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Original Research: Procedures |

Reduction of Peripherally Inserted Central Catheter-Associated DVTPeripherally Inserted Central Catheters and DVT FREE TO VIEW

R. Scott Evans, PhD; Jamie H. Sharp, RN, VA-BC; Lorraine H. Linford, RN, BS, CNSC; James F. Lloyd, BS; Scott C. Woller, MD; Scott M. Stevens, MD; C. Gregory Elliott, MD, FCCP; Jacob S. Tripp, PhD; Spencer S. Jones, PhD; Lindell K. Weaver, MD, FCCP
Author and Funding Information

From Medical Informatics (Drs Evans and Tripp and Mr Lloyd), Intermountain Healthcare; Biomedical Informatics (Dr Evans), and the Department of Medicine (Drs Woller, Stevens, Elliott, and Weaver), University of Utah School of Medicine; Nutrition Support Service/PICC Team (Mss Sharp and Linford), and Department of Medicine (Drs Woller, Stevens, Elliott, and Weaver), Intermountain Medical Center; RAND Corporation (Dr Jones); and Hyperbaric Medicine (Dr Weaver), Intermountain Medical Center and LDS Hospital, Salt Lake City, UT.

Correspondence to: R. Scott Evans, PhD, Medical Informatics, LDS Hospital, 8th Ave and C St, Salt Lake City, UT 84143; e-mail: rscott.evans@imail.org.


For editorial comment see page 589

Funding/Support: This work was a quality improvement project funded by Intermountain Healthcare.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(3):627-633. doi:10.1378/chest.12-0923
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Background:  As peripherally inserted central catheter (PICC) use has increased, so has the upper extremity DVT rate. PICC diameter may pose the most modifiable risk for PICC-associated DVT.

Methods:  A 3-year, prospective, observational study of all PICC insertions by a specially trained and certified team using a consistent and replicable approach was conducted at a 456-bed, level I trauma and tertiary referral hospital during January 1, 2008, through December 31, 2010. An intensified effort by the PICC team in 2010 was introduced to discuss and reach interdisciplinary consensus on the need for each lumen of the PICC and a change to smaller diameter 5F triple-lumen PICC.

Results:  Significantly more 4F single-lumen PICCs were used during 2010 (n = 470) compared with 2008 and 2009 (n = 338, 382; P < .0001). DVT rates were similar with the use of 5F triple-lumen PICCs in 2010 as 5F double-lumen PICCs and lower rates than 6F triple-lumen catheters used in 2008 and 2009. The PICC-associated DVT rate was significantly lower (1.9% vs 3.0%, P < .04) in 2010 compared with 2008 and 2009. The cost and length of stay attributable to PICC-associated DVT were $15,973 and 4.6 days.

Conclusions:  A significant increase in the use of single-lumen PICCs in addition to the institutional adoption of smaller 5F triple-lumen PICCs was associated with a significant decrease in the rate of PICC-associated DVT.

Figures in this Article

Use of peripherally inserted central catheters (PICCs) has increased during the past 35 years.16 PICC use has also extended beyond the hospital to ambulatory care, skilled nursing facilities, and homecare. The increase in PICC use is due to fewer insertion complications and less insertion time than other central venous catheters (CVCs).7,8 The use of ultrasound-guided PICC insertion has improved difficult venous access by visualization of vein size, patency, and venous flow.4 Using ECG with bedside ultrasound eliminates chest radiographs to verify PICC tip location in many patients.9 However, PICC use continues to carry important risks, most notably infection and thrombosis.

There are studies that challenge the assertion that the infection risk from PICCs is greater than that from traditional CVCs.1012 In contrast, as PICC use has increased, so has upper extremity DVT.13 PICC-associated DVT rates have ranged from 0 to 20%7 and are a more common complication than infection.14 Two studies reported an increased risk of PICC-associated DVT compared with other CVCs,15,16 and we found the presence of PICC was a risk factor for DVT in medical inpatients.17 PICC-associated thrombosis can also lead to infection, pulmonary embolism, and the formation of thromboemboli in the right atrium.18 In a previous study, we found that in addition to previous DVT and surgery duration > 1 h, PICC diameter was a risk factor for upper extremity DVT.19 As prior DVT history is not modifiable, and it is difficult to change the length of surgery, this study reports our efforts to reduce the rate of DVT through use of smaller diameter PICC.

