Journal of Pediatric Nursing (2014) xx, xxx–xxx
Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support1,2,3,4,5 Maeve Giangregorio BSN, RN, CPN ⁎, Sandra Mott PhD, RN-BC, CPN, Elizabeth Tong MSN, RN, CPNP, Sonia Handa MPH, Kimberlee Gauvreau ScD, Jean Anne Connor PhD, RN, CPNP Boston Children's Hospital, Boston, MA
Key words: Peripherally inserted central catheter; Pediatric; Heart failure; Cardiac; Inotrope; Inotropic infusion; Heparin
The study aim was to evaluate present practice of maintaining PICC line patency in pediatric heart failure patients receiving continuous inotropes by comparing one cohort receiving low dose continuous heparin with one receiving no heparin. A case control retrospective chart review compared the two cohorts on duration of patency (measured in days) and need for thrombolytic agents. Median duration of patency for the heparin group was 24 days versus 16 days for the no heparin group (p = 0.07). Use of thrombolytic agents was 28% in the heparin group compared to 50% in the no heparin group (p = 0.08). Although not statistically significant, findings were clinically significant and supportive of current practice. © 2013 Elsevier Inc. All rights reserved.
Background Pediatric heart failure patients with deteriorating status and life expectancy less than a year are hospitalized for 1
Extramural Funding: None. Commercial Financial Support: None. 3 Poster Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2011, October). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Poster Session presented at the 16th Annual Update on Pediatric and Congenital Cardiovascular Disease, Orlando, FL. 4 Poster Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2012, December). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Poster Session presented at the Pediatric Cardiac Intensive Care Society, Miami, FL. 5 Podium Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2012, February). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Podium Presentation at the 2011 Northeast Pediatric Cardiology Nurses Association Conference, Boston, MA. ⁎ Corresponding author: Maeve Giangregorio BSN, RN, CPN. E-mail address: [email protected]. 2
0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2013.12.002
continuous inotopic infusion while awaiting cardiac transplant. The vesicant properties of inotropes require administration by way of a central venous access device. Peripherally inserted central catheters (PICC) are a specific type of central venous access that are inserted into particular peripheral veins and threaded into the central venous circulation. PICC lines are not as restrictive as other central lines and therefore commonly used in pediatric heart failure patients. Inotropes are drugs that improve the strength of contraction in heart muscle. Therefore, maintaining a continuous infusion of inotropes is life-sustaining therapy. Since the length of time a heart failure patient may require inotropic support varies greatly between patients and ultimately is unknown due to the nature of organ donation, maintaining PICC line patency is crucial. Central venous access is an essential tool in modern day healthcare for administering vital infusions such as total parenteral nutrition (TPN), medications including chemotherapy, vesicants, and long-term antibiotics as well as for gathering treatment-related intracardiac data (Beheshti, 2011; Griffiths & Philpot, 2002; Ryder, 1993). PICC lines provide a reliable IV site for children who have a known
2 history of difficult IV access, require frequent blood draws or need long-term intravenous therapy. The use of PICC lines in pediatric patients escalated in the early 1990s (Gabriel, 1994; Goodwin & Carlson, 1993; Mauro, 1998; Ryder, 1993). In 2010, almost 15 million central venous access cases of all types were performed (Beheshti, 2011). The history of central venous IV therapy can be referenced back to hundreds of years ago, but the evolution of modern day central venous access is less than 100 years old. In 1929, Werner Forssmann, MD, documented the first peripherally inserted line into an intracardiac position (Sette, Dorizzi, & Azzini, 2012). The 1940s showed refinement of techniques that facilitated cardiovascular research (Beheshti, 2011). Central venous access by way of the subclavian vein was perfected by 1950. By 1968, the first internal jugular line was documented and used for central venous pressure (CVP) monitoring, which is an important element of cardiovascular management (Beheshti, 2011; Griffiths & Philpot, 2002; Ryder, 1993). In 1970 the concept of tunneled catheters was introduced (Beheshti, 2011; Ryder, 1993). With these essential concepts and techniques in place, the use of central venous access gained widespread acceptance and use. Since the beginning of the 21st century, the number of published articles describing PICC line use, management and complications has increased dramatically, thus reflecting the general acceptance and use of this particular type of central line (Westergaard, Classen, & Walther-Larsen, 2013). Better quality catheter construction, advanced insertion techniques, and less incidence of serious complications associated with PICC lines all contributed to the steady increased use of PICC lines since 1980 (Goodwin & Carlson, 1993; Westergaard et al., 2013). In addition, PICC line insertion generally is performed with light or no sedation and with little risk of procedural complications (Westergaard et al., 2013). PICC lines also allow a patient to be mobile and provide the opportunity to complete IV treatment outside of the hospital setting making them a safe and valuable home care option (Westergaard et al., 2013). Although complications such as infection and occlusion still exist with PICC lines, their occurrence is not greater than with other central lines, and typically they are more easily rectified with fibinolytics and antibiotic locks (Griffiths & Philpot, 2002; Westergaard et al., 2013). Catheter occlusion is one of the most frequently documented complications of PICC line management, and rates can be as high as 36% of lines (Kerner, Garcia-Careaga, Fisher, & Poole, 2006). Catheter occlusion is described as a blockage resulting in the loss of patency for infusion and/or the loss of a blood return in the PICC line (Buswell & Beyea, 1998). Complications other than occlusion include, but are not limited to: cardiac arrhythmia, cardiac tamponade, catheter related thrombosis, and catheter related infection (Barrier, Williams, Connelly, & Creech, 2012; Feehery, Allen, & Bey, 2003; Hadaway, 1990; Masoorli, 1997; Richardson & Bruso, 1993; Ryder, 1995; Vesely, Stranz, Masoorli, & Hadaway, 2002; Wickham, 1990).
