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A new formula to estimate the length of peripherally inserted central catheter from a left upper arm vein puncture based on patient height and weight

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A new formula to estimate the length of peripherally inserted central catheter from a left upper arm vein puncture based on patient height and weight Poster No.: C-1225 Congress: ECR 2013 Type: Authors:
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A new formula to estimate the length of peripherally inserted central catheter from a left upper arm vein puncture based on patient height and weight Poster No.: C-1225 Congress: ECR 2013 Type: Authors: Keywords: DOI: Scientific Exhibit E. Y. Jeon, J. H. Hur, S.-G. Park; Anyang/KR Interventional vascular, Cardiovascular system, CT-Angiography, Ultrasound, Venous access, Arteriosclerosis /ecr2013/C-1225 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. 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Page 1 of 19 Purpose After the first trial of using upper extremity vein to access to the central venous system in 1912, upper extremity veins are increasingly used during peripherally inserted central catheter (PICC) and totally implantable venous-access port procedures providing extended and reliable venous access routes for the purpose of delivery of medication, laboratory testing, and hemodynamic monitoring [1-3]. Many reports are focusing on the importance of correct position of central venous catheter tip (optimally superior vena cava) because improper catheter tip position is one of important factors to cause complications such as catheter malfunction and venous thromboembolism, combined with other factors such as site of PICC insertion and patient characteristics of malignancy [4-7]. For adequate catheter tip positioning, fluoroscopy guided insertion is best, but specially trained nurses commonly place PICC at the patient's bedside with individually incorporated methods of catheter length determination for each patients such as using tape ruler in the PICC sets. But the resultant rates of successful central tip positioning is quite variable (44 to 99 %) [6, 8, 9]. In addition, measuring the length of catheter from the puncture point to central vein after venipuncture can be very cumbersome and vulnerable to infectious contamination. A 'tailored fit formula' to individual patient height based on the anatomic measurement results of humerus and clavicle has been reported variable accuracy also [9-11]. Although several reports about length of insertion guidelines for the depth of a central venous catheter through internal jugular or subclavian veins in relation to the height are present, in our knowledge, for PICC, equation of venous length through left upper arm vein in relation to patient height and weight is not present except our previous report about that of right side elbow crease to carina length (ECL) based on patient height [12, 13-15]. This study was conducted to measure the length of left upper arm vein between the elbow crease and the carina (elbow crease to carina length, ECL), for predicting the optimal length of catheter during blind bedside procedure of PICC based on patient height and body weight and to facilitate appropriate positioning of the tip of PICC. Methods and Materials This retrospective study was approved by our institutional review board. From January 2011 to June 2012, 172 PICCs were inserted through left upper arm vein in 158 patients in our hospital. Seven cases were excluded (1 incomplete radiologic record, 2 incomplete Page 2 of 19 insertions of central vein catheter due to central vein stenosis or obstruction, 1 severe mediastinal shift, and 3 less than 20 years age) and 165 cases in 151 patients constitute the study group (table 1. male to female ratio, 72:79, mean age, male, / years, range 20-89, female, / years, range 32-87). In 14 patients of this 151 patient group, PICC procedures were done twice (male, 6 cases, female 8 cases). Because different veins were selected each time of repeated procedures in the same patient if possible because of the possibility of local infection and possible venous stenosis or thrombosis related to prior procedure, all cases were dealt with indifferently. In 8 patients, the data of body weight were not usable. Number of selected veins in all patients is presented in table 2. PICC procedure and measurement methods All PICC insertion procedures were done with the patient supine on the angiographic table. The elbow joint was fully extended and the arm was externally rotated as possible and abducted to about 40 degrees. Usable vein among basilic or cephalic veins was selected under US examination (basilic vein first) and brachial vein was selected if no other veins were