The Journal of JVA Vascular Access Review

The Journal of Vascular Access 1–11 Long peripheral catheters for ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions intravenous access in adults and DOI: 10.1177/1129729820927272 children: A systematic review of journals.sagepub.com/home/jva the literature

Kirby R Qin1,2 , Nicholas Ensor1,2, Richard Barnes3 , Anna Englin3, Ramesh M Nataraja1,2,4 and Maurizio Pacilli1,2,4

Abstract Background: Long peripheral catheters are peripheral intravenous catheters of 6–15 cm in length. They are commonly inserted into the forearm, antecubital fossa or upper arm using a direct . They have proven to be valuable for peripheral intravenous catheters, particularly in patients with difficult intravenous access. Methods: We conducted a systematic review of studies reporting the use of long peripheral catheters. The following keywords were used: ‘long’, ‘Seldinger’, ‘guidewire’, ‘peripheral’, ‘venous’, ‘intravenous’, ‘IV’, ‘vascular’, ‘cannula’ and ‘catheter’. Results: Three hundred forty-one publications were identified; 16 were included in the systematic review. There were 11 adult studies and 5 paediatric studies documenting 1288 long peripheral catheters in 1271 patients. Majority of studies (12/ 16) were conducted in acute care settings, (emergency department, n ¼ 6; intensive care unit, n ¼ 3; high dependency unit, n ¼ 1; surgical unit, n ¼ 2). The most frequently studied long peripheral catheter was 8 cm in length and 20 G in size. Nine studies recruited patients with difficult intravenous access; 11 studies used ultrasound guidance. Insertion success rate and mean procedural time ranged between 86% and 100% and 8 and 16.8 minutes, respectively. Average catheter duration ranged between 4 and 14.7 days (mean) and 1.1 and 9 days (median). Catheter failure occurred in 4.3–52.5% of long peripheral catheters, with leakage, infiltration and dislodgement being the most frequent causes of failure. In 3 randomised controlled trials, long peripheral catheters outperformed peripheral intravenous catheters in terms of duration and failure rate. Conclusion: Long peripheral catheters are safe and reliable in both adults and children. In addition, long peripheral catheters may provide improved quality of care over peripheral intravenous catheters for multi-day .

Keywords New devices, peripheral venous access, long peripheral catheter, direct Seldinger technique, cannula

