ORIGINAL CONTRIBUTION
Risk of Catheter-Associated Deep Venous Thrombosis in Inflammatory Bowel Disease Avinash Bhakta, M.D. • Marcel Tafen, M.D. • Mushfique Ahmed, B.S. Ashar Ata, M.B.B.S. • Christa Abraham, M.D. • David Bruce, R.N. Brian T. Valerian, M.D. • Edward C. Lee, M.D. Department of Surgery, Albany Medical College, Albany, New York
BACKGROUND: Inflammatory bowel disease confers a hypercoagulable state. A large number of these patients require central venous access in the form of peripherally inserted central catheters for long-term intravenous therapies. Our clinical observations suggested that these patients had a higher incidence of catheter-associated deep venous thrombosis than that of the general population. OBJECTIVE: The aim of this study was to examine the relationship between IBD and catheter-associated deep venous thrombosis. DESIGN: A retrospective chart review was conducted of all patients who underwent peripherally inserted central catheter line placement between 2009 and 2011. SETTING: This study was performed at a singleinstitution tertiary referral center. PATIENTS: All patients who underwent peripherally inserted central catheter line placement were identified. OUTCOME MEASURES: The risk of catheter-associated
deep venous thrombosis in IBD patients was assessed. This risk was compared with known risk factors such as malnutrition, malignancy, diabetes mellitus, and tobacco use. Multivariate analysis was performed. Catheter size, indication for placement, and vein location of catheterassociated deep venous thrombosis were identified in the IBD population.
RESULTS: There were 7179 peripherally inserted central catheter lines placed during the study period; the overall incidence of catheter-associated deep venous thrombosis was 2.1% (148/7179). The incidence of catheterassociated deep venous thrombosis among patients with IBD was 6.8% (9/132). The incidence of catheterassociated deep venous thrombosis among non-IBD patients was 1.9% (139/7047) (relative risk, 3.5; 95% CI, 1.8–6.6; p < 0.001). The incidence of catheter-associated deep venous thrombosis was increased for patients with malnutrition (4.8%, 30/628, p < 0.001) and increasing age (95% CI, 1.01–1.12; p = 0.02). There was no increased incidence of catheter-associated deep venous thrombosis for patients with diabetes mellitus (1.6%, 25/1574, p < 0.14), malignancy (2.8%, 30/1041, p = 0.06), or tobacco use (1.6%, 31/1938, p = 0.10). After multivariate analysis, IBD, malnutrition, and increasing age were found to be significant risk factors for the development of catheter-associated deep venous thrombosis. LIMITATIONS: The inability to track the number of catheter days, the inaccuracy of administrative data, the lack of outpatient follow-up, and the small number of events in the study cohort were limitations of this study. CONCLUSIONS: This is the first study to demonstrate IBD as an independent risk factor to the development of catheter-associated deep venous thrombosis. The placement of a peripherally inserted central catheter line in IBD should be utilized selectively.
Financial Disclosure: None reported. Podium presentation at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Edward C. Lee, M.D., Albany Medical College, 43 New Scotland Ave, Mail Code MC-194, Albany, NY 12208-3479. E-mail: [email protected]. Dis Colon Rectum 2014; 57: 1379–1383 DOI: 10.1097/DCR.0000000000000257 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 12 (2014)
KEYWORDS: Inflammatory bowel disease; Deep venous thrombosis; Peripherally inserted central catheter; Catheter-associated deep venous thrombosis.
A
large number of patients with IBD require longterm intravenous access for nutritional supplementation in the setting of prolonged diarrhea, high-output fistulas, short-bowel syndrome, and malnutrition; some require long-term intravenous antibiotic 1379
1380
Bhakta et al: Catheter-Associated DVT in IBD
TABLE 1. Demographic comparison of patients with IBD versus those without IBD
Age, y Male sex, % Average length of stay, d White race, %
IBD
Non-IBD
42.14 ± 22.07 53.03 15.46 ± 13.59 84.84
47.85 ± 27.39 54.46 18.74 ± 30.68 80.84
therapy.1 For these reasons, peripherally inserted central catheters (PICCs) have become a mainstay in the management of many patients with IBD. Despite numerous advantages, there are many complications associated with PICC use, including catheter-associated deep venous thrombosis (CADVT).2–6 This poses an even greater challenge in IBD patients because research has clearly demonstrated that a hypercoagulable state exists in both forms of IBD, placing patients at increased risk for CADVT development.7,8 The aim of this study was to investigate the risk of developing symptomatic CADVT in patients with IBD.