determined usable or prior venipunctures were failed. Venipuncture was done with micropuncture needle in PICC set (5 Fr. Turbo-flo PICC Set. Cook R, Bloomington, USA, or 6 F dual lumen Pro-Picc CT Basic IR set, Medicomp R, Harleysville, PA, USA) (Fig. 1, 2). Page 3 of 19 Fig. 1: Under the sonographic guidance, peripheral vein (arrow) was punctured. References: Radiology, Hallym University Sacred Heart Hospital - Anyang/KR Page 4 of 19 Fig. 2: Vein puncture was done proximal to the elbow crease. References: Radiology, Hallym University Sacred Heart Hospital - Anyang/KR After insertion of guidewire and dilatation of the tract with dilator sheath, the catheter was cut according to the length estimated by previously suggested formula based on patient height (ECL = [0.24 * height (cm)] for right upper arm vein)plus 4.0 cm because left upper arm vein is longer than right one [7, 15]. Then, PICC catheter insertion was done into the sheath slowly advancing as deeply as possible. If any resistance was felt during catheter advancement, fluoroscopy and/or venography through the catheter was done and adequate method was used to finally locate the catheter tip in the superior vena cava (SVC), such as selection and overcoming acute curvature or stenosis of main venous route using guidewire. The external portal of the catheter from skin was fixed with fixation device in the PICC set. Punctured veins in 165 cases were recorded in table 2. Finally, the last fluoroscopy or spot radiography was stored on PACS system showing the ultimate catheter tip position in relation to SVC and right heart. The distances from elbow crease to puncture point of skin and catheter length inside the body were recorded on radiology reports in all procedures. According to the records on radiology report about the distance between elbow crease to puncture point (a) and catheter length inside the body (b), and the measured distance Page 5 of 19 from the carina to the catheter tip on stored PACS image (c), we calculated the length of left upper extremity vein from elbow crease to carina (elbow crease to carina length, ECL, d=a+b-c) as the same method described previously [14] (table 1). Equations of ECL through left upper arm vein in relation to patient height and weight were obtained by these results. Statistical analysis Descriptive statistics were expressed as mean standard deviation (SD). Student t-tests were done if there are significant differences in age, height, weight, elbow crease to puncture point, catheter length inside the body, carina to catheter tip length, and ECL between male and female groups. Analysis of variance test was done if there is significant difference of ECL among the groups of punctured veins (basilic, cephalic, and brachial veins), although the number of patients in whom cephalic and brachial veins were punctured was small. Multiple linear regression analysis was done if height with or without weight are capable of predicting the ECL. Finally, equations of ECL based on patient height and weight in 157 cases because of absent weight data in 8 patients, and based on patient height in 165 cases were obtained. Statistical analyzes were performed using Sigma plot 2000 and SPSS version 10.0 (SPSS Inc. Chicago, IL). P-value less than 0.05 were considered significant. Images for this section: Page 6 of 19 Table 1: Basic data of patients and the lengths of measurements in male and female groups. Table 2: Selected veins in 165 cases in male and female patients. Page 7 of 19 Fig. 1: Under the sonographic guidance, peripheral vein (arrow) was punctured. Page 8 of 19 Fig. 2: Vein puncture was done proximal to the elbow crease. Page 9 of 19 Results The height and weight of the patients were ± 6.8 cm (range, 152 ~ 183) and 64.5 ± 13.7 kg (range, 42 ~ 140) in male, and ± 5.4 cm (range, 140 ~ 168) and 54.5 ± 10.9 kg (range, 34 ~ 95) in female group, and they were significantly different in two groups (p 0.05) (table 1). Table 1: Basic data of patients and the lengths of measurements in male and female groups. References: Radiology, Hallym University Sacred Heart Hospital - Anyang/KR The catheter length inside the body was 45.8 ± 2.4 cm (range, 40.0 ~ 52.0) in male and 43.0 ± 2.1 cm (range, 37.0 ~ 47.0) in female (p 0.01). The elbow crease to puncture point (mean 4.7 ± 1.4 cm, range, 2.0 ~ 8.0 in male, and mean 4.2 ± 1.6 cm, range, 1.0 ~ 9.0 in female) and carina to catheter tip length (mean 3.5 ± 2.5 cm, range, -2.0 ~ 9.0 in male and 3.3 ± 2.8 cm, range, -4.0 ~ 9.5 in female) were not significantly different in male and female patients (p 0.05). The mean ECL through left upper arm vein was 47.1 ± 2.6 cm (range, 42 ~ 55) in male and 44.0 ± 2.9 cm (range, 34.0 ~ 50.0) in female patients and was longer in male (p 0.01) (table 1). Selected vein were basilic in 70.3 %, cephalic in 