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JBUON 2019; 24(6): 2546-2552
ISSN: 1107-0625, online ISSN: 2241-6293 • www.jbuon.com
Email: editorial_oce@jbuon.com
ORIGINAL ARTICLE
Corresponding author: Dr. Fengxiang Sui. Department of Respiration, Qingdao Municipal Hospital, No.1 Jiaozhou Rd, Qingdao
266000, P.R. China
Tel/Fax: +86 0532 82789159, Email: fokez5@163.com
Received: 06/04/2019, Accepted: 14/05/2019
Perioperative application of midline catheter and PICC in
patients with gastrointestinal tumors
Fengying Tao1, Xiaohe Wang1, Jiumei Liu2, Jing Li3, Fengxiang Sui4
1
Section two of Oncology Department, Qingdao Municipal Hospital, Qingdao 266000, P.R. China;
2
Department of Breast Surgery,
Qingdao Central Hospita, Qingdao 266042, P.R. China; 3Department of Surgery, People’s Hospital of Zhangqiu District, Jinan
250200, P.R. China; 4Department of Respiration, Qingdao Municipal Hospital, Qingdao 266000, P.R. China.
Summary
Purpose: This study aimed to compare the application value
of midline catheter and peripherally inserted central catheter
(PICC) in patients with gastrointestinal tumors during the
perioperative period.
Methods: 487 patients with gastrointestinal tumors ad-
mitted to Qingdao Municipal Hospital from August 2016
to September 2018 were selected and retrospectively ana-
lyzed. 279 patients treated with midline catheters during
the treatment were regarded as the study group, and another
208 patients treated with PICC were regarded as the control
group. The incidence of perioperative adverse reactions, the
cost of daily catheter maintenance and the the total cost of
catheter indwelling were compared between the two groups.
Meanwhile, each patient was investigated for treatment sat-
isfaction at the time of discharge.
Results: The total incidence of adverse reactions in the study
group was signicantly lower than that in the control group
(p=0.0001). The catheter indwelling duration in the study
group was signicantly shorter than that in the control group
(p<0.001). The 24-h drainage volume in the study group was
signicantly higher than that in the control group (p<0.001).
The average cost of daily maintenance and total cost of cath-
eter indwelling in the study group were signicantly lower
than those in the control group (p<0.001). The satisfaction
rate in the study group (69.53%) was signicantly higher
than that in the control group (51.92%) (p<0.001). The dis-
satisfaction rate in the study group (3.23%) was signicantly
lower than that in the control group (15.38%) (p<0.001).
Conclusion: Compared with PICC, the perioperative appli-
cation of midline catheter in patients with gastrointestinal
tumors can eectively reduce catheter-related adverse reac-
tions, with higher medical economic benets and satisfaction
rate, and is worthy of clinical promotion and application.
Key words: adverse reactions, economic benets of treat-
ment, gastrointestinal tumor, midline catheter, PICC, sat-
isfaction rate
Introduction
Gastrointestinal tumors are very common ma-
lignancies in the clinic and are included among the
deadliest cancers [1]. According to relevant data, the
proportion of new patients suering of this disease
in 2018 has exceeded 23.5% [2], and with the rapid
population growth in recent years, its incidence
is increasing year by year [3]. Moreover, gastroin-
testinal tumors are usually characterized by acute
onset, rapid course of disease and treatment dif-
culties, which pose a great threat to patients [4].
They have been classied as key research projects
in clinical practice, and researchers at home and
abroad are committed to continuously and deeply
studying their diagnosis and treatment [5,6]. At pre-
sent, preoperative and postoperative chemotherapy
and intravenous nutritional support are usually re-
quired in clinical treatment of gastrointestinal tu-
mors, while intravenous infusion of chemotherapy
This work by JBUON is licensed under a Creative Commons Attribution 4.0 International License.
Application of midline catheter and PICC in gastrointestinal tumors
2547
JBUON 2019; 24(6): 2547
drugs and nutrient solutions will greatly increase
the risk of thrombosis in patients [7]. Therefore,
deep vein intubation or peripherally inserted cen-
tral catheter (PICC) are usually used in establishing
intravenous infusion [8]. Many studies around the
world have shown that PICC can eectively reduce
the probability of catheter-related infections and
thrombosis in patients [9], but some studies have
pointed out that PICC is more likely to cause blood
infection and increase the risk of adverse reactions
compared with Hickman catheter [10]. Therefore,
nding a safer and more eective catheter place-
ment method is a hotspot in clinical practice.