Background

Intermountain Medical Center (IMC) is a 456-bed teaching hospital affiliated with the University of Utah. Approximately 78% of PICC insertions at IMC during 2008 through 2010 were performed by the PICC team that reports through the Nutrition Support Service, and these were included in our study. Patients with PICC insertion by interventional radiology or inserted before admission were excluded. The PICC team is composed of 10 nurses with special training, internal certification, and national vascular access board certification. The protocol used during this study to verify candidacy for PICC team insertion has been published previously.19 The diameter of all single-lumen PICCs was 4F, and the diameter of all double-lumen PICCs was 5F. The diameter of triple-lumen PICCs changed from 6F in 2008 and 2009 to 5F in 2010. During 2010, the PICC team began an intensified effort to discuss and reach interdisciplinary consensus on the need for each lumen of the PICC. Bedside nurses charted routine PICC care information in the electronic medical record during each shift.

Study Design

A prospective observational study was performed of all PICC team insertions during 2008 through 2010 at IMC. Each patient was monitored for symptomatic DVT using computerized surveillance of venous duplex ultrasonography dictation reports20,21 and PICC nurse adjudication.

A study database was created that included patient demographics, nurse charting, medication therapy, and PICC team documentation. Medical conditions were collected from the admission diagnosis International Classification of Diseases, 9th Revision codes. PICC duration was calculated from the day of insertion until the removal or patient discharge date. Reason for PICC use was extracted from the PICC team documentation. Patients were followed for this outcome until 5 days after PICC removal or hospital discharge.

Definition of Outcome Measures

Symptomatic DVT associated with PICC was the primary outcome measure. Assessment for DVT during all 3 years occurred in patients whose medical provider suspected DVT based on symptoms, such as swelling in the upper extremity, pain, or leaking at the PICC site. All suspected DVTs were assessed with use of venous duplex ultrasound, and DVTs were identified by the hospital peripheral vascular laboratory. The definition of DVT for this study consisted of noncompressibility of the relevant vein using the ultrasound probe during direct visualization.

Statistical Analysis

Initial analyses to ascertain statistically significant differences in patient characteristics, PICC types used, and DVT rates across the 3 years were performed using Cochran-Mantel-Haenszel χ2 tests. These analyses were followed by multivariable regressions that sought to evaluate whether PICC diameter was associated with DVT risk. To accommodate for repeated measurements (ie, patients who received more than one PICC), the association of DVT with PICC diameter was evaluated using generalized estimating equations—an extension of generalized linear models that account for correlated repeated measurements within individuals.​This analytical strategy was executed using a multivariable logistic regression model. We initially evaluated the following covariates for inclusion to the multivariable model: patient age, patient sex, patient’s medical condition, reason for PICC placement, arm of PICC placement, vein of PICC placement, Charlson comorbidity index, patient on anticoagulant drug (yes/no), use of thrombolytic drug alteplase (yes/no), and duration of PICC placement. PICC line infection was not included because there were only two patients with DVT and line infection each year during 2009 and 2010 and none in 2008. The association between each covariate and the odds of DVT was assessed via single variable logistic regression, and covariates that demonstrated some association (P < .10) were entered into the multivariable mode that included PICC diameter, patient on anticoagulant drug (yes/no), use of alteplase drug (yes/no), and duration of PICC placement. Pairwise comparisons were used to evaluate whether PICC diameter was associated with DVT. All analyses were conducted using SAS, version 9.2 (SAS Institute Inc).

