subsequent risk forcatheter-related infection in hemodialysispatients
Patients requiring hemodialysis with catheterplacements and exchanges at 1 universityhospital from September 2003 to September2008
PICC Prior PICC use was 2.46 times more likely to beassociated with catheter-related infectioncompared with patients who never receivedthis device
Caparas and Hu, 2014 (38) 54 Prospective,controlled,randomizedclinical trial
Assess whether vancomycin can be safelyadministered through a new midlinecatheter compared with PICCs
Patients scheduled to receive short-term IVvancomycin at a single medical center inQueens, New York
Midlinecatheter,PICC
Short-term midline catheters were safe andcost-effective for delivering vancomycin fordurations ≤6 d
Cape et al, 2013 (116) 66 Retrospective cohortstudy
Analyze PICC-related complications inpregnant women who received PICCs forvarious clinical indications
Pregnant women with PICCs inserted betweenJanuary 2000 and June 2006 at 1 medicalcenter
PICC PICC insertion in pregnant women wasassociated with high rates of bacteremiaand thrombosis.
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Table 1—Continued
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Catalano et al, 2011 (117) 500 Prospective cohortstudy
Analyze rates of catheter-related thoracicDVT in patients with cancer by usingmultidetector CT
Cancer patients who had a CVAD and underwentCT for any reason
CVC, PICC,port
CVC-related thrombosis is common in patientswith cancer and can be difficult to detect byclinical means
Chakravarthy et al,2005 (118)
31 Randomized,controlled clinicaltrial
Evaluate the incidence of PICC-related DVTin ICU patients
Critically ill patients who received a PICC duringroutine clinical care at 1 academic medicalcenter
PICC PICC-related DVT in critically ill patients iscommon (65%) and largely asymptomatic;vigilance for DVT in this population issuggested
Chemaly et al, 2002 (119) 2063 Retrospective cohortstudy
Assess the safety of PICCs used forlong-term IV antibiotic administration
Patients at the Cleveland Clinic Foundation whohad a PICC placed for IV antibiotics betweenJanuary 1994 and October 1996
PICC PICC use was associated with UEDVT. Patientswho were younger, had prior VT, orreceived amphotericin infusion through thePICC were at greater risk for DVT
Cheong et al, 2004 (120) 17 Retrospective cohortstudy
Document the frequency of PICCcomplications in patients with solidtumors
Patients with solid tumors treated at FlindersMedical Centre, South Australia, betweenJanuary 2000 and March 2001
PICC Compared with patients without cancer, a highrate of complications (sepsis, thrombosis,blockage, and leakage) was found inpatients with cancer who received PICCs
Chittick et al, 2013 (121) 265 Prospective cohortstudy
Compare patients with early- and late-onsetPICC-related CLABSI to assess risk factors
Patients who developed PICC-related CLABSI at 1academic center
PICC There are significant differences in themicrobiological characteristics of patientswith early- and late-onset CLABSI; thesedifferences may influence choice ofantibiotic and strategy of prevention
Chopra et al, 2012 (17) NA Review Describe evolution of PICCs and theiradoption in modern medicine; evaluateearly studies of DVT and CLABSI; providefocus for areas of uncertainty and risk
Human studies with specific keywords related toPICCs, CLABSI, and DVT; full text, abstracts, andposters were included
PICC Introduction of a conceptual model,highlighting uncertainties and knowledgegaps pertaining to PICCs and specificadverse outcomes
Chopra et al, 2012 (9) NA Review Examine the risk and benefit of PICC use inhospitalized patients
Evaluation of PICC decision making and changesin the epidemiology of CVC use in hospitalsettings
PICC Highlights the need for more PICC researchand caution in placing PICCs, given the riskfor adverse events
Chopra et al, 2013 (22) 144 Cross-sectionalsurvey
Web-based survey designed to understandhospitalist experience, practice, opinions,and knowledge related to PICC use, care,and management in Michigan
Hospitalists from 10 academic and communityhospitals in Michigan
PICC Substantial variation in hospitalist experience,practice, opinions, and knowledgeregarding PICCs was observed
Chopra et al, 2013 (21) 2112 Cross-sectionalsurvey
Web-based survey designed to understandhospitalist experience, practice, opinionsand knowledge related to PICC use, care,and management across the United States
Hospitalist providers who are members of theSociety of Hospital Medicine across the UnitedStates
PICC Hospitalist knowledge and experiences relatedto PICCs varied, with knowledge gapsrelated to the rationale for PICC tippositioning and outcomes related to PICCuse. Treatment of complications variedsubstantially, including in duration ofanticoagulation and catheter removal in thesetting of PICC-related DVT
Chopra et al, 2013 (15) 57 250 Systematic reviewand meta-analysis
Risk for CLABSI with PICCs vs. CVCs Twenty-three studies including adults who hadeither a PICC or CVC and reported CLABSI
PICC, CVC Hospitalized patients are just as likely todevelop CLABSI with PICCs as with CVCs; inoutpatients, PICCs were associated with alower risk for CLABSI
Chopra et al, 2013 (16) 29 503 Systematic reviewand meta-analysis
Risk for DVT with PICCs vs. nontunneledCVCs
64 studies including adult patients with PICCs orCVCs
CVC, PICC Patients with cancer and those with criticalillness had the highest rate of PICC-relatedDVT; PICCs were associated with 2.5 timesgreater risk for DVT compared with CVCs
Chopra et al, 2014 (122) 747 Retrospective cohortstudy
Identify rates; patterns; and patient,provider, and device characteristicsassociated with PICC-related CLABSI
Patients who underwent PICC placement betweenJune 2009 and July 2012 at a VA medical centerin Michigan
PICC PICC-related BSI was associated with hospitallength of stay, ICU status, and number ofPICC lumens
Cortelezzia et al, 2003 (123) 126 Retrospective cohortstudy
Analyze the incidence of thrombotic andinfectious complications in CVCs vs. PICCsin cancer patients
Patients with hematologic cancer and low plateletcount with either a CVC or a PICC; patientsreceived DVT prophylaxis at the discretion ofthe provider
CVC, PICC Thrombosis occurred more frequently withPICCs than with CVCs; patients whoreceived LMWH were less likely toexperience DVT than those who receivedheparin
Cotogni et al, 2013 (59) 254 Prospective cohortstudy
Evaluate the incidence of VAD-relatedcomplications in cancer patients whoreceive home parenteral nutrition
Cancer patients who received parenteral nutritionbetween June 2008 to November 2009 at auniversity hospital in Italy
PICC,tunneledcatheter,port
Home parenteral nutrition was safe and welltolerated in patients with cancer; risk forcomplications across devices was low andacceptable
Couban et al, 2005 (124) 255 Multicenter,randomized,placebo-controlled clinicaltrial
Assesse whether low-dose daily warfarinreduces the incidence of symptomaticCVC thrombosis in patients with cancer
Patients who required a CVC for at least 7 d wererandomly assigned to receive 1 mg warfarindaily vs. placebo
CVC Symptomatic CVC-associated thrombosis wasless common than previously thought in thispopulation; daily 1-mg doses of warfarin didnot reduce symptomatic CVC-relatedthrombotic events
Crnich and Maki, 2002 (125) NA Review Invited article that examined use of novelapproaches, such as securement devices,dressings, catheter coatings, and locksolutions, in preventing CLABSI
Examining the risk for IVD-related infections,pathogenesis, prevention, and novel technologyavailable for control of BSI associated withlong-term devices
CVC, port,PICC
Newer technologies may help reduce CLABSI.;identification, adaptation, and evaluation ofthese novel approaches is necessary
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Table 1—Continued
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Curigliano et al, 2007 (126) 188 Prospective cohortstudy
Evaluate the efficacy and safety of low-doseaspirin for prevention of VTE
Patients with stage II–IV breast cancer with CVCsfor continuous chemotherapy from April 2000 toMarch 2004 in a single center
CVC Although no control or comparison arm wasincluded, low-dose aspirin was a reasonablywell tolerated method of DVT prevention inthis population
Daneman et al, 2012 (127) 348 Retrospective cohortstudy
Assess the risk for recurrent bacteremia inpatients with recent CLABSI within 6weeks
Bacteremic patients undergoing PICC insertion atan academic health center were reviewed forrisk for recurrent infection
PICC Recurrent bacteremia within 30 d of PICCinsertion occurred in 33 patients but ofteninvolved a different organism (25 patients);after adjudication, only 3 of 8 recurrentinfections were determined to be "true"relapses (0.9%)
Dariushnia et al, 2010 (68) NA Guidelines Guidelines from the Society of InterventionalRadiology that were written for qualityimprovement programs seeking to assesscentral venous access procedures
Comprehensive review of indications for centralvenous access, QI efforts, and management ofcomplications
PICC, CVC,port
These guidelines provide target success ratesfor insertion of various catheters as well asmajor complication rates and suggestedthresholds for venous access devices
Dawson et al, 2013 (128) NA Review Examined published evidence on midlinecatheters in reducing the risk for CLABSI
Calls for greater use of midline catheters as part ofa multifaceted effort to reduce CLABSI inhospitals
CVAD,CVC,PICC,midlinecatheter
Midline catheters are effective tools forintermediate-duration infusions that areperipherally compatible. They can be usedfor blood draws and infusion and, as part ofa multifaceted approach, can reducehospital rates of CLABSI
Debourdeau et al, 2013 (36) NA Guidelines Establishment of good clinical practicesguidelines for the management of CRT inpatients with cancer
Guideline examined prophylaxis and treatment ofthrombosis associated with CVCs in patientswith cancer
CVC Dissemination and implementation of theseguidelines is a public health priority in orderto reduce CRT
DeLemos et al, 2011 (129) 35 Prospective cohortstudy
Evaluation of PICCs as an alternative to CVCsin neurosurgical critical care settings
Neurologic critical care patients at 1 center whohad PICCs (as opposed to CVCs) for IV accessand monitoring
PICC, CVC Use of PICCs (rather than CVCs or pulmonaryartery catheters) reduced procedural andinfection risk
Del Principe et al, 2013 (56) 71 Retrospective cohort Assess rates of catheter-related thrombosisin relation to catheter exit site infection
Patients with acute myeloid leukemia whounderwent CVC placement before eachchemotherapy cycle
CVC Patients with sepsis and exit-site infections hadsignificantly higher rates of thrombosis thanthose without these events, independent ofother factors
Diaz et al, 2012 (130) 50 Prospective cohortstudy
Determine baseline CLABSI rates forED-inserted CVCs and describeindications, duration of use, and naturalhistory of these devices
Patients at a level I trauma, academic ED whorequired central catheter insertion
CVC No CLABSI events occurred; notably, 42% ofCVCs had no date of removal, suggestingthe need to improve documentation in thisregard
Di Nisio et al, 2010 (131) NA Systematic review Examine the utility of US to diagnosePICC-related DVT
17 articles assessing diagnostic accuracy of testsfor clinically suspected UEDVT
CVC, PICC Compression US is an acceptable alternative tovenography, given high sensitivity andspecificity for catheter thrombosis
Duerksen et al, 1999 (132) NR Prospective cohortstudy
Assess type of CVC and complicationsassociated with delivery of parenteralnutrition
Patients at St. Boniface General Hospital inWinnipeg, Manitoba, Canada, who received aCVC for nutrition between 1987 and 1997
CVC, PICC,tunneledcatheter
Over the 10-year study, use of PICCs increasedto replace CVCs in providing parenteralnutrition; PICCs did not increase risk forsepsis or thrombosis compared withhistorical cohorts
Durrani, 2009 (133) 623 Retrospective cohortstudy
Test whether anticoagulants can prevent VTin patients with PICCs
Patients admitted to a single medical centerbetween January 2004 to July 2009 whoreceived a PICC and antiplatelet agents
PICC Receipt of aspirin or clopidogrel duringhospitalization did not affect the risk forPICC-related DVT
Elia et al, 2012 (41) 100 Randomizedcontrolled trial
Compare survival rates betweenstandard-length catheters vs. longperipheral catheters inserted by US
100 patients in an urban high-dependency unitwere randomly assigned to receive either shortor long peripheral catheters
PIVC Both short and long peripheral cathetersplaced with US have a high success rate;catheter failure occurred more frequently inthe short catheter group (45% vs. 14%;P = 0.001)
El Ters et al, 2012 (49) 282 Case–control study Assess the association between history ofPICC use and subsequent malfunctioningor nonfunctioning arteriovenous fistula
Hemodialysis outpatients in 7 Mayo Clinic units inRochester, Minnesota
PICC A strong and independent association (3.2times greater odds of a nonfunctioningfistula) was noted in patients who hadreceived prior PICCs
Evans et al, 2010 (73) 1728 Prospective cohortstudy
Assess the prevalence and risk factorsassociated with symptomatic PICC-relatedDVT in hospitalized patients
Patients with PICC insertions at a largeuniversity-based health system
PICC PICC insertion in patients who have cancer,undergo surgery lasting greater than 1 h, orhave experienced prior thrombosis isassociated with greater risk for DVT;Catheter gauge is a strong and modifiablefactor associated with PICC DVT
Evans et al, 2013 (74) 5018 Prospective cohortstudy
Assess whether small-diameter PICCs mayreduce the risk for DVT in hospitalizedpatients
All patients with PICC insertions at 1 hospital fromJanuary 2008 to December 2010
PICC Use of smaller-gauge PICCs was associatedwith substantially lower rates of DVT
Faganani et al, 2007 (134) 1410 Prospective cohortstudy
Evaluate the association betweenantiplatelet therapy and risk ofsubsequent catheter-related thrombosis
Patients attending 1 of 18 participating hospitalswho had solid or hematological tumors and aCVC, PICC, or port
CVC, PICC,port
Antithrombotic prophylaxis did not preventcatheter-related VT in this high-risk cohort
Fearonce et al, 2010 (135) 31 Retrospective cohortstudy
Compare the use and safety of PICCs vs.CVCs in a cohort of patients admitted to aburn ICU
Burn patients at a single center who received oneor more PICCs between July 2005 and June2007
PICC, CVC Compared with PICCs, CVCs had a higher rateof catheter-related BSI; PICCs wereassociated with greater risk for DVT
Continued on following page
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Table 1—Continued
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Fletcher and Bodenham,2000 (70)
501 Retrospective cohortstudy
Assess the incidence rate and clinicalsignificance of PICC-related DVT incritically ill patients in a neurologic ICU
479 patients who received 501 PICCs duringclinical care in a neurologic ICU at a quaternaryacademic medical center
PICC The incidence of symptomatic PICC-relatedDVT was 8.1%; PE attributable to the PICCoccurred in 15% of patients, often requiringanticoagulation or superior vena cava filterplacement
Fletcher et al, 2011 (136) 2150 Retrospective cohortstudy
Understand the incidence rate andsignificance of symptomatic PICC-relatedDVT in critically ill patients in aneurosurgical ICU
PICCs placed in neurosurgical ICU patientsbetween March 2008 and February 2010
PICC, CVC PICCs are associated with a high rate of DVT;placement in a hemiparetic arm and infusionof mannitol or vasopressors through thePICC were associated with greater odds ofDVT
Freixas et al, 2013 (137) 2176 healthcareworkers
Quasi-experimentalbefore-after study
Determine the effect of a multimodalintervention to reduce the incidence ofCLABSI outside the ICU
Adult patients hospitalized in non-ICU settingsbetween 2009 and 2010 at 11 affiliatedhospitals in Catalonia, Spain
PIVC, CVC Implementation of the program reducedCLABSI and CVC utilization; PIVC utilizationremained unchanged
Frizzelli et al, 2008 (138) 848 Prospective cohortstudy
Evaluate risk for US-confirmed DVT inpatients who received a CVC duringcardiac surgery
