19 February 2020

Researchers have voiced concerns about the number of children who suffer venous thromboembolism (VTE) through the use of peripherally inserted central catheters (PICCs) to administer medicine and draw blood.

Results from the Clot Incidence Rates in Central Lines (CIRCLE) study suggest that using PICCs is associated with a significantly increased risk of VTE compared with central venous catheters (CVCs) placed directly into the neck or chest.

The study, published in Blood, also found a significantly increased rate of CVC-related bloodstream infections and catheter malfunctions among paediatric patients receiving PICCs.

PICCs have been used increasingly because they can be quickly and easily inserted at the bedside by a nurse with light sedation, the researchers say. By contrast, inserting a tunnelled line (TL) is a more invasive, time-consuming and costly procedure requiring a surgeon or interventional radiologist.

CIRCLE is the first multi-centre, prospective, observational cohort study to compare VTEs in children with newly placed PICCs and TLs. It involved 1,967 newly placed CVCs in 1,742 children aged six months to 18 years.

CVC-related VTEs occurred in 6% of children within six months of follow up. Of the 94 VTEs observed, 75 (80%) were seen in children with PICCs.

The researchers’ analysis found that children who received a PICC were 8.5 times more likely to develop a blood clot compared to those with a TL.

Dr Julie Jaffray, senior study author from Children’s Hospital Los Angeles and University of Southern California, said: “Now we can say definitively that patients who have PICCs have a much higher rate of thrombosis as well as central line associated bloodstream infections and catheter malfunctions when compared to TLs. PICCs are not as benign as we once thought.”

They found that catheter-related blood clots were highest among patients with a prior VTE history.  VTE was also more likely among children receiving a larger calibre catheter carrying multiple lines, and those with leukaemia. Patients who had a line malfunction or an infection were also more likely to develop VTE.

Dr Jaffray said up to one in four paediatric patients with VTE develop post-thrombotic syndrome. Venous stenosis is also a clinically significant complication as it can limit blood flow and make it harder to insert catheters in patients who need to undergo surgeries over the course of their treatment.

She said that in her view, the observed incidence of PICC-related VTE is too high to justify their frequent use.

Dr Jaffray and her team hope to conduct further additional analyses to assess if the underlying reason for inserting the line could play a role in the development of VTEs.

Source: Jaffray J, Witmer C, O'Brien SH, Diaz R, Ji L, Krava E, Young G (2020) “Peripherally inserted central catheters lead to a high risk of venous thromboembolism in children”, Blood,
doi: 10.1182/blood.2019002260


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