M. Giangregorio et al.
Clinical Issue and Practice Prior to 1990, at a northeast pediatric institution, heart failure patients who remained hospitalized while awaiting heart transplant were managed in the cardiac intensive care unit (CICU). Maintaining a continuous infusion of inotropes to these patients was the most important element of their care as the cardiac function of these heart failure patients was very poor. Without the continuous infusion of inotropes, their low cardiac output causes life-threatening symptoms associated with cardiogenic shock. Management in the CICU was necessary based on their dependence on invasive central lines for medication delivery and central venous pressure (CVP) monitoring; both of which require intensive nursing supervision. Since inotropes had to be administered into a central vein due to their vesicant properties, peripheral access was not an option unless used as a short-term bridge in therapy. By the early 1990s the successful placement and use of PICC lines permitted the care of pediatric heart failure patients on the inpatient cardiac unit. PICC lines offered reliable delivery of inotropes, the ability to monitor CVP, and required less intensive monitoring by nurses. As the number of heart failure patients managed on the inpatient cardiac unit increased, practice issues related to PICC line management became more evident. The most common issues related to identifying proper flushing practices and catheter occlusion. Inotropes typically infuse at a slow continuous rate, which promotes stasis and allows catheter occlusion to occur more easily. Low flow states are described in the literature as a contributing factor to catheter occlusion (Krafte-Jacobs, Sivit, Mejia, & Pollack, 1995). The retrograde back up of stagnate blood into lines is also a major contributor to occlusion making adequate flushing crucial to maintaining line patency (Krafte-Jacobs et al., 1995). The standard of PICC line care at our institution includes routine intermittent manual flushes with low dose heparin to maintain line patency. This practice is based on line maintenance recommendations from the official professional organization (Infusion Nurses Society, 2000, 2006, 2011). However, manually flushing a PICC line that is delivering an inotropic infusion generates a bolus of inotropic medication to the heart failure patient. A bolus of inotropes can cause symptomatic tachycardia, hypotension, diaphoresis and dizziness. Prolonged presence of these symptoms required examination by a physician and increased monitoring by nursing staff until symptoms resolved. Due to the frequent and often severe symptoms experienced by the heart failure patients receiving inotropes through a PICC line following the manual flushing of their line, the practice was discontinued. Subsequently the incidence of PICC line occlusions increased. When antithrombolytics did not restore patency to a PICC line, a new PICC line had to be placed as maintaining the infusion of inotropes was essential. As the perceived incidence of complications grew, clinicians sought to change practice. After many failed strategies, the use of continuous low dose heparin (heparin
Management of PICC in Pediatric Heart Failure Patients
3
1unit/ml in NS or dextrose 5% @ 1–2 ml/hour) bifused through the same lumen as the inotrope became the standard PICC line management strategy for pediatric heart failure patients. Although not specifically referenced in the literature for this unique population, the use of continuous low dose heparin as a basic method of line management had been explored (Flint, McIntosh, & Davies, 2005; Isemann, Sorrels, & Akinbi, 2012; Jonker, Osterby, Vermeulen, Kleppin, & Kudsk, 2010; Kalyn, Blatz, & Pinelli, 2000; Shah & Shah, 2008; Shah et al., 2007). A similar practice had also been well accepted in the management of arterial lines (Whitta, Hall, Bennetts, Welman, & Rawlins, 2006). As our nursing clinicians promoted the use of continuous low dose heparin bifused with inotropes, they observed that there were fewer clotted PICC lines. The improved clinical outcomes therefore enhanced the overall support of the practice change in our program. The need to support our practice change with evidence and data was the goal of our study.
continuous infusions without compromising catheter patency in neonates. Conversely, Shah et al. (2007) conducted a multicenter randomized controlled trial of low dose heparin infusion (0.5 units/kg per hour) versus placebo with 201 neonates. Baseline demographics were similar between the two groups. Duration of catheter use was longer in the heparin group (63% vs. 42% completed therapy), and occlusion rates were also lower (6% vs. 31%) for the heparin group. Shah and colleagues conducted systematic reviews on heparin infusions in 2005 and 2008 (Shah, Ng, & Sinha, 2005; Shah & Shah, 2008). In 2011, Shah and Shah updated their systematic review for the Cochrane Collaboration regarding the use of continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters. The primary objective of this review was to assess the effectiveness of heparin for prevention of catheter related thrombosis. Secondary objectives included but were not limited to assessing the effectiveness of heparin on catheter occlusion and duration of catheter patency. Three randomized trials were identified. A total of 477 infants were included in these three trials. Findings included no statistically significant differences in the risk of catheter related thrombus but did find a reduced risk of catheter occlusion with the use of low dose heparin. Although there was no statistically significant difference in the duration of catheter patency, the authors noted a trend towards increased duration of catheter patency. The authors concluded that the use of prophylactic heparin in peripherally placed central venous catheters allows a greater number of infants to complete their therapy by reducing the incidence of catheter occlusion. The effectiveness of intermittent low dose heparin flushes in maintaining patency in a CVAD was examined by Jonker et al. (2010). The authors found a significant increase in the number of patients requiring alteplase (p = 0.04), a recombinant tissue plasminogen activator, to restore line patency in patients who did not receive intermittent low dose heparin flushes to maintain patency in their CVAD. The conclusion of this synthesis of the findings is that a standard of care for managing PICC lines does not exist. Although the use of heparin does tend to extend the duration of patency in a PICC line and decrease the occurrence of PICC line occlusions, it does not do so at a level of statistical significance. Additional questions left unanswered by these studies include the effect on line patency when various solutes, such as vesicants, lipids, and antibiotics, are added to the infusing fluid; whether findings are the same for older children as for infants.
Literature Review A comprehensive review of the literature from 1989 through 2012 was conducted. Medline and CINAHL databases were searched. Search terms included: “peripherally inserted central catheters”, “PICC”, and “heparin and catheterization, peripheral”. Thirty one original articles and two systematic reviews for the Cochrane Database were retrieved; only the articles that examined the use of heparin to maintain patency in a central venous access device (CVAD) or PICC line were used. The published work examined for this literature review included three studies that compared the use of continuous heparin to saline or placebo for prolonging the patency of PICC lines or other peripherally inserted CVAD in neonates (Isemann et al., 2012; Shah & Shah, 2008; Shah et al., 2007) and one study that examined the use of intermittent flushing compared to the use of continuous infusions to maintain line patency (Jonker et al., 2010). However, there were no published articles that focused on the management of PICC lines in pediatric heart failure patients receiving continuous inotropic infusions. Therefore, a gap in the literature exists, as there was no evidence on which to base sound practice strategies to prolong patency and limit the need for thrombolytic therapy for these and similar pediatric patients. According to Knue, Doellman, and Jacobs (2006) who surveyed 72 infusion nurses from 72 different hospitals, there was no consensus regarding the standard of care for PICC lines in pediatric patients. Patterns of care regarding PICC lines in the children were varied leaving the debate about how best to maintain patency of the line unresolved. Isemann et al. (2012) conducted a before and after comparison following the exclusion of heparin from a continuous infusion through 189 PICC lines to assess the effect of heparin in PICC lines in neonates. The authors concluded that heparin could be safely omitted from
Purpose The purpose of this study was to describe and compare the management of PICC lines in two cohorts of hospitalized
4 pediatric heart failure patients being managed on inotropes while awaiting cardiac transplant. The first cohort representing past practice received no heparin with the continuous inotropic infusion through the PICC line. The second cohort representing present practice received low dose heparin bifused with the inotrope as a continuous infusion through the PICC line. Two hypotheses were formulated to examine if present practice provides improved outcomes compared to past practice.
