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DOI: 10.1542/peds.99.2.e4
1997;99;e4Pediatrics
Ravi R. Thiagarajan, Chandra Ramamoorthy, Theresa Gettmann and Susan L. Bratton
Survey of the Use of Peripherally Inserted Central Venous Catheters in Children
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of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
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Survey of the Use of Peripherally Inserted Central Venous Catheters in
Children
Ravi R. Thiagarajan, MBBS, MRCP*; Chandra Ramamoorthy, MBBS, FRCA*; Theresa Gettmann, RN, BSN‡;
and Susan L. Bratton, MD, MPH*
ABSTRACT. Objective. Use of peripherally inserted
central venous catheters (PICCs) to provide prolonged
intravenous (IV) access in children is increasing. Our
goal was to describe the children treated with PICCs
in our institution, and to study catheter features such
as catheter life, completion of therapy, and complica-
tions. Furthermore, we also evaluated PICC use in
children completing therapy after discharge from our
institution.
Methods. A prospective study of all PICCs inserted at
the Children’s Hospital and Medical Center (CHMC), a
university-affiliated teaching institution, during a period
of 18 months (January 1994 to July 1995).
Results. A total of 441 PICCs were inserted in 390
patients. Patient age ranged from 0 to 22 years with a
mean of 5.4 66.0 years. No insertion complications oc-
curred. Treatment of infectious disease (46%) was the
most frequent reason for PICC insertion. All pediatric
medical and surgical services used PICCs. Average cath-
eter life was 13 612 days. Sixty-one percent of PICCs
were used entirely at CHMC, while 39% were also used
at home or at an outside hospital. Completion of therapy
was achieved in 69% of PICCs. Among children who
completed therapy outside our hospital, there was no
difference in the rates of occlusion, accidental dislodg-
ment, or infection.
One hundred twenty-nine (29%) PICCs were removed
for complications. Occlusion (7%), accidental displace-
ment (8%), and suspicion of sepsis (8%) were the most
common complications. Only 2% of PICCs had docu-
mented catheter-associated sepsis.
Conclusions. PICCs provide reliable and safe access
for prolonged IV therapy in neonates and children. The
low incidence of complications with PICCs make them
an attractive device for prolonged IV access. Similar
complication rates with use in and out of hospital sug-
gest that home IV therapy can be safely delivered with
PICCs, avoiding expensive hospitalization. Pediatrics
1997;99(2). URL: http://www.pediatrics.org/cgi/content/
full/99/2/e4; peripherally inserted central venous catheter,
vascular access, catheter related sepsis, completion of
therapy, occlusion, accidental dislodgment, home therapy,
phlebitis.
ABBREVIATIONS. PICC, peripherally inserted central venous
catheter; IV, intravenous; TPN, total parenteral nutrition; CHMC,
Children’s Hospital and Medical Center; SVC, superior vena cava;
IVC, inferior vena cava.
Peripherally inserted central venous catheters
(PICCs) are frequently used to provide prolonged
intravenous (IV) access in both acute and home care
settings. Shaw described PICC use in 1973 as a
method of providing reliable vascular access for total
parenteral nutrition (TPN) in neonates.1,2 PICCs were
subsequently used to provide IV access for adminis-
tration of prolonged antibiotic courses in children
with cystic fibrosis during pulmonary exacerba-
tions.3PICCs lasted twice as long as conventional
peripheral IV cannulae, reducing the number of ve-
nipunctures by half and enabling home therapy.3
PICC utilization has continued to increase because
these catheters are easy to insert and have a low
incidence of complications compared with other sur-
gically placed central lines.2,4–10
PICCs are made of biocompatible material, usually
polyurethane or silicone. Insertion is simple and is
usually done by nursing personnel who have com-
pleted a recommended certification process.6The
success rate for insertion of PICCs ranges from 78%
to 92%.4,5,11,12 Veins of the antecubital fossa are com-
monly used; however, the saphenous, axillary, or
even scalp veins can be used.3,6,9 Complications asso-
ciated with PICC insertion are infrequent, but in-
clude bleeding, tendon or nerve damage, cardiac
arrhythmias, chest pain, catheter malposition, and
catheter embolism.5–7
Few studies have examined the use of these cath-
eters in a large pediatric population. We examined
PICC utilization in a university-affiliated children’s
hospital. Our goals were to describe the patient pop-
ulation treated with PICCs as well as catheter fea-
tures such as average catheter life, completion of
therapy, reasons for removal, and complications. Fi-
nally, we compared PICC-related data of children
receiving therapy at home, or at an outside hospital,
with those hospitalized for the entire time of PICC
use.