Peripheral venous midline catheters, also
known as midline catheters for short, are the latest
infusion tools for peripheral vein catheterization,
which not only reduce the pain of patients during
venipuncture, but also decrease the stimulation of
drugs on blood vessels. Moreover, X-ray localiza-
tion is not necessary during puncture, thus great-
ly improving medical benets [11,12]. Studies at
home and abroad have proved that midline catheter
can eectively reduce the incidence of exudation
and other complications [13,14]. However, as it is
generally inserted from vein or cephalic vein with
its tip not beyond axillary vein, the use of midline
catheter when injecting chemotherapy drugs and
nutrient solution is not recommended in clinical
practice [15]. Our hospital has achieved remark-
able results by increasing the insertion depth of
catheters to the subclavian vein and applying it to
chemotherapy and nutritional support for patients
in the Department of Gastroenterology.
The purpose of this study was to compare the
application value of midline catheter and PICC in
patients with gastrointestinal tumors during the
perioperative period, and to provide reference and
guidance for clinical practice.
Methods
General information
487 patients with gastrointestinal tumors admitted
to the Department of Digestive and Oncology of Qingdao
Municipal Hospital from August 2016 to September
2018 were selected and retrospectively analyzed, includ-
ing 309 males and 178 females, aged 42-73 years, with
an average age of 58.63±8.84 years. 279 patients treat-
ed with midline catheters during the treatment were
regarded as the study group and another 208 patients
treated with PICC were regarded as the control group.
Inclusion and exclusion criteria
Inclusion criteria: According with clinical manifesta-
tions of gastrointestinal tumors; diagnosed with gastro-
intestinal tumor by biopsy in our pathology department;
indications for surgery; being on treatment in Qingdao
Municipal Hospital aer diagnosis; receiving periopera-
tive chemotherapy and intravenous nutrition support
during perioperative period; receiving no radiotherapy
and chemotherapy within 3 months before surgery; with
complete case data; cooperating with the medical sta
of our hospital; aged 30-80 years.
Exclusion criteria: complicated with other tumors;
severe cardio-cerebrovascular diseases; abnormal blood
routine tests and coagulation dysfunction; organ failure;
hepatic and renal insuciency; vein defect, infection and
thrombosis in anterior cubital region; physical disability;
mental disorders; long-term bed rest, unable to take care
of themselves; transferring to another hospital.
Methods
Aer being evaluated by Qingdao Municipal Hos-
pital’s chief digestive surgeon, both groups of patients
were required to undergo chemotherapy and intrave-
nous nutrition support during the perioperative pe-
riod. Catheterization operations were all completed by
the nursing sta in Qingdao Municipal Hospital who
possessed qualied certicates for PICC catheteriza-
tion. PICCs were purchased from Bard Company, USA,
Groshong NXT CleraVue, with the batch number of
RECN0713. The midline catheters were purchased from
Health Line International Corporation, USA, with the
product code of A120121303. PICC in the control group:
patients were placed in supine position, then ultrasound
was applied to conduct elbow vascular examination in
order to determine the puncture location. The distance
from the puncture point to the third rib of the lateral
sternoclavicular joint was measured to determine the
length of the catheter. Venipuncture was performed af-
ter routine disinfection of the puncture point, then the
catheter length was recorded. Aer daily infusion, 10 mL
of normal saline was used to ush the catheter, and 3 ml
of 10 U/ml heparin saline was used to seal the catheter.
Midline catheter in the study group: the puncture loca-
tion and puncture process were the same as above, but
the length of catheter was determined by measuring the
distance from the puncture point to the midpoint of the
lateral clavicle. Aer daily infusion, 10 mL of normal
saline was used to ush and then to seal the catheter.
Outcome measures
The incidence rate of adverse reactions in the perio-
perative period of patients in the two groups such as
catheter-related blood stream infection, phlebitis, cath-
eter displacement was evaluated. The incidence rate of
adverse reactions equaled to the number of the adverse
reactions /total number of cases × 100%. Catheter in-
dwelling duration and drainage volume within 24 h
were recorded. Economic benets of treatment were
also recorded: the cost of daily catheter maintenance
and the the total cost of catheter indwelling of patients
in the two groups. Satisfaction survey: referring to the
research of Becker-Schiebe et al, the treatment satisfac-
tion survey was carried out on each patient at discharge
[16]. The results were divided into satisfaction, needing
improvement and dissatisfaction, and the satisfaction
rate of patients in the two groups was calculated.