MATERIALS AND METHODS After institutional review board approval, a retrospective chart review was conducted of all consecutive patients who underwent PICC placement at Albany Medical Center between 2009 and 2011. This patient list was generated by obtaining procedure codes for PICC placement from the administrative database. This population was then subdivided into patients with and without IBD by using International Classification of Diseases, Ninth Revision (ICD-9) coding for Crohn’s disease and ulcerative colitis (5550, 5551, 5552, 5556, 5559, 5561, 5562, 5563, 5564, 5565, 5566, 5568, 5569). The number of acquired symptomatic CADVTs in each subgroup was also tallied by extracting ICD-9 codes for upper extremity venous thrombosis (45183, 45184, 45189). There were no exclusion criteria. Demographic data were then extracted (Table 1). The PICC lines were placed with the patient’s consent by a specialized team of registered nurses, who used ultrasound guidance under sterile universal precautions. Proper placement was confirmed by chest radiograph, and use was authorized by house staff. Criteria for proper placement included the absence of pneumothorax and catheter tip at or within 2 cm proximal to the cavoatrial junction. The incidence of CADVT was calculated in the 2 groups. The relative risk was determined to assess the risk that IBD confers to the development of CADVT. Known risk factors, such as tobacco abuse, diabetes mellitus, malignancy, and malnutrition were then identified by obtaining their corresponding ICD-9 codes to determine their contribution to the development of symptomatic CADVT in both the IBD and non-IBD population (250, 263, 305, 140–239). Risk factors that were found to be significant in
bivariate analysis were then used in the multivariate analysis. Procedure notes for patients with IBD that underwent PICC placement were reviewed for catheter lumen diameter, indication for placement, and vein accessed. Duplex ultrasonography records were then obtained from the vascular laboratory and reviewed for the presence of upper extremity deep venous thrombosis. Upper extremity deep venous thrombosis was defined as acute thrombus within the axillary, subclavian, or internal jugular vein. Statistical analysis was performed by STATA, version 11.1. Bivariate and multivariate analysis was used to assess if IBD was an independent risk factor for the development of symptomatic CADVT.
RESULTS During the 36-month period, 7179 upper extremity PICCs were placed in unique individuals. The mean age for this study population was 47.5 years; 53.74% were of male sex and 82.84% were white. The mean length of stay was 17.10 days (Table 2). Overall, 148 patients developed CADVT (2.1%) (Fig. 1). There were 132 patients with IBD, and 9 (6.8%) of these patients developed a symptomatic CADVT on the same admission as the PICC placement. Thirty of these patients experienced ulcerative colitis, and 3 of those patients developed symptomatic CADVT (10%); the remaining 102 had Crohn’s disease, and symptomatic CADVT developed in 6 of these patients (5.9%). None of these patients experienced a hypercoaguable disorder, such as factor V Leiden, protein C deficiency, or hyperhomocysteinemia, and none of these patients had a history of CADVT. Conversely, 139 of 7047 (1.9%) patients without IBD developed a similar outcome (relative risk [RR], 3.6; 95% CI, 1.8–7.3; p = 0.002) (Fig. 2). Of these patients, 6 had primary hypercoaguable states. Furthermore, none of the patients in the IBD group had sustained upper extremity trauma, whereas 7 patients in the non-IBD group had sustained upper extremity trauma. There were 1574 patients with diabetes mellitus, and 25 (1.6%) of these patients developed a symptomatic CADVT, in comparison with 123 of 5605 (2.2%) patients without diabetes mellitus (RR, 0.72; 95% CI, 0.47–1.11; p < 0.14). There were 628 patients with malnutrition, and a symptomatic CADVT developed in 30 (4.8%) of these patients, in comparison with 118 of 6551 (1.8%) patients without malnutrition (RR, 2.6; 95% CI, 1.8–3.9; p < 0.001). It should be noted that our study identified malnutrition based on ICD-9 codes, which defines malnutrition when 2 of the following characteristics are present: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, generalized fluid accumulation that may mask weight loss, or diminished functional status as measured by hand grip strength. There were 1938 patients with tobacco use, and a symptomatic
1381
Diseases of the Colon & Rectum Volume 57: 12 (2014)
TABLE 2. Relative risk for CADVT development in IBD, malnutrition, malignancy, tobacco, diabetes mellitus, and increasing age Unadjusted
IBD Malnutrition Malignancy Tobacco Diabetes mellitus Age (10-y increase)
Adjusted
%DVT
RR
95% CI
RR
95% CI
p
6.82 4.78 2.8 1.6 1.59
3.63 2.73 1.46 0.72 0.72 1.07
