Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor; Patient Safety Enhancement Program and Center for Clinical Management Research, VA Ann Arbor Health Care System, Mich; Michigan Hospital Medicine Safety Consortium, Ann Arbor.
Henry Ford Health System, Detroit, Mich.
Am J Med. 2018 Jun;131(6):651-660. doi: 10.1016/j.amjmed.2018.01.017. Epub 2018 Feb 1.
Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.
We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.
Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).
Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.
外周静脉置入中心静脉导管（PICC）故障时，常需经导丝进行导管交换。但目前尚不清楚这种导管交换是否会增加静脉血栓栓塞症（venous thromboembolism，VTE）的风险。
我们进行了一项回顾性队列研究，以评估 PICC 交换与血栓形成风险之间的关系。这项研究纳入了在密歇根医院医学安全联盟的 51 家医院中接受治疗的成年住院患者，他们在临床治疗中接受了 PICC 置管。主要结局是发生有症状的 VTE（经影像学证实的上肢深静脉血栓形成和肺栓塞）的风险，比较行 PICC 交换的患者与未行 PICC 交换的患者。
在这项研究中，有 23010 例患者接受了 PICC 置管，其中 589 例（2.6%）接受了 PICC 交换。几乎一半的交换都是为了处理导管移位或堵塞。共有 480 例（2.1%）患者发生了与 PICC 相关的深静脉血栓形成。与未行 PICC 交换的患者相比，行 PICC 交换的患者深静脉血栓形成的发生率更高（3.6% vs 2.0%，P<0.001）。与未行 PICC 交换的患者相比，行 PICC 交换的患者血栓形成的中位时间更短（5 天 vs 11 天，P=0.02）。在校正混杂因素后，PICC 交换与血栓形成风险增加 2 倍相关（风险比[HR] 1.98；95%置信区间[CI]，1.37-2.85），而与不交换相关。PICC 交换对血栓形成的影响大小仅次于导管腔数（HR 2.06；95%CI，1.59-2.66 和 HR 2.31；95%CI，1.6-3.33，分别用于双腔和三腔装置）。
PICC 经导丝交换可能与血栓形成风险增加相关。鉴于一些交换可能是可以预防的，因此在临床实践中需要考虑交换的风险和获益。
