PICCs Increase Thromboembolism Risk
in Children

Nicola M. Parry, DVM

January 07, 2020

Use of peripherally inserted central catheters (PICCs) in children may significantly increase their risk for venous thromboembolism (VTE), a recent study published online today in the journal Blood has shown.

In this multi-institutional, prospective cohort study, children with PICCs had a significantly increased risk of developing a catheter-related VTE compared with tunnelled lines (TLs), write Julie Jaffray, MD, Children's Hospital Los Angeles, California, and colleagues.

"PICCs were also more likely to have a CLABSI [central line associated bloodstream infection] and malfunction as compared to TLs."

Central venous catheters (CVCs) are commonly used to draw blood and administer medications when treating children with serious health conditions.

Among the different types of these catheters, PICCs tend to be the preferred choice for children because they can be easily placed at the bedside into small-caliber peripheral vessels in the arm, requiring only light to no sedation. By contrast, placement of a tunneled line (TL) is more invasive, requiring insertion of the catheter into a large central vein in an anesthetized patient.

However, despite playing a critical role in the care of many children, these devices can lead to serious complications such as VTE and CLABSIs. And studies have indicated a sharply rising incidence of VTE during the last two decades, with most of these cases in children being associated with use of CVCs.

With this in mind, Jaffray and colleagues conducted the Clot Incidence Rates in Central Lines (CIRCLE) study at four US tertiary care centers to compare the incidence of VTEs in children aged 6 months to 18 years with newly placed PICCs and TLs.

Their study included 1967 newly placed CVCs (1257 PICCs [64%] and 710 TLs [36%]) in 1742 children (53% male).

Of the 1967 CVCs, 94 (4.8%) were associated with VTEs within 6 months of placement. The overall incidence rate of catheter-related VTE was 5.9 ± 0.63%.

Most VTE events occurred in children with PICCs (n = 75; 80%), which had a catheter-related VTE incidence rate of 9.0 ± 1.4%. By contrast, TLs had an incidence rate of 2.9 ± 0.64%.

Overall, children with PICCs were 8.5 times more likely to have a catheter-related VTE than children with TLs (P < .001).

The median time from placement of any CVC to VTE diagnosis was 15.5 days (range 1-162 days). In children with PICCs, the median time to VTE diagnosis was 14 days compared with 42 days in those with TLs.

According to the researchers, 173 CLABSI events occurred in 158 children within 6 months of CVC placement, with an overall incidence rate of 17 ± 1.3%.

Children with PICCs were 1.6 times more likely to have a CLABSI (P = .002) than children with TLs (incidence rate, 22 ± 2.8% vs 15 ± 1.4%).

The median time from placement of any CVC to CLABSI diagnosis was 1.4 months.

Jaffray and colleagues also identified 444 CVC malfunctions in 402 children within 6 months of CVC placement, with an overall incidence rate of 35 ± 1.5%.

Children with PICCs were 2.0 times more likely to experience CVC malfunction (P < .001) than children with TLs (incidence rate, 41 ± 2.7% vs 29 ± 1.8%).

Using a multivariable model, the researchers analyzed the association between occurrence of catheter-related VTE and specific patient and CVC characteristics. They found a greater risk of CVC-related VTE in children with PICCs (HR, 8.5; P < .001), a previous history of VTE (HR, 23; P < .001), a multi-lumen CVC (HR, 3.9; P = .003), and a diagnosis of leukemia (HR, 3.5; P = .031).

"We did not find an associated catheter-related VTE risk between various CVC insertion characteristics, such as CVC tip location, insertion attempts, vein accessed, French size, CVC length, access side, catheter brand, or material," the authors add.

Overall, Jaffray and colleagues stress that "the results of the CIRCLE study should give pause to the community of pediatricians and pediatric specialists who care for children who require intravenous treatments, especially when central venous access is not obviously necessary, as a VTE rate of 9% from an iatrogenic cause (PICCs) is in our view too high to justify the current approach."

To reduce the CVC-related VTE rate, the authors emphasize the need to focus on modifiable risk factors, such as limiting multi-lumen CVCs, preventing CLABSIs, or inserting a TL instead of a PICC when possible.

There was no funding source for this study. The authors have disclosed no relevant financial relationships.

Blood. Published online January 7, 2020. Abstract

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