Date received: 1 November 2019; accepted: 25 April 2020 1 Department of Paediatric Surgery, Monash Children’s Hospital, Melbourne, VIC, Australia Introduction 2 Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Venous access devices (VADs) that terminate in or distal to Melbourne, VIC, Australia the subclavian and femoral are termed peripheral 3 Department of Anaesthesia, Monash Children’s Hospital, Melbourne, venous catheters. Peripheral venous catheters can be VIC, Australia 4 Department of Surgery, School of Clinical Sciences at Monash Health, divided into peripheral intravenous catheters (PIVCs), long Faculty of Medicine, Nursing and Health Sciences, Monash University, peripheral catheters (LPCs) and midline catheters Melbourne, VIC, Australia (MCs).1,2 PIVCs (commonly referred to as ‘cannulae’ or ‘cannu- Corresponding author: las’) are the most common VADs. They are 3–6 cm in Maurizio Pacilli, Department of Paediatric Surgery, Monash Children’s Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC 3168, length and are inserted using a catheter-over-needle tech- Australia. nique. LPCs are peripheral dwelling catheters of 6–15 cm Email: [email protected] 2 The Journal of Vascular Access in length and are commonly inserted using a direct Seldin- Results ger technique, the catheter-over-guidewire method origi- A total of 341 titles and abstracts were screened. Of these, nally described for arterial catheterization.2,3 They are 27 articles met the initial inclusion criteria. Following inserted into the forearm, antecubital fossa or upper arm assessment of full-text documents, 11 articles were and terminate before reaching the axilla, generally no fur- excluded: six studies6–11 used guidewire-inserted PIVCs, ther than the mid-upper arm. MCs are 15–25 cm long and two studies12,13 used standard PIVCs, one study14 did not inserted at or above the antecubital fossa, with distal exten- report the number of LPCs used and one study15 did not sion past the axilla. Insertion is achieved with a modified report the number of patients investigated. A final study16 Seldinger technique, which involves the initial introduction was excluded as the authors primarily described LPCs of a tissue dilator to accommodate for the longer and larger placed in the internal jugular (95.1%) – a decision MC.4 was made to exclude this article as the results would be In recent years, LPCs have grown in popularity because difficult to compare with LPCs placed in limb veins. Over- of their clinical utility, particularly in patients with difficult all, 16 studies were included in the final analysis (Figure intravenous access (DIVA). Many patients presenting to 1). the emergency department (ED) will require admission and extended intravenous (IV) therapy. LPCs could reduce the number of catheters required in patients receiving 7–28 days of IV therapy and decrease the incidence of Main findings catheter-related complications.5 The aim of this article is The characteristics of included studies are summarised in to provide a comprehensive summary of the experience of Table 1. Sixteen studies reporting 1288 LPCs in 1271 LPCs across various institutions, based on the results of a patients are included in this review. All studies were pub- systematic review. lished between 2005–2019. These included 13 prospective (four RCTs17–20 and nine cohort studies5,21–28) and three retrospective reviews.15,29–31 Three RCTs17–19 compared 20 Methods LPCs and PIVCs; one compared LPCs and peripherally inserted central catheters (PICCs). Eleven adult stud- This review was prospectively registered with the PROS- ies15,17–23,25,26,30 reported 647 patients, and five paediatric PERO (International Prospective Register of Systematic studies5,24,27,29,31 documented 624 patients. Studies were Reviews) database (ID: CRD42018090335). conducted in EDs17,19,23,27,28,30 (n ¼ 6), medical units24–26 A literature search of PubMed, Scopus, MEDLINE, (n ¼ 3), surgical units5,21 (n ¼ 2), intensive care Web of Science and the Cochrane Library was performed units22,29,31 (ICU) (n ¼ 3), a high-dependency unit18 in September 2019. The following keywords were used: (n ¼ 1) and in patients receiving IV vancomycin15 (n ¼ 1). ‘long’, ‘Seldinger’, ‘guidewire’, ‘peripheral’, ‘venous’, Table 2 displays catheter insertion details. In nine stud- ‘intravenous’, ‘IV’, ‘vascular’, ‘cannula’ and ‘catheter’. ies,18,19,21–23,25,27,28,30 DIVA status was an inclusion criter- The search was limited to human studies with abstracts ion. DIVA was defined by multiple criteria including written in English and published since 1980. failure of multiple PIVC insertion attempts, lack of visible Inclusion criteria included any primary research arti- or palpable veins and history suggesting DIVA. All LPCs cles (i.e. randomised controlled trials (RCTs) and cohort were placed under ultrasound guidance (USG) per study studies) that described a peripheral-dwelling venous protocol in 11 cases,17–23,25,27,28,30 while in the remainder, catheter of 6–15 cm in length inserted using the direct the decision to use USG was practitioner dependent (Table Seldinger method. Studies of both adult and paediatric 2). DIVA status and USG were both common features patient populations were considered for inclusion in this among adult studies; 10 of 11 studies investigated patients review. Case reports, editorials and abstract-only articles with DIVA and used USG for all catheters. were excluded. Twelve studies reported the successful insertion rate Two authors (K.Q. and N.E.) performed independent ranging from 86%–100%, with five reporting literature searches. Full texts for all potential studies were 100%.21,22,24,27,30 The cumulative success rates were reviewed and critically appraised according to predeter- 95.3% (1124/1179) in all patients, 96.2% (477/496) in mined inclusion and exclusion criteria. References of all adult patients and 91.5% (647/683) in children. Catheter included articles were reviewed to ensure all relevant arti- dimensions ranged from 6–15 cm in length and 16–23G in cles were included. Any disagreement over the eligibility diameter (Table 2). The most common length and diameter of studies was resolved through discussion with a third were 8 cm and 20G, respectively. Seven brands of VADs author (M.P.). Two authors (K.Q. and N.E.) independently were reported in 12 studies; of these, eight studies used extracted relevant data from all included studies. Data catheters marketed as LPCs,5,19,20,24–26,30,31 while the extracted from included studies was evaluated by a third remaining used arterial catheters21,22,28 and central venous author (M.P.). catheters (CVCs).18,23 All studies, except one, used direct Qin et al. 3

Figure 1. PRISMA flowchart showing the systematic review process. PIVC: peripheral intravenous catheter; VAD: venous access device; CVC: ; LPC: long peripheral catheter.