Application of midline catheter and PICC in gastrointestinal tumors
2548
JBUON 2019; 24(6): 2548
Statistics
SPSS24.0 statistical soware (Beijing Strong-Vinda
Information Technology Co., Ltd.) was used to calculate
all experimental results, and the Graphpad8 (Shenzhen
So Head Soware Technology Co., Ltd.) was used to
draw all gures and double check the results. Counting
data were expressed as rates, and chi-square test was
used for comparison between groups. The measurement
data were all expressed as mean ± standard deviation,
and t-test was used for the comparison between groups.
P<0.05 indicated statistical signicance.
Results
Comparison of clinical data
There was no signicant dierence in terms of
age, body mass index (BMI), blood routine tests,
gender, tumor type, pathological stage, nodal me-
tastasis, dierentiation grade, residence, smoking
habits and exercise habits between the two groups
(p>0.05), proving the comparability between the
two groups (Table 1).
Comparison of incidence of adverse reactions
In the study group, 2 patients (0.72%) devel-
oped phlebitis, 3 (1.08%) developed catheter-related
blood stream infection, 2 (0.72%) developed throm-
bosis and zero catheter obstruction and zero cath-
eter displacement, whereas in the control group,
5 patients (2.40%) developed phlebitis, 6 (2.88%)
developed catheter-related blood stream infection,
1 (0.48%) had catheter displacement, 7 (3.37%)
developed thrombosis, and zero catheter obstruc-
tion. The total incidence of adverse reactions in
Study group (n=279) Control group (n=208) t or x2p
Age (years), mean±SD 59.17±9.07 58.62±10.55 0.617 0.538
BMI (kg/m2), mean±SD 20.59±6.41 20.87±7.05 0.457 0.648
White blood cells (×109/L), mean±SD 4.05±1.04 4.11±0.95 0.653 0.514
Red blood cells (×1012/L), mean±SD 4.84±1.58 4.92±1.83 0.516 0.606
Platelets (×109/L), mean±SD 218.64±42.66 221.63±45.07 0.747 0.456
Gender, n (%) 0.034 0.853
Male 178 (63.80) 131 (62.98)
Female 101 (36.20) 77 (37.02)
Tumor type, n (%) 2.220 0.330
Gastric cancer 117 (41.94) 95 (45.67)
Colorectal cancer 94 (33.69) 74 (35.58)
Esophageal cancer 68 (24.37) 39 (18.75)
Pathological stage, n (%) 0.503 0.478
I-II 92 (32.97) 75 (36.06)
III-IV 187 (67.03) 133 (63.94)
Lymph node, n (%) 0.246 0.620
Yes 42 (15.05) 28 (13.46)
No 237 (84.95) 180 (86.54)
Grade of dierentiation, n (%) 1.401 0.496
High 53 (19.00) 31 (14.90)
Moderate 164 (58.78) 128 (61.54)
Poor 62 (22.22) 49 (23.56)
Residence, n (%) 0.274 0.601
City 194 (69.53) 140 (67.31)
Countryside 85 (30.47) 68 (32.69)
Smoking, n (%) 0.377 0.539
Yes 164 (58.78) 128 (61.54)
No 115 (41.22) 80 (38.46)
Exercise, n (%) 1.254 0.263
Yes 64 (22.94) 39 (18.75)
No 215 (77.06) 169 (81.25)
Table 1. Comparison of clinical data
Application of midline catheter and PICC in gastrointestinal tumors
2549
JBUON 2019; 24(6): 2549
the study group was 2.51%, signicantly lower
than that in the control group (9.13%) (p=0.0001)
(Table 2).
Comparison of catheter indwelling duration and drain-
age volume within 24 hours
The mean indwelling duration of catheter in
the study group was 4.16±1.12 days, signicantly
shorter than that in the control group (6.27±2.18
days, p<0.001). The mean 24-h drainage volume
in the study group was 472.62±61.53 mL, sig-
nicantly higher than that in the control group
(309.68±40.57, p<0.001 (Figures 1 and 2).
Comparison of therapeutic economic benets
The mean daily maintenance cost in the study
group (127.62±12.63 yuan) was signicantly lower
than that in the control group (178.26±15.63 yuan,
p<0.001). The mean total cost of catheter indwell-
ing in the study group was 972.86±40.57 yuan
which was also signicantly lower than that in the
control group (1418.62±60.84 yuan, p<0.001) (Fig-
ures 3 and 4).