Patients recovering in the ICU after heart surgeryfor 5–7 d from 6 centers were included
CVC CVC-related DVT was a frequent outcome,occurring in 386 patients (48%). Patientswho received prophylactic anticoagulationdid not experience PE. Screening via US inthis high-risk cohort may be valuable to preventPE
Furuya et al, 2011 (139) 441 hospitals Cross-sectional study Assess the implementation of elementsembedded within the central line"bundle" across US hospitals and effect onsubsequent CLABSI rates
Hospitals must have conducted NationalHealthcare Safety Network CLABSI surveillancein 2007 to be included
CVC Reduction in CLABSI was only observed inICUs that had a CLABSI policy, monitoredadherence, and had >95% adherence rate
Gong et al, 2012 (140) 180 Prospective cohortstudy
Compare PICC complications via use of amodified Seldinger technique with USguidance vs. the traditional method ofplacement
Patients with cancer who had PICCs at theDepartment of Chemotherapy in JiangsuCancer Hospital
PICC PICCs placed using a modified Seldingerapproach and US were less likely toexperience thrombotic complications
Göransson and Johansson,2012 (141)
83 Prospective cohortstudy
Investigate the association betweenprehospital PIVC placement andfrequency of phlebitis
Hospitalized patients who underwent PIVCplacement before hospitalization by ambulancecrews in Stockholm, Sweden
PIVC Of 83 patients, 45% developedthrombophlebitis (54%); no associationbetween thrombophlebitis and prehospitalrisk factors was found
Grant et al, 2008 (142) 189 Retrospective cohortstudy
Examine characteristics of patients whodeveloped PICC UEDVT
Patients who underwent PICC placement at UCLAMedical Center between January 2003 andDecember 2006
PICC Patients who experienced multiple PICCinsertions had a 4-fold greater risk for DVTthan those who had only 1 insertion
Grant et al, 2012 (143) NA Review Provide a summative and clinically relevantapproach for the diagnosis, managementand prevention of UEDVT in high-riskpatients with and without catheters
Narrative review PICC, CVC,port
Pharmacologic thrombosis prophylaxis is noteffective in reducing risk for UEDVT inpatients with CVCs; anticoagulation iscommonly used for treatment of UEDVT andis recommended largely from extrapolationof studies involving lower-extremity DVT
Gregg et al, 2010 (144) 59 Retrospective cohortstudy
Report success and complications related toUS-guided PIVC placement in critically illpatients
Critically ill patients who underwent US-guidedPIVC placement as part of their routine care at asingle medical center in the United States
PIVC, CVC Of the 148 PIVCs requested, 147 were placedsuccessfully by US guidance; complicationsincluded infiltration (3.4%), inadvertentremoval (2.7%), and phlebitis (0.7%). As aresult of successful PIVC placement, 40CVCs were discontinued and 34 CVCs wereavoided
Griffiths, 2007 (145) NA Review Overview of midline catheters inserted bynurses for short- and long-term IVinfusions
Narrative review Midlinecatheter
Nurse involvement in determining theappropriateness of venous access can helpimprove patient outcomes; midlinecatheters are one example of a device thatcan provide both short and long-terminfusions with low risk for complications
Grove and Pevec, 2000 (146) 678 Retrospective cohortstudy
Determine risk factors that may lead to DVTin patients who receive PICCs
Patients with PICC insertions in 1997cross-referenced with venous duplex exams at 1hospital
PICC PICC-related DVT rates were 4.5% for nursesand 2.7% for IRs; the smallest-gaugecatheter should be used to decrease risk forthrombosis
Gunst et al, 2011 (2) 121 Prospective cohortstudy
Assess whether use of PICCs results inreduced rate of BSI compared toantiseptic-coated CVCs
Patients admitted to a surgical ICU for ≥14 dbetween July 2005 and July 2006
PICC, CVC The only independent predictor of infectionwas dwell time; catheter coating and PICCuse did not predict infection, though PICCswere associated with infections lessfrequently than CVCs
Guyatt et al, 2012 (35) NA Guidelines Summary of evidence for therecommendations on antithrombotictherapy and prevention of thrombosis
Summary recommendations related to therapyand prevention of thrombosis includingcatheter-related DVT
PICC, CVC This summary is the 9th edition of theAmerican College of Chest PhysiciansAntithrombotic Guidelines; a methodsarticle with recommendations and gradingof the evidence are included
Hadaway, 2001 (147) NA Review Address the risk for catheter-related BSI andhub disinfection methods and practice
Narrative review CVC, PICC Clinicians should closely follow manufacturerinstructions regarding disinfectiontechnique and chemical composition ofdisinfectant used
Continued on following page
Michigan
Appropriateness
Guide
forIntravenous
Catheters(M
AG
IC)S
UPPLEM
ENT
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ofInternalMedicine
•V
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Table 1—Continued
Study, Year (Reference) Participants,n
Design Focus or Overview Study Sample and Characteristics Device Findings and Comments
Hadaway et al, 2011 (148) 554 healthcareworkers
Survey-based study Assess the knowledge gap of health careworkers about practice with needlelessconnectors
Health care workers were invited to participate in a22-question survey
CVC, PICC Among respondents (response rate, !14%), asignificant gap of knowledge regardingneedleless connectors; cleansing practices;and flushing, clamping sequence
Hadaway, 2012 (149) NA Review Analysis of 45 studies to assess knowledgegaps and inadequate clinical practicesassociated with catheter-related BSI
Narrative review CVADs, IV Insertion techniques and other clinicalpractices differ greatly among countries;these variations may increase the risk forBSI. Catheters should be changed onlywhen clinically indicated
Hadaway, 2012 (150) NA Review Describe currently used needlelessconnectors and their potential forcomplications associated with differingmedical practices
Narrative review Needlelessconnectors
Device design, user knowledge deficits, andimproper hygiene can influence risk forinfections; such interventions as scrubbingthe connection surface, flushing, changingthe needleless connectors, and intermittentIV administration can reduce risk forinfection
Harnage, 2007 (151) 32 ICU beds Prospective cohort Assess the effect of a newly developed PICCbundle on catheter-related BSI
Patients with PICCs in 2 ICU units in 1 Californiahospital
PICC A PICC bundle that combined practice andtechnology successfully decreasedcatheter-related BSI
Harnage, 2012 (152) NR Retrospective cohortstudy
Evaluate sustainability and lessons learnedafter implementation of a PICC bundle at1 medical center
Patients in 1 California hospital PICC Catheter stabilization and zero-displacementIV connections helped reduce CLABSI
Hornsby et al, 2005 (88) NR Prospective cohortstudy
Analysis of the creation and effect of 2full-time vascular access specialtypositions at 1 medical center
500-bed facility in Saginaw, Michigan PIVC PICC More PICCs were placed proactively at thebeginning of hospital stays. Peripheralcatheter restarts were replaced with PICCsand delayed discharges related to PICCplacement were reduced
Hoshal, 1975 (86) 35 Prospective cohortstudy
Examine the feasibility of using peripherallyinserted silicone elastomer CVCs for totalIV nutrition
Patients receiving total IV nutrition at 1 medicalfacility
PICC This first-ever report of PICCs found thatperipherally inserted silicone elastomerCVCs were safe, effective, and durable fordelivery of total IV nutrition in outpatients
Hughes, 2011 (153) NA Systematic review Examine PICC-related thrombosis incidence,morbidity and effect of US guidance onoutcomes
Systematic review PICC PICC-related DVT is common, especiallyamong patients with cancer. Althoughlimited, available evidence suggests US canreduce risk for thrombosis
Hughes, 2014 (154) 31 Prospective cohortstudy
Assessing the feasibility of SecurAcath(Interrad Medical, Plymouth, Minnesota), asubcutaneous device, on inadvertent PICCmigration
Patients at 1 cancer hospital who received PICCsand the SecurAcath device during clinical care
PICC A single case of migration among 32 patientswas recorded; however, some initialproblems with infection and pain occurred
Infusion Nurses Society,2011 (32)
NA Guidelines Review of current literature for thedevelopment of standards of practice fornurses working with VADs
Standards for insertion, care, and management ofVADs for nursing professionals
PIVC, CVC,PICC,tunneledcatheter,port
Topics ranging from patient care, accessdevices, and infusion therapies to safe andeffective methods for working with VADswere included; basic requirements ineducation and competencies for insertionand management of devices are also outlined
Itkin et al, 2014 (155) 332 RCT Evaluate the risk for DVT in PICCs that arereverse-tapered vs. PICCs that are not
Patients 18–90 years of age requiring PICCinsertion at a quaternary academic medicalcenter
PICC Although tapering of PICCs did not influencerisk for PICC-related DVT, up to threequarters of patients experiencedasymptomatic thrombosis in this study,suggesting a high overall rate of thrombosis
Jin et al, 2013 (156) NA Systematic review Describe potential repositioning techniquesfor PICCs that were malpositioned duringor after insertion
Systematic review PICC Malpositioning of PICCs can occur from theright ventricle to peripheral veins.Repositioning techniques, including manualadvancement or catheter replacement, areoften necessary
Joffe and Goldhaber,2002 (157)
Review Examine the pathogenesis, signs, andsymptoms of UEDVT and the associationbetween the increasing incidence ofUEDVT and CVCs
Narrative review CVC, PICC Secondary thrombosis related to CVC use is onthe rise; thrombolysis reserved for specificinstances
Johansson et al, 2013 (6) NA Systematic review Examine the advantages and disadvantagesof PICCs vs. CVCs on the basis of availableevidence
48 studies were assessed for eligibility, of which 11were included in the qualitative analysis; 9 ofthe 11 were excluded owing to low quality
PICC, CVC,port
PICCs are commonly used in oncology;however the quality of the evidencesupporting use of these devices is limited
Johansson et al, 2013 (158) 23 oncologydepartments
Survey-based study National survey to examine use of PICCs inadult oncology departments in Sweden
Heads of 23 adult oncology departments inSweden
PICC Twenty-two of 23 sites responded (96%).Vascular nurses most often placed PICCswith US in most sites; 9 of 16 sites reportedhaving specific indications for type of deviceused; one third of departments did notplace PICCs
Continued on following page
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Tabl
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Retr
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eter
tipth
atw
asd
eem
edap
pro
pria
tely
pos
ition
edon
follo
w-u
pch
est
rad
iog
rap
hyLe
roye
reta
l,20
13(1
67)
222
Pros
pec
tive
coho
rtst
udy
Rep
ortc
omp
licat
ions
afte
rPIC
Cp
lace
men
tin
aFr
ench
teac
hing
hosp
ital
Patie
nts
havi
ngun
der
gon
ePI
CC
pla
cem
enti
nIR
ata
teac
hing
hosp
itali
nB
ord
eaux
,Fra
nce
PIC
CPI
CC
sw
ere
asso
ciat
edw
ithse
vera
lco
mp
licat
ions
incl
udin
gob
stru
ctio
n(2
0.5%
),D
VT(2
.5%
),an
din
fect
ion
(10%
);34
%of
PIC
Cs
wer
ere
mov
edow
ing
toco
mp
licat
ions
Leun
get
al,2
006
(168
)12
0Re
tros
pec
tive
coho
rtst
udy
Revi
ewin
dic
atio
nsfo
rPIC
Cin
sert
ion,
dw
ell
time,
and
rem
oval
inC
hine
sep
atie
nts
soas
tod
eter
min
ete
chni
calr
equi
rem
ents
forn
ewca
thet
ers
Patie
nts
who
rece
ived
fluor
osco
pic
ally
gui
ded
PIC
Cin
tod
ista
lsup
erio
rven
aca
vavi
ath
ean
tecu
bita
lreg
ion
ofth
efo
rear
m
PIC
CO
ozin
g,p
hleb
itis,
and
occl
usio
nof
ten
occu
rred
inp
atie
nts
with
thro
mb
ocyt
open
iaan
dle
ukem
ia;d
evic
esth
atp
reve
ntp
late
let
cons
ump
tion
may
be
valu
able
inp
reve
ntin
gth
ese
typ
esof
even
tsLe
ung
etal
,201
1(1
4)27
6Re
tros
pec
tive
coho
rtst
udy
Eval
uate
fact
ors
asso
ciat
edw
ithPI
CC
failu
reb
yco
mp
arin
gp
erio
ds
afte
rthe
rollo
utof
nurs
ing
care
imp
rove
men
ts
Patie
nts
with
med
ical
reco
rds
who
und
erw
ent
silic
one-
rub
ber
–con
stru
cted
4-Fr
ench
sing
le-lu
men
PIC
Cs
inTa
ipei
,Chi
na
PIC
CA
ftern
ursi
nged
ucat
ion–
bas
edin
terv
entio
ns,
com
plic
atio
nssu
chas
oozi
ng,w
ound
leak
age,
and
phl
ebiti
sw
ere
red
uced
Liet
al,2
014
(13)
100
RCT
Com
par
eth
eef
fect
sof
PIC
Cp
lace
men
tus
ing
B-m
ode
US
with
mod
ified
Seld
ing
erte
chni
que
vs.b
lind
inse
rtio
n
100
pat
ient
sun
der
goi
ngch
emot
hera
py
wer
ere
crui
ted
and
rand
omly
assi
gne
dto
blin
dvs
.g
uid
edp
lace
men
tgro
up
PIC
CB
-mod
eU
Sw
ithm
odifi
edSe
ldin
ger
tech
niq
uere
duc
edco
mp
licat
ions
and
pat
ient
cost
sco
mp
ared
with
the
blin
dap
pro
ach
Liu
etal
,201
4(3
9)N
ASy
stem
atic
revi
ewEx
amin
eth
eef
ficac
yof
US
gui
dan
cefo
rthe
pla
cem
ento
fPIV
Cs
Patie
nts
with
diffi
cult
PIVC
acce
ssPI
VCRo
utin
eus
eof
PIVC
gui
dan
cew
ithU
Sis
not
stro
ngly
sup
por
ted
by
the
liter
atur
e;us
eof
this
tech
nolo
gy
shou
ldb
ere
serv
edfo
rp
rovi
der
sw
hoar
ead
equa
tely
trai
ned
und
erap
pro
pria
teco
nditi
ons
Con
tinue
don
follo
win
gpa
ge
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S31
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Lob
oet
al,2
009
(7)
777
Retr
osp
ectiv
eco
hort
stud
yA
sses
sris
kfo
rVT
ing
ener
alho
spita
lized
pat
ient
sw
hore
ceiv
edPI
CC
sPa
tient
sw
hore
ceiv
eda
PIC
Cw
hile
hosp
italiz
edat
asi
ngle
faci
lity
asp
arto
fthe
ircl
inic
care
PIC
CTh
ein
cid
ence
ofPI
CC
-rel
ated
DVT
was
4.89
%;
PIC
Cs
that
did
nott
erm
inat
ein
the
SVC
had
a2.
61tim
esg
reat
erfo
rthr
omb
osis
than
thos
ein
this
area
.PIC
C-r
elat
edD
VTw
as10
-fold
gre
ater
inp
atie
nts
with
ahi
stor
yof
thro
mb
osis
Loup
uset
al,2
008
(169
)44
Retr
osp
ectiv
eco
hort
stud
yRe
por
tthe
risk
forP
ICC
-rel
ated
DVT
inp
atie
nts
with
cerv
ical
spin
eco
rdin
jurie
sco
mp
ared
with
othe
rpop
ulat
ions
Qua
drip
leg
icp
atie
nts
with
PIC
Cs
at1
med
ical
cent
erPI
CC
The
inci
den
ceof
PIC
C-r
elat
edD
VTw
as7.
1%p
erPI
CC
inse
rtio
nan
d9.
1%p
erp
erso
n
Mak
ieta
l,20
06(1
70)
NA
Syst
emat
icre
view
Defi
nean
dre
por
tthe
risk
forB
SIw
ithva
rious
IVD
s20
0st
udie
sre
por
ting
BSI
rate
sth
atw
ere
pro
spec
tive,
pub
lishe
d,a
ndin
clud
eda
dev
ice
ofin
tere
st
PIVC
,m
idlin
eca
thet
er,
CVC
,PI
CC
Exp
ress
ing
BSI
per
1000
IVD
-day
sis
ab
ette
res
timat
eof
risk;
allt
ypes
ofIV
Ds
pos
ea
risk
forB
SI.D
wel
ltim
eis
asi
gni
fican
tasp
ecto
fris
k;ris
kfo
rBSI
varie
sb
yd
evic
ety
pe.
Mal
inos
kiet
al,2
013
(171
)18
4Pr
osp
ectiv
eco
hort
stud
yD
eter
min
ew
hich
CVC
isas
soci
ated
with
the
gre
ates
tris
kfo
rDVT
insu
rgic
alcr
itica
lca
rep
atie
nts
Patie
nts
with
aC
VCin
asu
rgic
alIC
Uat
2tr
aum
ace
nter
sC
VC,P
ICC
CVC
sp
lace
din
the
inte
rnal
jug
ular
vein
and
PIC
Cs
pla
ced
inar
mve
ins
had
the
gre
ates
tris
kfo
rcat
hete
r-as
soci
ated
DVT
Mar
nejo
net
al,2
012
(172
)40
0C
ase–
cont
rols
tud
yId
entifi
catio
nof
risk
fact
ors
asso
ciat
edw
ithPI
CC
-rel
ated
DVT
by
com
par
ing
case
sof
PIC
C-D
VTto
cont
rols
Con
secu
tive
pat
ient
sw
ithan
dw
ithou
tDVT
afte
rPI
CC
inse
rtio
nat
1ho
spita
lin
Ohi
oPI
CC
Patie
nts
with
ahi
stor
yof
trau
ma
orre
nal
failu
re,t
hose
with
had
left-
sid
edin
sert
ions
,an
dth
ose
who
rece
ived
vanc
omyc
inw
ere
atg
reat
erris
kfo
rthr
omb
osis
than
cont
rols
Mar
scha
llet
al,2
014
(173
)N
AG
uid
elin
ePr
ovid
eev
iden
ce-b
ased
reco
mm
end
atio
nsto
assi
stac
ute
care
hosp
itals
inC
LAB
SIp
reve
ntio
n
Exp
ert-
gui
dan
ced
ocum
entt
hatw
assp
onso
red
by
mul
tiple
med
ical
soci
etie
sai
min
gto
iden
tify
bes
tpra
ctic
esto
pre
vent
CLA
BSI
CVC
,PIC
C,
por
tTh
isco
mp
end
ium
ofev
iden
ce-b
ased
stra
teg
ies
pro
vid
eske
yd
irect
ion
for
focu
sing
onhi
gh-
risk
pop
ulat
ions
and
max
imiz
ing
stra
teg
ies
pro
ven
tore
duc
eris
kfo
rCLA
BSI
Mer
mel
etal
,199
5(4
0)23
8Pr
osp
ectiv
eco
hort
stud
yEv
alua
teris
kan
db
enefi
tsfr
omus
eof
2m
idlin
eca
thet
ers
inth
eho
spita
lset
ting
238
pat
ient
sin
asi
ngle
med
ical
cent
erre
ceiv
ed25
1m
idlin
eca
thet
ers
toas
sess
the
risk
asso
ciat
edw
ithus
eof
this
dev
ice
inho
spita
lized
pat
ient
s
Mid
line
cath
eter
The
mea
nd
urat
ion
ofm
idlin
eca
thet
erus
ew
as9
d,a
ndth
eov
eral
lris
kfo
rCRB
SIw
as0.