Seldinger (catheter-over-guidewire) devices. The single complications, documented in individual studies, were exception, a paediatric study,29 used 6–8 cm breakaway- venous thrombosis, pain, catheter-related bloodstream needle (catheter-through-needle) devices. LPCs were infection, allergy to dressing material and local inflam- inserted by nurses, physicians, vascular access teams and mation. The majority (73.1%, 899/1230) of LPCs were ultrasound specialists. In six studies that reported insertion removed electively after the completion of IV therapy. time, an average of 8–16.8 minutes5,18,19,23,28,30 was Combined outcomes of adult and paediatric studies are required to site an LPC (Table 2). LPCs were generally displayed in Table 4. limited to the upper limb, either in the upper arm, antecu- Four RCTs were identified during the review process, bital fossa or forearm. The basilic vein was the most com- three of which compared LPCs to PIVCs in adult patients mon site of insertion (50.9%, 355/697), followed by the (Table 5). Elia et al.18 recruited 100 patients with DIVA in cephalic (14.9%, 104/697) and brachial vein (11.8%, 82/ a high-dependency unit. Each participant received one (of 697). In two paediatric studies, LPCs were also placed in their allocated) catheter while enrolled in the trial. LPCs 29 5,29 the scalp (n ¼ 29) and lower limb (n ¼ 25). were superior in terms of catheter duration (6.2 vs 3.5 days, p ¼ 0.02), overall failure rate (14.0 vs 42.9%,p< 0.001) and ‘dislocation and/or infiltration’ rate (2.3 vs Outcomes 40.5%, p < 0.0001). De Prospo et al.17 randomised 211 All studies measured LPC lifespan as a primary or sec- prospective patients to receive IV therapy through LPCs ondary outcome. This was reported as average duration or PIVCs for their entire admission. Many patients (either mean or median) in all but one study30 (Table 3). received multiple catheters; 105 and 106 patients, respec- The mean and median duration of LPCs ranged from tively, received 108 LPCs and 231 PIVCs. LPCs demon- 4.0–14.7 and 1.1–9.0 days, respectively, with 4.3%– strated significantly improved duration (9 vs 3 days, p ¼ 52.5% of catheters failing before completion of IV ther- 0.01) and failure rate (16.4 vs 185.9 failures per 1000 apy. The most frequently cited causes of failure catheter-days, p < 0.01). Finally, Bahl et al.19 included included infiltration (0–24.2%), phlebitis (0–5.9%), dis- 70 patients in an ED. This study showed a superior life- lodgement (0–13.9%), occlusion (0–17.6%) and leakage span of LPCs (4.0 vs 1.3 days, p ¼ 0.002) but did not from the insertion site (2.6–13.1%). Other compare the rate of failure. 4 The Journal of Vascular Access

Table 1. Study characteristics.

Difficult intravenous access (DIVA) status and No. of Study Study design Setting criteria patients Adult GIlardi et al.28 Prospective cohort Emergency department Yes 50 study Non-visible or non-palpable veins Known history of a difficult venous access 2 failed PIVC attempts Bahl et al.19 Randomised Emergency department Yes 33 controlled trial History of 2x failed PIVC attempts on a previous (70 in total) (LPC vs. PIVC) hospital visit Self-reported history of need for a rescue catheter such as an ultrasound-guided IV, midline catheter, PICC or central venous catheter History of IV drug use History of end-stage renal disease on dialysis Fabiani et al.21 Prospective cohort Cardiac surgery unit Yes 71 study 3 failed PIVC attempts and lack of readily visible or palpable veins Scoppettuolo Retrospective Emergency department Yes 76 et al.30 review Lack of readily visible or palpable veins De Prospo Randomised Emergency department No 105 et al.17 controlled trial (requiring > 72 hours of (211 in total) (LPC vs. PIVC) intravenous therapy) Caparas and Randomised Patients receiving short-term No 29 Hu20 controlled trial intravenous vancomycin (54 total) (LPC vs. PICC) (> 1 dose and < 6 days) Meyer et al.22 Prospective cohort Intensive care unit Yes 29 study 3x failed PIVC attempts Elia et al.18 Randomised High-dependency unit Yes 50 controlled trial 3x failed PIVC attempts (100 in total) (LPC vs. PIVC) Warrington Prospective cohort Hospitalised patients Yes 157 et al.25 study (requiring > 72 hours of 2x failed PIVC attempts intravenous therapy) History of difficult venous access Mills et al.23 Prospective cohort Emergency department Yes 25 study 2x failed PIVC attempts Carroll Prospective Cystic fibrosis unit No 22 et al.26 comparative (54 in total) cohort study (LPC vs. PICC) Paediatric Chenoweth, Retrospective Neonatal intensive care unit No 432 et al.31 review Paladini Prospective Emergency department Yes 20 et al.27 comparative 2x failed PIVC attempts (40 in total) cohort study (LPC vs. PIVC) Pacilli et al.5 Prospective cohort Surgical unit No 18 study Anderson Retrospective Intensive care unit No 122 et al.29 review Qian et al.24 Prospective cohort Cystic fibrosis unit No 32 study