METHODS
Information was prospectively collected on all PICCs inserted
at Seattle Children’s Hospital and Medical Center (CHMC) during
an 18-month period from January 1994 to July 1995. PICCs were
inserted primarily by the IV nursing team. Referrals for catheter
From the *Department of Anesthesiology, University of Washington School
of Medicine, Department of Anesthesia and Critical Care, Children’s Hos-
pital and Medical Center, Seattle, Washington; and the ‡Department of
Nursing, Children’s Hospital and Medical Center, Seattle, Washington.
Received for publication Apr 19, 1996; accepted Jul 16, 1996.
Address correspondence to: Susan L. Bratton, MD, MPH, Department of
Anesthesia and Critical Care, Children’s Hospital and Medical Center, 4800
Sandpoint Way NE, Seattle, WA 98105.
PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad-
emy of Pediatrics.
http://www.pediatrics.org/cgi/content/full/99/2/e4 PEDIATRICS Vol. 99 No. 2 February 1997 1of4
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placement occurred at the discretion of the patient’s primary
physician and were made directly to the IV team.
All insertions were done as inpatient procedures. Per-Q-Cath
(Gesco Inc, San Antonio, TX) or L-Cath (Luther Medical Products
Inc, Tustin, CA) catheters of sizes ranging from 2- to 5-French
(catheter size 23-gauge to 16-gauge) were used. The size and
choice of catheter was determined by the IV team member insert-
ing the catheter. Anesthesia was provided with 1% lidocaine local
infiltration or EMLA cream (Astra Pharmaceuticals, Westborough,
MA), supplemented when needed with oral chloral hydrate or IV
midazolam.
Patient preparation and insertion techniques were standard-
ized by hospital protocol. After a suitable vein for insertion was
identified, the area of skin at the proposed insertion site was
cleaned with povidone-iodine solution, and covered with sterile
drapes. The IV team member inserting the catheter wore a cap,
mask, sterile gown, and sterile gloves. After infiltrating the site
with 1% lidocaine, the vein was punctured using the introducer
needle. The catheter was then inserted through the needle, to a
premeasured length. The needle was then removed and the exit
site was dressed with dry sterile gauze. The dressing was changed
every week, or earlier if soiled. The location of the catheter tip was
determined radiographically. When the tip was not easily visible
by the plain radiograph, contrast material injected through the
catheter was used to delineate the tip. The tip was considered to be
in a central vein if it was placed in the superior vena cava (SVC),
the inferior vena cava (IVC), or subclavian vein. Afterwards, cath-
eter care was administered by the nurses caring for the patient. At
insertion, patient demographic information was recorded on a log
sheet by the IV team member inserting the catheter. The IV team
monitored these catheters closely and recorded complications for
the duration of catheter use on the log sheet.
PICCs were used for IV fluid therapy, administration of med-
ication, and blood products. TPN solutions with dextrose concen-
trations of more than 12.5% were administered through centrally
placed catheters. Catheters were accessed continuously or inter-
mittently. For PICCs accessed continuously, the use of heparin to
maintain line patency was at the discretion of the primary physi-
cian. When PICCs were accessed intermittently, they were flushed
with heparin-containing saline solution after each use. Insertion
and removal complications were noted. For patients who were
discharged home or to another institution with a catheter in situ,
care was given by local nursing personnel, maintaining telephone
contact with the IV team at CHMC.