Hypothesis #1 Continuous low dose heparin (heparin 1 unit/ml in NS or dextrose 5% @ 1–2 ml per hour) bifused with an inotropic infusion would provide a longer duration of catheter patency. The duration of patency was measured in days. Duration of catheter patency was defined as the number of consecutive days a PICC line remained patent for continuous infusion and did not require antithrombolytics therapy.
Hypothesis #2 The use of antithrombolytics to restore line patency would be lower in the PICC lines managed with low dose continuous heparin bifused with the continuous inotropic infusion as compared to the PICC lines with no heparin added to the continuous inotropic infusion.
M. Giangregorio et al. patent for continuous inotropic infusion were recorded. Inclusion criteria for both cohorts included all available pediatric heart failure patients between the years of 2003– 2007, ages 0–21 years old, admitted to the inpatient acute cardiac unit with the expectation of being hospitalized until transplant. All eligible patients had at least one continuous inotropic infusion running through a PICC line. Continuous variables were summarized as medians and ranges, and categorical variables as frequencies with percentages. Comparisons were made either between patients receiving and not receiving heparin, or between PICC lines with and without heparin using the Wilcoxon rank sum test for continuous variables and Fisher's exact test for categorical variables. For analyses conducted at the PICC line level, two lines in the same patient were assumed to be independent. Data were collected and analyzed using SAS® software.
Results A total of 33 patients with a total of 47 PICC lines met inclusion criteria (Table 1). Age at admission ranged from less than 1 year–21 years. Gender was well balanced across the population with 18 (55%) male and 15 (45%) female. The
Table 1
Demographics. Heparin(n = 22) No heparin(n = 11) p value Median (range) Median (range)
Methods A 2:1 case control research design was chosen to provide rigor for this single site retrospective study. Prior to data collection institution review board approval was obtained. A case report form was developed by the research team to organize and standardize the data collected. Data collected were classified into a check box format. Charts were reviewed, and data were collected from the patients' medical records. Two members of the research team reviewed each chart at two different times. Two members of the research team reviewed each case report form to assess for completion of data collection. Two cohorts of pediatric heart failure patients were identified. Each cohort was taken from a different period in time. Both cohorts of patients were receiving continuous inotropic infusions through a single lumen of their PICC line. One cohort, identified as the control group, received no heparin through the PICC line lumen delivering the inotropic infusion during the time frame of 2003–2005. The second cohort, identified as the case group, received continuous low dose heparin bifused with the inotropic infusion through a single lumen of their PICC line during the years of 2005–2007. Demographic and clinical characteristics were compared without any attempt for matching between the two cohorts. Use of thrombolytic agents and the total number of days the PICC line remained
Median age (in years) Gender Male Race White Non-White Congenital disease Acquired disease Reason for admission Elective Emergent Unknown Number of PICC lines for each patient 1 2 3 4
1 (0–21)
14 (1–21)
0.0001 ⁎
n (%)
n (%)
13 (59)
5 (45)
14 (64) 8 (36) 12 (55)
9 (82) 2 (18) 3 (27)
p value 0.49 0.65 0.27
10 (45)
9 (82)
0.07 0.01 ⁎
3 (14) 14 (64) 5 (23)
7 (64) 4 (36) 0 (0)
16 (73) 5 (23) 1 (5) 0 (0)
6 (55) 4 (36) 0 (0) 1 (9)
⁎ Indicates statistical significance: p b 0.05.
0.39
Management of PICC in Pediatric Heart Failure Patients Table 2 Comparison of PICC Line Patency With and Without Continuous Heparin.
Patency duration (in consecutive days) Anti-thrombolytic intervention
Heparin (n = 29) Median (range)
No heparin (n = 18) Median (range)
p value
24 (4–93)
16 (3–49)
0.07
n (%) 8 (28)
n (%) 9 (50)
p value 0.08
population was reported as predominantly White in both cohorts. Diagnoses were also well matched between subjects born with a congenital heart defect and subjects with acquired heart disease. The level of significance was set at p b 0.05 for tests of association. In comparing the two cohorts, both age at admission and admission status (defined as elective versus emergent) were found to be significantly different. In comparing the 47 PICC lines between the two cohorts, 8 (28%) in the heparin group required antithrombolytic intervention compared to 9 (50%) in the non heparin group, p = 0.08 (Table 2). For the PICC lines in the heparin group (n = 29) the median duration of patency was 24 days (with a range of 4–93 days) compared to the PICC lines in the non heparin group (n = 18) in which the median duration of patency was 16 days (with a range of 3–49 days), p = 0.07.
Discussion It is important to maintain reliable venous access for infusing inotropes to pediatric heart failure patients because their cardiac output is not sufficient to sustain their life without the medication. The first hypothesis stated that an infusion of continuous low dose heparin bifused with the inotrope would help extend the duration of patency in a PICC line. The median number of days as well as the maximum number of days the PICC line remained patent between the two groups was greater in the heparin group; meaning that, on average, the heparin group had more sequential days of uninterrupted therapy and did not require the use of antithrombolytics to restore patency in the PICC line. This is consistent with other studies that showed a trend towards prolonging patency in central venous catheters when a low dose heparin infusion was used for line management (Isemann et al., 2012; Shah & Shah, 2008; Shah et al., 2007). Although our result for duration of patency was not statistically significant, it did show a longer period of patency when heparin was used. Prolonging catheter patency potentially reduces time without therapy during PICC line repair or replacement, and can potentially reduce the number
5 of PICC lines a patient may need while hospitalized. For heart failure patients awaiting transplant, the time a PICC line will be needed to infuse inotropes cannot be predicted, as the availability of a suitable organ is unknown. Therefore, the goal is to provide maximum duration of patency for uninterrupted administration of therapies. Legitimate arguments against the use of continuous heparin infusions exist such as compromise to vascular integrity from endothelium irritation of the vein and increasing nursing time to manage another infusion (NietoRodriguez, Garcia-Martin, Barreda-Hernandez, Hervas, & Cano-Real, 1992). However, these arguments pale in comparison to the documented requirement for life-sustaining continuous inotropic infusion for children with heart failure in order to effectively manage their disease. In evaluating the second hypothesis we found a decrease in the use of antithrombolytics to restore line patency in the group receiving continuous low dose heparin, which demonstrates a lower incidence of line occlusion. This is similar to findings from Shah et al. (2007) and Shah and Shah (2008) where the use of continuous low dose heparin resulted in fewer line occlusions. The loss of patency in a PICC line signifies a halt in therapy to patients. The preparation and instillation of antithrombolytics is both time consuming and expensive. The use of antithrombolytics also exposes the patient to an additional medication and potential dosing errors. If antithrombolytics are unsuccessful in restoring line patency, that patient must then undergo another PICC line insertion procedure. PICC line procedures are costly and likely increases distress to the patient and family. Not anticipated by either hypothesis were the statistically significant findings. Both “age at admission” and “admission status” were found to be statistically significant between the two cohorts. In the case group, the median age of the patients was 1 year of age versus the control group with a median age of 14 years (p = 0.001). The control group sample of patients was from 2003–2005 representing an earlier practice standard while the case group was from 2005–2007 representing the present standard. The evolving practice of our PICC line management mirrored many other practice changes that were occurring at the same time, so it is difficult to state one clear explanation for this difference in the ages between the two groups. Historically, all patients receiving continuous inotropes were cared for within the CICU. When the administrative decision was made to transfer these patients to the inpatient cardiac unit, clinicians initially transferred the older patients, perceiving them more suitable for transfer. Thus they became part of the no heparin cohort. It is also possible that since inotrope dosing is based on weight, the infusion rate for the younger patients was slower allowing for stasis in the line making clinicians hesitant to transfer them. This phenomenon of line stasis was also described by Krafte-Jacobs et al. (1995). As the clinician's confidence increased newborns and infants were also transferred to the inpatient setting thus accounting for