Comparison of treatment satisfaction rate
There was no signicant dierence between
the two groups in patients assessed as needing
improvement (p>0.05). The satisfaction rate in the
study group (69.53%) was signicantly higher than
that in the control group (51.92%, p<0.001). The
dissatisfaction rate in the study group was 3.23%,
signicantly lower than that in the control group
(15.38%, p<0.001) (Table 3).
Discussion
Intravenous infusion and intravenous nutri-
tion support are very common in clinical nursing.
At present, there are many methods of intravenous
infusion treatment, including midline catheter,
PICC, tunnel catheter, embedded infusion port,
etc. [17]. However, patients with gastrointestinal
tumors are oen accompanied by low nutrition,
decreased motor function and poor vascular elas-
ticity, so repeated common vascular puncture is not
conducive to the treatment [18]. Therefore, indwell-
ing catheter is the most common intravenous infu-
Study group (n=279)
n (%)
Control group (n=208)
n (%)
x2p
Phlebitis 2 (0.72) 5 (2.40)
Catheter-related blood stream infection 3 (1.08) 6 (2.88)
Catheter obstruction 0 (0.00) 0 (0.00)
Catheter displacement 0 (0.00) 1 (0.48)
Thrombosis 2 (0.72) 7 (3.37)
Total incidence (%) 2.51 9.13 10.352 0.001
Table 2. Comparison of incidence of adverse reactions
Figure 1. Comparison of catheter indwelling duration. The
indwelling duration of catheter in the study group was sig-
nicantly shorter than that in the control group (*p<0.001).
Figure 2. Comparison of drainage volume within 24 hours.
The 24-h drainage volume in the study group was signi-
cantly higher than that in the control group (*p<0.001).
Application of midline catheter and PICC in gastrointestinal tumors
2550
JBUON 2019; 24(6): 2550
sion tool in patients with gastrointestinal tumors.
PICC is a technique that uses a catheter to puncture
the peripheral vein and then insert into the great
vein near the heart, which has been widely used in
clinical practice, with high success rate and high
application value [19]. PICC can not only reduce the
stimulation and injury of chemotherapy drugs to
blood vessels, but also decrease the occurrence rate
of secondary injury and infection in the treatment
process due to long indwelling duration. Currently,
it is most commonly used in cancer patients [20].
However, as a new vein indwelling tool, the mid-
line catheter is mainly punctured from brachioce-
phalic vein, basilic vein or median cubital vein to
great vein, with a indwelling duration reaching 1-7
weeks [21]. Midline catheter has the same value
as PICC for intravenous infusion, and some stud-
ies have even pointed out that the application of
midline catheter is more valuable than PICC in the
treatment of pediatric diseases [22]. However, due
to the fact that the research on the application of
midline catheters in China has not yet been popu-
larized, the exact analysis of their eects is still
controversial. Therefore, through strict inclusion
and exclusion criteria, advanced statistical soware
and long-term sample collection, this experiment
compared the application value of midline cath-
eter and PICC in gastrointestinal tumors, provid-
ing a new direction for future clinical selection of
treatments.
Results of this experiment showed that the
incidence of adverse reactions in the study group
treated with midline catheters was signicantly
lower than that in the control group with PICC,
which is consistent with the results of Anderson et
al [22] using midline catheters in the treatment of
pediatric diseases. Therefore, the midline catheters
are better than PICC in reducing the incidence rate
of adverse reactions of gastrointestinal patients
during the perioperative period. The reason for
the dierence is attributed to the dierent place-
ment methods between the midline catheter and
PICC. Puncture can be performed under direct vi-
sion with midline catheter and PICC, which can
eectively avoid pneumothorax, hemothorax and
other complications caused by blind puncture [23].
However, cancer patients are highly likely to have
blood hypercoagulability, resulting in a high risk
of thrombosis [24], while blood cell attachment in
subclavian veins is signicantly lower compared
with other parts because of the large quantity and
speedy blood ow [25], which also greatly reduces
the probability of venous thrombosis caused by
midline catheters. The midline catheter place-
ment is quite away from the heart and does not
require X-ray uoroscopy during the perioperative
Study group (n=279)
n (%)
Control group (n=208)
n (%)
x2p
Satisfaction 196 (70.25) 108 (51.92) 15.693 <0.001
Needing improvement 74 (26.52) 68 (32.69) 2.195 0.138
Dissatisfaction 9 (3.23) 32 (15.38) 22.852 <0.001
Table 3. Comparison of treatment satisfaction rate between two groups
Figure 3. Comparison of average daily maintenance cost.