PICCs were removed for various reasons including: completion
of therapy, occlusion, accidental dislodgement, and suspicion of
catheter-associated infection. The following definitions were used
to define infectious complications: 1) phlebitis was defined as
inflammation tracking along the course of the vein from the in-
sertion site, with or without a palpable venous cord; 2) exit-site
infection was present when inflammation and purulent discharge
were noted at the insertion site; and 3) catheter-associated sepsis
was diagnosed in patients with fever without another identifiable
source, who had a positive blood or catheter-tip culture (Maki roll
technique).
To compare catheter use and function in different age groups,
patients were divided into four groups: 0 to 30 days old; 31 days
to 1 year old; 1 to 5 years old; and older than 5 years. Continuous
data were compared with analysis of variance and the ttest.
Adjustments for multiple comparisons were done with the
Tukey-B test. Categorical data were compared using the
x
2and
Fisher’s exact tests. Significance was defined as P,.05.
RESULTS
A total of 444 PICCs were inserted in 390 patients
during the 18-month period. Data was complete for
441 of 444 PICC insertions. Demographic informa-
tion of the study subjects is presented in Table 1. The
median age of patients in the group was 3.4 years
(range 0 days to 22 years). No complication from
insertion was noted.
Catheter size ranged from 2- to 5-French (Table 2).
Three-French catheters were most frequently used in
all ages (48%). Two-French was the most commonly
used catheter size in the 0 to 30 day group (93%) and
in infants 31 days to 1 year old (85%), while 3-French
was most commonly used in children 1 to 5 years old
(60%) and older than 5 years (82%). The veins most
commonly accessed were antecubital (89%). The tip
was located in a central location in 53% of insertions
and a peripheral location in 47% of insertions.
Antecedent medical diagnosis and services refer-
ring patients for PICC placement are outlined in
Tables 3 and 4. Treatment of infectious disease was
the most common cause for PICC insertion (46%).
Referral for PICC insertion was most commonly
made by the general pediatric service (20%); how-
ever, PICCs were used by most pediatric medical
and surgical subspecialty services.
Sixty-one percent of PICCs were used entirely in
CHMC, while 39% were also used at home or in a
referring community hospital. The average catheter
life was 13 612 days. Neither patient age nor cath-
eter lumen size were significantly related to catheter
life. Catheter lives for each lumen size were 2-French
(12.9 days), 2.7-French (11 days), 3-French (12.4
days), 4-French (16.6 days), and 5-French (13.4 days).
Completion of therapy was achieved with 69% of
catheters. Significantly fewer PICCs used entirely at
CHMC (69%) completed therapy compared with
those used outside the institution (77%), (P5.01).
A total of 129 PICCs (29%) were removed for com-
plications (Table 5) with accidental dislodgement
TABLE 1. Patient Demographic Information
n (%)
Total number of patients 390
Total PICC lines (N) 441
Males 252 (57)
Females 189 (43)
Age
0–30 days 118 PICCs (27)
30 days–1 year 66 PICCs (15)
1–5 years 62 PICCs (14)
.5 years 195 PICCs (44)
CHMC use only 271 (62)
Outside use 170 (38)
Abbreviations: PICC, peripherally inserted central venous cathe-
ters; CHMC, Children’s Hospital and Medical Center.
TABLE 2. Catheter Characteristics
n%
Catheter size
2-French 192 43
2.7-French 1 0.2
3-French 212 49
4-French 31 7
5-French 5 1
Veins accessed
Antecubital 393 89
Saphenous 37 9
Others 11 3
Tip placement
Deep arm 178 40
Superior vena cava 106 24
Subclavian 99 22
Deep leg 18 4
Right atrium 12 3
Inferior vena cava 10 2
Iliacs 8 2
Not recorded 10 2
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(8%), suspected infection (8%), and occlusion (7%)
being the most common reasons. No increase in oc-
clusion rate between home and hospital use was
found. Occlusion was significantly more common
with smaller lumen sizes. Eleven percent of 2-French
catheters became occluded compared with 4% of 3-
French and 7% of 4-French catheters. Accidental dis-
lodgement was more common with older infants 31
days to 1 year old and children 1 to 5 years old (17%
and 11.3%, respectively) than in those 0 to 30 days
old or children older than 5 years (5.9% and 4.6%,
respectively). The influence of the methods used to
secure PICCs on the incidence of dislodgement could
not be determined. Rate of dislodgement did not
differ between out of CHMC use and CHMC use.