Cost of PICC-Associated DVT

Hospital length of stay and cost were secondary outcome measures and were determined by matching patients with PICC with DVT to patients with PICC without DVT based on sex, age (± 10 years), medical condition, reason for PICC insertion, and same year of hospitalization. Patients who had multiple PICC-associated DVTs or who also experienced a hospital-acquired infection or an adverse drug event were excluded. Control patients without DVT were sequentially selected for each patient with DVT, and each patient with DVT was matched to as many patients without DVT as possible. Patients without DVT were matched to only one patient with a DVT. Costs of hospitalization were collected from the financial database linked to the electronic medical record. The mean difference in costs and length of hospitalization were calculated for patients with DVT and matched patients. Moreover, the attributable cost was calculated by first comparing the hospital cost of each patient with DVT to the specific matched patients (Fig 1). The sums of all the differences were then divided by the number of patients with DVT with matched patients. The same method was used to calculate the attributable difference in the length of hospitalization. This quality improvement project was approved by the Intermountain Office of Research for publication (ID: 1023318).

Figure Jump LinkFigure 1. Example of method used to calculate the attributable cost and length of hospitalization due to peripherally inserted central catheter-associated DVT.Grahic Jump Location

Details of PICC team insertions during all 3 study years are found in Table 1. Although the total number of PICC team insertions declined during the study, the percent of admitted patients receiving a PICC only varied between 6.0% and 6.3%. PICC team insertion success rate remained constant at 97% during each year. An unsuccessful attempt was defined as inability of the PICC nurse to insert the PICC and subsequent patient referral to interventional radiology. Average PICC duration decreased from an average of 7.5 days in 2008 to 6.9 days in 2010, and the average length of hospitalization of patients with a PICC decreased from 14.5 days in 2008 to 12.8 days in 2010.

Table Graphic Jump Location
Table 1 —Characteristics of Patients With PICCs During 2008 Through 2010

IMC = Intermountain Medical Center; PICC = peripherally inserted central catheter; TPN = total parenteral nutrition.

a 

PICC insertion to removal or discharge.

b 

2009 compared with 2008.

c 

2010 compared with 2008.

d 

PICC could be inserted for more than one reason.

e 

Multiple differences across study years.

The use of multilumen PICCs showed a significant change during each year of the study period. Significantly fewer 6F triple-lumen PICCs (P < .0001) were used in 2009 compared with 2008, with a subsequent increase in use of single- and double-lumen PICCs. With the introduction of the 5F triple-lumen PICC in 2010, significantly more (P < .0001) triple-lumen PICCs were used compared with 2009. In 2010, we observed significantly (P < .0001) more single-lumen PICC use compared with the prior 2 years and a significant decline in double-lumen PICC use (P < .0002).

We also assessed the possibility that the smaller-gauge triple-lumen PICC adopted in 2010 may be more prone to line obstruction. Although we did not find an overall increase in alteplase use for PICC team patients over the study period, we did find a significant increase (P < .001) in the use of alteplase for patients with triple-lumen PICCs in 2010 compared with 2008 but not between 2010 and 2009 (P < .266). Moreover, we did not find PICC team or nurse documentation indicative of increased removal due to clotting.

PICC-Associated DVT

Three percent of the patients with PICCs in 2008 and 2009 experienced symptomatic PICC-associated DVT compared with 1.9% in 2010 (P < .04) (Table 2). The DVT rate was higher based on the number of lumens for 2008 and 2009, whereas the rate for the 5F triple-lumen PICC during 2010 was similar to the 5F double-lumen catheters during all 3 years (Fig 2). This, in addition to the significant (P < .0001) increase in the use of single-lumen PICCs in 2010, was likely responsible for the overall decrease in PICC-associated DVT.

Table Graphic Jump Location
Table 2 —Characteristics of Patients With PICC-Associated DVT During 2008 Through 2010

Data are shown as No. (%) unless otherwise indicated. See Table 1 legend for expansion of abbreviations.

a 

P < .04.

b 

Multiple veins could be involved during the same incidence of DVT.

c 

Anticoagulation medication administered at the bedside while PICC was inserted.