DIVA: difficult intravenous access; IV: intravenous; LPC: long peripheral catheter; PIVC: peripheral intravenous catheter; PICC: peripherally-inserted central catheter. Qin et al. 5

Table 2. Catheter brand, dimensions and insertion factors.

Success rate (LPCs inserted/ Insertion Insertion LPC Inserting Insertion US attempted) time location Study LPC brand dimensions practitioner technique guided N/N (%) (minutes) N (%)

Adult Gilardi et al.28 Vygon Leadercath 8 cm 3Fr Emergency Direct Yes 46/50 (92) 10.2 + Basilic vein ¼ 34 (19.5G) department Seldinger 3.1 (68) staff (mean Brachial vein ¼ + SD) 25 (50) Cephalic vein ¼ 1 (2) Bahl et al.19 Access Scientific 6 cm 3Fr Nurses, Direct Yes 33/38 (86.8) 8.7 + Basilic vein ¼ 20 POWERWAND (19.5G) physicians, Seldinger 7.4 (60.6) vascular (mean + Brachial vein ¼ access team, SD) 7 (21.2) US specialists Cephalic vein ¼ 5 (15.2) Not recorded ¼ 1 (3) Fabiani et al.21 Vygon Leadercath 8 cm 20G Nurses, vascular Direct Yes 71/71 (100) – Basilic vein ¼ 56 10 cm 18G access team Seldinger (78.9) 18 cm 18G Brachial vein ¼ 11 (15.5) Cephalic vein ¼ 4 (5.6) Scoppettuolo Vygon Leaderflex 8 cm 20G Nurses, Direct Yes 76/76 (100) 9.5 + Basilic vein ¼ 34 et al.30 10 cm 18G physicians Seldinger 2.3 (44.7) (mean + Brachial vein ¼ SD) 17 (22.4) Cephalic vein ¼ 11 (14.5) Forearm ¼ 14 (18.4) De Prospo – 12cm Nurses, Direct Yes 108/– – – et al.17 physicians Seldinger Caparas and Access Scientific 8 cm 3Fr Vascular access Direct Yes 30/– – – Hu20 POWERWAND (19.5G) team Seldinger Meyer et al.22 Prodimed 8 cm 20G Intensive care Direct Yes 29/29 (100) – Basilic vein ¼ 19 Seldicath 8 cm 18G staff Seldinger (65.5) Cephalic vein ¼ 10 (34.5) Elia et al.18 Teleflex Arrow 12 cm 20G Nurses, Direct Yes 43/50 (86) 16.8 Basilic vein ¼ 34 Central Venous physicians Seldinger (mean) (79.1) Catheter Brachial vein ¼ 6 (14.0) Cephalic vein ¼ 3 (7.0) Warrington Access Scientific 8 cm 5Fr Vascular access Direct Yes 156/157 (99.4) – Basilic vein ¼ et al.25 POWERWAND (16G) team Seldinger 130 (82.8) Cephalic vein ¼ 11 (7.1) Median cubital vein ¼ 11 (7.1) Brachiocephalic vein ¼ 1 (0.6) Forearm ¼ 3 (1.9)

(continued) 6 The Journal of Vascular Access

Table 2. (continued) Success rate (LPCs inserted/ Insertion Insertion LPC Inserting Insertion US attempted) time location Study LPC brand dimensions practitioner technique guided N/N (%) (minutes) N (%)

