title: Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg.
abstract: OBJECTIVE
  To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children.
  
  
  METHODS
  Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis.
  
  
  RESULTS
  PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001).
  
  
  CONCLUSIONS
  Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.
authors.affiliation: Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada.
authors.forename: Roy Y
authors.initials: RY
authors.lastname: Yang
authors.forename: Rahim
authors.initials: R
authors.lastname: Moineddin
authors.forename: Doina
authors.initials: D
authors.lastname: Filipescu
authors.forename: Dimitri
authors.initials: D
authors.lastname: Parra
authors.forename: Joao
authors.initials: J
authors.lastname: Amaral
authors.forename: Philip
authors.initials: P
authors.lastname: John
authors.forename: Michael
authors.initials: M
authors.lastname: Temple
authors.forename: Bairbre
authors.initials: B
authors.lastname: Connolly
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000704:Analysis of Variance; D015901:Angiography, Digital Subtraction; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D002406:Catheterization, Peripheral / Q000009:adverse effects* / Q000295:instrumentation; D002408:Catheters, Indwelling / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D004867:Equipment Design; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D009864:Ontario; D010690:Phlebography; D015641:Radiography, Interventional / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D014680:Veins / Q000293:injuries / Q000503:physiopathology; D055815:Young Adult