8p
er10
00ca
thet
er-d
ays;
2se
vere
unex
pec
ted
reac
tions
occu
rred
dur
ing
the
stud
yth
atm
ayha
veb
een
rela
ted
toa
par
ticul
arm
idlin
eca
thet
erm
anuf
actu
rer
and
/orc
athe
term
ater
ial
Mer
mis
etal
,201
4(1
74)
117
Retr
osp
ectiv
eco
hort
stud
yA
sses
sp
oten
tialr
isk
fact
ors
fors
ymp
tom
atic
PIC
C-r
elat
edD
VTan
dim
ple
men
taQ
Ip
roje
ctto
red
uce
PIC
C-r
elat
edD
VTin
pat
ient
sw
ithcy
stic
fibro
sis
Ad
ultp
atie
nts
with
cyst
icfib
rosi
sw
hore
ceiv
eda
PIC
Cb
etw
een
July
2006
toM
arch
2013
PIC
CQ
Istr
ateg
ies
that
focu
son
usin
gsm
alle
r-d
iam
eter
4-Fr
ench
PIC
Cs
and
avoi
din
gPI
CC
sin
hig
h-ris
kp
atie
nts
are
likel
yto
mee
twith
succ
ess
inp
atie
nts
with
CF
Mer
rell
etal
,199
4(1
75)
460
Pros
pec
tive
coho
rtst
udy
Eval
uate
the
use
ofPI
CC
sfo
rong
oing
veno
usac
cess
ing
ener
alm
edic
alan
dsu
rgic
alp
atie
nts
ina
VAm
edic
alce
nter
Gen
eral
and
surg
ical
pat
ient
sw
ithPI
CC
sin
aVA
med
ical
cent
erb
etw
een
1985
and
1988
;in
sert
ion
was
don
eb
ytr
aine
dnu
rses
PIC
CPI
CC
sw
ere
asso
ciat
edw
itha
mea
nd
urat
ion
ofus
eof
27d
.Com
plic
atio
ns,i
nclu
din
gp
hleb
itis,
bac
tere
mia
,mec
hani
calf
ailu
re,
and
loca
linf
ectio
n,w
ere
unco
mm
onM
eyer
,201
1(1
76)
1307
Retr
osp
ectiv
eco
hort
stud
yEv
alua
teth
eef
fect
iven
ess
ofcl
inic
alp
ract
ice
chan
ges
tore
duc
ePI
CC
-rel
ated
thro
mb
osis
Patie
nts
who
und
erw
entP
ICC
inse
rtio
nat
Duk
eU
nive
rsity
Med
ical
Cen
terf
orva
rious
clin
ical
ind
icat
ions
PIC
CPr
actic
esfo
rred
uctio
nof
PIC
C-r
elat
edD
VTin
clud
edU
Sg
uid
ance
and
verifi
catio
nof
tiplo
catio
n;ro
utin
em
easu
rem
ento
fvei
nd
iam
eter
sal
sop
rove
dhe
lpfu
lin
red
ucin
gth
rom
bos
isris
kM
eyer
,201
2(3
)N
ARe
view
Exp
lore
the
effe
ctof
anal
tern
ativ
ew
orkfl
ow,
incl
udin
ga
cent
raliz
edp
roce
dur
ero
omPa
tient
sw
houn
der
wen
tPIC
Cin
sert
ion
atD
uke
Uni
vers
ityM
edic
alC
ente
rfor
vario
uscl
inic
alin
dic
atio
ns
PIC
CC
entr
aliz
ing
PIC
Cop
erat
ions
inm
edic
alfa
cilit
ies
isan
effic
ient
mod
elfo
rdev
ice
pla
cem
ent,
imp
rove
dnu
rsin
gp
rod
uctiv
ityan
dw
ork
cultu
re,a
ndd
ecre
ased
pat
ient
care
del
ays
Mils
tone
and
Seng
upta
,20
10(1
77)
NA
Revi
ewEx
amin
eth
ere
latio
nshi
pb
etw
een
PIC
Cd
wel
ltim
ean
dC
LAB
SIris
k,as
wel
las
stra
teg
ies
such
asca
thet
erre
pla
cem
entt
op
reve
ntC
LAB
SI
Nar
rativ
ere
view
PIC
CTh
eha
zard
risk
forC
LAB
SIw
ithPI
CC
sis
nonl
inea
rbut
cons
tant
lyin
crea
sing
over
time;
rep
lace
men
tofP
ICC
sas
ast
rate
gy
top
reve
ntC
LAB
SIca
nnot
be
reco
mm
end
edon
the
bas
isof
avai
lab
led
ata
Min
kovi
chet
al,2
011
(178
)26
9Re
tros
pec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
cean
dris
kfa
ctor
sas
soci
ated
with
PIC
Cm
alp
ositi
onin
pat
ient
sw
ithhe
adan
dne
ckca
ncer
who
wer
eun
der
goi
ngsu
rger
y
Patie
nts
und
erg
oing
free
flap
reco
nstr
uctiv
esu
rger
yfo
rhea
dan
dne
ckca
ncer
at1
acad
emic
med
ical
cent
er
PIC
CPI
CC
sin
sert
edw
ithou
tim
agin
gg
uid
ance
wer
em
ore
com
mon
lyas
soci
ated
with
mal
pos
ition
ing
;lef
t-si
ded
PIC
Cs
had
alo
wer
risk
form
alp
ositi
onin
gM
iyag
akie
tal,
2012
(179
)26
RCT
Com
par
eth
ep
erfo
rman
ceof
2m
ajor
PIC
Cs
with
diff
eren
tmat
eria
land
tipd
esig
nPa
tient
sun
der
goi
ngg
astr
oint
estin
alsu
rger
yw
houn
der
wen
tPIC
Cp
lace
men
tbet
wee
nA
ugus
t20
10an
dD
ecem
ber
2010
at1
faci
lity
inO
saka
,Ja
pan
PIC
CN
od
iffer
ence
ind
urab
ility
and
com
plic
atio
nsb
etw
een
the
Gro
shon
g(w
ithd
ista
lsid
esl
its)
and
pol
yure
than
eca
thet
er(w
ithop
en-e
nded
tip)w
asno
ted
Mol
lee
etal
,201
1(5
2)72
7Pr
osp
ectiv
eco
hort
stud
yD
eter
min
eth
ein
cid
ence
ofan
dris
kfa
ctor
sfo
rCLA
BSI
inp
atie
nts
with
canc
erA
dul
tsw
houn
der
wen
tCVC
pla
cem
enti
non
ehe
mat
olog
y–on
colo
gy
unit
inA
ustr
alia
PIC
C,C
VC,
tunn
eled
cath
eter
Non
tunn
eled
and
tunn
eled
cath
eter
sha
dg
reat
erris
kfo
rCLA
BSI
than
PIC
Cs
(od
ds
ratio
,3.5
5an
d1.
77,r
esp
ectiv
ely)
Con
tinue
don
follo
win
gpa
ge
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S32 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Mor
den
etal
,201
4(1
80)
NA
Invi
tro
Det
erm
ine
the
rate
and
caus
eof
dis
pla
cem
ento
fCT
pow
er-in
ject
able
PIC
Cs
dur
ing
cont
rast
mat
eria
land
salin
eflu
shin
ject
ion
Inth
ela
bor
ator
yse
ttin
g,i
nvi
tro
mod
elin
gof
CT-
ind
uced
PIC
Cd
isp
lace
men
twas
exam
ined
whi
leva
ryin
gra
tes
and
natu
reof
pow
erin
ject
ion
PIC
CH
ighe
rrat
esof
salin
eflu
shw
ere
asso
ciat
edw
ithg
reat
erm
ovem
ents
ofth
ePI
CC
tip
Mou
reau
etal
,200
2(1
81)
5047
0Re
tros
pec
tive
coho
rtst
udy
Doc
umen
tthe
natu
ralh
isto
ryof
CVC
san
dd
eter
min
eth
era
teof
com
plic
atio
nsin
pat
ient
sre
ceiv
ing
hom
ein
fusi
ons
Patie
nts
who
und
erw
enth
ome
infu
sion
care
and
pla
cem
ento
faC
VCPI
CC
,CVC
,m
idlin
eca
thet
er,
por
t,tu
nnel
edca
thet
er
Cat
hete
rdys
func
tion
isal
mos
ttw
ice
aslik
ely
asin
fect
ion
inth
isp
opul
atio
n;th
isre
sults
ind
elay
sin
ther
apy,
reho
spita
lizat
ions
,and
dev
ice
rep
lace
men
t
Mou
reau
etal
,201
3(8
9)N
AG
uid
elin
esSt
and
ard
ize
defi
nitio
nsof
and
reco
mm
end
atio
nsfo
rtra
inin
gan
din
sert
ion
ofC
VAD
sb
yth
eW
orld
Con
gre
ssof
Vasc
ular
Acc
ess
Con
sens
usof
anex
per
tpan
elto
dev
elop
min
imal
crite
riafo
rtra
inin
gan
dce
rtifi
catio
nof
cath
eter
pla
cem
ents
CVC
,PIC
CA
glo
bal
ratin
gsc
ale
rath
erth
annu
mb
erof
pro
ced
ures
per
form
edsh
ould
be
used
tod
eter
min
ecl
inic
alco
mp
eten
ce;
stan
dar
diz
eded
ucat
ion,
sim
ulat
ions
,and
sup
ervi
sed
inse
rtio
nsar
ere
com
men
ded
for
oper
ator
sp
laci
ngth
ese
dev
ices
Muk
herje
eet
al,2
001
(182
)38
5PI
CC
sRe
tros
pec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceof
and
risk
fact
ors
forC
RTin
pat
ient
sw
ithg
astr
oint
estin
alca
ncer
All
PIC
Cin
sert
ions
bet
wee
nJu
ne19
99an
dM
ay20
00,f
ound
inth
ePI
CC
reg
iste
rin
1ho
spita
lin
the
Uni
ted
King
dom
PIC
CTh
eov
eral
lrat
eof
thro
mb
osis
was
5.2%
.B
ecau
seof
the
risk
forb
leed
ing
,an
ticoa
gul
atio
nw
asno
tdee
med
wis
ein
this
sett
ing
.Fut
ure
stud
ies
exam
inin
gup
per
vs.
low
erg
astr
oint
estin
altr
actt
umor
sar
ene
eded
Nas
het
al,2
009
(183
)52
4Re
tros
pec
tive
coho
rtst
udy
Det
erm
ine
inci
den
ceof
PIC
C-r
elat
edD
VTin
pat
ient
sw
ithan
dw
ithou
tBur
khol
deria
cepa
cia
com
ple
xin
fect
ion;
inve
stig
ate
asso
ciat
ion
bet
wee
nPI
CC
-rel
ated
DVT
and
eryt
hroc
yte
sed
imen
tatio
nra
te
Patie
nts
with
cyst
icfib
rosi
sw
houn
der
wen
tPIC
Cin
sert
ion
ata
sing
lein
stitu
tion
over
6y
PIC
CPa
tient
sw
ithB.
cepa
cia
com
ple
xha
da
hig
her
inci
den
ceof
DVT
;hig
here
ryth
rocy
tese
dim
enta
tion
rate
sin
pat
ient
sw
ithPI
CC
-rel
ated
DVT
may
sug
ges
ttha
tin
flam
mat
ion
isa
risk
fact
orfo
rsub
seq
uent
thro
mb
osis
Nat
iona
lKid
ney
Foun
dat
ion,
2002
(48)
NA
Gui
del
ines
Defi
neth
eap
pro
ach
tod
iag
nosi
s,ev
alua
tion,
man
agem
enta
ndve
nous
acce
ssin
pat
ient
sw
ithC
KD
NA
PIC
C,C
VC,
smal
l-b
ore
cath
eter
s
Use
ofPI
CC
sis
notr
ecom
men
ded
inp
atie
nts
with
adva
nced
orp
rog
ress
ive
rena
lin
suffi
cien
cy
Nat
iona
lKid
ney
Foun
dat
ion,
2013
(44)
NA
Gui
del
ines
Up
dat
eto
the
earli
erg
uid
elin
esto
pro
vid
ere
com
men
dat
ions
ond
iag
nosi
s,ev
alua
tion,
man
agem
ent,
and
veno
usac
cess
inp
atie
nts
with
CKD
NA
PIC
C,C
VC,
smal
l-b
ore
cath
eter
s
Veno
usp
rese
rvat
ion
forfi
stul
ap
lace
men
tis
aco
rner
ston
eof
man
agin
gp
atie
nts
with
CKD
Nifo
ngan
dM
cDev
itt,
2011
(184
)N
AIn
vitr
oex
per
imen
tal
stud
yC
alcu
late
dre
lativ
eflo
wra
tes
asre
late
dto
the
ratio
ofth
eca
thet
erto
vein
dia
met
erSi
mul
atio
nst
udy
that
exam
ined
risk
fort
hrom
bos
isin
rela
tion
tocr
oss-
sect
iona
lves
seld
iam
eter
PIC
CPI
CC
sm
ayd
ecre
ase
veno
usflo
wra
tes
by
asm
uch
as93
%b
yoc
cup
ying
muc
hof
the
lum
inal
dia
met
er.U
sing
the
smal
lest
-gau
ge
cath
eter
may
pre
vent
veno
usst
asis
and
red
uce
risk
forD
VTN
unoo
etal
,201
1(1
85)
1648
Pros
pec
tive
coho
rtst
udy
Inve
stig
ate
the
cont
ribut
ion
ofPI
CC
sto
VTE
rate
sin
pat
ient
sun
der
goi
ngco
loni
cre
sect
ion
Patie
nts
who
und
erw
entm
ajor
bow
elre
sect
ion
over
3y
ina
sing
leho
spita
lsys
tem
PIC
CPa
tient
sw
ithPI
CC
sw
ere
11tim
esm
ore
likel
yto
dev
elop
sub
seq
uent
VTE
O'B
rien
etal
,201
3(7
5)13
28Q
uasi
-exp
erim
enta
lb
efor
e–af
ters
tud
yA
dd
ress
the
freq
uenc
yof
inap
pro
pria
teve
nous
cath
eter
use
and
effe
ctof
aQ
Ip
rog
ram
tore
duc
ePI
CC
lum
ens
Patie
nts
rece
ivin
gC
VCs
atM
cGill
Uni
vers
ityH
ealth
Cen
terf
rom
May
2011
toJa
nuar
y20
12PI
CC
Aho
spita
l-wid
eef
fort
tod
ecre
ase
the
inse
rtio
nof
mul
tilum
enPI
CC
sw
ithou
tan
app
rop
riate
ratio
nale
resu
lted
ind
ecre
ased
cost
san
dco
mp
licat
ions
from
PIC
Cs
O'G
rad
yan
dC
hert
ow,
2011
(186
)N
ARe
view
Revi
ewfo
rdia
gno
sis,
man
agem
ent,
and
trea
tmen
tofC
LAB
SIou
tsid
eth
eIC
Usp
ecifi
cally
dire
cted
tow
ard
sno
n–cr
itica
lca
rep
rovi
der
s
Det
ectio
n,su
rvei
llanc
e,an
dm
anag
emen
tof
CLA
BSI
outs
ide
ICU
sis
chal
leng
ing
and
may
req
uire
uniq
uean
dno
vela
pp
roac
hes
asco
mp
ared
toth
eIC
Use
ttin
g
CVC
,PIC
CIn
fect
ious
dis
ease
spec
ialis
tssh
ould
be
cons
ulte
dw
hen
nece
ssar
y;in
put
reg
ard
ing
reta
inin
gor
rem
ovin
gth
eca
thet
eran
dty
pe
ofan
tibio
ticth
erap
yar
eke
yto
ensu
ring
safe
outc
omes
Oliv
eran
dJo
nes,
2014
(187
)N
ARe
view
Det
erm
ine
whe
ther
EKG
-gui
ded
PIC
Cp
lace
men
tis
the
pre
fera
ble
met
hod
for
PIC
Cp
ositi
onin
g
Nar
rativ
ere
view
ofth
elit
erat
ure
that
sum
mar
izes
avai
lab
leev
iden
cefo
rEKG
-gui
ded
pla
cem
ent
PIC
C,C
VCB
estp
ract
ices
and
reco
mm
end
atio
nssh
ould
be
esta
blis
hed
tous
eEK
Gas
ag
old
stan
dar
dfo
rche
ckin
gC
VCp
lace
men
tO
nget
al,2
006
(188
)31
7Re
tros
pec
tive
coho
rtst
udy
Det
erm
ine
the
freq
uenc
yan
dris
kfa
ctor
sfo
rPI
CC
-rel
ated
DVT
at1
med
ical
cent
erSy
mp
tom
atic
pat
ient
sw
itha
pos
itive
upp
er-e
xtre
mity
veno
usd
uple
xsc
anov
er3
yw
ere
revi
ewed
tod
eter
min
eris
kfa
ctor
sas
soci
ated
with
UED
VT
PIC
CPa
tient
sw
ithPI
CC
s,th
ose
rece
ivin
gch
emot
hera
py,
and
thos
ew
ithca
ncer
wer
em
ostl
ikel
yto
exp
erie
nce
DVT
Paau
wet
al,2
008
(189
)56
Pros
pec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceof
PIC
C-a
ssoc
iate
dD
VTw
ithan
dw
ithou
tpro
phy
lact
ican
ticoa
gul
ants
Inp
atie
nts
with
PIC
Cs
used
forp
aren
tera
lnut
ritio
nor
antib
iotic
sat
1m
edic
alce
nter
PIC
CPr
ophy
laxi
sfo
rDVT
with
hep
arin
and
LMW
Hw
asas
soci
ated
with
alo
wer
rate
ofD
VTin
pat
ient
sw
ithPI
CC
s,al
thou
gh
thes
ere
sults
wer
eno
tad
just
edfo
rcon
foun
der
sPa
riet
al,2
011
(190
)70
Pros
pec
tive
coho
rtst
udy
Initi
alap
plic
atio
nan
dre
sults
ofim
ple
men
tatio
nof
acl
inic
alp
athw
ayto
choo
seth
eb
estv
enou
sac
cess
for
ind
ivid
ualp
atie
nts
Patie
nts
with
PIC
Cs
inse
rted
thro
ugh
the
new
'Sha
red
Clin
ical
Path
way
'too
lat1
canc
erce
nter
PIC
CU
seof
the
pat
hway
imp
rove
dp
atie
ntq
ualit
yof
life,
dec
reas
edco
sts,
and
imp
rove
dw
orkfl
ow
Con
tinue
don
follo
win
gpa
ge
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S33
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Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Pate
leta
l,20
07(1
91)
1788
Retr
osp
ectiv
eco
hort
stud
yD
eter
min
ew
heth
erth
eus
eof
open
-end
edPI
CC
sfo
rinv
asiv
em
onito
ring
can
dec
reas
eth
eris
kfo
rCLA
BSI
Patie
nts
bef
ore
and
afte
rthe
intr
oduc
tion
ofa
hem
odyn
amic
mon
itorin
gw
ithPI
CC
sin
acl
osed
med
ical
–sur
gic
alIC
Uat
anac
adem
icm
edic
alce
nter
PIC
CO
pen
-end
edPI
CC
sm
ayb
eas
soci
ated
with
ash
orte
rcat
hete
rdw
ellt
ime,
red
uced
BSI
s,an
dan
over
alld
ecre
ase
inan
tibio
ticus
e
Pate
leta
l,20
14(1
92)
70RC
TC
omp
are
the
safe
tyan
dco
stof
PIC
Cs
vs.