6
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the increased number of younger patients in the later established heparin cohort. In addition, as infusion nurses became more skilled with placing PICC lines in younger patients, the overall median age of patients with a PICC line also decreased. Emergent admissions accounted for 64% of the admissions in the case group compared to 36% in the control group (p = 0.01). One possible explanation for the increase in present day emergent admission is the shift in care that allows patients to stay at home until admission is absolutely necessary and, therefore, emergent. Another practice change was the discontinuation of elective admissions for periodic supportive inotropic therapy as medical and surgical advancements have provided more options for these patients. The advances in care have not only increased the survival rates of children with heart failure but also increased their need for further medical intervention. While the implications of the statistically significant results are solely descriptive data, they show that treatment and admission practices have changed so that more infants are surviving early stages of palliation and are able to be cared for at home. It also indicates that techniques, equipment and skill sets have advanced to include infants as part of our PICC population. Regardless, it is significant that currently the median age of our heart failure patients is 1 year and they are more likely to be admitted emergently than electively. Therefore, it is essential to provide high quality family/patient-centered nursing care and that includes long duration PICC line patency for infusing life-sustaining inotropes while awaiting cardiac transplant.
it is important that the PICC line remains patent and usable for the entire duration of time the patient needs it.
Limitations
Conclusion
The limitations of this study are the population size and the parallel factors related to the evolution of heart transplant management strategies. First, the population of patients awaiting cardiac transplant is a reality variable beyond human control. Inherently, this is a precise group of patients within a small population of pediatric patients; therefore, all eligible patients from 2003 through 2007 were included. Knowing that the small sample size could sway statistical analysis, the research team implemented a rigorous 2:1 case– control method to compensate for that possibility. Second, comparing clinical practices at two different points in time suggests that there could have been other changes in the management of heart failure patients that contributed to the findings. However, the changes that occur over time are not always measurable and certainly could not be controlled. It may also be beneficial for a future study to account for the number of days a PICC line remained patent compared to the total number of days the patient needed a continuous inotropic infusion. Since some patients receive their heart transplant much sooner than expected, the total number of days they need a PICC line could be very low. Nevertheless,
Controversy surrounding the use of intermittent versus continuous heparin flush has been and continues to be an active question in the literature. The differences among patients are both numerous and subtle, and any one of these differences could contribute to the various practice routines in line management. Differences may include but are not limited to age, developmental level, diagnosis, acuity, length of hospitalization and treatment plan, including the rate and type of an infusion. PICC line management practices vary widely across clinicians and institutions. However, continuity in PICC line management has the potential to improve patient outcomes. Clinicians need to share their experiences with PICC line management successes to aid in the development of data based care standards within specialized populations so that transfer and generalization to other populations may be explored. The need to establish successful PICC line management strategies that can be replicated across studies and generalized to other populations is a crucial element in providing optimal patient care realizing excellent patient outcomes in pediatric patients with PICC lines.
Clinical Implications The clinical significance of this study is to demonstrate the existence of a group of patients who do not fit into a standard PICC line management strategy that has been supported by evidence. The use of intermittent heparin flushes to maintain patency in PICC lines is a common practice across the country that also is supported by the definitive agent of infusion therapy, the Infusion Nurses Society (2000; 2006; 2011). However, there is no evidence based practice or recommendations from the Infusion Nurses Society for managing PICC lines with continuous infusions that cannot be intermittently flushed with heparin. For that reason, it is important to build and share a data driven intervention that prolongs the duration of patency and decreases the occurrence of occlusion in pediatric PICC lines that cannot be intermittently flushed with heparin so that other patients may benefit. The findings of this study showed a prolonged duration of catheter patency and a lower incidence of line occlusion when continuous low dose heparin was bifused with the medication enabling the patient to remain medically stable for an indeterminate amount of time while awaiting cardiac transplant. Therefore, our present practice of managing PICC lines in heart failure patients awaiting transplant is supported.
Management of PICC in Pediatric Heart Failure Patients
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7 Knue, M., Doellman, D., & Jacobs, B. R. (2006). Peripherally inserted central catheters in children: A survey of practice patterns. Journal of Infususion Nursing, 29, 28–33. Krafte-Jacobs, B., Sivit, C. J., Mejia, R., & Pollack, M. M. (1995). Catheterrelated thrombosis in critically ill children: Comparison of catheters with and without heparin bonding. The Journal of Pediatrics, 126, 50–54. Masoorli, S. (1997). What to do about PICC line problems. Nursing, 27, 32aaa. Mauro, M. (1998). Delayed complications of venous access. Techniques in Vascular and Interventional Radiology, 1, 158–167. Nieto-Rodriguez, J., Garcia-Martin, M., Barreda-Hernandez, M., Hervas, M., & Cano-Real, O. (1992). Heparin and infusion phlebitis: A prospective study. The Annals of Pharmacotherapy, 26, 1211–1214. Richardson, D., & Bruso, P. (1993). Vascular access devices–management of common complications. Journal of Intravenous Nursing, 16, 44–49. Ryder, M. A. (1993). Peripherally inserted central venous catheters. Nursing Clinics of North America, 28, 937–971. Ryder, M. A. (1995). Peripheral access options. Surgical Oncology Clinics of North America, 4, 395–427. Sette, P., Dorizzi, R. M., & Azzini, A. M. (2012). Vascular access: An historical perspective from Sir William Harvey to the 1956 Nobel prize to Andre F. Cournand, Werner Forssmann, and Dickinson W. Richards. Journal of Vascular Access, 13, 137–144. Shah, P. S., Kalyn, A., Satodia, P., Dunn, M. S., Parvez, B., Daneman, A., Salem, S., Glanc, P., Ohlsson, A., & Shah, V. (2007). A randomized, controlled trial of heparin versus placebo infustion to prolong the usability of peripherally placed percutaneous central venous catheters (PVCVs) in neonates: The HIP (Heparin Infusion for PVCV) study. Pediatrics, 119, e284–e291. Shah, P. S., Ng, E., & Sinha, A. K. (2005). Heparin for prolonging peripheral intravenous catheter use in neonates. Cochrane Database of Systematic Reviews http://dx.doi.org/10.1002/14651858.CD002774.pub2. Shah, P. S., & Shah, V. S. (2008). Continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters. Cochrane Database of Systematic Reviews http://dx.doi.org/10.1002/14651858.CD002772.pub3. Vesely, T., Stranz, M., Masoorli, S., & Hadaway, L. (2002). The diverse and conflicting standards and practices in infusion therapy. Journal of Vascular Access Devices, 7, 9–12. Westergaard, B., Classen, V., & Walther-Larsen, S. (2013). Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations. Acta Anaesthesiologica Scandinavica, 57, 278–287. Whitta, R. K. S., Hall, K. F. M., Bennetts, T. M., Welman, L., & Rawlins, P. (2006). Comparison of normal or heparinised saline flushing on function of arterial lines. Critical Care and Resuscitation, 8, 205–208. Wickham, R. S. (1990). Advances in venous access devices and nursing management strategies. Nursing Clinics of North America, 25, 345–364.
Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support1,2,3,4,5 Maeve Giangregorio BSN, RN, CPN ⁎, Sandra Mott PhD, RN-BC, CPN, Elizabeth Tong MSN, RN, CPNP, Sonia Handa MPH, Kimberlee Gauvreau ScD, Jean Anne Connor PhD, RN, CPNP Boston Children's Hospital, Boston, MA
Key words: Peripherally inserted central catheter; Pediatric; Heart failure; Cardiac; Inotrope; Inotropic infusion; Heparin
The study aim was to evaluate present practice of maintaining PICC line patency in pediatric heart failure patients receiving continuous inotropes by comparing one cohort receiving low dose continuous heparin with one receiving no heparin. A case control retrospective chart review compared the two cohorts on duration of patency (measured in days) and need for thrombolytic agents. Median duration of patency for the heparin group was 24 days versus 16 days for the no heparin group (p = 0.07). Use of thrombolytic agents was 28% in the heparin group compared to 50% in the no heparin group (p = 0.08). Although not statistically significant, findings were clinically significant and supportive of current practice. © 2013 Elsevier Inc. All rights reserved.
Background Pediatric heart failure patients with deteriorating status and life expectancy less than a year are hospitalized for 1
Extramural Funding: None. Commercial Financial Support: None. 3 Poster Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2011, October). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Poster Session presented at the 16th Annual Update on Pediatric and Congenital Cardiovascular Disease, Orlando, FL. 4 Poster Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2012, December). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Poster Session presented at the Pediatric Cardiac Intensive Care Society, Miami, FL. 5 Podium Presentation: Giangregorio, M., Tong, E., Handa, S., Gauvreau, K., Connor. J. (2012, February). Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support. Podium Presentation at the 2011 Northeast Pediatric Cardiology Nurses Association Conference, Boston, MA. ⁎ Corresponding author: Maeve Giangregorio BSN, RN, CPN. E-mail address: [email protected]. 2
0882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2013.12.002
continuous inotopic infusion while awaiting cardiac transplant. The vesicant properties of inotropes require administration by way of a central venous access device. Peripherally inserted central catheters (PICC) are a specific type of central venous access that are inserted into particular peripheral veins and threaded into the central venous circulation. PICC lines are not as restrictive as other central lines and therefore commonly used in pediatric heart failure patients. Inotropes are drugs that improve the strength of contraction in heart muscle. Therefore, maintaining a continuous infusion of inotropes is life-sustaining therapy. Since the length of time a heart failure patient may require inotropic support varies greatly between patients and ultimately is unknown due to the nature of organ donation, maintaining PICC line patency is crucial. Central venous access is an essential tool in modern day healthcare for administering vital infusions such as total parenteral nutrition (TPN), medications including chemotherapy, vesicants, and long-term antibiotics as well as for gathering treatment-related intracardiac data (Beheshti, 2011; Griffiths & Philpot, 2002; Ryder, 1993). PICC lines provide a reliable IV site for children who have a known
2 history of difficult IV access, require frequent blood draws or need long-term intravenous therapy. The use of PICC lines in pediatric patients escalated in the early 1990s (Gabriel, 1994; Goodwin & Carlson, 1993; Mauro, 1998; Ryder, 1993). In 2010, almost 15 million central venous access cases of all types were performed (Beheshti, 2011). The history of central venous IV therapy can be referenced back to hundreds of years ago, but the evolution of modern day central venous access is less than 100 years old. In 1929, Werner Forssmann, MD, documented the first peripherally inserted line into an intracardiac position (Sette, Dorizzi, & Azzini, 2012). The 1940s showed refinement of techniques that facilitated cardiovascular research (Beheshti, 2011). Central venous access by way of the subclavian vein was perfected by 1950. By 1968, the first internal jugular line was documented and used for central venous pressure (CVP) monitoring, which is an important element of cardiovascular management (Beheshti, 2011; Griffiths & Philpot, 2002; Ryder, 1993). In 1970 the concept of tunneled catheters was introduced (Beheshti, 2011; Ryder, 1993). With these essential concepts and techniques in place, the use of central venous access gained widespread acceptance and use. Since the beginning of the 21st century, the number of published articles describing PICC line use, management and complications has increased dramatically, thus reflecting the general acceptance and use of this particular type of central line (Westergaard, Classen, & Walther-Larsen, 2013). Better quality catheter construction, advanced insertion techniques, and less incidence of serious complications associated with PICC lines all contributed to the steady increased use of PICC lines since 1980 (Goodwin & Carlson, 1993; Westergaard et al., 2013). In addition, PICC line insertion generally is performed with light or no sedation and with little risk of procedural complications (Westergaard et al., 2013). PICC lines also allow a patient to be mobile and provide the opportunity to complete IV treatment outside of the hospital setting making them a safe and valuable home care option (Westergaard et al., 2013). Although complications such as infection and occlusion still exist with PICC lines, their occurrence is not greater than with other central lines, and typically they are more easily rectified with fibinolytics and antibiotic locks (Griffiths & Philpot, 2002; Westergaard et al., 2013). Catheter occlusion is one of the most frequently documented complications of PICC line management, and rates can be as high as 36% of lines (Kerner, Garcia-Careaga, Fisher, & Poole, 2006). Catheter occlusion is described as a blockage resulting in the loss of patency for infusion and/or the loss of a blood return in the PICC line (Buswell & Beyea, 1998). Complications other than occlusion include, but are not limited to: cardiac arrhythmia, cardiac tamponade, catheter related thrombosis, and catheter related infection (Barrier, Williams, Connelly, & Creech, 2012; Feehery, Allen, & Bey, 2003; Hadaway, 1990; Masoorli, 1997; Richardson & Bruso, 1993; Ryder, 1995; Vesely, Stranz, Masoorli, & Hadaway, 2002; Wickham, 1990).