Mills, 200723 Cook Medical 15 cm 16G Physicians, US Direct Yes 23/25 (92) 8 Brachial vein ¼ Central Venous specialists Seldinger (median) 12 (52.2) Catheter Basilic vein ¼ 7 (30.4) Not recorded ¼ 4 (17.4) Carroll, Vygon Leaderflex 8 cm 22G Physicians Direct No 22/– – – et al.26 Seldinger Paediatric Chenoweth NeoMedical EPIV 6 cm 1.9Fr Nurses Direct – 432/– – – et al.31 (23G) Seldinger 8 cm 1.9Fr (23G) Paladini – 8 cm 20G Nurses, Direct Yes 20/20 (100) – Cephalic vein ¼ et al.27 physicians Seldinger 9 (45) Basilic vein ¼ 8 (40) Brachial vein ¼ 3 (15) Pacilli et al.5 Vygon Leaderflex 8 cm 22G Physicians Direct No 17/18 (94.4) 8 + 3.7 Antecubital Seldinger (mean + fossa ¼ 15 SD) (88.2) Saphenous vein ¼ 2 (11.8) Anderson – 6 cm 1.9Fr Nurses, vascular Breakaway No 106/122 – Antecubital et al.29 (23G) access team needle (86.9) fossa/cephalic 8 cm 1.9Fr vein ¼ 38 (23G) (35.8) 8 cm 3Fr Upper arm/ (19.5G) brachial vein/ basilic vein ¼ 3 (2.8) Wrist/hand/ forearm ¼ 13 (12.3) Scalp ¼ 29 (27.4) Lower limb ¼ 23 (21.7) Qian et al.24 Vygon Leaderflex 8 cm 22G Physicians Direct No 40/40 (100) – Upper arm ¼ 9 Seldinger (22.5) Antecubital fossa ¼ 8 (20) Forearm ¼ 23 (57.5)

LPC: long peripheral catheter; US: ultrasound; SD: standard deviation.

Discussion found that despite major differences in methodology and LPCs have gained popularity in recent years because of reporting of outcomes, the current available evidence sug- their clinical utility and versatility. This is the first sys- gests that LPCs are superior to PIVCs for extended IV tematic review of LPC use in the medical literature. We therapy, particularly in regard to complication rates. Table 3. Outcomes of included studies.

Duration (days) Mean + SD LPC failure Infiltration Phlebitis Dislodgement Occlusion Study Median (IQR) N/N (%) N (%) N (%) N (%) N (%) Other N (%) Adult GIlardi et al.28 7.9 + 5.7 8/46 (17.4) – – 4 (8.6) – Other ¼ 4 (8.6) Bahl et al.19 4 (median) 17/33 (51.5) 8 (24.2) 0 1 (3) 0 Pain ¼ 2 (6.1) Other ¼ 3 (9.1) Leakage ¼ 1 (3) Kinked ¼ 2 (6.1) Fabiani, 14.7 + 11.1 24/71 (33.8) 0 2 (2.8) 9 (12.7) 7 (9.9) Leakage ¼ 5 (7) et al.21 Catheter-related bloodstream infection ¼ 1 (1.4) Scoppettuolo “27% removed before 7 days, 73% 21/76 (27.6) – – – – – et al.30 removed after 7–8 days”y De Prospo 9 (5–11) 27/108 (25) 3 (2.8) 0 15 (13.9) 4 (3.7) – et al.17 Caparas and 5.8 (mean) 6/30 (20) 3 (10) 0 2 (6.6) 0 Leakage ¼ 1 (3.3) Hu20 Meyer et al.22 5.7 (5–7) 2/29 (6.9) 0 0 0 2 (6.9) – Elia et al.18 6.2 + 5.1 6/43 (14) – – “Dislocation and/or “Occlusion and/or – infiltration” ¼ 1 (2.3) thrombophlebitis” ¼ 5 (11.6) Warrington 6.8 + 5.1 17/156 (10.9) 0 2 (1.3) 3 (1.9) 2 (1.3) Leakage ¼ 4 (2.6) et al.25 Haematoma ¼ 3 (1.9) Venous thrombosis ¼ 2 (1.3) Allergy to dressing material ¼ 1 (0.6) Mills et al.23 1.1 (0.3–2.5) 1/23 (4.3) 1 (4.3) 0 0 0 – Carroll 12.2 + 3.1 – – – – – – et al.26 Paediatric Chenoweth 4 + 2.3 121/432 (28) 29 (6.7) 18 (4.2) 14 (3.2) 15 (3.5) Leakage ¼ 37 (8.6) et al.31 Other ¼ 8 (1.8) Paladini 9.2 + 6 4/20 (20) 0 0 2 (10) 0 Venous thrombosis ¼ 2 (10) et al.27 Pacilli et al.5 6.4 + 5.1 4/17 (22.2) 0 1 (5.9) 0 Improper use occlusion ¼ 2 – (11.8) Idiopathic occlusion ¼ 1 (5.9) Anderson 8.9 + 5.9 52/106 (42.6) 7 (5.7) 6 (4.9) 14 (11.5) 6 (4.9) Leakage ¼ 16 (13.1) et al.29 Other ¼ 3 (2.5) Qian et al.24 10.1 + 5 21/40 (52.5) 0 0 0 0 Local inflammation ¼ 7 (17.5) Pain ¼ 7 (17.5) Other ¼ 7 (17.5)