A total of 37 PICCs (8%) were removed for sus-
pected catheter infection. Fourteen PICCs (3%) were
removed because of fever without another identifi-
able source. Nine (2%) were associated with a posi-
tive blood or catheter tip culture (catheter-associated
sepsis). Of these, 8 PICCs were used only in CHMC,
while 1 PICC was used outside CHMC. Coagulase
negative staphylococcus species, enterococcus, Esch-
erichia coli, and candidia species were the organisms
cultured from blood or catheter tip in patients with
documented catheter-associated sepsis. Eight PICCs
(2%) were removed due to purulent drainage and
inflammation at exit site. Of these, 6 PICCs were
used in CHMC and 2 outside. Phlebitis resulted in
the removal of 16 PICCs (3.6%)—10 during use at
CHMC compared with 6 during outside use. Patients
whose PICCs were removed for exit site infection or
phlebitis did not have fever or other signs of sys-
temic sepsis.
TPN solutions were administered in 34% of cath-
eters. TPN administration did not decrease catheter
life (14.1 days) compared with catheters not used for
TPN administration (12.2 days). Seven cases of cath-
eter-associated sepsis occurred in children receiving
TPN; however, this association was not statistically
significant. No complications were noted during
catheter removal and no deaths were directly attrib-
uted to PICC use.
One infant developed bilateral pleural effusions 1
week after PICC placement for TPN administration
with the catheter tip located in the SVC. Fluid
drained from the pleural space had glucose and tri-
glyceride levels similar to the TPN administered
through the PICC, which was removed. The pleural
effusions did not recur and the infant recovered.
DISCUSSION
Our study demonstrated that PICCs are a safe and
reliable IV access device in neonates and children.
They are also safe in the home setting if parents and
home nursing personnel are properly instructed in
catheter care and recognition of catheter complica-
tions.
In our study, PICCs were used by a wide range of
pediatric subspecialties, therapy was completed in
two thirds of PICCs inserted and the incidence of
phlebitis and catheter-associated sepsis was low. Pa-
tients using PICC for therapy outside our institution
had similar catheter life and completion of therapy
rates. Complications associated with PICC use out-
side were fewer compared with their exclusive hos-
pital use. This is not surprising because hospitalized
children are typically sicker and have increased risk
of nosocomial infections and exposure to multiple
medications, increasing the risk of thrombophlebitis.
Prior reports of therapy completion have ranged
from 50% to 96% in patients with a single PICC.6,8
Our study demonstrated therapy completion in 69%
of PICCs. The increased occlusion rate in smaller-
lumen catheters, however, did not significantly
lower the rate of completion of therapy in infants
compared with older children. PICCs in our study
were used in many patients who required prolonged
IV access. An average catheter life of almost 2 weeks
provided prolonged uninterrupted IV access. The
longest catheter life in our study was 132 days. No
limits as to the duration of leaving the catheter in situ
have been established.6,13
No complications were related to catheter inser-
tion. Risks associated with placement of PICCs are
TABLE 3. Antecedent Diagnosis
Diagnosis n %
Infectious diseases 205 46
Prematurity 77 18
Cystic fibrosis 51 12
Malignancy 27 6
Surgical abdomen 21 5
Inflammatory bowel disease 5 1
Dehydration 5 1
Miscellaneous 49 11
Not recorded 1 0.2
TABLE 4. Referring Services
Service n %
General pediatrics 90 20
Neonatal ICU 76 17
Pulmonary 66 15
General surgery 65 15
Hematology-oncology 32 7
Cardiothoracic surgery 20 5
Renal 16 4
Pediatric intensive care unit 11 3
Gastroenterology 9 2
Cardiology 5 1
Other medical services 5 1
Other surgery 44 10
Not recorded 2 0.5
TABLE 5. Reason for Removal of Peripherally Inserted Cen-
tral Venous Catheters: CHMC vs Outside Use
Reason Total n
(%) CHMC Use
n (%) Outside Use
n (%)
Total number 441 271 170
Therapy complete 305 (69) 175 (65) 130 (77)
Suspected infection 37 (8) 28 (10) 9 (5)
Occlusion 32 (7) 20 (7) 12 (7)
Accidental dislodgement 34 (8) 21 (8) 13 (8)
Leakage 7 (2) 6 (2) 1 (1)
Breakage 8 (2) 6 (2) 2 (1)
Infiltration 9 (2) 8 (3) 1 (1)
Catheter rupture 2 (1) 1 (0.4) 1 (1)
Placement incorrect 2 (1) 2 (1) 0 (0)
Removed after death 5 (1) 4 (2) 1 (1)
Abbreviation: CHMC, Children’s Hospital and Medical Center.
