The Efficacy and Safety of Peripherally Inserted Central Catheters in Neuro Intensive Care Management: A Retrospective Study

Abstract

Objective:

This study aimed to analyze the efficacy and safety of peripherally inserted central catheters (PICCs) inserted by the PICC nursing team in the neuro intensive care unit (ICU).

Methods:

A retrospective analysis was conducted on 756 patients admitted to the neuro ICU of a clinical neurosciences center in Shanghai, China, between January 2019 and December 2022. All patients required elective central venous access and had a PICC inserted by the PICC nursing team. Data on patient demographics, catheter type, insertion approach, puncture site, tip position, insertion success rate, and complications were extracted from electronic medical records using Questionnaire Star software. The study compared outcomes before and after the implementation of a specialized training program for the PICC nursing team, which included theoretical and practical training on PICC insertion techniques, maintenance, and complications management.

Results:

Following the implementation of the trained PICC nursing team, significant changes were observed in catheter type and insertion technique. The use of 3-way valve Solo catheters and power-injectable open-ended catheters increased, while the use of 3-way valve catheters decreased. In addition, the use of ultrasound-guided modified Seldinger technique (MST) increased significantly, with a corresponding decrease in conventional PICC insertion and MST without ultrasound guidance. Malpositioned tips occurred in 6.3% of cases. Notably, after the implementation of the trained team, complications significantly decreased (P<0.05) and the first-attempt success rate significantly increased (P<0.05) compared with the period before the training program.

Conclusions:

In neuro ICU patients, the use of PICCs inserted by a well-trained, competent PICC nursing team demonstrated improved outcomes, including reduced complications, increased first-attempt success rates, and higher quality of care. These findings highlight the importance of specialized training for PICC nursing teams in neurointensive care management.

Intravenous fluids are a crucial and frequently performed nursing task in the neurointensive care unit (NICU). Patients admitted to the NICU often necessitate central venous access due to their critical conditions.¹ For instance, those with elevated intracranial pressure require rapid intravenous infusion of 20% mannitol for dehydration, while patients with hypertensive cerebral hemorrhage need vasoactive drugs to manage their blood pressure. In addition, those with subarachnoid hemorrhage from aneurysms require nimodipine to prevent cerebral vasospasm, and patients with multidrug-resistant bacterial infections necessitate vancomycin antibacterial therapy.^2–5 Notably, while some of these medications, such as mannitol and vancomycin, can be administered peripherally, their irritant nature can cause significant damage to peripheral blood vessels, rendering traditional peripheral intravenous administration suboptimal for meeting these clinical needs. Therefore, suitable venous access is paramount in these cases.

Peripherally inserted central catheters (PICCs) were introduced in China in the 1990s⁶ and have gradually emerged as a prevalent device for reliable intravenous therapy administration across various medical scenarios, including chemotherapy, total parenteral nutrition, and vasoactive drug infusion.⁷ With the advent of the ultrasound-guided modified Seldinger technique (US-MST) in China, the success rate of punctures and accurate tip placement has seen substantial improvements.⁸ Furthermore, nurse-led bedside PICC placement offers convenience to both health care professionals and patients.⁹

In the early 21st century, China introduced the Standard of Practice for Infusion Therapy.¹⁰ Changhai Hospital adopted the international PICC intravenous infusion standard in its nursing practice and, in 2005, established the Intravenous Infusion Safety Management Committee (INSMC). Over the course of 2 decades of clinical practice and research, PICC catheterization technology has become increasingly refined and effective.

The Clinical Neuroscience Center of Changhai Hospital boasts 16 neuro ICU beds, primarily accommodating severely ill patients with cerebral hemorrhage, infarction, subarachnoid hemorrhage, intracranial infection, and traumatic brain injury. Under the guidance of the INSMC, the NICU has formed a dedicated PICC nursing team responsible for PICC insertion, care, and quality assurance. This article examines the efficacy and safety of PICCs inserted by the NICU PICC nursing team.

METHODS

Establishing an NICU PICC Nurse Team

In January 2020, with the support of the Intravenous Infusion Safety Management Committee (INSMC), the NICU established a peripherally inserted central catheter (PICC) nurse team. One of the primary objectives of our team is to provide standardized care based on scientific evidence to minimize the risk of complications. To accomplish this, the nurse team thoroughly assesses each patient and the PICC insertion site. In conjunction with the INSMC, unified insertion and maintenance procedures were instituted, along with a defined materials portfolio recommending the smallest gauge catheters and fewest lumens necessary to deliver required intravenous fluids. In addition, PICC selection algorithms were drafted.

Our NICU PICC nurse team comprises 1 Junior Infusion Nurse (JIN), 2 Senior Infusion Nurses (SINs), and 7 Infusion Nurse Specialists (INSs). Each member plays a specific role in our mission.

The JIN is responsible for daily PICC care, including routine catheter insertions, maintenance, documentation, and educating families. The JIN also trains NICU nurses on proper PICC maintenance and oversees their work. If difficult insertions are anticipated, the JIN consults with an SIN.