13.3 % and brachial in 16.4 % (table 2). Page 10 of 19 Table 2: Selected veins in 165 cases in male and female patients. References: Radiology, Hallym University Sacred Heart Hospital - Anyang/KR There was no significant difference of ECL among the groups of punctured veins (basilic, cephalic, and brachial veins) (p value 0.05). ECL was significantly correlated with height and weight (Fig. 3) Fig. 3: Scatter flot of ECL based on patient height (cm). References: Radiology, Hallym University Sacred Heart Hospital - Anyang/KR Equations of ECL based on patient height in 165 patients and based on patient height and weight in 158 patients were as follows. ECL = height * (p 0.001, R-square=0.293) Page 11 of 19 ECL = height * weight * (height, p 0.001, weight, p= 0.012, R- square=0.336) Images for this section: Table 1: Basic data of patients and the lengths of measurements in male and female groups. Table 2: Selected veins in 165 cases in male and female patients. Page 12 of 19 Fig. 3: Scatter flot of ECL based on patient height (cm). Page 13 of 19 Conclusion Elbow crease to puncture point and carina to catheter tip length were similar in male and female groups because we used same method of PICC insertion. Because the height and weight were different between male and female groups, the catheter length inside the body and ECL were different, that is, ECL was determined by height or/and weight by multiple linear regression analysis. In addition, no difference of ECL among the three selected veins (basilic, cephalic and brachial) was present. So, we can use this equation of ECL determination by height and/or weight regardless of the sexuality and selected veins. The elbow crease to puncture point can be variable inevitably due to patient characteristics and procedural difficulty, such as difficult arm abduction and supination and poor patient cooperation during the procedure, and initial venipuncture failure. The carina to catheter tip length was dispersed widely about 11 cm in male and 13.5 cm in female groups although the mean was 3.5 ± 2.5 cm in male and 3.3 ± 2.8 cm in female, because we used the formula based on patient height only and the weight was not considered that was dispersed widely about 98 kg in male and 61 kg in female group as well. For multiple reasons, PICCs have become among the most frequently encountered central venous catheter in non-icu patient. For instance, these devices are safer to insert than CVCs, eliminate the discomfort associated with phlebotomy and scheduled peripheral intravenous line changes, and provide extended and reliable venous access [7]. Blind bedside insertion of PICC without the aid of fluoroscopy is necessary and sometimes inevitable, and many efforts should be done for correct central location of the catheter tip for long-term use of PICC without complications because it resulted in as much as 60 % of catheter tips located in a suboptimal position [6, 7, 9]. Most of all, the venous length from the puncture point to carina should be estimated correctly in each patients before the procedure but is not easy because the patient's body size is quite different and venous puncture point could be variable. In addition, direct measurement along the presumed course with tape ruler outside the body as already incorporated in many institutions is quite cumbersome and especially quite vulnerable to infectious complication. So, our study result is greatly useful in those situations of blind bedside procedure of PICC for the correct positioning of catheter tip because our equation can estimate the length of upper arm vein in relation to the patient's height and weight. The recommended tip location of PICC is central vein, more specifically junction of SVC and right atrium, distal SVC, or the carina [16-19]. Some argue that right atrium is a satisfactory position also if the tip does not abut the atrial wall or traverse the tricuspid valve or coronary sinus [20]. Tip position of a central venous access is of paramount Page 14 of 19 importance and should be verified before starting infusion. Because of difficulty to appreciate the junction of SVC and right atrium in the standard AP chest radiograph, we decided to use the carina as the radiographic landmark of measurement. Considering the recommendation of Food and Drug Administration guidelines for central venous catheter placements that catheter tips never enter the atrium and a report about catheter migration with movement of the patient's arms or head 1-3 cm caudally, we tried to locate the tip of PICC in the distal SVC fast the carina [19, 20, 21]. In addition, because all of our cases were done from left side and the catheter tip usually abut the right SVC wall with obtuse angle when the catheter tip ends near the carina because of the natural anatomy of the junction of