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very low; thus, catheters can be replaced at another
site without putting a patient at significant risk.9,10
Furthermore, accessibility of peripheral veins for
compression make control of bleeding easy during
insertion. Therefore, PICCs can be used safely in
patients with a bleeding diathesis to provide central
access for therapy.9
About 30% of PICCs in our study were removed
for complications. Occlusion was more common in
2-French catheters (the smallest lumen) than with
others. This finding is similar to the study in adults,
where occlusion was more common in smaller cath-
eters (18-gauge vs 20-gauge).9Occlusion can some-
times be relieved by flushing with urokinase.6,8,9
However, excessive force to flush catheters may re-
sult in catheter rupture or cause thromboembolism.9
Occluded catheters that cannot be relieved with gen-
tle flushing should be removed and replaced.9Al-
though catheters can break or rupture at the external
portion, they can be repaired with the repair kit
supplied without having to replace the catheter.6
Catheter-associated sepsis requires removal of the
catheter and appropriate antibiotic therapy. The in-
cidence of catheter-associated sepsis with PICCs
ranged from 0 to 2.2% in previous studies.6,8,9,12 In our
study, the incidence of catheter-associated sepsis
(2%) was similar to previous reports and lower than
catheter-associated infection associated with other
central venous devices (3% to 20%) or peripheral
venous catheters (4.6% to 9%).9,10,14,15 The incidence of
infections tended to be higher with PICCs used in the
hospital and with TPN administration; however, this
was not statistically significant.
The occurrence of pleural effusion in one patient
was a serious complication of PICC use. Although,
no complications were noted with PICC removal,
difficulty with removal attritubable to fibrin deposi-
tion around the catheter may occur as a rare compli-
cation.6
In conclusion, PICCs are a reliable method of pro-
viding prolonged IV therapy in children of all ages.
Decreased number of catheter placements, compared
with peripheral IV catheters per therapy, can be ex-
pected to decrease patient pain and apprehen-
sion.3,4,6– 8 PICCs have fewer insertion and infectious
complications compared with other central venous
devices. Furthermore, these catheters allow safe com-
pletion of IV therapy outside the hospital setting,
saving continued expensive hospitalization. Mea-
sures to prevent accidental dislodgement in infants
and children younger than 5 years old must be rein-
forced. Care givers of patients discharged home with
an indwelling catheter must be taught good aseptic
techniques and be advised to seek medical advice if
the patient develops fever or catheter-related pain.
PICCs can provide safe and prolonged IV access
for neonates and children in the hospital or home
setting.
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DOI: 10.1542/peds.99.2.e4
1997;99;e4Pediatrics
Ravi R. Thiagarajan, Chandra Ramamoorthy, Theresa Gettmann and Susan L. Bratton
Survey of the Use of Peripherally Inserted Central Venous Catheters in Children
Services
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andpublication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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