por
tsus
edto
del
iver
chem
othe
rap
yPa
tient
sw
ithno
nhem
atol
ogic
canc
erre
ceiv
ing
chem
othe
rap
yei
ther
thro
ugh
aPI
CC
ora
por
tPI
CC
,por
tPo
rts
wer
eas
soci
ated
with
alo
wer
risk
for
com
plic
atio
nsin
this
pop
ulat
ion;
ther
ew
asno
diff
eren
cein
cost
usin
ga
PIC
Cvs
.por
tap
pro
ach
Paz-
Fum
agal
liet
al,
1997
(193
)11
3Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eth
eef
fect
ofPI
CC
pla
cem
enti
np
atie
nts
with
spin
alco
rdin
jury
who
wer
eat
hig
hris
kfo
rinf
usio
np
hleb
itis
All
pat
ient
sw
itha
spin
alco
rdin
jury
and
ap
erip
hera
lIV
from
July
1993
toD
ecem
ber
1994
who
wer
eev
alua
ted
atle
asto
nce
by
the
nurs
ing
IVte
am
PIC
C,C
VCA
lthou
gh
they
wer
eas
soci
ated
with
DVT
,PIC
Cus
ew
asas
soci
ated
with
are
duc
edris
kfo
rp
hleb
itis
Penn
ey-T
imm
ons
and
Seve
dg
e,20
04(1
94)
NA
Retr
osp
ectiv
eco
hort
stud
yEv
alua
teou
tcom
ed
ata
forP
ICC
sp
lace
din
hosp
italiz
edp
atie
nts,
by
usin
gan
exis
ting
dat
ase
t
Hos
pita
lized
pat
ient
sw
ithPI
CC
sPI
CC
Com
plic
atio
ns,i
nclu
din
gex
it-si
tean
dB
SIs,
phl
ebiti
s,an
dth
rom
bos
is,o
ccur
red
freq
uent
lyin
this
pop
ulat
ion;
chan
ges
innu
rsin
gp
ract
ice
info
rmed
by
accu
mul
atin
gev
iden
cehe
lped
dec
reas
eth
eris
kfo
rthe
seev
ents
Peria
rdet
al,2
008
(195
)60
RCT
Com
par
eth
esa
fety
,effi
cacy
,and
cost
-effe
ctiv
enes
sof
PIC
Cs
toPI
VCs
Hos
pita
lized
pat
ient
sre
qui
ring
IVth
erap
yfo
r≥5
day
sw
ere
rand
omly
assi
gne
dto
rece
ive
eith
erPI
CC
sor
PIVC
sin
this
sing
le-c
ente
rstu
dy
PIVC
,PIC
CPI
CC
sar
eef
ficie
ntfo
rhos
pita
lized
pat
ient
sre
qui
ring
IVth
erap
yfo
r≥5
dho
wev
er,r
isk
fora
sym
pto
mat
icD
VTm
ayb
ehi
ghe
rtha
np
revi
ousl
yre
por
ted
inp
erso
nsw
hore
ceiv
ePI
CC
sPe
riard
,201
0(1
96)
NA
Revi
ewRe
view
ofth
ere
latio
nshi
pb
etw
een
inse
rtio
nsi
tean
dris
kfo
rthr
omb
osis
inp
atie
nts
with
canc
er
Patie
nts
with
leuk
emia
and
PIC
Cs
pla
ced
atd
iffer
ents
ites
PIC
CSt
udie
ssu
gg
estt
here
may
be
anas
soci
atio
nb
etw
een
PIC
Cp
lace
men
tand
thro
mb
osis
risk;
smal
lerP
ICC
sin
sert
edin
tola
rger
vein
sar
ele
astl
ikel
yto
dev
elop
thro
mb
osis
Petr
eeet
al,2
012
(197
)N
ASy
stem
atic
revi
ewD
eter
min
eef
fect
ive
met
hod
sfo
rhea
lthca
rep
rovi
der
sto
red
uce
PIC
C-r
elat
edB
SId
urin
gd
evic
ein
sert
ion
Eval
uate
and
rep
orto
np
ract
ices
atth
etim
eof
inse
rtio
nth
atm
ayre
duc
eth
eris
kfo
rCLA
BSI
inho
spita
lized
pat
ient
s
PIC
CC
ontin
uing
educ
atio
nis
less
exp
ensi
veth
anth
eco
stof
CLA
BSI
;nee
dle
less
conn
ecto
rs,
pos
itive
-pre
ssur
eva
lves
,and
pro
per
secu
rem
entw
ithan
chor
ing
dev
ices
wer
em
oste
ffect
ive
inre
duc
ing
CLA
BSI
Pikw
eret
al,2
012
(12)
NA
Syst
emat
icre
view
Exam
ine
risks
and
com
plic
atio
nsas
soci
ated
with
cent
ralv
s.p
erip
hera
lrou
tes
for
cent
ralv
enou
sca
nnul
atio
n
Com
par
eris
ksas
soci
ated
with
PIC
Cs
with
thos
eof
trad
ition
alC
VCs
PIC
C,C
VCC
athe
tert
ipm
alp
ositi
onin
g,t
hrom
bop
hleb
itis,
and
cath
eter
dys
func
tion
occu
rred
mor
efr
eque
ntly
with
PIC
Cs
than
CVC
s.N
od
iffer
ence
inra
tes
ofin
fect
ion
bet
wee
nC
VCs
and
PIC
Cs
wer
efo
und
inth
e12
incl
uded
stud
ies
Ping
leto
net
al,2
013
(80)
NA
Qua
si-e
xper
imen
tal
bef
ore–
afte
rstu
dy
Red
uctio
nof
VTE
inho
spita
lized
pat
ient
sb
yus
ing
educ
atio
nan
dsy
stem
-wid
eop
erat
iona
lpla
ns
Hos
pita
lized
pat
ient
sat
asi
ngle
univ
ersi
ty-b
ased
med
ical
cent
erin
the
Uni
ted
Stat
esPI
CC
Afte
rim
ple
men
tatio
nof
spec
ific
actio
np
lans
,us
eof
PIC
Cs
dro
pp
edfr
om36
0in
sert
ions
to<
200
inse
rtio
nsov
er2
year
s;ra
tes
ofVT
Ein
hosp
italiz
edp
atie
nts
sim
ilarly
dec
lined
Pitt
iruti
etal
,200
9(1
98)
NA
Gui
del
ines
Gui
del
ines
forC
VCac
cess
,car
e,d
iag
nosi
s,an
dth
erap
yof
com
plic
atio
nsG
uid
elin
est
atem
entd
rafte
db
yth
eEu
rop
ean
Soci
ety
forC
linic
alN
utrit
ion
and
Met
abol
ism
PIC
C,C
VC,
por
tPr
ovid
esre
com
men
dat
ions
onus
e,ca
re,a
ndm
anag
emen
tofp
rob
lem
sre
late
dto
vasc
ular
dev
ices
forp
aren
tera
lnut
ritio
nPi
ttiru
tiet
al,2
012
(199
)89
Retr
osp
ectiv
eco
hort
stud
yEx
amin
eou
tcom
esre
late
dto
use
ofp
ower
-inje
ctab
lePI
CC
sin
ICU
sett
ing
sC
ritic
ally
illp
atie
nts
und
erg
oing
pow
er-in
ject
able
PIC
Cp
lace
men
tPI
CC
PIC
Cs
that
wer
ep
ower
-cap
able
wer
eas
soci
ated
with
mul
tiple
ther
apeu
ticad
vant
ages
and
low
risk
forc
omp
licat
ions
incr
itica
llyill
pat
ient
sPi
ttiru
tian
dLa
mp
erti,
2015
(71)
NA
Revi
ewRe
view
the
liter
atur
eon
the
inci
den
ceof
card
iac
tam
pon
ade
afte
rPIC
Cin
sert
ion
Cas
ere
por
tsan
dca
sese
ries
ofPI
CC
rece
ipt;
revi
ewof
sent
inel
even
tsPI
CC
Late
card
iac
tam
pon
ade
afte
rPIC
Cin
sert
ion
inad
ults
isra
rePo
ngru
ang
por
net
al,
2013
(200
)16
2N
este
dca
se–c
ontr
olst
udy
Eval
uate
the
role
ofp
atie
nt-,
pro
vid
er-,
and
dev
ice-
spec
ific
risk
fact
ors
inPI
CC
-rel
ated
BSI
Hos
pita
lized
pat
ient
sat
asi
ngle
univ
ersi
tyho
spita
lin
the
Uni
ted
Stat
esPI
CC
The
PIC
CB
SIra
tew
as3.
13p
er10
00ca
thet
er-d
ays
(sim
ilart
oth
atof
othe
rCVC
s);
PIC
CB
SIw
asas
soci
ated
with
dev
ice
(num
ber
oflu
men
s)an
dp
atie
ntfa
ctor
s,su
chas
Clo
strid
ium
diffi
cile
infe
ctio
nan
dco
nges
tive
hear
tfai
lure
Pote
teta
l,20
13(6
1)10
1Pr
osp
ectiv
eco
hort
stud
yEx
amin
eth
esa
fety
ofPI
CC
inse
rtio
nin
pat
ient
sw
ithp
rofo
und
thro
mb
ocyt
open
ia14
3PI
CC
inse
rtio
nsin
101
pat
ient
sw
ithca
ncer
at1
canc
erce
nter
PIC
CPI
CC
pla
cem
entw
asas
soci
ated
with
ahi
gh
rate
ofte
chni
cals
ucce
ssan
dfe
wad
vers
eev
ents
inp
atie
nts
with
seve
reth
rom
boc
ytop
enia
Qui
etal
,201
4(2
01)
551
Retr
osp
ectiv
eco
hort
stud
ySt
udy
the
inci
den
ceof
,ris
kfa
ctor
sfo
r,an
dou
tcom
esof
spon
tane
ous
PIC
Cd
islo
dg
emen
tsin
pat
ient
sw
ithca
ncer
inC
hina
551
pat
ient
sw
ithca
ncer
dia
gno
ses
rece
ivin
gca
reat
1ce
nter
inC
hina
PIC
CTh
ein
cid
ence
rate
ofsp
onta
neou
sd
islo
dg
emen
twas
4.1%
;pat
ient
sw
hod
evel
oped
dis
lod
gem
enth
ada
sub
stan
tially
gre
ater
risk
fors
ubse
que
ntPI
CC
-rel
ated
DVT
(rel
ativ
eris
k,17
.46)
Con
tinue
don
follo
win
gpa
ge
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S34 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Raad
etal
,199
4(2
02)
72C
ase
serie
sA
sses
sth
efr
eque
ncy
ofth
rom
bot
ican
din
fect
ious
com
plic
atio
nsof
CVC
use
inp
atie
nts
with
canc
er
72ca
ncer
pat
ient
sin
a50
0-b
edte
rtia
ryca
rece
nter
wer
ein
clud
ed;p
ostm
orte
mex
amin
atio
nsof
cath
eter
ized
vein
sw
ere
per
form
ed
CVC
Thro
mb
osis
resu
lting
from
vasc
ular
cath
eter
sin
clud
edfib
rinsl
eeve
tooc
clus
ive
thro
mb
osis
.Sep
ticem
iaw
asm
ore
com
mon
inp
atie
nts
with
occl
usiv
eth
rom
bos
isth
anin
pat
ient
sw
ithno
nmur
alth
rom
bos
is,
sug
ges
ting
anas
soci
atio
nb
etw
een
thes
e2
outc
omes
Rich
ters
etal
,201
4(2
03)
439
Retr
osp
ectiv
eco
hort
stud
yRe
por
tthe
inci
den
cean
dris
kfa
ctor
sfo
rg
ram
pos
itive
bac
tere
mia
and
thro
mb
osis
inp
atie
nts
who
rece
ived
CVC
s
439
pat
ient
sun
der
goi
ngst
emce
lltr
ansp
lant
atio
nC
VCD
urat
ion
ofne
utro
pen
iaan
dle
ft-si
ded
pla
cem
entw
asas
soci
ated
with
bac
tere
mia
.Pe
rsis
tent
bac
tere
mia
and
tipco
loni
zatio
nw
ere
asso
ciat
edw
ithth
rom
bos
isRi
ckar
det
al,2
012
(84)
3283
RCT
Rout
ine
vs.c
linic
ally
war
rant
edre
pla
cem
ent
ofp
erip
hera
lIVs
inho
spita
lset
ting
Hos
pita
lized
pat
ient
sat
3ho
spita
lsin
Aus
tral
iaPI
VCC
omp
ared
with
rout
ine
rem
oval
,PIV
Cs
can
be
rem
oved
ascl
inic
ally
ind
icat
edw
ithou
tin
crea
sing
adve
rse
even
ts;t
his
pra
ctic
eca
nre
duc
eco
stsu
bst
antia
lly,a
ccor
din
gto
the
auth
ors
Rob
inso
net
al,2
005
(204
)N
APr
osp
ectiv
eco
hort
stud
yEf
fect
ofd
edic
ated
PIC
Cte
amon
pat
ient
care
and
cost
sas
soci
ated
with
PIC
Cin
sert
ion
Hos
pita
lized
pat
ient
sre
ceiv
ing
care
ata
sing
lem
edic
alce
nter
inB
osto
n,M
assa
chus
etts
PIC
CIn
trod
uctio
nof
ad
edic
ated
PIC
Cte
amd
ecre
ased
inap
pro
pria
tePI
CC
pla
cem
ent,
wai
ttim
esto
inse
rtio
n,an
dov
eral
lcos
tsRo
mag
noli
etal
,201
0(2
05)
49Pr
osp
ectiv
eco
hort
stud
yRi
skfo
rPIC
C-r
elat
edD
VTin
pat
ient
sw
ithca
ncer
52PI
CC
sp
lace
din
49p
atie
nts
with
canc
erin
asi
ngle
med
ical
cent
erin
Feltr
e,Ita
lyPI
CC
3p
atie
nts
(5.7
%)d
evel
oped
PIC
C-r
elat
edD
VT;
allp
atie
nts
rece
ived
antic
oag
ulat
ion
with
LMW
Hfo
r≥3
mo;
noPE
was
rep
orte
dRo
oden
etal
,200
5(2
06)
NA
Syst
emat
icre
view
Revi
ewof
the
liter
atur
eon
dia
gno
sis
of,r
isk
fact
ors
for,
and
com
plic
atio
nsof
CVC
-rel
ated
DVT
NA
CVC
,PIC
CU
Sis
reco
mm
end
edas
the
dia
gno
stic
test
ofch
oice
;var
ious
pat
ient
and
dev
ice
fact
ors
are
asso
ciat
edw
ithD
VT;a
ndro
utin
ep
rop
hyla
xis
top
reve
ntth
rom
bos
isis
not
war
rant
edon
the
bas
isof
the
avai
lab
led
ata
Ros
etal
,200
5(2
07)
36Re
tros
pec
tive
coho
rtst
udy
Eval
uate
PIC
C-r
elat
edD
VTin
pat
ient
sw
ithhe
adan
dne
ckca
ncer
36p
atie
nts
with
head
and
neck
canc
erat
1m
edic
alho
spita
lin
Spai
nPI
CC
The
rate
ofPI
CC
-rel
ated
DVT
was
11.1
%,
sug
ges
ting
ahi
gh
rate
ofth
rom
bos
isin
this
pat
ient
pop
ulat
ion
Rose
ntha
l,20
08(2
08)
NA
Revi
ewEv
alua
tead
vant
ages
,con
sid
erat
ions
,and
man
agem
ento
fmid
line
cath
eter
sco
mp
ared
with
othe
rdev
ices
,with
the
aim
ofid
entif
ying
utili
tyof
thes
ed
evic
esin
pat
ient
s
Nar
rativ
ere
view
Mid
line
cath
eter
Mid
line
cath
eter
sar
eid
ealf
oris
oton
icin
fusi
ons
that
may
last
bey
ond
5d
Rup
pet
al,2
012
(34)
NA
Gui
del
ines
Prac
tice
gui
del
ines
forc
entr
alve
nous
acce
ssp
rep
ared
by
the
Am
eric
anSo
ciet
yof
Ane
sthe
siol
ogis
ts
Prov
ides
upd
ated
reco
mm
end
atio
nson
inse
rtio
nsi
tese
lect
ion,
use
ofU
S,an
dve
rifica
tion
ofca
thet
erlo
catio
n
CVC
,PIC
CTh
eg
uid
elin
esin
dic
ate
ap
refe
renc
efo
rup
per
-ext
rem
ityin
sert
ion
site
s,us
eof
US
tog
uid
ein
sert
ion
whe
np
laci
ngC
VCs
and
PIC
Cs,
and
confi
rmat
ion
ofth
eve
nous
loca
tion
ofth
eca
thet
eran
dca
thet
ertip
loca
tion
usin
gva
rious
tech
niq
ues
Rutk
off,
2014
(209
)25
7Q
uasi
-exp
erim
enta
lb
efor
e–af
ter
des
ign
Eval
uate
the
effic
acy
ofan
timic
rob
ial
(min
ocyc
line–
rifam
pin
)–co
ated
PIC
Cs
inre
duc
ing
PIC
C-r
elat
edB
SI
Hos
pita
lized
pat
ient
sat
1m
edic
alce
nter
inC
alifo
rnia
PIC
CA
ntim
icro
bia
lPIC
Cs
resu
lted
insi
gni
fican
td
ecre
ases
inC
LAB
SIfr
om4.