left innominate vein and SVC and stiffness of the catheter, so, we tried to insert more deeply fast the carina as possible to distal SVC or proximal atrium. Possibility of catheter tip movement according to phase of respiration, catheter type, insertion site, body habitus, and body position contributed to this decision, also [22-24]. Although some debates about the preferential laterality of PICCs are present, we selected mostly left basilic vein as a first choice because of various causes such as non-dominant arm selection, higher rates of venous thrombosis in cases of cephalic vein selection and median nerve bisection in case of brachial vein selection [25-27]. We used the formula of our previous report of ECL through right basilic vein based on patient height when we decide the catheter length inside the body, and considered the report that left innominate vein is 3.5 to 4 cm longer than the right one [7, 15]. Although there are documentations about the length of upper extremity veins including cephalic, basilic, axillary, subclavian, and innominate veins as well as SVC, those are only for the average-sized adult [5, 10]. So, we think our equation is more useful because it reflects correctly the patient's height and weight statistically significantly. Although the estimation from the equation is not used initially during peripherally implantable venous access port insertion, we believe this equation would be helpful for the calculation of the length of upper arm vein to carina in the case of exchange. Among the intra-procedural methods for correct catheter tip positioning without the aid of fluoroscopy, the electrocardiography (EKG) method was proved to have many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and more cost-effective [28]. So, with the result of our equation of ECL through upper arm vein, the rate of successful central location of PICC tip could be greatly increased when combined with the method of catheter length determination using our equation. PICC tip movement of an average of 3.2 cm on changing position is more pronounced in overweight patients and with larger catheters [24]. This is one of the reasons why Page 15 of 19 the weight should be considered during the process of catheter length determination, in addition to the fact that overweight patient has wider chest width than thin patient. There are several limitations to our study. First, the distance from the carina to the tip of PICC catheter on PACS image was measured by only one radiologist. But, we believe the data is quite correct, because the radiologist inserted most of the PICC. Second, the PICC catheter itself is not straight but slightly curved roundly, so, the discrepancy is inevitable between the straightly measured distance from the carina to the tip of catheter and slightly curved catheter length. But, it is thought to be not great. Third, there can be anthropometric difference in the length of upper extremity in various races. All of our patients were Korean. There was significant correlation between the height and weight of the patient and the length of left upper extremity vein from elbow crease to carina. We could get equations of ECL, and could estimate the length of left upper extremity vein simply by height and weight of the patient. When the PICC insertion procedure is required without the aid of fluoroscopy, the results of our study will be very helpful to locate the catheter tip at the central vein correctly. References 1. Ng PK, Ault MJ, Ellrodt AG, Maldonado L. Peripherally inserted central catheter in general medicine. Mayo Clin Proc.1997;72: Bottino J, McCredie KB, Groschel DH, Lawson M. Long-term intravenous therapy with peripherally inserted silicon elastomer central venous catheters in patients with malignant disease. Cancer. 1979;43: Goltz JP, Scholl A, Ritter CO, Wittenberg G, Hahn D, Kickuth R. Peripherally Placed Totally Implantable Venous-access Port Systems of the Forearm: Clinical Experience in 763 Consecutive Patients. Cardiovasc Intervent Radiol. 2010;33: Kearns PJ, Coleman S, Wehner JH. Complications of long arm-catheters: a randomized trial of central vs. peripheral tip locationjpen J Parenter Enteral Nutr. 1996;20: Tip of peripherally inserted central catheters. A position statement of the National Association of Vascular Access Networks. J Vasc Access Devices. 1998;3:8-10. Page 16 of 19 6. Neuman ML, Murphy BD, Rosen MP. Bedside placement of peripherally inserted central catheters: a cost-effectiveness analysis. Radiology. 1998;206: Vineet Chopra, Scott A. Flanders, Sanjay Saint. The Problem with Peripherally Inserted Central Catheters JAMA. 2012;308: Cardella JF, Cardella K, Bacci N, Fox PS, Post JH. Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. J Vasc Interv
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