M. Giangregorio et al.
Clinical Issue and Practice Prior to 1990, at a northeast pediatric institution, heart failure patients who remained hospitalized while awaiting heart transplant were managed in the cardiac intensive care unit (CICU). Maintaining a continuous infusion of inotropes to these patients was the most important element of their care as the cardiac function of these heart failure patients was very poor. Without the continuous infusion of inotropes, their low cardiac output causes life-threatening symptoms associated with cardiogenic shock. Management in the CICU was necessary based on their dependence on invasive central lines for medication delivery and central venous pressure (CVP) monitoring; both of which require intensive nursing supervision. Since inotropes had to be administered into a central vein due to their vesicant properties, peripheral access was not an option unless used as a short-term bridge in therapy. By the early 1990s the successful placement and use of PICC lines permitted the care of pediatric heart failure patients on the inpatient cardiac unit. PICC lines offered reliable delivery of inotropes, the ability to monitor CVP, and required less intensive monitoring by nurses. As the number of heart failure patients managed on the inpatient cardiac unit increased, practice issues related to PICC line management became more evident. The most common issues related to identifying proper flushing practices and catheter occlusion. Inotropes typically infuse at a slow continuous rate, which promotes stasis and allows catheter occlusion to occur more easily. Low flow states are described in the literature as a contributing factor to catheter occlusion (Krafte-Jacobs, Sivit, Mejia, & Pollack, 1995). The retrograde back up of stagnate blood into lines is also a major contributor to occlusion making adequate flushing crucial to maintaining line patency (Krafte-Jacobs et al., 1995). The standard of PICC line care at our institution includes routine intermittent manual flushes with low dose heparin to maintain line patency. This practice is based on line maintenance recommendations from the official professional organization (Infusion Nurses Society, 2000, 2006, 2011). However, manually flushing a PICC line that is delivering an inotropic infusion generates a bolus of inotropic medication to the heart failure patient. A bolus of inotropes can cause symptomatic tachycardia, hypotension, diaphoresis and dizziness. Prolonged presence of these symptoms required examination by a physician and increased monitoring by nursing staff until symptoms resolved. Due to the frequent and often severe symptoms experienced by the heart failure patients receiving inotropes through a PICC line following the manual flushing of their line, the practice was discontinued. Subsequently the incidence of PICC line occlusions increased. When antithrombolytics did not restore patency to a PICC line, a new PICC line had to be placed as maintaining the infusion of inotropes was essential. As the perceived incidence of complications grew, clinicians sought to change practice. After many failed strategies, the use of continuous low dose heparin (heparin
Management of PICC in Pediatric Heart Failure Patients
3
1unit/ml in NS or dextrose 5% @ 1–2 ml/hour) bifused through the same lumen as the inotrope became the standard PICC line management strategy for pediatric heart failure patients. Although not specifically referenced in the literature for this unique population, the use of continuous low dose heparin as a basic method of line management had been explored (Flint, McIntosh, & Davies, 2005; Isemann, Sorrels, & Akinbi, 2012; Jonker, Osterby, Vermeulen, Kleppin, & Kudsk, 2010; Kalyn, Blatz, & Pinelli, 2000; Shah & Shah, 2008; Shah et al., 2007). A similar practice had also been well accepted in the management of arterial lines (Whitta, Hall, Bennetts, Welman, & Rawlins, 2006). As our nursing clinicians promoted the use of continuous low dose heparin bifused with inotropes, they observed that there were fewer clotted PICC lines. The improved clinical outcomes therefore enhanced the overall support of the practice change in our program. The need to support our practice change with evidence and data was the goal of our study.
continuous infusions without compromising catheter patency in neonates. Conversely, Shah et al. (2007) conducted a multicenter randomized controlled trial of low dose heparin infusion (0.5 units/kg per hour) versus placebo with 201 neonates. Baseline demographics were similar between the two groups. Duration of catheter use was longer in the heparin group (63% vs. 42% completed therapy), and occlusion rates were also lower (6% vs. 31%) for the heparin group. Shah and colleagues conducted systematic reviews on heparin infusions in 2005 and 2008 (Shah, Ng, & Sinha, 2005; Shah & Shah, 2008). In 2011, Shah and Shah updated their systematic review for the Cochrane Collaboration regarding the use of continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters. The primary objective of this review was to assess the effectiveness of heparin for prevention of catheter related thrombosis. Secondary objectives included but were not limited to assessing the effectiveness of heparin on catheter occlusion and duration of catheter patency. Three randomized trials were identified. A total of 477 infants were included in these three trials. Findings included no statistically significant differences in the risk of catheter related thrombus but did find a reduced risk of catheter occlusion with the use of low dose heparin. Although there was no statistically significant difference in the duration of catheter patency, the authors noted a trend towards increased duration of catheter patency. The authors concluded that the use of prophylactic heparin in peripherally placed central venous catheters allows a greater number of infants to complete their therapy by reducing the incidence of catheter occlusion. The effectiveness of intermittent low dose heparin flushes in maintaining patency in a CVAD was examined by Jonker et al. (2010). The authors found a significant increase in the number of patients requiring alteplase (p = 0.04), a recombinant tissue plasminogen activator, to restore line patency in patients who did not receive intermittent low dose heparin flushes to maintain patency in their CVAD. The conclusion of this synthesis of the findings is that a standard of care for managing PICC lines does not exist. Although the use of heparin does tend to extend the duration of patency in a PICC line and decrease the occurrence of PICC line occlusions, it does not do so at a level of statistical significance. Additional questions left unanswered by these studies include the effect on line patency when various solutes, such as vesicants, lipids, and antibiotics, are added to the infusing fluid; whether findings are the same for older children as for infants.