Figure Jump LinkFigure 2. Rates of symptomatic DVT associated with peripherally inserted central catheter diameter. *Triple-lumen catheters were 6F in 2008 and 2009 and 5F in 2010.Grahic Jump Location

Table 3 shows the results of the pairwise comparisons made based on our multivariable regression model that controlled for a number of patient-level characteristics. The odds of PICC-associated DVT were significantly higher for double-lumen 5F compared with single-lumen 4F (OR, 2.23; 95% CI, 1.16-4.31), and the same was true for triple-lumen 6F vs single-lumen 4F (OR, 6.35; 95% CI, 2.78-14.52). DVT risk associated with triple-lumen 6F PICC was significantly higher than the risk associated with double-lumen 5F (OR, 2.83; 95% CI, 1.6-4.9). Finally, a trend toward a decrease in PICC-associated DVT among patients with the triple-lumen 5F compared with the triple-lumen 6F was observed, but the P value (P = .05) did not reach statistical significance because of the relatively small number of triple-lumen PICCs.

Table Graphic Jump Location
Table 3 —ORs for DVT Associated With PICC Diameter

The following covariates were included in the multivariable regression models: PICC diameter, patient on anticoagulant drug (yes/no), use of alteplase drug (yes/no), and duration of PICC placement. See Table 1 legend for expansion of abbreviation.

In an earlier study,19 we found having a previous DVT and surgery lasting > 1 h were also risk factors in addition to increased PICC diameter. We did not find any difference in either of these two risk factors among patients with PICCs during the 3 study years that could be associated with a reduced DVT rate in 2010. Likewise, patients with PICCs in 2010 did not receive more anticoagulation medication during PICC insertion than during the two previous years.

Cost of PICC-Associated DVT

The average length and cost of hospitalization for inpatients at IMC during the study were 4.2 days and $11,249. Patients with PICC and DVT were admitted for an average of 25.3 days compared with 12.1 days for matched patients with PICC without DVT. Likewise, the average cost of hospitalization was higher for all patients with PICC and DVT ($84,221 vs $42,100). Of the 153 PICC-associated DVTs during the 3-year study period, there were 143 unique patients with only one DVT. Of those, 64 (44%) also had hospital-acquired infections, and three experienced an adverse drug event. Of the remaining 78 with DVT, we were able to match from one to 56 patients with PICC without a DVT to 72 (92%) patients with DVT. The average difference in length and cost of hospitalization was higher for the matched patients with DVT by 3.5 days and $19,993. We found the attributable increase in length of hospitalization to be 4.6 days and the attributable cost of PICC-associated DVT to be $15,973.

PICC-associated DVTs are frequent, cause considerable patient harm, and increase the cost of medical care. The objective of this study was to reduce PICC-associated DVTs. We observed a significant decrease (3.0% vs 1.9%; P < .04) in PICC-associated DVTs following an increased use of smaller-diameter PICCs. We noted that DVT associated with 5F triple-lumen catheters was lower than the 6F triple- and similar to 5F double-lumen catheters. However, our findings suggest that the use of significantly (P < .0001) more single-lumen PICCs in 2010 than 2008 and 2009 was a major contributor to the decrease in PICC-associated DVTs.

By the third quarter of 2009, PICC team education concerning our previous study,19 which showed an increased DVT risk with larger PICC, was widely communicated to physicians and midlevel providers. Physician awareness and increased PICC team involvement in decision making are the only changes we can identify to explain the trend to use fewer lumen (smaller diameter) catheters in 2009 and especially in 2010. Moreover, with the introduction of a new 5F triple-lumen PICC in 2010, the use of 5F triple-lumen PICC more than doubled over 2009 without an increased DVT rate. Double- and triple-lumen PICCs are often needed to meet the needs of critically ill patients and decrease the need for multiple vascular access devices.4 In our previous study, we found that vascular studies were ordered based on clinical manifestations of DVT and not PICC size.19 Moreover, physicians’ clinical suspicion of thrombosis would have manifest as more vascular studies for multilumen PICCs in 2010 and increased the rate of DVT. We, therefore, do not think the reduction in DVTs can be attributed to ascertainment bias or Hawthorne effect.