1.81–7.30 1.82–4.12 0.97–2.20 0.50–1.10 0.47–1.11 1.01–1.12
3.19 2.44
1.52–6.68 1.60–3.72
1.06
1.00–1.11
0.002a
Risk of Catheter-Associated Deep Venous Thrombosis in Inflammatory Bowel Disease Avinash Bhakta, M.D. • Marcel Tafen, M.D. • Mushfique Ahmed, B.S. Ashar Ata, M.B.B.S. • Christa Abraham, M.D. • David Bruce, R.N. Brian T. Valerian, M.D. • Edward C. Lee, M.D. Department of Surgery, Albany Medical College, Albany, New York
BACKGROUND: Inflammatory bowel disease confers a hypercoagulable state. A large number of these patients require central venous access in the form of peripherally inserted central catheters for long-term intravenous therapies. Our clinical observations suggested that these patients had a higher incidence of catheter-associated deep venous thrombosis than that of the general population. OBJECTIVE: The aim of this study was to examine the relationship between IBD and catheter-associated deep venous thrombosis. DESIGN: A retrospective chart review was conducted of all patients who underwent peripherally inserted central catheter line placement between 2009 and 2011. SETTING: This study was performed at a singleinstitution tertiary referral center. PATIENTS: All patients who underwent peripherally inserted central catheter line placement were identified. OUTCOME MEASURES: The risk of catheter-associated
deep venous thrombosis in IBD patients was assessed. This risk was compared with known risk factors such as malnutrition, malignancy, diabetes mellitus, and tobacco use. Multivariate analysis was performed. Catheter size, indication for placement, and vein location of catheterassociated deep venous thrombosis were identified in the IBD population.
RESULTS: There were 7179 peripherally inserted central catheter lines placed during the study period; the overall incidence of catheter-associated deep venous thrombosis was 2.1% (148/7179). The incidence of catheterassociated deep venous thrombosis among patients with IBD was 6.8% (9/132). The incidence of catheterassociated deep venous thrombosis among non-IBD patients was 1.9% (139/7047) (relative risk, 3.5; 95% CI, 1.8–6.6; p < 0.001). The incidence of catheter-associated deep venous thrombosis was increased for patients with malnutrition (4.8%, 30/628, p < 0.001) and increasing age (95% CI, 1.01–1.12; p = 0.02). There was no increased incidence of catheter-associated deep venous thrombosis for patients with diabetes mellitus (1.6%, 25/1574, p < 0.14), malignancy (2.8%, 30/1041, p = 0.06), or tobacco use (1.6%, 31/1938, p = 0.10). After multivariate analysis, IBD, malnutrition, and increasing age were found to be significant risk factors for the development of catheter-associated deep venous thrombosis. LIMITATIONS: The inability to track the number of catheter days, the inaccuracy of administrative data, the lack of outpatient follow-up, and the small number of events in the study cohort were limitations of this study. CONCLUSIONS: This is the first study to demonstrate IBD as an independent risk factor to the development of catheter-associated deep venous thrombosis. The placement of a peripherally inserted central catheter line in IBD should be utilized selectively.
Financial Disclosure: None reported. Podium presentation at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Edward C. Lee, M.D., Albany Medical College, 43 New Scotland Ave, Mail Code MC-194, Albany, NY 12208-3479. E-mail: [email protected]. Dis Colon Rectum 2014; 57: 1379–1383 DOI: 10.1097/DCR.0000000000000257 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 12 (2014)
KEYWORDS: Inflammatory bowel disease; Deep venous thrombosis; Peripherally inserted central catheter; Catheter-associated deep venous thrombosis.
A
large number of patients with IBD require longterm intravenous access for nutritional supplementation in the setting of prolonged diarrhea, high-output fistulas, short-bowel syndrome, and malnutrition; some require long-term intravenous antibiotic 1379
1380
Bhakta et al: Catheter-Associated DVT in IBD
TABLE 1. Demographic comparison of patients with IBD versus those without IBD
Age, y Male sex, % Average length of stay, d White race, %
IBD
Non-IBD
42.14 ± 22.07 53.03 15.46 ± 13.59 84.84
47.85 ± 27.39 54.46 18.74 ± 30.68 80.84
therapy.1 For these reasons, peripherally inserted central catheters (PICCs) have become a mainstay in the management of many patients with IBD. Despite numerous advantages, there are many complications associated with PICC use, including catheter-associated deep venous thrombosis (CADVT).2–6 This poses an even greater challenge in IBD patients because research has clearly demonstrated that a hypercoagulable state exists in both forms of IBD, placing patients at increased risk for CADVT development.7,8 The aim of this study was to investigate the risk of developing symptomatic CADVT in patients with IBD.
