Coagulation

High VTE risk with peripherally inserted central catheters in children

Thursday, 23 Jan 2020


Clinicians are being advised to curb the growing use of peripherally inserted central catheters (PICCs) in children after a US study confirmed they are associated with a significantly increased risk of venous thromboembolism compared with central venous catheters (CVCs).

Findings from the Clot Incidence Rates in Central Lines (CIRCLE) study, published in Blood, also reveal a significantly higher rate of CVC-related bloodstream infections and catheter malfunctions among pediatric patients receiving PICCs.

The multi-centre, prospective, observational cohort study analysed VTE and malfunction rates in 1,967 newly placed CVCs in 1,742 children aged six months to 18 years.

The incidence of CVC-related VTE was 5.9%, and most of the cases (75 of 94, or 80%) were in children with PICCs, which had a significantly higher risk of catheter-related VTE than children with tunnelled lines (hazard ratio [HR] = 8.5).

PICCs were significantly more likely to have a central line–associated bloodstream infection (CLABSI, HR = 1.6) and CVC malfunction (HR = 2.0).

Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR = 23), multilumen CVC (HR = 3.9), and leukemia (HR = 3.5).

Study lead author Dr Julie Jaffray of the Children’s Hospital of Los Angeles, said the study showed that the incidence of PICC-related VTE was too high to justify their frequent use.

“Now we can say definitively that patients who have PICCs have a much higher rate of thrombosis as well as central line associated bloodstream infections and catheter malfunctions when compared to TLs,” she said

“PICCs are not as benign as we once thought.”

While CVCs are an essential part of medical care for many children, the increasing rates of CVC-related VTE must be addressed, the study authors said.

Dr Jaffray suggested the use of PICCs be reduced, perhaps in favour of using peripheral intravenous lines in patients who don’t really need a CVC or using a more permanent central line in those whose medical condition demands ongoing access.

“Paediatricians and paediatric subspecialists need to reconsider how quickly and easily decisions to place CVCs, especially PICCs, are being placed.

“Inserting a PICC is tempting to avoid repeat venipuncture or surgical intervention with TL placement, but results from the CIRCLE study showing increased risks of VTE, CLABSI, and malfunction with PICCs should give practitioners pause,” they concluded.

And to lower the CVC-related VTE rate, there must also be a focus on modifiable risk factors, such as limiting multilumen CVCs, preventing CLABSIs, or placing a TL over a PICC if possible, they added.

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