10to
0.47
infe
ctio
nsp
er10
00ca
thet
er-d
ays
Sab
eret
al,2
011
(54)
NA
Patie
nt-le
vel
syst
emat
icre
view
and
met
a-an
alys
is
Exam
ine
risk
fact
ors
forC
RTin
pat
ient
sw
ithca
ncer
Patie
nts
from
5RC
Tsan
d7
pro
spec
tive
stud
ies
incl
udin
g56
36p
atie
nts
wer
ein
clud
edC
VC,P
ICC
,p
ort
Thro
mb
osis
risk
was
incr
ease
dw
ithPI
CC
s,hi
stor
yof
DVT
,sub
clav
ian
veni
pun
ctur
ein
sert
ion,
and
imp
rop
erca
thet
ertip
pos
ition
Safd
aran
dM
aki,
2005
(81)
115
Pros
pec
tive
coho
rtst
udy
Exam
ine
risk
fori
nfec
tion
with
PIC
Cs
inho
spita
lized
pat
ient
sco
mp
ared
with
that
asso
ciat
edw
ithC
VCs
115
hosp
italiz
edp
atie
nts
who
had
251
PIC
Cs
pla
ced
wer
ein
clud
ed(fr
omw
ithin
ala
rger
RCT)
PIC
CRi
skfo
rPIC
C-r
elat
edB
SIw
as2–
5p
er10
00ca
thet
er-d
ays,
anu
mb
erth
atw
asg
reat
erth
anra
tes
rep
orte
din
outp
atie
ntse
ttin
gs
and
thos
ere
late
dto
cuffe
dor
tunn
eled
CVC
sSa
nsiv
ero
etal
,201
1(2
10)
50Pr
osp
ectiv
eco
hort
stud
yEv
alua
teth
eef
ficac
yof
ano
velc
athe
ter
secu
rem
entd
evic
e50
pat
ient
sre
ferr
edfo
rPIC
Cin
sert
ion
toa
nurs
ing
vasc
ular
acce
sste
aman
dto
IRPI
CC
Ano
vels
ecur
emen
tsys
tem
resu
lted
ina
favo
rab
leco
mp
licat
ion
pro
file,
with
cost
savi
ngs
rela
ted
tore
duc
edd
ress
ing
san
dd
isp
osab
lese
cure
men
tsys
tem
sSa
ntol
imet
al,2
012
(211
)N
AQ
uasi
-exp
erim
enta
lb
efor
e–af
ter
des
ign
Und
erst
and
the
effe
ctof
ap
roto
colt
ose
lect
IVD
sin
aB
razi
lian
hosp
itali
na
QIp
roje
ctU
nive
rsity
pat
ient
sin
Bra
zila
ndva
scul
arac
cess
nurs
ing
team
PIC
C,C
VC,
por
tIm
ple
men
tatio
nof
ap
roto
colr
esul
ted
ind
ecre
ased
rate
sof
phl
ebiti
san
dim
pro
ved
nurs
ing
satis
fact
ion
Sasa
due
szet
al,1
999
(50)
34Pr
osp
ectiv
eco
hort
stud
yEv
alua
teth
eef
fect
ofsm
all-b
ore
tunn
eled
cath
eter
sas
am
eans
top
rese
rve
vein
sco
mp
ared
with
PIC
Cs
34p
atie
nts
with
end
-sta
ge
rena
ldis
ease
at1
sing
leac
adem
icm
edic
alce
nter
PIC
C,
smal
l-b
ore
cath
eter
Two
min
orin
sert
ion
com
plic
atio
ns(a
rter
ial
pun
ctur
ean
dca
thet
erd
amag
ed
urin
gsu
turin
g)o
ccur
red
.Thi
sap
pro
ach
resu
lted
ina
nove
lfor
mof
acce
ss,p
rese
rvin
gp
erip
hera
lvei
nsan
dlim
iting
risk
forc
entr
alve
inst
enos
isin
this
pat
ient
pop
ulat
ion
Schi
mp
etal
,200
3(2
12)
264
Retr
osp
ectiv
eco
hort
stud
yEv
alua
tein
cid
ence
and
outc
omes
rela
ted
toU
EDVT
inp
atie
nts
with
gyn
ecol
ogic
canc
er
264
wom
enw
hore
ceiv
ed32
5to
talc
athe
ters
ata
univ
ersi
tyho
spita
lPI
CC
,por
t13
pat
ient
sd
evel
oped
cath
eter
-rel
ated
DVT
;11
ofth
ep
atie
nts
had
por
tsan
d2
had
PIC
Cs.
No
pat
ient
sd
evel
oped
PE
Con
tinue
don
follo
win
gpa
ge
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S35
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Seel
eyet
al,2
007
(213
)23
3Re
tros
pec
tive
coho
rtst
udy
Dev
elop
aris
k-p
red
ictio
nm
odel
and
iden
tify
fact
ors
asso
ciat
edw
ithPI
CC
-rel
ated
DVT
Hos
pita
lized
pat
ient
sre
ceiv
ing
care
ata
Mid
wes
tco
mm
unity
hosp
ital
PIC
C17
pat
ient
sd
evel
oped
DVT
;log
istic
reg
ress
ion
mod
els
foun
dth
atb
edre
st,l
ocal
ized
tend
erne
ss,s
mok
ing
,ant
icoa
gul
antu
se,
and
oste
omye
litis
wer
eas
soci
ated
with
PIC
C-r
elat
edD
VTSh
arp
etal
,201
4(6
3)64
Retr
osp
ectiv
eco
hort
stud
yEv
alua
tesa
fety
and
effic
acy
ofm
idlin
eca
thet
ers
com
par
edw
ithPI
CC
sin
adul
tsw
ithcy
stic
fibro
sis
231
mid
line
cath
eter
san
d97
PIC
Cs
wer
ep
lace
din
64p
atie
nts
PIC
C,
mid
line
cath
eter
Rate
sof
adve
rse
even
tsw
ithPI
CC
san
dm
idlin
eca
thet
ers
wer
esi
mila
r,b
utre
mov
alra
tes
form
idlin
eca
thet
ers
wer
etw
ice
that
ofPI
CC
sSh
eaet
al,2
006
(214
)57
5Re
tros
pec
tive
coho
rtst
udy
Eval
uate
risk
forP
ICC
-rel
ated
DVT
inp
atie
nts
with
infla
mm
ator
yb
owel
dis
ease
15p
atie
nts
met
incl
usio
nan
dex
clus
ion
crite
ria,
and
3ha
dPI
CC
-rel
ated
DVT
PIC
CA
20%
inci
den
ceof
PIC
C-r
elat
edD
VTin
hosp
italiz
edp
atie
nts
with
infla
mm
ator
yb
owel
dis
ease
and
PIC
Cs
was
note
d.T
hein
cid
ence
rate
ofPI
CC
-rel
ated
DVT
was
2.17
%p
erd
aySi
mco
ck,2
008
(215
)19
1Q
uasi
-exp
erim
enta
ld
esig
nU
nder
stan
dth
eef
fect
ofus
eof
US
onra
teof
PIC
Cco
mp
licat
ions
Patie
nts
adm
itted
toa
UK
hosp
italw
hore
ceiv
edPI
CC
sat
vario
ustim
ep
oint
sPI
CC
Rate
sof
DVT
,inf
ectio
ns,a
ndot
her
com
plic
atio
nsd
eclin
edaf
teru
seof
US
Sim
onov
aet
al,2
012
(76)
NA
Invi
tro
stud
yEv
alua
teth
eab
ility
oftis
sue
adhe
sive
san
dcy
anoa
cryl
ate
glu
eto
secu
rein
trav
enou
sca
thet
ers
com
par
edw
ithSt
atLo
ckd
evic
es(B
ard
Med
ical
,Cov
ing
ton,
Geo
rgia
)in
anim
alm
odel
s
NA
PIC
C,C
VCTi
ssue
adhe
sive
sco
mp
ared
favo
rab
lyw
ithSt
atLo
ckd
evic
esan
dtr
ansp
aren
tp
olyu
reth
ane
dre
ssin
gs
toin
crea
seth
e"p
ull-o
ut"
forc
eof
cath
eter
s
Skaf
feta
l,20
12(2
16)
147
Retr
osp
ectiv
eco
hort
stud
yC
omp
are
and
cont
rast
the
use
ofH
ickm
an(tu
nnel
ed)c
athe
ters
and
PIC
Cs
inp
atie
nts
with
acut
ele
ukem
iare
ceiv
ing
ind
uctio
nch
emot
hera
py
147
pat
ient
sw
ithne
wly
dia
gno
sed
acut
ele
ukem
iaw
hore
ceiv
edei
ther
aH
ickm
anca
thet
eror
aPI
CC
(with
orw
ithou
tUS
gui
dan
ce)
PIC
C,
tunn
eled
cath
eter
Hic
kman
cath
eter
sin
sert
edaf
ter2
007
by
IRw
ere
asso
ciat
edw
ithfe
wer
com
plic
atio
ns(b
acte
rem
iaan
dex
it-si
tein
fect
ion)
;PIC
Cs
wer
eas
soci
ated
with
less
loca
linfl
amm
atio
nb
uthi
ghe
rrat
esof
phl
ebiti
san
db
lock
age
req
uirin
gly
tictr
eatm
ents
.Sk
iest
etal
,200
0(2
17)
66Pr
osp
ectiv
eco
hort
stud
yD
eter
min
eris
kfo
rcom
plic
atio
nsin
pat
ient
sw
ithH
IVin
fect
ion
who
req
uire
dlo
ng-t
erm
veno
usac
cess
ortr
eatm
ents
and
rece
ived
PIC
Cs
97PI
CC
sw
ere
inse
rted
in66
pat
ient
sfo
rvar
ious
clin
ical
ind
icat
ions
PIC
C53
%(5
1of
97)o
fPIC
Cs
wer
eas
soci
ated
with
aco
mp
licat
ion,
fora
nov
eral
lcom
plic
atio
nra
teof
6.1
per
1000
cath
eter
-day
s;m
edia
ntim
eto
aca
thet
er-r
elat
edco
mp
licat
ion
was
115
d.E
leve
nca
thet
ers
wer
ein
fect
ed,7
ofw
hich
wer
eas
soci
ated
with
ab
acte
rem
ia.
The
over
alln
onin
fect
ious
com
plic
atio
nra
tew
as4.
6p
er10
00ca
thet
er-d
ays
Smith
etal
,199
8(2
18)
441
Retr
osp
ectiv
eco
hort
stud
yC
omp
are
ind
icat
ions
fori
nser
tion,
com
plic
atio
ns,a
ndec
onom
icef
fect
ofC
VCs
vs.P
ICC
s
441
men
who
rece
ived
838
(283
CVC
,555
PIC
C)
cons
ecut
ivel
yp
lace
dve
nous
cath
eter
sre
flect
ing
4936
5C
VC-d
ays
and
1181
4PI
CC
-day
s
PIC
C,C
VCA
tota
lof5
7(1
9%)c
omp
licat
ions
wer
eid
entifi
edin
the
CVC
gro
upan
d19
7(3
5%)
com
plic
atio
nsin
the
PIC
Cg
roup
.The
rew
ere
sig
nific
antly
few
erto
talc
omp
licat
ions
,ca
thet
erm
alfu
nctio
ns,e
pis
odes
ofp
hleb
itis,
and
"oth
er"
com
plic
atio
nsin
the
CVC
gro
upth
anin
the
PIC
Cg
roup
Smith
and
Nol
an,2
013
(219
)N
ASy
stem
atic
revi
ewPr
ovid
ean
over
view
ofC
VCs
and
inse
rtio
nte
chni
que
s,an
dco
nsid
erth
ep
reve
ntio
nan
dm
anag
emen
tofc
omm
onco
mp
licat
ions
NA
PIC
C,C
VCTo
red
uce
rate
sof
thro
mb
osis
rela
ted
tolo
ng-t
erm
cath
eter
sin
pat
ient
sw
ithca
ncer
,th
eca
thet
ertip
shou
ldlie
atth
eju
nctio
nof
the
SVC
and
right
atriu
m.M
ultil
umen
cath
eter
sm
ayb
eas
soci
ated
with
asl
ight
lyhi
ghe
rris
kfo
rinf
ectio
nth
ansi
ngle
-lum
enon
es.P
rop
hyla
ctic
antib
iotic
sb
efor
elin
ein
sert
ion,
antib
iotic
lock
solu
tions
,or
antib
iotic
oint
men
tsap
plie
dto
the
inse
rtio
nsi
tear
eno
trec
omm
end
edSn
ellin
get
al,2
001
(220
)28
Retr
osp
ectiv
eco
hort
stud
yC
omp
are
trea
tmen
tsuc
cess
with
tunn
eled
cath
eter
svs
.PIC
Cs
and
exam
ine
rate
ofan
dris
kfo
rcom
plic
atio
nsw
ithb
oth
dev
ices
inp
atie
nts
with
gas
troi
ntes
tinal
canc
er
16tu
nnel
edca
thet
ers
and
18PI
CC
sw
ere
inse
rted
in28
pat
ient
sun
der
goi
ngp
rotr
acte
dIV
infu
sion
ther
apy
PIC
C,
tunn
eled
cath
eter
Afte
r120
d,t
unne
led
cath
eter
surv
ival
was
bet
tert
han
that
ofPI
CC
s(P
=0.