The average daily maintenance cost in the study group was
signicantly lower than that in the control group (*p<0.001).
Figure 4. Comparison of total cost of catheter indwelling.
The total cost of catheter indwelling in the study group was
signicantly lower than that in the control group (*p<0.001).
Application of midline catheter and PICC in gastrointestinal tumors
2551
JBUON 2019; 24(6): 2551
period, so it is safer and has no radiation in pa-
tients. However, there are many factors aecting
the occurrence of venous thrombosis, thus the ex-
act mechanism needs to be further conrmed. This
study showed that the indwelling duration of cath-
eter in the study group was signicantly shorter
than that in the control group, while the drainage
volume within 24 h was signicantly higher than
that in the control group, suggesting that the ef-
fects of midline catheter on drainage and shorten-
ing indwelling duration were signicantly higher
than that of PICC in patients with gastrointestinal
tumors during the perioperative period. This study
also found that the economic benets in the study
group were signicantly better than those in the
control group, which also suggests that the use
of midline catheter to treat gastrointestinal tu-
mors costs less and reduces the nancial burden
of patients. This is due to the fact that the midline
catheter is located in the axillary vein and does not
need to use X-ray for tip location aer puncture,
and the sealing can be accomplished with normal
saline without additional expenses. In addition, the
survey results demonstrated that the treatment sat-
isfaction rate in the study group was signicantly
higher than that in the control group, suggesting
that the popularization of midline catheters in pa-
tients with gastrointestinal tumors is feasible, and
the experience is better than that of PICC. Midline
catheter reduces the pressure of nursing sta on
puncture and also eectively adjusts their work-
ing eciency, also relieving the pain of patients.
Moreover, the ow rate of the drug infused is high-
er than that of the blood in supercial vein of the
upper arm, which eectively dilutes the side eects
of the drug, reduces the stimulation to the vascular
endothelium, and thus reduces the incidence rate
of adverse reactions [26]. Moreover, compared with
PICC, its more aordable medical expenses produce
less pressure on patients and their families.
This study compared the application value of
midline catheter and PICC in gastrointestinal tu-
mors. However, due to the limited experimental
conditions, our study presents some limitations.
Firstly, there was a lack of specic comparison
with more kinds of infusion tools. Secondly, the
exact impact of midline catheter on gastrointes-
tinal tumor patients still remains unclear, so fur-
ther experimental analysis is still needed to verify
our hypothesis. Thirdly, the tumors studied in this
study were mainly gastric cancer, colorectal can-
cer and esophageal cancer, so it is impossible to
analyze in detail the eect of midline catheters on
each tumor. Therefore, we will expand the sample
size of the research object and further explore the
application of midline catheters to obtain the best
experimental results.
To sum up, compared with PICC, the periopera-
tive application of midline catheter in patients with
gastrointestinal tumors can eectively reduce cath-
eter-related adverse reactions, with higher medi-
cal economic benets and satisfaction rate, and is
worthy of clinical promotion and application.
Conict of interests
The authors declare no conict of interests.
References
1.
Marusawa H, Jenkins BJ. Inammation and gastrointes-
tinal cancer: an overview. Cancer Lett 2014;345:153-6.
2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA,
Jemal A. Global cancer statistics 2018: GLOBOCAN
estimates of incidence and mortality worldwide for 36
cancers in 185 countries. CA Cancer J Clin 2018;68:394-
424.
3. Pourhoseingholi MA, Vahedi M, Baghestani AR. Bur-
den of gastrointestinal cancer in Asia; an overview.
Gastroenterol Hepatol Bed Bench 2015;8:19-27.
4.
Peery AF, Dellon ES, Lund J et al. Burden of gastro-
intestinal disease in the United States: 2012 update.
Gastroenterology 2012;143:1179-87.e1173.
5. Li T, Meng XL, Yang WQ. Long Noncoding RNA PVT1
Acts as a “Sponge” to Inhibit microRNA-152 in Gastric
Cancer Cells. Dig Dis Sci 2017;62:3021-8.
6. Shao YG, Ning K, Li F. Group II p21-activated kinases
as therapeutic targets in gastrointestinal cancer. World
J Gastroenterol 2016;22:1224-35.
7. Tuzovic M, Herrmann J, Iliescu C, Marmagkiolis K, Zi-
aeian B, Yang EH. Arterial Thrombosis in Patients with
Cancer. Curr Treat Options Cardiovasc Med 2018;20:40.
