METHODS

Search Strategy

For this study, we considered colorectal patients who were hospitalized from January 1, 2017 to January 1, 2019, when a CVC was inserted. Comparisons of additional costs and related complications were made between colorectal patients with PCs and PICCs.


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Detailed data on patients were collected by the principal investigator from all colorectal cancer patients’ medical records. The registered patient characteristics included age, gender, catheter type, vein choice, use of ultrasound, hemostatic and laboratory results, such as partial thromboplastin time (PTT), platelets’ count, use of Tranexamic acid, date of CVC insertion and removal, reason for CVC insertion and removal, and the incidence of complications related to CVC insertion and usage. Patients were fully informed on all potential issues associated with the use of PCs and PICCs, including information on the quality of life, costs and potential complications. The study was approved by Jiangsu Province People’s Hospital Ethical Committee. All enrolled patients were informed of the purpose of the study and signed informed consent forms were obtained.

Selection Criteria

Overall, 789 colorectal cancer patients were evaluated. Patients were excluded from the study if their platelet count was less than 20,000/mm, had an international normalized ratio (INR) that was higher than 2, or had sepsis, or severe behavioral problems, which would make CVC insertion more difficult. CVCs were maintained by experienced nursing staff, who changed the dressing at the insertion sites and the caps connected with the catheters. The PICC was flushed with a 10mL of 0.9% saline solution after administration of medication, followed by 5 mL heparinized saline solution (100IU/mL). When the PC was not in use, it was flushed with 5mL of heparinized saline (50IU/mL) every 4 weeks. CVCs care guidelines have been as congruent as possible in our institute. Chest radiography was used to ensure the correct location (the superior vena cava-right atrial junction) of the catheter tip.

Early complications included hemothorax, pneumothorax, excessive bleeding at the insertion site, accidental arterial puncture, cardiac arrhythmia, and pericardial and brachial plexus injuries.5 Late complications included catheter dysfunction, catheter-related blood stream infection (CRBSI), rupture, catheter allergy, extravasation, migration or embolization, drop out of the Huber needle, CVC-associated eczema, catheter-related thrombosis, local skin/tunnel infection, port inversion and “pinch-off” syndrome.6,7

The total cost included costs of catheters’ insertion, maintenance, and associated treatment complications. Medical costs over the 6-month period, that started from the day of catheters’ insertion, were recorded for each patient. Insertion costs also included costs of drugs, devices, and operational procedures. The charges for drugs and devices were based on manufacturers’ prices that were applied during the study. Operational costs were fixed by the National Administration for Commodity Prices. The maintenance costs were estimated based on the charges for CVCs’ connector changes, dressing and monthly flushing of the catheters. The costs of treatment complications were obtained through the analysis of related overall costs for each case. The costs associated with Maintenance and complications were calculated based on the CVC total usage time and all recorded complications. Cost estimates were converted from Chinese yuan to US dollars at a conversion rate of 7:1.

Statistical Analysis

Statistical variables were compared using the chi-squared test or Fisher’s exact test, while the Student’s t-test was used for comparing normally distributed parametric data and the Mann–Whitney U-test for non-parametric skewed data. A p-value of <0.05 was considered statistically significant. All analyses and figures were performed using the SPSS software version 21.0; SPSS Inc. (IBM Corp, Armonk, NY, USA).

RESULTS

A total of 777 colorectal cancer patients were eligible for this study, which included 69 with PICC and 698 with PC. The basilica vein was used for PICC, and 4 PICCs were excluded due to 1 cephalic vein puncture and 3 brachial vein punctures (Table 1). The PICC and PC both used Brand silicon single-lumen catheters that were inserted with a modified Seldinger technique. All PICC lines were inserted using ultrasound guidance. The PC systems were inserted through the axillary vein without ultrasound guidance and fixed at the chest wall. In addition to the use of ultrasound, the laterality of CVC insertion is also shown in Table 1: 65% of PICCs in the left arm and 96% of PCs on the right side.

Table 1

We analyzed the early and late complication rates during the 6-month period of catheter implantation. Our study did not take into account factors, such as the duration of chemotherapy cycles or patients’ death. The most common complications for patients with CVC include hematoma, arteriovenous fistula, arterial puncture, pneumothorax, and nerve injury. The cannulation success rate was 92~95% on the first pass.

Early complications occurred in 5 (7%) patients with PICCs and in 22 (3%) patients with PCs (p=0.377). In the PICC group, these complications included 2 cases of insertion site wound bleeding, 1 case of arterial puncture and 2 cases of ecchymoma. In the PC group, ecchymoma was observed in 15 patients, arterial puncture in 3 patients, and PC insertion site wound bleeding in 4 patients. Despite these complications, all cannulations were successfully completed. The late complication and total complication rates were higher in the PICC group compared to the PC group with 45% versus 4% (p < 0.001) and 52% versus 7%, respectively (p<0.001) (Table 2). Ruptures of the catheter devices occurred in 2 patients with PICCs and 3 clinically significant CRBSI were recorded, with 1 in the PICC group and 2 in the PC group, one of whom required a PC replacement and one PC case was kept with antibiotics treatment. A total of 3 patients (0.39%) underwent CVCs permanent removal due to complications. Two patients who received PICCs had complications that were due to CRBSI and occlusion, while the other patient with PC underwent premature PC removal due to CRBSI.

Table 2

In contrast with other charges, the amount of medical expenses was variable and mainly dependent on the patient medical insurance (government and/or new rural medical insurance). In China, compensations for PICC insertion can be reimbursed up to 50% of the total incurred medical costs which depend on the type of medical insurance. However, the costs of PC insertion are excluded from insurance coverage. Patients who are implanted with PCs must pay for the total insertion costs. With a social medical insurance, the patient pays US $874 for a PC insertion and US $292.60 for a PICC insertion. The monthly compensation mean for the maintenance costs of PICC is US $60.4 versus US $30 for PC. The mean cost of treatment complications for PICC is US $78.3 versus US $48 for PC. The removal costs for PICCs and PCs are US $4.9 versus US $24, respectively, regardless of the type of medical insurance (Table 3).

Table 3

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