051)
.C
omp
licat
ions
occu
rred
in61
%of
pat
ient
sw
ithtu
nnel
edca
thet
ers
and
67%
ofp
atie
nts
with
PIC
Cs
Song
and
Li,2
013
(11)
3012
Retr
osp
ectiv
eco
hort
stud
yO
bse
rve
and
anal
yze
the
caus
esof
mis
pla
cem
ento
fPIC
Ctip
sin
pat
ient
sw
ithca
ncer
3012
pat
ient
sw
ithca
ncer
who
rece
ived
aPI
CC
(159
0m
en,1
121
wom
en,a
nd30
1ch
ildre
n;ag
era
nge,
1–94
y[m
edia
nag
e,52
y])f
orch
emot
hera
py
ornu
triti
onal
sup
por
t
PIC
CM
alp
ositi
onw
asob
serv
edin
237
case
s(7
.87%
),w
ithth
em
ostf
req
uent
site
bei
ngth
ein
tern
alju
gul
ar,f
ollo
wed
by
the
axill
ary
vein
;PIC
Cs
wer
ere
loca
ted
bac
kto
the
SVC
orsu
bcl
avia
nve
inus
ing
vario
uste
chni
que
sSp
erry
etal
,201
2(2
21)
798
Retr
osp
ectiv
eco
hort
stud
yEv
alua
teth
ein
fluen
ceof
late
ralit
yof
PIC
Cin
sert
ion
(rig
htar
mvs
.lef
tarm
)on
the
risk
fors
ubse
que
ntPI
CC
-rel
ated
DVT
798
seq
uent
ialP
ICC
pla
cem
ents
at1
med
ical
cent
erin
Was
hing
ton,
DC
PIC
CA
rmof
PIC
Cp
lace
men
twas
nota
ssoc
iate
dw
ithsy
mp
tom
atic
VTE
Stok
owsk
ieta
l,20
09(2
22)
538
Retr
osp
ectiv
eco
hort
stud
yEv
alua
tion
ofth
eef
fect
ofU
Son
risk
forP
ICC
com
plic
atio
ns53
8p
atie
nts
(bot
hin
pat
ient
and
outp
atie
nt)w
hore
ceiv
edPI
CC
sat
aC
anad
ian
med
ical
cent
erPI
CC
Com
par
edw
ithp
alp
atio
n,PI
CC
sp
lace
dvi
aU
Sha
dlo
wer
sub
seq
uent
rate
sof
thro
mb
osis
Stra
hile
vitz
etal
,200
1(2
23)
40Re
tros
pec
tive
coho
rtst
udy
Exam
ine
outc
omes
rela
ted
toPI
CC
use
inp
atie
nts
with
acut
em
yelo
idle
ukem
iaFo
rty
pat
ient
sw
hore
ceiv
ed52
PIC
Cs
dur
ing
the
stud
yp
erio
dPI
CC
PIC
Cs
wer
eas
soci
ated
with
early
mec
hani
cal
com
plic
atio
nsan
din
fect
ions
;how
ever
,the
com
plic
atio
nra
tew
asd
eem
ed"a
ccep
tab
le"
inth
isp
atie
ntp
opul
atio
n
Con
tinue
don
follo
win
gpa
ge
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S36 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
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Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Teje
dor
etal
,201
2(1
8)89
Retr
osp
ectiv
eco
hort
stud
yD
escr
ibe
pat
tern
sof
use
ofte
mp
orar
yC
VCs
and
PIC
Cs
inno
n-IC
Uw
ard
s89
pat
ient
sw
ith14
6C
VCs
(56%
ofw
hich
wer
ePI
CC
s)at
1ac
adem
icm
edic
alce
nter
PIVC
,CVC
,PI
CC
An
aver
age
of4.
1id
led
ays
with
aC
VCan
da
mea
nof
3.4
idle
day
sw
ithb
oth
aC
VCan
da
PIVC
wer
eno
ted
;pat
ient
sw
itha
PIC
Cha
d5.
4d
inw
hich
they
also
had
aPI
VC,
com
par
edw
ith10
din
pat
ient
sw
itha
CVC
Thak
arar
etal
,201
4(2
24)
3273
Retr
osp
ectiv
eco
hort
stud
yEv
alua
tion
oftP
Aus
eas
am
arke
rfor
insi
tuth
rom
bos
isan
dris
kfo
rsub
seq
uent
PIC
C-r
elat
edC
LAB
SI
3273
pat
ient
sat
ate
rtia
ryca
rece
nter
,40%
ofw
hom
rece
ived
tPA
PIC
CU
seof
tPA
was
asso
ciat
edw
ith3.
59tim
esg
reat
erris
kfo
rCLA
BSI
com
par
edw
ithp
atie
nts
who
did
notr
ecei
veth
istr
eatm
ent
Tim
site
tal,
1998
(225
)26
5Pr
osp
ectiv
eco
hort
stud
yA
ssoc
iatio
nb
etw
een
cath
eter
thro
mb
osis
and
cath
eter
infe
ctio
n26
5p
atie
nts
rece
ivin
gIC
Uca
rein
aFr
ench
hosp
ital
CVC
Cat
hete
rthr
omb
osis
was
asso
ciat
edw
ith2.
62-fo
ldg
reat
erris
kfo
rcat
hete
r-re
late
dse
psi
sTi
war
ieta
l,20
11(2
26)
436
Pros
pec
tive
coho
rtst
udy
Ap
pro
pria
tene
ssof
vasc
ular
dev
ice
use
inho
spita
lized
pat
ient
s43
6ho
spita
lized
pat
ient
sw
hore
ceiv
ed87
6IV
Ds
over
2909
hosp
ital-d
ays
PIVC
,CVC
31%
ofto
talc
athe
ter-
day
sw
ere
adju
dic
ated
asin
app
rop
riate
(usi
ngth
eau
thor
s'cr
iteria
for
app
rop
riate
vs.i
nap
pro
pria
teus
e)To
uré
etal
,201
5(2
27)
196
Pros
pec
tive
coho
rtst
udy
Com
par
eth
era
tes
ofco
mp
licat
ions
asso
ciat
edw
ithtu
nnel
edca
thet
ers
(Bro
viac
)and
PIC
Cin
pat
ient
sre
ceiv
ing
hom
ep
aren
tera
lnut
ritio
n
204
cath
eter
sw
ere
inse
rted
in19
6p
atie
nts
who
rece
ived
care
ina
hom
ep
aren
tera
lnut
ritio
np
rog
ram
PIC
C,
tunn
eled
cath
eter
Com
plic
atio
nsw
ere
sim
ilarb
etw
een
bot
hca
thet
erg
roup
s;ho
wev
er,c
athe
teri
nfec
tion
rate
sw
ere
low
erin
the
PIC
Cg
roup
Tran
etal
,201
0(6
0)47
8Re
tros
pec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
cean
dou
tcom
esas
soci
ated
with
PIC
C-r
elat
edD
VTSi
ngle
-cen
tera
naly
sis
ofp
atie
nts
with
hem
atol
ogic
canc
er,P
ICC
s,an
dsy
mp
tom
atic
UED
VTPI
CC
Hig
hin
cid
ence
ofD
VTas
soci
ated
with
PIC
Cs
inp
atie
nts
rece
ivin
gm
yelo
sup
pre
ssiv
ech
emot
hera
py;
cent
rally
pos
ition
edPI
CC
stu
nnel
edin
toth
ein
tern
alju
gul
arve
inw
ere
asso
ciat
edw
ithlo
win
cid
ence
ofth
rom
bos
isTr
erot
ola
etal
,200
7(2
28)
1654
PIC
Cs
Retr
osp
ectiv
eco
hort
stud
yD
eter
min
eth
ein
cid
ence
and
loca
tion
ofPI
CC
tipm
alp
ositi
onSi
ngle
-cen
tera
naly
sis
of23
67b
edsi
de
atte
mp
tsat
inse
rtio
nPI
CC
Tip
mal
pos
ition
occu
rred
in16
3ca
ses
afte
rb
edsi
de
inse
rtio
n;m
ostm
alp
ositi
onin
gs
wer
eco
rrec
ted
by
cath
eter
exch
ang
e(5
8%)
and
rep
ositi
onin
g(3
6%)
Trer
otol
aet
al,2
010
(229
)50
Pros
pec
tive
coho
rtst
udy
Eval
uate
outc
omes
asso
ciat
edw
ithus
eof
atr
iple
-lum
enPI
CC
inth
eIC
Use
ttin
gC
ritic
ally
illp
atie
nts
who
rece
ived
trip
le-lu
men
PIC
Cs
PIC
CTh
est
udy
was
stop
ped
afte
ran
inte
riman
alys
isd
emon
stra
ted
extr
emel
yhi
gh
rate
sof
sym
pto
mat
icD
VTin
20%
ofp
atie
nts
Tric
ket
al,2
004
(230
)32
0C
ross
-sec
tiona
lsu
rvey
Eval
uate
how
ofte
nC
VCs
wer
ep
lace
dw
ithou
tclin
ical
just
ifica
tion
inth
em
edic
alre
cord
Hos
pita
lized
adul
tpat
ient
sin
a60
0-b
edp
ublic
hosp
ital
CVC
Unj
ustifi
edus
eof
CVC
sw
asm
ore
com
mon
inp
atie
nts
rece
ivin
gca
reou
tsid
eth
eIC
U;
how
ever
,mos
tpat
ient
sre
ceiv
edC
VCs
whi
lein
anIC
Use
ttin
gTu
ffaha
etal
,201
4(8
5)N
AC
ost-
effe
ctiv
enes
san
alys
isA
sses
sth
eco
st-e
ffect
iven
ess
ofcl
inic
ally
ind
icat
edvs
.rou
tine
rep
lace
men
tofP
IVC
sD
ata
from
anRC
Tw
ere
used
tod
eter
min
eco
st-e
ffect
iven
ess
PIVC
Clin
ical
lyin
dic
ated
rep
lace
men
tstr
ateg
yw
asas
soci
ated
with
cost
-sav
ing
sp
erp
atie
ntof
AU
$7.6
0(9
5%C
I,A
U$4
.96–
AU
$10.
62)
Turc
otte
etal
,200
6(2
31)
NA
Syst
emat
icre
view
Eval
uate
infe
ctio
us,t
hrom
bot
ic,p
hleb
itic,
and
othe
rcom
mon
com
plic
atio
nsof
PIC
Cs
com
par
edw
ithC
VC
48ar
ticle
sw
ere
incl
uded
;com
plic
atio
nsfr
omPI
CC
sw
ere
com
par
edw
ithth
ose
from
CVC
sac
ross
seve
rals
tud
yp
opul
atio
ns
PIC
C,C
VCPI
CC
sw
ere
asso
ciat
edw
itha
com
plic
atio
np
rofil
eth
atw
assi
mila
rto
orex
ceed
edth
atof
CVC
s.PI
CC
sw
ere
mor
eco
mm
only
asso
ciat
edw
ithp
hleb
itis
and
mal
pos
ition
ing
than
CVC
sU
gas
etal
,201
2(2
32)
NA
Syst
emat
icre
view
Revi
ewth
eev
iden
ceon
the
inci
den
ceof
cent
rala
ndp
erip
hera
lven
ous
CRB
SIs
incr
itica
llyill
surg
ical
pat
ient
s,an
dou
tline
pat
hway
sfo
rpre
vent
ion
and
inte
rven
tion
Crit
ical
lyill
ICU
pat
ient
sin
surg
ical
ICU
sett
ing
sPI
CC
,CVC
Div
erse
defi
nitio
nsof
the
dia
gno
sis
ofce
ntra
lan
dp
erip
hera
lven
ous
CRB
SIs
and
asm
all
pop
ulat
ion
ofp
atie
nts
with
PIC
Cs
led
toin
cons
iste
ntco
nclu
sion
san
dfin
din
gs
Vese
ly,2
003
(66)
NA
Revi
ewSu
mm
ariz
eth
eev
iden
cere
late
dto
optim
altip
pos
ition
ofa
CVC
Nar
rativ
ere
view
PIC
C,C
VCTh
esc
ient
ific
evid
ence
atth
etim
ed
idno
tp
rovi
de
suffi
cien
tevi
den
ceto
sup
por
tor
cond
emn
the
pla
cem
ento
faca
thet
ertip
inth
erig
htat
rium
Vid
alet
al,2
008
(233
)11
5Pr
osp
ectiv
eco
hort
stud
yEv
alua
teco
mp
licat
ions
inp
atie
nts
who
rece
ived
PIC
Cs
forp
aren
tera
lnut
ritio
n,an
tibio
tics,
blo
odtr
ansf
usio
ns,a
ndot
her
infu
sion
s
115
hosp
italiz
edp
atie
nts
who
rece
ived
127
PIC
Cs
fora
varie
tyof
clin
ical
ind
icat
ions
;PIC
Cs
wer
ein
sert
edin
the
nond
omin
anta
rmin
94of
the
115
pat
ient
s
PIC
CO
cclu
sion
(17%
),ru
ptu
re(1
.6%
),ac
cid
enta
lw
ithd
raw
al(2
.4%
),in
fect
ion
(3.1
%),
and
VT(2
.4%
)wer
eth
em
ostc
omm
onco
mp
licat
ions
Vizc
arra
etal
,201
4(2
34)
NA
Infu
sion
Nur
ses
Soci
ety
gui
del
ine/
pos
ition
pap
er
Iden
tify,
pro
mot
e,an
dd
evel
opre
com
men
dat
ions
and
tool
sto
imp
rove
pat
ient
safe
typ
ract
ices
rela
ted
toth
eus
eof
shor
tPIV
Cs
NA
;pos
ition
stat
emen
trev
iew
ing
the
liter
atur
ean
dre
com
men
din
gb
estp
ract
ices
PIVC
Hea
lthca
rep
rovi
der
know
led
ge,
educ
atio
n,an
dtr
aini
ng,a
long
with
org
aniz
atio
nal
pol
icie
san
dp
roce
dur
es,s
houl
db
ed
evel
oped
toen
sure
PIVC
safe
ty;i
nad
diti
on,s
urve
illan
cep
rog
ram
sto
ensu
resa
fety
with
aud
itsan
dfe
edb
ack
are
nece
ssar
yto
imp
rove
dev
ice
safe
tyW
alke
rand
Tod
d,2
013
(4)
Surv
ey-b
ased
stud
yC
omp
are
inse
rtio
nco
st,p
atie
ntsa
tisfa
ctio
n,an
din
fect
ion
rate
sof
PIC
Cs
inse
rted
by
trai
ned
nurs
esan
dra
dio
log
ists
Hos
pita
lized
pat
ient
sun
der
goi
ngPI
CC
inse
rtio
nin
ad
istr
ictg
ener
alho
spita
lin
the
Uni
ted
King
dom
PIC
CPI
CC
sp
lace
db
yIR
wer
eas
soci
ated
with
gre
ater
cost
than
nurs
e-le
dPI
CC
inse
rtio
ns.
Patie
ntsa
tisfa
ctio
nre
gar
din
gex
pla
natio
nof
trea
tmen
twas
hig
heri
nth
enu
rse
gro
up
Con
tinue
don
follo
win
gpa
ge
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S37
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Wal
liset
al,2
014
(235
)32
83RC
TSe
cond
ary
anal
ysis
ofan
exis
ting
RCT
dat
ase
tto
eval
uate
risk
fact
ors
forP
IVC
failu
re32
83ad
ultm
edic
alan
dsu
rgic
alp
atie
nts
(590
7ca
thet
ers)
with
aPI
VCw
ith≥
4d
ofex
pec
ted
use
PIVC
PIVC
surv
ival
isim
pro
ved
by
pre
fere
ntia
lfo
rear
min
sert
ion,
sele
ctio
nof
app
rop
riate
PIVC
dia
met
er,a
ndin
sert
ion
by
IVte
ams
orot
hers
pec
ialis
tsW
alsh
eet
al,2
002
(51)
335
Pros
pec
tive
coho
rtst
udy
Eval
uate
com
plic
atio
nsaf
terP
ICC
inse
rtio
nin
aco
hort
ofad
ulta
ndp
edia
tric
canc
erp
atie
nts
335
pat
ient
sw
hore
ceiv
ed35
1PI
CC
sd
urin
gho
spita
lizat
ion;
pat
ient
sw
ere
care
dfo
reith
erb
ya
hom
ein
fusi
onag
ency
(205
)orb
yth
eho
spita
lst
aff(
146)
PIC
C11
5(3
2.8%
)of3
51PI
CC
sw
ere
rem
oved
asa
resu
ltof
aco
mp
licat
ion,
fora
rate
of10
.9p
er10
00ca
thet
er-d
ays;
pat
ient
sw
ithhe
mat
olog
icca
ncer
orb
one
mar
row
tran
spla
ntw
ere
mor
elik
ely
tod
evel
opa
com
plic
atio
nW
ebst
eret
al,2
013
(83)
NA
Syst
emat
icre
view
Eval
uate
whe
ther
rout
ine
chan
ges
ofPI
Vca
thet
ers
ever
y72
–96
hw
assu
pp
orte
db
yev
iden
ceof
effic
acy
orsa
fety
7tr
ials
with
ato
talo
f489
5p
atie
nts
wer
ein
clud
edin
the
revi
ewPI
VCN
oev
iden
cew
asfo
und
tosu
pp
ortr
outin
ePI
VCch
ang
esev
ery
72–9
6h;
cons
eque
ntly
,he
alth
care
org
aniz
atio
nsm
ayco
nsid
erp
olic
ies
whe
reb
yca
thet
ers
are
chan
ged
only
ifcl
inic
ally
ind
icat
edW
ilson
etal
,201
2(6
4)43
1Re
tros
pec
tive
coho
rtst
udy
Ana
lyze
and
iden
tify
risk
fact
ors
asso
ciat
edw
ithla
rge
vein
thro
mb
osis
inp
atie
nts
with
PIC
Cs
Neu
rosu
rgic
alIC
Up
atie
nts
PIC
CSu
rger
yfo
r>1
h,hi
stor
yof
VTE,
rece
ipto
fm
anni
tol,
and
und
erg
oing
pla
cem
enti
na
par
etic
arm
wer
eid
entifi
edas
risk
fact
ors
for
DVT
Wils
onet
al,2
013
(236
)43
1Re
tros
pec
tive
coho
rtst
udy
Com
par
eris
kfo
rcom
plic
atio
nsw
ithPI
CC
sw
ithth
ose
asso
ciat
edw
ithC
VCs
incr
itica
llyill
pat
ient
s
Neu
rosu
rgic
alIC
Up
atie
nts
PIC
C,C
VCD
urin
gth
est
udy
per
iod
,431
uniq
uePI
CC
sw
ere
pla
ced
,with
acu
mul
ativ
ein
cid
ence
ofsy
mp
tom
atic
thro
mb
osis
of8.