8. Nolan ME, Yadav H, Cawcutt KA, Cartin-Ceba R. Com-
plication rates among peripherally inserted central
venous catheters and centrally inserted central cath-
eters in the medical intensive care unit. J Crit Care
2016;31:238-42.
9.
Grau D, Clarivet B, Lotthe A, Bommart S, Parer S. Com-
plications with peripherally inserted central catheters
(PICCs) used in hospitalized patients and outpatients:
a prospective cohort study. Antimicrob Resist Infect
Contro 2017;l6:18.
Application of midline catheter and PICC in gastrointestinal tumors
2552
JBUON 2019; 24(6): 2552
10.
Christensen LD, Holst M, Bech LF et al. Comparison
of complications associated with peripherally inserted
central catheters and Hickman catheters in patients
with intestinal failure receiving home parenteral nutri-
tion. Six-year follow up study. Clin Nutr 2016;35:912-7.
11. Woller SC, Stevens SM, Evans RS. The Michigan Ap-
propriateness Guide for Intravenous Catheters (MAG-
IC) initiative: A summary and review of peripherally
inserted central catheter and venous catheter appropri-
ate use. J Hosp Med 2016;11:306-10.
12.
Nuckols TK, Keeler E, Morton SC et al. Economic Evalu-
ation of Quality Improvement Interventions for Blood-
stream Infections Related to Central Catheters: A Sys-
tematic Review. JAMA Intern Med 2016;176:1843-54.
13. Mushtaq A, Navalkele B, Kaur M et al. Comparison of
complications in midlines versus central venous cath-
eters: Are midlines safer than central venous lines? Am
J Infect Control 2018;46:788-92.
14. Caparas JV, Hu JP. Safe administration of vancomycin
through a novel midline catheter: a randomized, pro-
spective clinical trial. J Vasc Access 2014;15:251-6.
15.
Johnston AJ, Holder A, Bishop SM, See TC, Streater
CT. Evaluation of the Sherlock 3CG Tip Conrmation
System on peripherally inserted central catheter mal-
position rates. Anaesthesia 2014;69:1322-30.
16.
Becker-Schiebe M, Pinkert U, Ahmad T, Schafer C, Ho-
mann W, Franz H. Predictors of overall satisfaction of
cancer patients undergoing radiation therapy. Patient
Prefer Adherence 2015;9:1381-8.
17. Xu T, Kingsley L, DiNucci S et al. Safety and utiliza-
tion of peripherally inserted central catheters versus
midline catheters at a large academic medical center.
Am J Infect Control 2016;44:1458-61.
18. Zhang L, Lu Y, Fang Y. Nutritional status and related
factors of patients with advanced gastrointestinal can-
cer. Br J Nutr 2014;111:1239-44.
19. Harrold K, Martin A, Scarlett C. Proactive PICC place-
ment: evaluating the patient experience. Br J Nurs
2016;25:S4-14.
20. Kabsy Y, Baudin G, Vinti H et al. Peripherally inserted
central catheters (PICC) in onco-hematology. PICC line
in onco-hematology. Bull Cancer 2010;97:1067-71.
21.
Adams DZ, Little A, Vinsant C, Khandelwal S. The
Midline Catheter: A Clinical Review. J Emerg Med
2016;51:252-8.
22.
Day DL, Conde F. Evaluation of Dwell Time for Pe-
ripheral Intravenous Catheters Started in the Field
for Geriatric Blunt Trauma Patients. J Trauma Nurs
2018;25:165-70.
23. Cotogni P, Pittiruti M. Focus on peripherally inserted
central catheters in critically ill patients. World J Crit
Care Med 2014;3:80-94.
24.
Mager R, Daneshmand S, Evans CP et al. Renal cell
carcinoma with inferior vena cava involvement: Prog-
nostic eect of tumor thrombus consistency on cancer
specic survival. J Surg Oncol 2016;114:764-8.
25.
Ballard DH, Samra NS, Giord KM, Roller R, Wolfe
BM, Owings JT. Distance of the internal central venous
catheter tip from the right atrium is positively cor-
related with central venous thrombosis. Emerg Radiol
2016;23:269-73.
26.
Wada M, Kitayama M, Hashimoto H et al. Brief reports:
plasma ropivacaine concentrations aer ultrasound-
guided rectus sheath block in patients undergoing
lower abdominal surgery. Anesth Analg 2012;114:
230-2.