LPC: long peripheral catheter; SD: standard deviation; IQR: interquartile range. 7 8 The Journal of Vascular Access

Table 4. Outcomes of long peripheral catheters in adult and paediatric studies.

Outcome Adult studies (n ¼ 11) Paediatric studies (n ¼ 5) Insertion success rate 86%–100%18,19,21–23,25,28,30 (n ¼ 8) 86.9%–100%5,24,27,29 (n ¼ 4) Duration Mean 5.8–14.7 days18,20,21,25,26,28 (n ¼ 6) 4–10.1 days5,24,27,29,31 (n ¼ 5) Median 1.1–9 days17,19,22,23 (n ¼ 4) – Failure rate* 4.3%–51.5%17–23,25,28,30 (n ¼ 10) 20%–52.5%5,24,27,29,31 (n ¼ 5) Infiltration 0%–24.2%17,19–23,25 (n ¼ 7) 0%–6.7%5,24,27,29,31 (n ¼ 5) Phlebitis 0%–2.8%17,19,21–23,25 (n ¼ 6) 0%–5.9%5,24,27,29,31 (n ¼ 5) Dislodgement 0%–13.9%17,19–23,25,28 (n ¼ 8) 0%–11.5%5,24,27,29,31 (n ¼ 5) Occlusion 0%–9.9%17,19,21–23,25 (n ¼ 6) 0%–17.6%5,24,27,29,31 (n ¼ 4) Leakage 2.6%–7%19–21,25 (n ¼ 4) Other Leakage: 2.6%,25 3%,19 7%21 Leakage: 8.6%,31 13.1%29 Allergy to dressing material: 0.6%25 Venous thrombosis: 10%27 Catheter-related bloodstream infection: 1.4%21 Pain: 17.5%24 Kinked: 6.1%19 Local inflammation: 17.5%24 Pain: 6.1%19 Venous thrombosis: 1.3%25

*Complications requiring catheter removal

The first description of LPCs in the literature was in short duration, all but one LPC (95.7%) were removed 2005 Carroll et al.26 Patients with cystic fibrosis were without complications. In contrast, Fabiani et al.21 reported offered a choice between a traditional PICC or novel LPC the longest duration of 14.7 days. However, this study was for IV antibiotic therapy. Fewer patients (41%) opted for conducted in post-cardiac surgery patients who were the LPC; however, durability was comparable between the admitted for an average of 55 days. As a result, their LPCs groups (12.2 vs 12.6 days, p ¼ 0.68). remained in situ for longer and appeared to outperform To date, 16 studies have investigated LPCs in various those in other studies. clinical settings. Despite the use of similar catheters, there Nearly all studies in this review expressed catheter out- is great inconsistency in the nomenclature. Over a dozen comes in terms of average duration and failure rate. Dura- names appeared in the literature, and these included ‘8-cm tion is not directly comparable as it is largely determined midline’,15 ‘15-cm catheter’,23 ‘catheter inserted with a by the duration of IV therapy. Furthermore, failure rate is Seldinger method’,22 ‘extended dwell catheter’,19 also incomparable, unless catheter duration is similar. As a ‘extended dwell/midline peripheral catheter’,29 ‘extended result, meta-analysis was not appropriate in this review. dwell peripheral intravenous catheter’,31 ‘Leaderflex Consequently, we feel that failure rate should be expressed line’,26 ‘long catheter’,17,18,24 ‘long IV catheter’,24 ‘long in terms of relative incidence, such as ‘per 1000 catheter- peripheral cannula’,5,27 ‘long peripheral catheter’,2,30 ‘long days’. This is a standard measure used to assess CVCs33,34 peripheral venous catheter’,21 ‘long polyurethane cathe- and is derived using the following formula: ter’,30 ‘midline cannula’,17 ‘midline catheter’,20 Failure rate per 1000 catheter days ‘mini-midline’,28,32 ‘peripheral intravenous catheter’,25 ! 24 30 ‘Seldinger catheter’, ‘short midline catheter’, ‘short X 1000 26 ¼ No: of f ailures long line’ and ‘ultrasound-guided peripheral intravenous ðÞCatheter duration in days catheter’.22 This issue has been previously highlighted, and for this systematic review, we used the definition of LPC as This measure was only implemented by De Prospo reported by Qin et al.2 et al.17 and Fabiani et al.21 who had 16.4 and 27.7 failures The average duration of LPCs in the literature ranged per 1000 catheter-days, respectively. We recommend that from 1.1–14.7 days, representing a significant variance future studies of LPCs adopt this measure of performance. across studies. This variance is likely a result of catheter Our systematic review suggests that LPCs may address duration being subject to both the length of IV therapy as vascular access issues in many acutely unwell patients. In well as the natural lifespan of the catheter. LPCs in patients the majority of studies, LPCs were used in acute settings requiring weeks of therapy appeared to outperform those in including emergency, intensive care and surgical units. patients receiving days of therapy. Mills et al.23 reported Acutely unwell patients are often peripherally compro- the shortest duration of 1.1 days. In this study, prospective mised;32 contributing to difficulties establishing access patients with DIVA who presented to an ED received an with standard PIVCs. In patients with DIVA, US-guided LPC. All LPCs were removed by day three, with most PIVC placement has been shown to reduce the potentially patients discharged before this timeframe. Despite the unnecessary use of CVCs.35,36 However, PIVCs may be Qin et al. 9