4%,C
LAB
SIof
2.8%
,and
line
inse
rtio
n–re
late
dco
mp
licat
ions
of0.
0%W
ojna
rand
Bea
man
,20
13(2
3)26
0Re
tros
pec
tive
coho
rtst
udy
Eval
uate
clin
ical
app
rop
riate
ness
ofPI
CC
use
com
par
edw
ithav
aila
ble
reco
mm
end
atio
ns
PIC
Cin
sert
ion
dur
ing
hosp
italiz
atio
nfo
rany
clin
ical
ind
icat
ion;
pat
ient
sw
ere
rand
omly
sele
cted
from
ala
rger
coho
rt
PIC
CRe
sults
sug
ges
ttha
teac
hp
atie
ntha
d≥
3in
dic
atio
nsfo
rPIC
Cp
lace
men
t.H
owev
er,i
n7
pat
ient
s,us
eof
PIC
Cs
did
notm
eet
curr
entC
DC
and
Infu
sion
Nur
ses
Soci
ety
reco
mm
end
atio
nsin
that
the
dur
atio
nof
use
was
<7
day
sW
orle
yet
al,2
007
(237
)46
8Re
tros
pec
tive
coho
rtst
udy
Eval
uate
outc
omes
rela
ted
tous
eof
PIC
Cs
ina
spec
ializ
edhe
adac
hetr
eatm
entu
nit
468
hosp
italiz
edad
ultp
atie
nts
ina
spec
ializ
edhe
adac
hetr
eatm
entu
nit
PIC
CO
nly
2p
atie
nts
(0.8
0%)e
xper
ienc
edPI
CC
-rel
ated
DVT
;the
inve
stig
ator
sco
nclu
ded
that
pat
ient
sw
ithPI
CC
sar
eno
tat
incr
ease
dris
kfo
rUED
VTco
mp
ared
with
othe
rhos
pita
lized
pat
ient
sW
orth
etal
,200
9(2
38)
66Pr
osp
ectiv
eco
hort
stud
yD
eter
min
eth
ena
tura
lhis
tory
and
rate
of,
and
risk
fact
ors
for,
CVC
-rel
ated
com
plic
atio
nsof
CLA
BSI
ina
hem
atol
ogy
pop
ulat
ion
106
CVC
s(7
5PI
CC
s,31
CVC
s)w
ere
eval
uate
din
66p
atie
nts,
over
2399
CVC
-day
sin
anam
bul
ator
yco
hort
PIC
C,C
VCD
VToc
curr
edin
16ca
ses
(15.
1%),
exit-
site
infe
ctio
nin
2ca
ses
(1.9
%),
and
CLA
BSI
in18
case
s(7
.5p
er10
00C
VC-d
ays)
.No
sig
nific
antd
iffer
ence
sw
ere
foun
dw
hen
com
plic
atio
nra
tes
bet
wee
nPI
CC
and
CVC
sw
ere
com
par
edX
ing
etal
,201
2(2
39)
187
Retr
osp
ectiv
eco
hort
stud
ySt
udy
the
inci
den
ce,d
iag
nosi
s,p
reve
ntio
n,an
dtr
eatm
ento
fPIC
C-r
elat
edU
EDVT
inp
atie
nts
with
bre
astc
ance
r
187
pat
ient
sw
ithb
reas
tcan
cerw
hore
ceiv
eda
PIC
Cfo
rche
mot
hera
py
PIC
CFo
ur(2
.1%
)of1
88PI
CC
sw
ere
rem
oved
asa
resu
ltof
PIC
C-r
elat
edU
EDVT
in14
–112
cath
eter
-day
s,at
ara
teof
0.28
per
1000
cath
eter
-day
sYa
mad
aet
al,2
010
(240
)21
9Pr
osp
ectiv
eco
hort
stud
yC
larif
yth
ed
egre
eof
pat
ient
-per
ceiv
edco
mfo
rtan
dco
nven
ienc
e,in
add
ition
top
roce
dur
e-re
late
dd
istr
ess,
resu
lting
from
use
ofPI
CC
sin
term
inal
lyill
pat
ient
sw
ithca
ncer
Am
ong
219
pat
ient
sad
mitt
edto
ap
allia
tive
care
unit,
39(1
8%)u
nder
wen
tPIC
Cp
lace
men
t(a
tota
lof4
4p
roce
dur
esw
ere
per
form
edb
ecau
se5
pat
ient
sun
der
wen
tPIC
Cin
sert
ion
twic
e)
PIC
CPI
CC
sw
ere
safe
lyin
sert
edin
90%
ofte
rmin
ally
illp
atie
nts
with
canc
erw
ithin
20m
inut
es;
alth
oug
h30
%of
the
pat
ient
sex
per
ienc
edtr
ansi
entp
roce
dur
e-re
late
dd
istr
ess,
>90
%fe
ltth
atth
ep
aren
tera
lrou
tew
asm
ore
com
fort
able
and
conv
enie
ntYa
pet
al,2
006
(241
)88
Pros
pec
tive
coho
rtst
udy
Eval
uate
PIC
Cco
mp
licat
ion
rate
sin
2003
afte
rint
rod
uctio
nof
safe
tym
easu
res
and
com
par
eth
emw
ithth
ose
rep
orte
din
the
sam
ece
nter
in20
01(a
hist
oric
alco
hort
)
88PI
CC
lines
wer
ein
sert
edin
73p
atie
nts
und
erra
dio
log
icg
uid
ance
PIC
CTh
eov
eral
lcom
plic
atio
nra
tew
as15
.9%
.In
fect
ions
dev
elop
edin
5.7%
and
thro
mb
otic
even
tsoc
curr
edin
4.5%
ofPI
CC
s.Th
eco
mp
licat
ion
rate
for2
003
was
sig
nific
antly
low
erth
anth
era
tefo
r200
1(P
=0.
006)
,sug
ges
ting
that
stra
teg
ies
tore
duc
ePI
CC
com
plic
atio
nsw
ere
succ
essf
ulYi
etal
,201
4(2
42)
81Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eris
kfa
ctor
sfo
rPIC
C-r
elat
edD
VTin
pat
ient
sw
ithca
ncer
Hos
pita
lized
pat
ient
sw
ithca
ncer
sche
dul
edto
rece
ive
PIC
Cs
bet
wee
nSe
pte
mb
er20
09an
dM
ay20
12at
1ce
nter
PIC
CD
iab
etes
incr
ease
dth
eris
kfo
rPIC
C-r
elat
edD
VTin
pat
ient
sre
ceiv
ing
chem
othe
rap
y
Con
tinue
don
follo
win
gpa
ge
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S38 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by Vineet Chopra on 09/14/2015
Tabl
e1—
Con
tinue
d
Stud
y,Y
ear
(Ref
eren
ce)
Par
tici
pan
ts,
nD
esig
nFo
cus
orO
verv
iew
Stud
ySa
mp
lean
dC
hara
cter
isti
csD
evic
eFi
ndin
gs
and
Com
men
ts
Yue
etal
,201
0(2
43)
400
Pros
pec
tive
coho
rtst
udy
Exam
ine
inse
rtio
n,in
fect
ious
,and
noni
nfec
tious
com
plic
atio
nsre
late
dto
PIC
Cus
ein
pat
ient
sw
ithca
ncer
at1
med
ical
cent
erin
ap
rovi
nce
ofC
hina
400
amb
ulat
ory
pat
ient
sw
ithva
rious
typ
esof
canc
erw
hore
ceiv
edPI
CC
sfo
rche
mot
hera
py
PIC
CD
urin
gin
sert
ion,
arrh
ythm
iaoc
curr
edin
1.5%
(6of
400)
ofp
atie
nts,
diffi
cult
cath
eter
thre
adin
gin
3.75
%(1
5of
400)
,and
exce
ssiv
eoo
zing
ofb
lood
in0.
3%(1
of40
0).
Dur
ing
the
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eter
dw
ell-i
np
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d,
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itizi
ngd
erm
atiti
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curr
edin
8%(3
8of
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in7.
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,cat
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lusi
onin
9.5%
(38
of40
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cath
eter
-ass
ocia
ted
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atog
enou
sin
fect
ion
in3%
(12
of40
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ndVT
in2%
(8of
400)
Zhu
etal
,200
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44)
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eter
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orca
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(>7
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.8%
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nin
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-site
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non-
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s,ne
ither
the
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pla
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ASy
stem
atic
revi
ewRe
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the
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atur
esu
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san
dhi
ghl
ight
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epid
emio
log
y,p
atho
phy
siol
ogy,
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gno
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and
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agem
ento
fPIC
C-r
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edth
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isin
criti
cally
illp
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nts
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icre
view
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kfa
ctor
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gno
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and
trea
tmen
tofP
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ated
DVT
incr
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llyill
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ulat
ions
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ein
cid
ence
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CC
-rel
ated
thro
mb
osis
incr
itica
llyill
pat
ient
sis
uncl
ear.
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isth
ep
refe
rred
dia
gno
stic
imag
ing
mod
ality
.No
RCTs
onb
estt
reat
men
tofP
ICC
-rel
ated
thro
mb
osis
inth
eIC
Use
ttin
gto
info
rmp
ract
ice
are
avai
lab
leZw
icke
reta
l,20
14(5
3)N
ASy
stem
atic
revi
ewan
dg
uid
elin
ePr
ovid
ere
com
men
dat
ions
ford
iag
nosi
san
dm
anag
emen
tofC
VC-a
ssoc
iate
dD
VTin
pat
ient
sw
ithca
ncer
Syst
emat
icre
view
ofth
elit
erat
ure
and
exp
ert
opin
ion
from
ag
uid
elin
ew
ritin
gp
anel
ofth
eIn
tern
atio
nalS
ocie
tyon
Thro
mb
osis
and
Hae
mos
tasi
s
PIC
C,C
VCU
Sis
reco
mm
end
edas
the
initi
alte
stof
choi
ce.R
outin
ead
min
istr
atio
nof
pha
rmac
olog
icp
rop
hyla
xis
top
reve
ntD
VTis
notr
ecom
men
ded
.Ant
icoa
gul
atio
nw
ithLM
WH
with
outr
emov
alof
the
cath
eter
ifcl
inic
ally
nece
ssar
yis
reco
mm
end
ed
BSI
=b
lood
stre
amin
fect
ion;
CD
C=
Cen
ters
for
Dis
ease
Con
trol
and
Prev
entio
n;C
KD=
chro
nic
kid
ney
dis
ease
;CLA
BSI
=ce
ntra
llin
e–as
soci
ated
blo
odst
ream
infe
ctio
n;C
RBSI
=ca
thet
er-r
elat
edb
lood
stre
amin
fect
ion;
CRT
=ca
thet
er-r
elat
edth
rom
bos
is;C
T=
com
put
edto
mog
rap
hy;C
VAD
=ce
ntra
lven
ous
acce
ssd
evic
e;C
VC=
cent
ralv
enou
sca
thet
er;D
VT=
dee
pve
nous
thro
mb
osis
;ED
=em
erg
ency
dep
artm
ent;
EKG
=el
ectr
ocar
dio
gra
phy
;ES
A=
eryt
hrop
oies
is-s
timul
atin
gag
ent;
GRA
DE
=G
rad
ing
ofRe
com
men
dat
ions
Ass
essm
ent,
Dev
elop
men
tan
dEv
alua
tion;
ICU
=in
tens
ive
care
unit;
IR=
inte
rven
tiona
lrad
iolo
gy;
IV=
intr
aven
ous;
IVD
=in
trav
enou
sd
evic
e;LM
WH
=lo
w-m
olec
ular
-wei
ght
hep
arin
;N
A=
not
app
licab
le;
NR
=no
tre
por
ted
;PE
=p
ulm
onar
yem
bol
ism
;PIC
C=
per
iphe
rally
inse
rted
cent
ralc
athe
ter;
PIVC
=p
erip
hera
lIV
cath
eter
;QI=
qua
lity
imp
rove
men
t;RC
T=
rand
omiz
ed,c
ontr
olle
dtr
ial;
SVC
=su
per
ior
vena
cava
;TC
VC=
tunn
eled
cent
ralv
enou
sca
thet
er;t
PA=
tissu
ep
lasm
inog
enac
tivat
or;T
PN=
tota
lpar
ente
raln
utrit
ion;
UC
LA=
Uni
vers
ityC
alifo
rnia
,Los
Ang
eles
;UED
VT=
upp
er-e
xtre
mity
dee
pve
nous
thro
mb
osis
;US
=ul
tras
onog
rap
hy;V
A=
Vete
rans
Affa
irs;V
AD
=ve
nous
acce
ssd
evic
e;VT
=ve
nous
thro
mb
osis
;VTE
=ve
nous
thro
mb
oem
bol
ism
.
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
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To earn 5 CME credits, please take the quiz at www.annals.org/article.aspx?doi=10.7326/M15-0744&atab=7. To earn MOC points, you musttake the MOC quiz at www.acponline.org/magicmoc/; successful comple-tion qualifies for 8 MOC points, and this information will be transferred tothe ABIM.
These CME and MOC activities are free to ACP members and individualsubscribers to Annals of Internal Medicine. Others who are interested incompleting this MOC activity can learn more about ACP membership andindividual subscriptions to Annals of Internal Medicine at www.acponline.org.
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SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
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Appendix Table 1. Literature Search Strategy
Search Query Items Found, n
PubMed (searched9 March 2013)
#23 (#8 not (#12 or #21 or #22)) 1109#22 (("Case Reports"[pt] or "case report"[Title])) 1 664 821#21 (#19 not #20) 455 878#8 ((#3 OR #4) AND #7) 1542#20 (#16 or #17) 769 402#19 (#13 or #18) 507 993#17 ((#3 OR #4) AND #7) Filters: Adult: 19+ years 577#16 adult*[Title/Abstract] 768 894#13 ((#3 OR #4) AND #7) Filters: Child: birth-18 years 417#18 (pediatric or neonat*[Title]) 507 773#12 (#9 NOT (#10 or 11)) 56#10 ((#3 OR #4) AND #7) Filters: Humans 1435#9 ((#3 OR #4) AND #7) Filters: Other Animals 82#11 (human* or patient*[Title/Abstract]) 6 257 942#7 ("Guideline" [Publication Type] OR "Guidelines as Topic"[Mesh] OR "Practice Guideline" [Publication
Type] OR "Unnecessary Procedures" [MeSH] or (appropriate* or inappropriate* or indicat* orguideline* or unnecessary[Title/Abstract]))
2 824 018
#4 "peripherally inserted central catheter*" OR "peripherally inserted" or picc*[Title/Abstract] 1474#3 "Catheterization, Central Venous"[Majr] 8919
CINAHL 325S24 S20 not S23S23 S21 NOT S22S22 S20 Limiters–Age Groups: All AdultS21 S18 AND S19 Limiters–Age Groups: All ChildS20 S18 AND S19S19 S16 OR S17S18 TI (appropriate* or inappropriate* or indicat* or guideline* or unnecessary) OR AB ( appropriate* or
inappropriate* or indicat* or guideline* or unnecessary)S17 TI ("peripherally inserted central catheter*" OR "peripherally inserted" or picc*) OR AB (
"peripherally inserted central catheter*" OR "peripherally inserted" or picc*)S16 (MH "Catheter Care, Vascular+") OR (MH "Central Venous Catheters+")
Google Scholar "peripherally inserted central catheter*" AND (appropriate* or inappropriate* or indicat* orguideline* or unnecessary)
134 (only 131 imported)
ClinicalTrials.gov(searched 9 April2013)
peripherally inserted central catheter* or picc* 40
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Appendix Table 2. Characteristics of MAGIC Panel Members
Panelist Title Affiliation Clinical Specialty Area of Technical Expertise
Agnes Y. Lee, MD, PhD Medical Director, ThrombosisProgram; AssociateProfessor of Medicine
University of British Columbia;Vancouver Coastal Health;British Columbia CancerAgency; Vancouver, BritishColumbia, Canada
Hematology andoncology
Thrombosis in cancer patients
Anthony Courey, MD Assistant Professor ofMedicine
University of Michigan, AnnArbor, MI
Critical care Vascular access and use ofultrasound in critically illpatients
Elie Akl, MD, MPH, PhD Director, ClincialEpidemiology Unit;Co-director, Center forSystematic Reviews inHealth Policy and SystemsResearch (SPARK)
American University, Beirut,Lebanon; Department ofClinical Epidemiology andBiostatistics, McMasterUniversity, Hamilton, Ontario,Canada
Internal medicine;hospitalmedicine
Guideline development,thrombosis,evidence-based medicine
Jack LeDonne, MD Director of Vascular AccessPrograms; Past President,Association of VascularAcccess
Greater Baltimore MedicalCenter, Baltimore, MD
General surgery Vascular access in generalmedical and surgicalpatients
Mauro Pittiruti, MD Director of Vascular AccessDirector, GAVeCeLT
Catholic University, Rome, Italy General surgery Vascular access
Nancy Moureau, RN Chief Executive Office;Director of VascularEducation
PICC Excellence, Inc., Hartwell,GA
Vascular accessnursingeducation
Vascular access
Naomi O'Grady, MD,PhD
Director of Procedures,Vascular Access andConcious Sedation
National Institutes of HealthClinical Center, Bethesda,MD
Critical care Guideline development,central line–associatedbloodstream infection,critical care
Nasia Safdar, MD, PhD Associate Professor ofMedicine; Medical Director,Infection Control; AssociateChief of Staff for Research
University of Wisconsin; WilliamS. Middleton MemorialVeterans Hospital; Madison,WI
Infectiousdiseases
Central line-associatedbloodstream infection
Rajiv Saran, MD, MRCP,MS
Professor of Medicine andEpidemiology; Director, USRenal Data SystemCoordinating Center;Associate Director, KidneyEpidemiology and CostCenter, University ofMichigan
University of MichiganAnn Arbor, MI
Nephrology Chronic kidney disease;vascular access in patientswith end-stage renaldisease
Lakshmi Swaminathan,MD
Staff Hospitalist; PhysicianChampion, HMS PICCQuality ImprovementProject*
Oakwood Health System,Dearborn, MI
Internal medicine Hospital medicine; patientsafety; quality improvementin hospitalized medicalpatients
Scott O. Trerotola, MD Professor of Radiology;Associate Chair and Chief ofInterventional Radiology
University of Pennsylvania,Philadelphia, PA
Interventionalradiology
Guideline development;vascular access
Dana Wanschneider, RN Vascular Access Nurse St. Josephs Mercy HealthSystem, Ann Arbor, MI
Vascular access Vascular access; nursing
Scott C. Woller, MD Associate Professor ofMedicine
Intermountain Medical Center;University of Utah School ofMedicine, Salt Lake City, UT
Internal medicine Venous thromboembolism;anticoagulationmanagement
Stephen Wiseman,PharmD
Clinical Pharmacy Specialist;Assistant Professor ofPharmacy
University of Michigan; VA AnnArbor Healthcare SystemAnn Arbor, MI
Pharmacology Infectious diseases; homeintravenous therapy;management of parenteraltherapy
Georgiann Ziegler Patient Representative University of Michigan HealthSystem
– Personally experiencedmultiple vascular accessdevices; insights into thepatient experience
GAVeCeLT = Gruppo Aperto di Studio 'Gli Accessi Venosi Centrali a Lungo Termine; HMS = Hospital Medicine Safety Consortium; MAGIC =Michigan Appropriateness Guide for Intravenous Catheters; PICC = peripherally inserted central catheter; VA = Veterans Affairs.* A Blue Cross Blue Shield–funded collaborative quality initative focused on improving PICC use in hospitalized medical patients in 47 particiatinghositals in the State of Michigan.