Literature Review A comprehensive review of the literature from 1989 through 2012 was conducted. Medline and CINAHL databases were searched. Search terms included: “peripherally inserted central catheters”, “PICC”, and “heparin and catheterization, peripheral”. Thirty one original articles and two systematic reviews for the Cochrane Database were retrieved; only the articles that examined the use of heparin to maintain patency in a central venous access device (CVAD) or PICC line were used. The published work examined for this literature review included three studies that compared the use of continuous heparin to saline or placebo for prolonging the patency of PICC lines or other peripherally inserted CVAD in neonates (Isemann et al., 2012; Shah & Shah, 2008; Shah et al., 2007) and one study that examined the use of intermittent flushing compared to the use of continuous infusions to maintain line patency (Jonker et al., 2010). However, there were no published articles that focused on the management of PICC lines in pediatric heart failure patients receiving continuous inotropic infusions. Therefore, a gap in the literature exists, as there was no evidence on which to base sound practice strategies to prolong patency and limit the need for thrombolytic therapy for these and similar pediatric patients. According to Knue, Doellman, and Jacobs (2006) who surveyed 72 infusion nurses from 72 different hospitals, there was no consensus regarding the standard of care for PICC lines in pediatric patients. Patterns of care regarding PICC lines in the children were varied leaving the debate about how best to maintain patency of the line unresolved. Isemann et al. (2012) conducted a before and after comparison following the exclusion of heparin from a continuous infusion through 189 PICC lines to assess the effect of heparin in PICC lines in neonates. The authors concluded that heparin could be safely omitted from
Purpose The purpose of this study was to describe and compare the management of PICC lines in two cohorts of hospitalized
4 pediatric heart failure patients being managed on inotropes while awaiting cardiac transplant. The first cohort representing past practice received no heparin with the continuous inotropic infusion through the PICC line. The second cohort representing present practice received low dose heparin bifused with the inotrope as a continuous infusion through the PICC line. Two hypotheses were formulated to examine if present practice provides improved outcomes compared to past practice.
Hypothesis #1 Continuous low dose heparin (heparin 1 unit/ml in NS or dextrose 5% @ 1–2 ml per hour) bifused with an inotropic infusion would provide a longer duration of catheter patency. The duration of patency was measured in days. Duration of catheter patency was defined as the number of consecutive days a PICC line remained patent for continuous infusion and did not require antithrombolytics therapy.
Hypothesis #2 The use of antithrombolytics to restore line patency would be lower in the PICC lines managed with low dose continuous heparin bifused with the continuous inotropic infusion as compared to the PICC lines with no heparin added to the continuous inotropic infusion.
M. Giangregorio et al. patent for continuous inotropic infusion were recorded. Inclusion criteria for both cohorts included all available pediatric heart failure patients between the years of 2003– 2007, ages 0–21 years old, admitted to the inpatient acute cardiac unit with the expectation of being hospitalized until transplant. All eligible patients had at least one continuous inotropic infusion running through a PICC line. Continuous variables were summarized as medians and ranges, and categorical variables as frequencies with percentages. Comparisons were made either between patients receiving and not receiving heparin, or between PICC lines with and without heparin using the Wilcoxon rank sum test for continuous variables and Fisher's exact test for categorical variables. For analyses conducted at the PICC line level, two lines in the same patient were assumed to be independent. Data were collected and analyzed using SAS® software.
Results A total of 33 patients with a total of 47 PICC lines met inclusion criteria (Table 1). Age at admission ranged from less than 1 year–21 years. Gender was well balanced across the population with 18 (55%) male and 15 (45%) female. The
Table 1
Demographics. Heparin(n = 22) No heparin(n = 11) p value Median (range) Median (range)
Methods A 2:1 case control research design was chosen to provide rigor for this single site retrospective study. Prior to data collection institution review board approval was obtained. A case report form was developed by the research team to organize and standardize the data collected. Data collected were classified into a check box format. Charts were reviewed, and data were collected from the patients' medical records. Two members of the research team reviewed each chart at two different times. Two members of the research team reviewed each case report form to assess for completion of data collection. Two cohorts of pediatric heart failure patients were identified. Each cohort was taken from a different period in time. Both cohorts of patients were receiving continuous inotropic infusions through a single lumen of their PICC line. One cohort, identified as the control group, received no heparin through the PICC line lumen delivering the inotropic infusion during the time frame of 2003–2005. The second cohort, identified as the case group, received continuous low dose heparin bifused with the inotropic infusion through a single lumen of their PICC line during the years of 2005–2007. Demographic and clinical characteristics were compared without any attempt for matching between the two cohorts. Use of thrombolytic agents and the total number of days the PICC line remained
Median age (in years) Gender Male Race White Non-White Congenital disease Acquired disease Reason for admission Elective Emergent Unknown Number of PICC lines for each patient 1 2 3 4
1 (0–21)
14 (1–21)
0.0001 ⁎
n (%)
n (%)
13 (59)
5 (45)
14 (64) 8 (36) 12 (55)
9 (82) 2 (18) 3 (27)
p value 0.49 0.65 0.27
10 (45)
9 (82)
0.07 0.01 ⁎
3 (14) 14 (64) 5 (23)
7 (64) 4 (36) 0 (0)
16 (73) 5 (23) 1 (5) 0 (0)
6 (55) 4 (36) 0 (0) 1 (9)
⁎ Indicates statistical significance: p b 0.05.
0.39
Management of PICC in Pediatric Heart Failure Patients Table 2 Comparison of PICC Line Patency With and Without Continuous Heparin.
Patency duration (in consecutive days) Anti-thrombolytic intervention
Heparin (n = 29) Median (range)
No heparin (n = 18) Median (range)
p value
24 (4–93)
16 (3–49)
0.07
n (%) 8 (28)
n (%) 9 (50)
p value 0.08
population was reported as predominantly White in both cohorts. Diagnoses were also well matched between subjects born with a congenital heart defect and subjects with acquired heart disease. The level of significance was set at p b 0.05 for tests of association. In comparing the two cohorts, both age at admission and admission status (defined as elective versus emergent) were found to be significantly different. In comparing the 47 PICC lines between the two cohorts, 8 (28%) in the heparin group required antithrombolytic intervention compared to 9 (50%) in the non heparin group, p = 0.08 (Table 2). For the PICC lines in the heparin group (n = 29) the median duration of patency was 24 days (with a range of 4–93 days) compared to the PICC lines in the non heparin group (n = 18) in which the median duration of patency was 16 days (with a range of 3–49 days), p = 0.07.