MATERIALS AND METHODS After institutional review board approval, a retrospective chart review was conducted of all consecutive patients who underwent PICC placement at Albany Medical Center between 2009 and 2011. This patient list was generated by obtaining procedure codes for PICC placement from the administrative database. This population was then subdivided into patients with and without IBD by using International Classification of Diseases, Ninth Revision (ICD-9) coding for Crohn’s disease and ulcerative colitis (5550, 5551, 5552, 5556, 5559, 5561, 5562, 5563, 5564, 5565, 5566, 5568, 5569). The number of acquired symptomatic CADVTs in each subgroup was also tallied by extracting ICD-9 codes for upper extremity venous thrombosis (45183, 45184, 45189). There were no exclusion criteria. Demographic data were then extracted (Table 1). The PICC lines were placed with the patient’s consent by a specialized team of registered nurses, who used ultrasound guidance under sterile universal precautions. Proper placement was confirmed by chest radiograph, and use was authorized by house staff. Criteria for proper placement included the absence of pneumothorax and catheter tip at or within 2 cm proximal to the cavoatrial junction. The incidence of CADVT was calculated in the 2 groups. The relative risk was determined to assess the risk that IBD confers to the development of CADVT. Known risk factors, such as tobacco abuse, diabetes mellitus, malignancy, and malnutrition were then identified by obtaining their corresponding ICD-9 codes to determine their contribution to the development of symptomatic CADVT in both the IBD and non-IBD population (250, 263, 305, 140–239). Risk factors that were found to be significant in
bivariate analysis were then used in the multivariate analysis. Procedure notes for patients with IBD that underwent PICC placement were reviewed for catheter lumen diameter, indication for placement, and vein accessed. Duplex ultrasonography records were then obtained from the vascular laboratory and reviewed for the presence of upper extremity deep venous thrombosis. Upper extremity deep venous thrombosis was defined as acute thrombus within the axillary, subclavian, or internal jugular vein. Statistical analysis was performed by STATA, version 11.1. Bivariate and multivariate analysis was used to assess if IBD was an independent risk factor for the development of symptomatic CADVT.
RESULTS During the 36-month period, 7179 upper extremity PICCs were placed in unique individuals. The mean age for this study population was 47.5 years; 53.74% were of male sex and 82.84% were white. The mean length of stay was 17.10 days (Table 2). Overall, 148 patients developed CADVT (2.1%) (Fig. 1). There were 132 patients with IBD, and 9 (6.8%) of these patients developed a symptomatic CADVT on the same admission as the PICC placement. Thirty of these patients experienced ulcerative colitis, and 3 of those patients developed symptomatic CADVT (10%); the remaining 102 had Crohn’s disease, and symptomatic CADVT developed in 6 of these patients (5.9%). None of these patients experienced a hypercoaguable disorder, such as factor V Leiden, protein C deficiency, or hyperhomocysteinemia, and none of these patients had a history of CADVT. Conversely, 139 of 7047 (1.9%) patients without IBD developed a similar outcome (relative risk [RR], 3.6; 95% CI, 1.8–7.3; p = 0.002) (Fig. 2). Of these patients, 6 had primary hypercoaguable states. Furthermore, none of the patients in the IBD group had sustained upper extremity trauma, whereas 7 patients in the non-IBD group had sustained upper extremity trauma. There were 1574 patients with diabetes mellitus, and 25 (1.6%) of these patients developed a symptomatic CADVT, in comparison with 123 of 5605 (2.2%) patients without diabetes mellitus (RR, 0.72; 95% CI, 0.47–1.11; p < 0.14). There were 628 patients with malnutrition, and a symptomatic CADVT developed in 30 (4.8%) of these patients, in comparison with 118 of 6551 (1.8%) patients without malnutrition (RR, 2.6; 95% CI, 1.8–3.9; p < 0.001). It should be noted that our study identified malnutrition based on ICD-9 codes, which defines malnutrition when 2 of the following characteristics are present: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, generalized fluid accumulation that may mask weight loss, or diminished functional status as measured by hand grip strength. There were 1938 patients with tobacco use, and a symptomatic
1381
Diseases of the Colon & Rectum Volume 57: 12 (2014)
TABLE 2. Relative risk for CADVT development in IBD, malnutrition, malignancy, tobacco, diabetes mellitus, and increasing age Unadjusted
IBD Malnutrition Malignancy Tobacco Diabetes mellitus Age (10-y increase)
Adjusted
%DVT
RR
95% CI
RR
95% CI
p
6.82 4.78 2.8 1.6 1.59
3.63 2.73 1.46 0.72 0.72 1.07
1.81–7.30 1.82–4.12 0.97–2.20 0.50–1.10 0.47–1.11 1.01–1.12
3.19 2.44
1.52–6.68 1.60–3.72
1.06
1.00–1.11
0.002a