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Appendix Table 3. Sample Lists of Thematic Concerns Raised by Panelists*
Theme or Area Question or Top Concern
Appropriateness of PICC placementand concerns regarding deviceselection
Is the request for a PICC appropriate for what is needed (i.e., does the entity to be infused require a PICC, orwill a midline or peripheral catheter suffice?
Overuse of PICC for long-term care when tunneled, cuffed catheters (Hickman, cuffed Groshong, Broviac, etc.)or port would be more appropriate
PICCs ordered or maintained for blood draws—is this appropriate?PICCs ordered without trying other devicesPICCs ordered when all else fails for 1–3 doses of an infusion—is insertion appropriate?
Issues related to device insertionand selection of PICCcharacteristics
Is location of the tip of the catheter in the right atrium acceptable?Are dedicated lumens for parenteral nutrition still needed?How many lumens are appropriate for a given use?
Process concerns regardingutilization
Increasing use of PICCs when peripheral catheters may work? How can we drive this down?Unnecessary number/size of PICC lumensImplications of ordering chest radiographs for "PICC placement only" that are otherwise abnormalPatient “requested” PICC line appropriatenessHow do we resolve disagreement with radiology on where a PICC is located on chest radiograph?Strategies to minimize idle PICC-daysWhen should PICC tips be adjusted for optimal positioning?
Identifying best practices fortreatment and prevention ofPICC-related DVT
Optimal treatment is undefined. That covers everything from line removal? Anticoagulation? Duration andintensity of anticoagulation
Prophylaxis: Is primary prophylaxis indicated in those with "high-risk" factors? What are these factors, and if theyare present, how do we provide primary prophylaxis?
Prophylaxis: Is secondary prophylaxis indicated? I've had many patients who had a CRT as the index thromboticevent but then re-present with a DVT/PE. Is the risk for recurrence high enough to warrant secondaryprophylaxis? If a patient develops DVT and still requires central venous access, should we leave the catheterin situ?
If a symptomatic DVT is not improving clinically with a PICC in situ, how long should we wait before removingthe PICC or calling IR?
Management of specificcomplications
If a PICC is pulled out from original position, how far can it migrate out before it has to be pulled/replaced?Is it appropriate to empirically pull a PICC without other evidence of line infection?PICC in place when bacteremia occurs but no evidence of CLABSI—remove or treat through?Optimal timing of placement in bacteremia for long-term antibiotic treatment?
CLABSI = central line–associated bloodstream infection; CRT = catheter-related thrombosis; DVT = deep venous thrombosis; IR = interventionalradiology; PE = pulmonary embolism; PICC = peripherally inserted central catheter.* Edited by the authors for readability. Questions were selected at random from several panelists to illustrate the depth and breadth of focus.
Appendix Table 4. Example Scenarios From Ratings Material
How appropriate is theuse of each of thefollowing vascularaccess devices toobtain venous accessfor infusion oftherapeutics and/orlab draws in a patientwho is likely tobe hospitalized for apotential duration of:*
PeripheralIV Catheter
US-GuidedPeripheralIV Catheter
MidlineCatheter
PICC NontunneledCVC
Tunneled,CuffedCatheter
Port
≤5 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
Compared with PICCs, how preferable is the use of a midline in a hospitalized medical patient who requiresvenous access for infusion of a nonirritant, nonvesicant therapy for a proposed duration of:
Preference ofMidline Catheter vs.PICC†
≤5 d? 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9
CVC = central venous catheter; IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.* Rating scale: 1 = highly inappropriate; 5 = neutral or uncertain; 9 = highly appropriate.† Prefer midline catheter = 1; prefer PICC = 9.
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Continuing Medical Education/Maintenance of Certification ActivityIn addition to CME credit, physicians enrolled in the American Board of Internal Medicine’s (ABIM) Maintenance
of Certification (MOC) program can earn 8 medical knowledge self-assessment points for successful completing thefollowing module online. To earn 5 CME credits, please take this quiz at www.annals.org/article.aspx?doi=10.7326/M15-0744. To earn MOC points, you must take the MOC quiz at www.acponline.org/magicmoc; successful com-pletion qualifies for 8 MOC points, and this information will be transferred to the ABIM.
These CME and MOC activities are free to ACP members and individual subscribers to Annals of InternalMedicine. Others who are interested in completing this MOC activity can learn more about ACP membership andindividual subscriptions to Annals of Internal Medicine at www.acponline.org.
Question 1: The RAND/UCLA Appropriateness Method was developed to:A. Examine risks and benefits of medical and surgical procedures, regardless of their cost to estimate the over-
or underuse of specific medical and surgical proceduresB. To determine whether specific medical interventions are cost-effective.C. Develop consensus regarding appropriate medical and surgical procedures from a multidisciplinary panel.D. To determine whether insurers should cover the cost of an intervention
Question 2: According to the RAND/UCLA Appropriateness Method, which of the following is the hallmark of an“appropriate” rating?
A. When all participating panelists agree on the appropriateness of a clinical scenario.B. When the expected health benefits exceed the expected negative consequences and the panel median rating
is 7 to 9 without disagreement.C. When the majority of the panel rates the clinical scenario as highly appropriate.D. When no panel member rates the clinical scenario as inappropriate.
Question 3: According to the RAND/UCLA Appropriateness Method, which of the following indicates an “uncertain”rating?
A. When the panel median ranges from 4 to 6, or there is disagreement regardless of the median.B. When the panel median ranges from 1 to 3.C. When the panel median ranges from 7 to 9.D. When the panel median ranges from 5 to 7.
Question 4: Which of the following information sources was not used to develop the clinical scenarios for rating theappropriateness of various intravenous devices in this document?
A. Systematic reviews of the literatureB. List of controversial topics/key problems generated by expertsC. Clinical areas of ambiguity, controversy, or uncertaintyD. Medicare coverage of the procedure
Question 5: For this project, which of the following elements was NOT used to develop the clinical scenarios orindications that were rated by panelists?
A. Proposed duration of venous accessB. Device characteristicsC. Patient preferenceD. Maintenance and care practices
Question 6: In this project, a multidisciplinary panel of experts rated the appropriateness of a number of vascularaccess devices. Which of the following indications were rated as appropriate for use of peripherally inserted centralcatheters?
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A. Placement in a patient with active cancer for cyclical chemotherapy that can be administered through aperipheral vein, when the proposed duration of such treatment is 3 months or less and peripheral veins areavailable.
B. Delivery of non–peripherally compatible infusates (e.g., irritants/vesicants) regardless of proposed duration ofuse.
C. Patient or family requests for a patient who is not actively dying/on hospice for comfort from daily lab draws.D. Medical or nursing provider request in the absence of other appropriate criteria for peripherally inserted
central catheter use.
Question 7: In this project, a multidisciplinary panel of experts rated the appropriateness of practices associated witha number of venous access devices. Which of the following practices were rated as appropriate for peripherallyinserted central catheter insertion?
A. Urgent requests for peripherally inserted central catheter placement in a hemodynamically unstable patient inthe wards or intensive care unit setting.
B. Routine use of chest radiographs to verify peripherally inserted central catheter tip positioning followinguneventful placement via EKG guidance or fluoroscopy by staff who are technically proficient in this technology.
C. Preferential placement of a peripherally inserted central catheter based on the patient’s arm dominance.D. Consult with a relevant specialist (e.g., infectious disease, heme-oncology), operator (vascular access profes-
sional), and/or hospital pharmacist prior to ordering a peripherally inserted central catheter to determineoptimal device choice and characteristics.
Question 8: Which of the following were rated as an appropriate practice for peripherally inserted central cathetercare or maintenance by this multidisciplinary panel?
A. Removal of a peripherally inserted central catheter by a health care team member trained to remove centralvenous catheters, but not specifically trained to remove a peripherally inserted central catheter.
B. Removal of a peripherally inserted central catheter that is clinically necessary, centrally positioned, andotherwise functional in the setting of arm deep venous thrombosis.
C. Use of normal saline rather than heparin to flush a peripherally inserted central catheter following infusion orphlebotomy.
D. Routine removal and/or replacement of a peripherally inserted central catheter that remains clinically neces-sary without objective evidence of catheter-associated bloodstream infection in febrile patients.
Question 9: Which of the following was rated as an appropriate practice when caring for peripheral intravenouscatheters?
A. Routine replacement or continuation of a peripheral intravenous catheter in the absence of a clinical indica-tion warranting continued use.
B. Removal of a peripheral intravenous catheter in the setting of redness, swelling, pain, or phlebitis over thevein of insertion.
C. Replacement of a peripheral intravenous catheter on the basis of a routine schedule in the absence ofredness, swelling, or other signs of inflammation.
D. Removal of a functioning peripheral intravenous catheter because it was inserted in the field (e.g., ambulanceor nonhospital site) in the absence of redness, tenderness, or swelling over the insertion site.
Question 10: For the indication of infusion of peripherally compatible fluids, which of the following vascular accessdevices was rated as neutral for a proposed infusion for 6 to 14 days?
A. Ultrasound-guided peripheral intravenous cathetersB. MidlinesC. Peripherally inserted central cathetersD. Peripheral intravenous catheters
Question 11: For the infusion of peripherally compatible fluids, which of the following vascular access devices wererated as inappropriate for a proposed duration of 31 days or more?
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A. Peripherally inserted central cathetersB. Ultrasound-guided peripheral IVsC. Implanted portsD. Tunneled catheters
Question 12: According to the Fistula First Breakthrough Initiative, in what stages of chronic kidney disease may useof peripherally inserted central catheters be considered appropriate following expert consultation with nephrology?
A. Stage 1 onlyB. Stage 3b or greaterC. Stage 2 onlyD. Stage 1 to 3a
Question 13: For the infusion of peripherally noncompatible fluids in critically ill patients, which of the followingvascular access devices were rated as appropriate and preferred for a proposed duration of 5 days or less?
A. Nontunneled central venous cathetersB. Tunneled cathetersC. Peripheral intravenous cathetersD. Midlines
Question 14: For patients with difficult peripheral venous access, which of the following pairs of vascular accessdevices were rated as appropriate and preferred to peripherally inserted central catheters when the proposedduration of use is 14 days or less?
A. Midlines and portsB. Nontunneled central venous catheters and portsC. Midlines and central venous cathetersD. Tunneled-cuffed catheters and peripherally intravenous catheters
Question 15: According to our panel, which of the following was rated as appropriate for the treatment of periph-erally inserted central catheter-related deep venous thrombosis?
A. Provide at least 1 month of uninterrupted systemic anticoagulation.B. Low-molecular-weight heparin over warfarin in patients with cancer.C. Remove the peripherally inserted central catheter and replace this with another device to prevent clot
propagation.D. Refer all patients with peripherally inserted central catheter-related deep venous thrombosis to interventional
radiology for evaluation.
Question 16: Among scenarios examining use of vascular access devices in patients that require frequent phlebot-omy, which of the following statements are true?
A. Central venous catheters were rated as appropriate and preferred to peripherally inserted central catheterswhen the expected duration of venous access was 14 days or less in critically ill patients.
B. Ports were rated as appropriate to use in this population, regardless of duration of use.C. Peripheral intravenous catheters and ultrasound-guided peripheral intravenous catheters were rated as ap-
propriate for use for 5 days or less in patients that require frequent phlebotomy.D. The most appropriate vascular access device should be determined by patient preference in this setting.
Question 17: Among patients who require frequent phlebotomy for less than 5 days, which of the following resultedin panelist disagreement regarding appropriateness of device use?
A. MidlinesB. Central venous cathetersC. Peripherally inserted central cathetersD. Ports
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Question 18: Among patients receiving peripherally compatible infusions in home-based or skilled nursing facilities,which of the following expected durations of use was rated as being appropriate for peripherally inserted centralcatheter placement?
A. 6 to 14 daysB. Only 15 to 30 daysC. Only more than 30 daysD. More than 15 days
Question 19: Among patients who are likely to require lifelong venous access but are infrequently hospitalized (<5times per year), when is use of peripherally inserted central catheters considered appropriate according to thispanel?
A. When expected duration of venous access is 5 days or less.B. When the expected duration of venous access is 6 to 14 days.C. When the expected duration of venous access is 15 or more days.D. When the expected duration of access is not well-known.
Question 20: In critically ill populations, which of the following expected durations of venous access were rated asappropriate for midline insertion and use?
A. 5 days or lessB. 6 to 14 daysC. 15 to 30 daysD. More than 30 days
Question 21: A patient is diagnosed with active cancer and is recommended multiple cycles of nonvesicant, inter-mittent chemotherapy that can be administered into a peripheral vein for a total duration of 1 month. Based on therecommendations of this panel, which of the following vascular access devices is considered appropriate for this patient?
A. Peripherally inserted central cathetersB. Intermittent use of peripheral intravenous cathetersC. PortsD. Tunneled-cuffed catheters
Question 22: A patient with an unknown stage of chronic kidney disease is admitted to the hospital with pneumoniaand is likely to require venous access for 5 days or less. However, the patient is a “difficult stick” and nurses arehaving trouble establishing reliable peripheral access. According to this panel, which of the following are appropri-ate in this particular setting?
A. Because of the ambiguity regarding the stage of CKD, consultation with nephrology is appropriate prior toperipherally inserted central catheter insertion for any reason.
B. Should the patient be determined to have stage 3b or greater CKD or is possibly a candidate for hemodialysis(with estimated GFR < 45 mL/min), insertion of a peripherally inserted central catheter is appropriate.
C. If peripheral venous access for 5 days or less is likely, placement of a peripheral intravenous catheter in thedorsum of the hand is considered inappropriate.
D. Should longer-term intravenous antibiotics be necessary, placement of a small-bore central catheter forinfusion of 14 days of intravenous antibiotics is inappropriate in patients with stage 3b or greater CKD.
Question 23: A patient is being discharged from the hospital to a local skilled nursing facility for continuation of aplanned 6 weeks of intravenous antibiotics. According this panel, which of the following vascular access devices areconsidered appropriate for this patient in this scenario?
A. Nontunneled central venous catheterB. Peripheral intravenous catheterC. MidlineD. Peripherally inserted central catheter
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Question 24: A patient with an existing peripherally inserted central catheter is admitted to the hospital. A portablechest radiograph performed to ascertain the catheter tip position shows this to be located approximately 1 cm withinthe right atrium. Based on the recommendations of this panel, which of the following is the most appropriate nextcourse of action?
A. Adjust peripherally inserted central catheter so as to localize the catheter tip in the cavoatrial junction; repeatchest radiography to confirm.
B. No further action is needed; the catheter is well-positioned and okay to use.C. Withdraw tip so as to localize the catheter tip in the lower third of the superior vena cava.D. Perform computed tomography to confirm catheter placement.
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