The SINs handle more complex tasks, including difficult PICC insertions, and mentor the JIN. They have extensive experience in spotting and quickly responding to catheter complications, ensuring adherence to safety standards.

The INS leads the program, specializing in the most complex catheter insertions. They seek out cutting-edge techniques and tools to advance practice, lead education programs, and oversee quality improvement initiatives.

PICC Catheterization Procedure

Each patient eligible for PICC insertion signed informed consent. Before insertion, the JIN conducted a proactive assessment of the patient’s veins and selected the most appropriate catheter based on the patient’s veins and prescribed treatment. If difficult insertion was anticipated, consultation with an SIN or INS occurred as appropriate.

All PICCs were inserted at the bedside using maximal barrier precautions (cap, mask, sterile gown, sterile gloves, large sterile field) with 2% chlorhexidine skin antisepsis, following relevant guidelines (eg, Centers for Disease Control and Prevention guidelines). All catheters were secured with a Statlock stabilization device and a reinforced semipermeable transparent dressing. If minor bleeding occurred at the insertion site, a small gauze dressing was applied for hemostasis; otherwise, only a transparent dressing was used.

Correct tip placement at the cavoatrial junction was verified by chest x-ray post-procedure. In some cases, neck vein ultrasound was also performed to further confirm placement and rule out jugular tip malposition.

Data Collection

The Wen Juan Xing information system was used to record data for each PICC insertion, dwell time, tip location, and other relevant information. The goal of this database was to statistically analyze PICC insertion, dwelling, complications, and removal. By scanning the Wen Juan Xing quick response (QR) code in WeChat, infusion nurses could access and complete questionnaires in real time on their mobile devices.

Nurses collected data via QR code for each PICC insertion, including insertion method, expected and actual insertion length, external length, arm circumference 10 cm above the antecubital fossa, tip position, specific nurse qualifications, and professional title. For complications, nurses reported the puncture site, catheter dwell time, complication details, infused solutions/medications, and management, uploading relevant photos or images. If needed, JINs or SINs completed a Complication Consultation Form and sent it to an INS, including consultation purpose, brief medical history, and consultant information. Postconsultation, the diagnosis, resolution instructions, and treatment options were logged. Catheter integrity was reported preinsertion and postremoval.

Statistical Analysis

This study collected data over 4 years, from 2019 to 2022, including relevant information on 756 participants. Qualitative variables are described by a number of cases and percentage. Comparisons of qualitative variables were performed using χ² tests, with a significance level set at P<0.05 (2-tailed). Data analysis was performed using SPSS software, version 18.

RESULTS

From January 2019 to December 2022, a total of 756 patients underwent PICC line insertion. Among them, 575 (76.1%) were power injectable and 181 (23.9%) were nonpower injectable. Insertion techniques varied, with 48 (6.3%) using routine catheterization, 406 (53.7%) utilizing the modified Seldinger technique (MST), and 302 (39.9%) employing ultrasound-guided MST. The patient population included 479 males and 277 females, with ages spanning from 14 to 92 years. The median or mean age, based on the distribution, was not specified.

Regarding care provision, during the period from 2021 to 2022, 324 patients (42.9%) received care from the PICC nursing team, while 432 patients (57.1%) were cared for by nurses before the team’s implementation in the years 2019 to 2020. Vein usage patterns changed significantly, as detailed in Table 1. Specifically, basilic vein use decreased from 77.1% to 64.2%, median vein use increased from 14.8% to 22.8%, cephalic vein use decreased from 6.3% to 4.3%, and brachial vein use increased from 1.8% to 8.6%.

TABLE 1.

Demographic Data of Patients With PICCs in the Neurointensive Care Unit

	n (%)
	2019	2020	2021	2022
Patients’ characteristics	n=287	n=145	n=133	n=191
Gender
Male	178 (62.0)	88 (60.7)	81 (60.9)	132 (69.1)
Female	109 (38.0)	57 (39.3)	52 (39.1)	59 (30.9)
Age (y)	55±8.5	62±16.0	73±15.6	66±7.1
Puncture approaches
Routine catheterization	36 (12.5)	6 (4.1)	3 (2.3)	3 (1.6)
MST	212 (73.9)	104 (71.7)	40 (30.1)	50 (26.2)
US and MST	39 (13.6)	35 (24.1)	90 (67.7)	138 (72.3)
Via vein
Basilic vein	223 (77.7)	110 (75.9)	85 (63.9)	123 (64.4)
Cephalic vein	18 (6.3)	9 (6.2)	4 (3.0)	10 (5.2)
Median vein	41 (14.3)	23 (15.9)	37 (27.8)	37 (19.4)
Brachial vein	5 (1.7)	3 (2.0)	7 (5.3)	21 (11.0)

MST indicates modified Seldinger technique; US, ultrasound.