Other factors that could mitigate the risk of DVT from PICCs were stable over the period of this study. The use of ultrasound during PICC insertion has been shown to significantly reduce DVT22,23 and was used during all 3 study years. Likewise, some studies report that patients with PICCs who received anticoagulants had significantly fewer DVTs.24 We were not able to detect an increase in anticoagulant use during 2010.

In contrast to other studies,16 PICC use declined over the 3-year study period (Table 1). This resulted from fewer admissions because of the opening of a new Intermountain Healthcare hospital 14 miles away in the fourth quarter of 2009. However, the PICC rate per admission remained stable (6.2, 6.0, 6.3) (Table 1).

Although the DVT rate for the triple-lumen 6F PICC use in one study was found to be unacceptably high,9 we observed no significant differences in DVT between 5F triple lumen and 5F double lumen. There was no PICC team documentation in 2010 stating that any of the 5F triple-lumen PICCs were removed due to clotting or damage, and fewer patients needed multiple PICC as replacements during 2010. This suggests that the new 5F triple-lumen PICCs were not more prone to dysfunction compared with the 6F triple-lumen catheters, arguing that the decrease in DVT risk is not counterbalanced by an increased need for catheter replacement. We did find a significant (P < .001) increase in alteplase use in patients with the 5F triple-lumen PICC in 2010. The PICC team found that, because of the smaller gauges in the new 5F triple-lumen PICC, nurses felt more resistance when pushing fluids, causing them to think the line was starting to clot, and some nurses used more alteplase.

Hospitals continue to improve methods of PICC insertion, nurse education, and documentation.2527 Some report that improvement opportunities still exist to enhance nurse education surrounding PICC use.3 The prevention of DVT has been a primary goal of our PICC team since 2007. The reduction of PICC-associated DVT in 2010 seems to be the result of increased insertion education and training, persistent DVT surveillance and reporting, and influence regarding judicious PICC diameter selection. PICC selection should be based on safety, cost-effectiveness, ability to withstand increasing fluid volumes, durability, and low complication rates. Our findings suggest that clinicians should select the smallest-diameter PICC necessary for the patient’s care.

Limitations

Since patients at IMC could be from a four-state area, we were only able to reliably monitor PICC-associated DVT until day of discharge. Four percent more patients had their PICC in place up to the day of discharge in 2010 compared with 2008 and 2009. We hypothesize this was due to the shorter length of hospitalization in 2010. Although there is a chance that we may have failed to identify some PICC-associated DVTs in 2010 compared with 2008 and 2009, a search of International Classification of Diseases, 9th Revision codes for upper extremity DVT for 90 days after PICC insertion identified only four additional DVTs in 2010 compared with five in 2008 and six in 2009. In addition, we only reported symptomatic DVTs.

As shown in Table 1, the reason for PICC insertions and patient medical condition varied during the 3 study years. Although neither of these two variables was found to be risk factors for DVT in our previous study19 or the multivariable model in this study, the generalizability of our results needs to be validated at other hospitals.

A significant increase in the use of single-lumen and smaller 5F triple-lumen PICCs was associated with a significant decrease in PICC-associated DVT. PICC-associated DVT also increases the cost and length of hospitalization.

Author contributions: Dr Evans and Mr Lloyd had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Evans: contributed to the conception and design of the study, data acquisition, analysis and interpretation of data, and drafting the submitted article.