Table 5. Outcomes of randomised controlled trials.

PIVC LPC Relative risk Study N (%) N (%) (95% CI) P-value* Elia et al.18 5 cm 20G 12 cm 20G No. of patients 50 50 No. of catheters 42z 43z Catheter duration (mean – SD) (days) 3.5 + 4.2 6.2 + 5.1 0.02 Failure 18 (42.9) 6 (14) 3.2 (1.4–7.3) < 0.001 Dislocation and/or Infiltrationy 17 (40.5) 1 (2.3) 18.7 (2–134.2) < 0.0001 Occlusion and/or thrombophlebitisy 1 (2.3) 5 (11.6) 0.2 (0–1.8) 0.12 De Prospo et al.17 5cm§ 12cm§ No. of patients 106 105 No. of catheters 231 108 Catheter duration (median (IQR)) (days) 3 (2–5) 9 (5–22) 0.01 Total catheter-days 710 1769 Failure 132 (57.1) 29 (27) Per 1000 catheter-days 185.9 16.4 11.3 (7.6–16.8) < 0.01 Infiltration 47 (20.3) 3 (2.8) Per 1000 catheter-days 66.2 1.7 39 (12.2–125) < 0.01 Phlebitis 47 (20.3) 0 Per 1000 catheter-days 66.2 0 117 (16.2–847) < 0.01 Occlusion 16 (6.9) 4 (3.7) Per 1000 catheter-days 22.5 2.3 9.9 (3.3–29.7) < 0.01 Dislodgement 32 (13.9) 15 (13.9) Per 1000 catheter days 45.1 8.5 5.3 (2.9–9.6) < 0.01 Bahl et al.19 4.8 cm 20G 6 cm 19.5G No. of patients 37 33 No. of catheters 37 33 Catheter duration (median) (days) 1.3 4 0.002 Failure 27 (73) 17 (52) Infiltration 15 (40.5) 8 (24.2) Dislodgement 1 (2.7) 1 (3) Pain 2 (5.4) 2 (6.1) Leakage 3 (8.1) 1 (3) Kinked 3 (8.1) 2 (6.1) Other 3 (8.1) 3 (9.1)