Discussion It is important to maintain reliable venous access for infusing inotropes to pediatric heart failure patients because their cardiac output is not sufficient to sustain their life without the medication. The first hypothesis stated that an infusion of continuous low dose heparin bifused with the inotrope would help extend the duration of patency in a PICC line. The median number of days as well as the maximum number of days the PICC line remained patent between the two groups was greater in the heparin group; meaning that, on average, the heparin group had more sequential days of uninterrupted therapy and did not require the use of antithrombolytics to restore patency in the PICC line. This is consistent with other studies that showed a trend towards prolonging patency in central venous catheters when a low dose heparin infusion was used for line management (Isemann et al., 2012; Shah & Shah, 2008; Shah et al., 2007). Although our result for duration of patency was not statistically significant, it did show a longer period of patency when heparin was used. Prolonging catheter patency potentially reduces time without therapy during PICC line repair or replacement, and can potentially reduce the number
5 of PICC lines a patient may need while hospitalized. For heart failure patients awaiting transplant, the time a PICC line will be needed to infuse inotropes cannot be predicted, as the availability of a suitable organ is unknown. Therefore, the goal is to provide maximum duration of patency for uninterrupted administration of therapies. Legitimate arguments against the use of continuous heparin infusions exist such as compromise to vascular integrity from endothelium irritation of the vein and increasing nursing time to manage another infusion (NietoRodriguez, Garcia-Martin, Barreda-Hernandez, Hervas, & Cano-Real, 1992). However, these arguments pale in comparison to the documented requirement for life-sustaining continuous inotropic infusion for children with heart failure in order to effectively manage their disease. In evaluating the second hypothesis we found a decrease in the use of antithrombolytics to restore line patency in the group receiving continuous low dose heparin, which demonstrates a lower incidence of line occlusion. This is similar to findings from Shah et al. (2007) and Shah and Shah (2008) where the use of continuous low dose heparin resulted in fewer line occlusions. The loss of patency in a PICC line signifies a halt in therapy to patients. The preparation and instillation of antithrombolytics is both time consuming and expensive. The use of antithrombolytics also exposes the patient to an additional medication and potential dosing errors. If antithrombolytics are unsuccessful in restoring line patency, that patient must then undergo another PICC line insertion procedure. PICC line procedures are costly and likely increases distress to the patient and family. Not anticipated by either hypothesis were the statistically significant findings. Both “age at admission” and “admission status” were found to be statistically significant between the two cohorts. In the case group, the median age of the patients was 1 year of age versus the control group with a median age of 14 years (p = 0.001). The control group sample of patients was from 2003–2005 representing an earlier practice standard while the case group was from 2005–2007 representing the present standard. The evolving practice of our PICC line management mirrored many other practice changes that were occurring at the same time, so it is difficult to state one clear explanation for this difference in the ages between the two groups. Historically, all patients receiving continuous inotropes were cared for within the CICU. When the administrative decision was made to transfer these patients to the inpatient cardiac unit, clinicians initially transferred the older patients, perceiving them more suitable for transfer. Thus they became part of the no heparin cohort. It is also possible that since inotrope dosing is based on weight, the infusion rate for the younger patients was slower allowing for stasis in the line making clinicians hesitant to transfer them. This phenomenon of line stasis was also described by Krafte-Jacobs et al. (1995). As the clinician's confidence increased newborns and infants were also transferred to the inpatient setting thus accounting for
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the increased number of younger patients in the later established heparin cohort. In addition, as infusion nurses became more skilled with placing PICC lines in younger patients, the overall median age of patients with a PICC line also decreased. Emergent admissions accounted for 64% of the admissions in the case group compared to 36% in the control group (p = 0.01). One possible explanation for the increase in present day emergent admission is the shift in care that allows patients to stay at home until admission is absolutely necessary and, therefore, emergent. Another practice change was the discontinuation of elective admissions for periodic supportive inotropic therapy as medical and surgical advancements have provided more options for these patients. The advances in care have not only increased the survival rates of children with heart failure but also increased their need for further medical intervention. While the implications of the statistically significant results are solely descriptive data, they show that treatment and admission practices have changed so that more infants are surviving early stages of palliation and are able to be cared for at home. It also indicates that techniques, equipment and skill sets have advanced to include infants as part of our PICC population. Regardless, it is significant that currently the median age of our heart failure patients is 1 year and they are more likely to be admitted emergently than electively. Therefore, it is essential to provide high quality family/patient-centered nursing care and that includes long duration PICC line patency for infusing life-sustaining inotropes while awaiting cardiac transplant.
it is important that the PICC line remains patent and usable for the entire duration of time the patient needs it.
Limitations
Conclusion
The limitations of this study are the population size and the parallel factors related to the evolution of heart transplant management strategies. First, the population of patients awaiting cardiac transplant is a reality variable beyond human control. Inherently, this is a precise group of patients within a small population of pediatric patients; therefore, all eligible patients from 2003 through 2007 were included. Knowing that the small sample size could sway statistical analysis, the research team implemented a rigorous 2:1 case– control method to compensate for that possibility. Second, comparing clinical practices at two different points in time suggests that there could have been other changes in the management of heart failure patients that contributed to the findings. However, the changes that occur over time are not always measurable and certainly could not be controlled. It may also be beneficial for a future study to account for the number of days a PICC line remained patent compared to the total number of days the patient needed a continuous inotropic infusion. Since some patients receive their heart transplant much sooner than expected, the total number of days they need a PICC line could be very low. Nevertheless,
Controversy surrounding the use of intermittent versus continuous heparin flush has been and continues to be an active question in the literature. The differences among patients are both numerous and subtle, and any one of these differences could contribute to the various practice routines in line management. Differences may include but are not limited to age, developmental level, diagnosis, acuity, length of hospitalization and treatment plan, including the rate and type of an infusion. PICC line management practices vary widely across clinicians and institutions. However, continuity in PICC line management has the potential to improve patient outcomes. Clinicians need to share their experiences with PICC line management successes to aid in the development of data based care standards within specialized populations so that transfer and generalization to other populations may be explored. The need to establish successful PICC line management strategies that can be replicated across studies and generalized to other populations is a crucial element in providing optimal patient care realizing excellent patient outcomes in pediatric patients with PICC lines.
Clinical Implications The clinical significance of this study is to demonstrate the existence of a group of patients who do not fit into a standard PICC line management strategy that has been supported by evidence. The use of intermittent heparin flushes to maintain patency in PICC lines is a common practice across the country that also is supported by the definitive agent of infusion therapy, the Infusion Nurses Society (2000; 2006; 2011). However, there is no evidence based practice or recommendations from the Infusion Nurses Society for managing PICC lines with continuous infusions that cannot be intermittently flushed with heparin. For that reason, it is important to build and share a data driven intervention that prolongs the duration of patency and decreases the occurrence of occlusion in pediatric PICC lines that cannot be intermittently flushed with heparin so that other patients may benefit. The findings of this study showed a prolonged duration of catheter patency and a lower incidence of line occlusion when continuous low dose heparin was bifused with the medication enabling the patient to remain medically stable for an indeterminate amount of time while awaiting cardiac transplant. Therefore, our present practice of managing PICC lines in heart failure patients awaiting transplant is supported.
Management of PICC in Pediatric Heart Failure Patients
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