Ms Sharp: contributed to the conception and design of the study, data acquisition, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Ms Linford: contributed to the conception and design of the study, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version

Mr Lloyd: contributed to the conception and design of the study, data acquisition, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version

Dr Woller: contributed to analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Dr Stevens: contributed to analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Dr Elliott: contributed to analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Dr Tripp: contributed to data acquisition, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Dr Jones: contributed to data acquisition, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Dr Weaver: contributed to the conception and design of the study, analysis and interpretation of data, revising the article critically for important intellectual content, and approving the final version.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Elliott has received compensation from Bristol-Myers Squibb for his service on a data safety monitoring board for Apixaban. Drs Evans, Woller, Stevens, Tripp, Jones, and Weaver, Mss Sharp and Linford, and Mr Lloyd have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Other contributions: This work was performed at Intermountain Medical Center.

CVC

central venous catheter

IMC

Intermountain Medical Center

PICC

peripherally inserted central catheter

Periard D, Monney P, Waeber G, et al. Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy. J Thromb Haemost. 2008;6(8):1281-1288. [CrossRef] [PubMed]
 
Dubois J, Rypens F, Garel L, David M, Lacroix J, Gauvin F. Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents. CMAJ. 2007;177(10):1185-1190. [CrossRef] [PubMed]
 
Roslien J, Alcock L. The effect of an educational intervention on the RN’s peripherally inserted central catheters knowledge, confidence, and psychomotor skill. J Nurses Staff Dev. 2009;25(3):E19-E27. [CrossRef] [PubMed]
 
Nicholson J. Development of an ultrasound-guided PICC insertion service. Br J Nurs. 2010;19(10):S9-S17. [PubMed]
 
Akers AS, Chelluri L. Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist?. J Hosp Med. 2009;4(6):E1-E4. [CrossRef] [PubMed]
 
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Figures

Figure Jump LinkFigure 1. Example of method used to calculate the attributable cost and length of hospitalization due to peripherally inserted central catheter-associated DVT.Grahic Jump Location
Figure Jump LinkFigure 2. Rates of symptomatic DVT associated with peripherally inserted central catheter diameter. *Triple-lumen catheters were 6F in 2008 and 2009 and 5F in 2010.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Characteristics of Patients With PICCs During 2008 Through 2010

IMC = Intermountain Medical Center; PICC = peripherally inserted central catheter; TPN = total parenteral nutrition.

a 

PICC insertion to removal or discharge.

b 

2009 compared with 2008.

c 

2010 compared with 2008.

d 

PICC could be inserted for more than one reason.

e 

Multiple differences across study years.

Table Graphic Jump Location
Table 2 —Characteristics of Patients With PICC-Associated DVT During 2008 Through 2010

Data are shown as No. (%) unless otherwise indicated. See Table 1 legend for expansion of abbreviations.

a 

P < .04.

b 

Multiple veins could be involved during the same incidence of DVT.

c 

Anticoagulation medication administered at the bedside while PICC was inserted.

Table Graphic Jump Location
Table 3 —ORs for DVT Associated With PICC Diameter

The following covariates were included in the multivariable regression models: PICC diameter, patient on anticoagulant drug (yes/no), use of alteplase drug (yes/no), and duration of PICC placement. See Table 1 legend for expansion of abbreviation.

References

Periard D, Monney P, Waeber G, et al. Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy. J Thromb Haemost. 2008;6(8):1281-1288. [CrossRef] [PubMed]
 
Dubois J, Rypens F, Garel L, David M, Lacroix J, Gauvin F. Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents. CMAJ. 2007;177(10):1185-1190. [CrossRef] [PubMed]
 
Roslien J, Alcock L. The effect of an educational intervention on the RN’s peripherally inserted central catheters knowledge, confidence, and psychomotor skill. J Nurses Staff Dev. 2009;25(3):E19-E27. [CrossRef] [PubMed]
 
Nicholson J. Development of an ultrasound-guided PICC insertion service. Br J Nurs. 2010;19(10):S9-S17. [PubMed]
 
Akers AS, Chelluri L. Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist?. J Hosp Med. 2009;4(6):E1-E4. [CrossRef] [PubMed]
 