PIVC: peripheral intravenous catheter; LPC: long peripheral catheter; CI: confidence interval. *P-values obtained from the original manuscripts. yAs was reported by the original authors. z42 (84%) successful PIVC insertions and 43 (86%) successful LPC insertions. §Catheter gauge not reported. too short23 to reliably cannulate deep veins and subse- younger age is also a risk factor for catheter failure.46–48 quently exhibit high failure rates.37–40 Our review found Five studies documented LPC use in children, with all LPCs to have a high procedural success rate (86%–100%), authors highlighting the advantages of LPCs over PIVCs. especially in patients who had already failed multiple There is potential that LPCs may reduce the number of PIVC attempts. Moreover, LPCs placed into deep veins PIVCs required during an admission and subsequently with USG demonstrated superior outcomes when com- reduce the instances of needle trauma. This was demon- pared with PIVCs without the burden and potential com- strated by Paladini et al.27 in their comparative cohort plications associated with CVCs. study. LPCs were associated with improved dwell time Compared with adults, children have distinct IV access (p < 0.0001) and failure rates (p ¼ 0.002) than traditional issues. We, therefore, examined adult and paediatric stud- PIVCs. However, there remains a lack of level one evi- ies independently in this review. Needle trauma is a signif- dence (i.e. RCT) to show a more accurate effect in icant physical and psychological burden for children.41 children. They are more sensitive to procedural pain42,43 and exhibit greater fear of venepuncture44 than adults. Cannulation can also be a difficult and time-consuming procedure. Smaller Strengths veins combined with increased adiposity complicate the This is the only study to systematically review the use of identification of veins.45 Multiple attempts may be neces- LPCs in clinical practice. Two independent investigators sary, even for the experienced operator.44 Furthermore, performed a broad and rigorous literature search to 10 The Journal of Vascular Access appraise the current evidence surrounding LPCs in both published literature for conventional peripheral intravenous paediatric and adult settings. catheters. J Infus Nurs 2016; 39: 201–209. 7. Boniface KS, LeSaux MA, Mandoorah S, et al. Ultrasound- ® Limitations guided intravenous access in adults using SonoStik ,a novel encapsulated sterile guidewire: a prospective cohort A noticeable degree of variability was present between stud- trial. J Vasc Access 2018; 19: 441–445. ies included in this systematic review. There was a mix of 8. Chick JFB, Reddy SN, Chen JX, et al. A randomized com- experimental and observational, prospective and retrospec- parison between an intravenous catheter system with a tive evidence. The reporting of data between studies was retractable guidewire and conventional intravenous cathe- inconsistent, preventing symmetrical comparison of key ters. J Vasc Access 2017; 18: 530–534. characteristics and outcomes. Particularly, outcomes were 9. Jin LM, Medeck S, Ruley J, et al. Guidewire intravenous not expressed in relative terms (i.e. per 1000 catheter-days) catheter systems do not improve first-pass success rates for or as raw data. Data were, therefore, not comparable, which peripheral access when placed by army combat medics (68 hindered our ability to perform a meta-analysis. W) in a pre-hospital setting. A prospective, randomized controlled trial with crossover study design. Mil Med Conclusion 2018; 183: e730–e734. 10. Mahler SA, Wang H, Lester C, et al. Ultrasound-guided Our systematic review has shown that LPCs are a safe and peripheral intravenous access in the emergency department reliable peripheral VAD in children and adults. In addition, using a modified Seldinger technique. J Emerg Med 2010; LPCs may represent an improvement to the quality of care, 39: 325–329. as demonstrated by multiple RCTs in adults where they 11. Raio C, Elspermann R, Kittisarapong N, et al. A prospective outperformed PIVCs. There remains, however, a lack of feasibility trial of a novel intravascular catheter system with controlled studies to determine if this effect is replicable in retractable coiled tip guidewire placed in difficult intravas- children. cular access (DIVA) patients in the emergency department. Declaration of conflicting interests Int Emerg Med 2018; 13: 757–764. 12. Dargin JM, Rebholz CM, Lowenstein RA, et al. The author(s) declared no potential conflicts of interest with Ultrasonography-guided peripheral intravenous catheter respect to the research, authorship, and/or publication of this article. survival in ED patients with difficult access. Am J Emerg Med 2010; 28: 1–7. Funding 13. Butterfield M, Abdelghani R, Mohamad M, et al. Using The author(s) received no financial support for the research, ultrasound-guided peripheral catheterization of the internal authorship, and/or publication of this article. jugular vein in patients with difficult peripheral access. Am J Ther 2017; 24: e667–e669. ORCID iDs 14. DeVries M, Lee J and Hoffman L. Infection free midline Kirby R Qin https://orcid.org/0000-0001-5215-5985 catheter implementation at a community hospital (2 years). Richard Barnes https://orcid.org/0000-0002-0181-0094 Am J Infect Control 2019; 47: 1118–1121. Maurizio Pacilli https://orcid.org/0000-0003-1259-4304 15. Owen K. The use of 8 cm midlines in community IV ther- apy. 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