Three types of catheters were utilized during the study period. The usage of nonpower injectable 3-way PICCs decreased annually from 58.9% to 7.9%, while 3-way valved solo PICCs increased from 14.6% to 22.0%, and power injectable open-ended PICCs rose from 26.5% to 70.2%. These shifts are summarized in Figure 1.

FIGURE 1.

Distribution of catheter types.

Three insertion techniques were also employed. Following the implementation of the PICC nurse team, the use of routine catheterization decreased, as shown in Figure 2. Ultrasound-guided MST has emerged as the preferred method.

FIGURE 2.

Different puncture approaches of PICCs.

Optimal PICC tip positioning within the lower one-third of the superior vena cava (SVC) was achieved in 682 patients (90.2%), while 74 patients (9.8%) experienced malpositioning, primarily in the internal jugular vein and upper SVC, as shown in Figure 3. Complications encountered included malposition, phlebitis, catheter-related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and obstruction, as illustrated in Figure 4. The PICC team evaluated and intervened in cases of complications.

FIGURE 3.

Constituent ratio of different catheter tip malpositions.

FIGURE 4.

Distribution of PICC catheter-related complications.

Postimplementation of the PICC team, the complication rate decreased to 7.10%, with a first-attempt success rate of 93.21%. In contrast, preimplementation rates were 11.81% for complications and 74.77% for first-attempt success. χ² analysis indicated a statistically significant reduction in complications and an increase in first-attempt success following the implementation of the PICC team (P<0.05). These findings are presented in Table 2.

TABLE 2.

Comparison of the Complications and Successful Insertion at One Time before and After PICC Nursing Term

		Complication	Successful insertion
Group	n	n (%)	n (%)
Pre-PICC nursing team	432	51 (11.81)	323 (74.77)
Post-PICC nursing team	324	23 (7.10)	302 (93.21)
χ2	4.645	—	43.953
P	0.031	—	0.000

PICC indicates peripherally inserted central venous catheter.

DISCUSSION

The results of our study, which examines the insertion of peripherally inserted central catheters (PICCs) from January 2019 to December 2022, offer valuable insights into the implications of various insertion techniques and the implementation of a dedicated PICC nursing team on patient outcomes.

Over the 4-year study period, a total of 756 patients underwent PICC insertions, accompanied by a notable shift in catheter types and insertion methodologies. Our findings are consonant with those of comparable studies examining the impact of advanced PICC insertion techniques and specialized nursing teams. Quinn et al¹¹ reported a substantial increase in the utilization of power injectable PICCs, aligning with our observation of an escalating use from 26.5% to 70.2%. This trend underscores the growing acknowledgment of their clinical advantages, particularly in the administration of high-osmolarity and irritant medications.

Furthermore, our study notes a transition from conventional catheterization to the ultrasound-guided microintroduction sheath technique (MST), a pattern mirrored in existing literature. Oviedo-Torres MA, et al¹² found that the adoption of ultrasound-guided MST significantly enhanced first-attempt success rates and decreased the incidence of complications such as malposition and phlebitis. Similarly, our study demonstrates a marked increase in first-attempt success rates and a notable reduction in complication rates following the implementation of MST.

The establishment of a specialized PICC nursing team in our study exerted a profound influence on patient care, resulting in significant improvements in both first-attempt success rates and complication rates. These findings corroborate those of prior research. Several studies^13–15 show that specialized PICC teams were associated with lower complication rates and higher patient satisfaction. Our study extends these findings by presenting specific data on the reduction in complications, including malposition, phlebitis, catheter-related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and obstruction.

Moreover, our study observed changes in vein usage patterns that indicate a more strategic approach to insertion site selection by the PICC team. This shift towards utilizing alternative veins, such as the median and brachial veins, is also reported in other studies. Yin et al¹⁶ found that specialized PICC teams were more inclined to choose veins that minimized the risk of complications and enhanced patient comfort, consistent with our observations. The commendable high rate of optimal PICC tip positioning within the lower one-third of the superior vena cava (SVC) in our study underscores the importance of precise placement. Malpositioning, which occurred in 9.8% of cases, is a recognized risk factor for complications such as CRT and CRBSI. The intervention of the PICC team in these instances likely contributed to the overall decrease in complication rates, as similarly noted in other studies.

In summary, our study contributes to the existing evidence base supporting the benefits of adopting advanced insertion techniques and establishing specialized PICC nursing teams. The substantial improvements in first-attempt success rates and the reduction in complications underscore the importance of these interventions in optimizing patient care. As health care systems continue to evolve, the integration of specialized PICC teams and advanced insertion techniques should be considered as standard practices to augment patient safety and outcomes. Future research endeavors could further explore the long-term implications of these interventions on patient satisfaction, cost-effectiveness, and health care resource utilization, refining our understanding of how to best care for patients undergoing PICC insertions.

CONCLUSIONS

In patients admitted to the neurointensive care unit, peripherally inserted central catheters (PICCs) managed by the PICC Nursing Team were associated with statistically significant improvements in outcomes for the entire sample. In addition, the nursing quality and management of PICCs underwent continuous improvement.