Yamada R, Morita T, Yashiro E, et al. Patient-reported usefulness of peripherally inserted central venous catheters in terminally ill cancer patients. J Pain Symptom Manage. 2010;40(1):60-66. [CrossRef] [PubMed]
 
Trerotola SO, Stavropoulos SW, Mondschein JI, et al. Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology. 2010;256(1):312-320. [CrossRef] [PubMed]
 
Di Giacomo M. Comparison of three peripherally-inserted central catheters: pilot study. Br J Nurs. 2009;18(1):8-16. [PubMed]
 
Gebhard RE, Szmuk P, Pivalizza EG, Melnikov V, Vogt C, Warters RD. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg. 2007;104(1):65-70. [CrossRef] [PubMed]
 
Turcotte S, Dubé S, Beauchamp G. Peripherally inserted central venous catheters are not superior to central venous catheters in the acute care of surgical patients on the ward. World J Surg. 2006;30(8):1605-1619. [CrossRef] [PubMed]
 
Santolucito JB. The role of peripherally inserted central catheters in the treatment of the critically-ill. JAVA. 2007;12(4):208-217. [CrossRef]
 
Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high-risk short-term central venous catheters. Am J Infect Control. 2010;38(2):149-153. [CrossRef] [PubMed]
 
Seeley MA, Santiago M, Shott S. Prediction tool for thrombi associated with peripherally inserted central catheters. J Infus Nurs. 2007;30(5):280-286. [CrossRef] [PubMed]
 
Worth LJ, Seymour JF, Slavin MA. Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices. Support Care Cancer. 2009;17(7):811-818. [CrossRef] [PubMed]
 
Bonizzoli M, Batacchi S, Cianchi G, et al. Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients. Intensive Care Med. 2011;37(2):284-289. [CrossRef] [PubMed]
 
Saber W, Moua T, Williams EC, et al. Risk factors for catheter-related thrombosis (CRT) in cancer patients: a patient-level data (IPD) meta-analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312-319. [CrossRef] [PubMed]
 
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Burns KE, McLaren A. Catheter-related right atrial thrombus and pulmonary embolism: a case report and systematic review of the literature. Can Respir J. 2009;16(5):163-165. [PubMed]
 
Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic deep venous thrombosis associated with peripherally inserted central catheters. Chest. 2010;138(4):803-810. [CrossRef] [PubMed]
 
Evans RS, Linford LH, Sharp JH, White G, Lloyd JF, Weaver LK. Computer identification of symptomatic deep venous thrombosis associated with peripherally inserted central catheters. AMIA Annu Symp Proc. 2007;2007:266-230.
 
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Stokowski G, Steele D, Wilson D. The use of ultrasound to improve practice and reduce complication rates in peripherally inserted central catheter insertions: final report of investigation. J Infus Nurs. 2009;32(3):145-155. [CrossRef] [PubMed]
 
Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP. A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Crit Care Med. 2009;37(4):1217-1221. [CrossRef] [PubMed]
 
Paauw JD, Borders H, Ingalls N, et al. The incidence of PICC line-associated thrombosis with and without the use of prophylactic anticoagulants. JPEN J Parenter Enteral Nutr. 2008;32(4):443-447. [CrossRef] [PubMed]
 
Leung TK, Lee CM, Tai CJ, Liang YL, Lin CC. A retrospective study on the long-term placement of peripherally inserted central catheters and the importance of nursing care and education. Cancer Nurs. 2011;34(1):E25-E30. [CrossRef] [PubMed]
 
Tian G, Zhu Y, Qi L, Guo F, Xu H. Efficacy of multifaceted interventions in reducing complications of peripherally inserted central catheter in adult oncology patients. Support Care Cancer. 2010;18(10):1293-1298. [CrossRef] [PubMed]
 
Andreatta P, Chen Y, Marsh M, Cho K. Simulation-based training improves applied clinical placement of ultrasound-guided PICCs. Support Care Cancer. 2011;19(4):539-543. [CrossRef] [PubMed]
 
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