Table 4

Levels of evidence for recommendations of PICC-related thrombosis prevention in patients as reported in included CPGs

Recommendations*ASCO 2013ASH 2021INS 2024
(1) Identify patient risk factors––

  • History of thrombosis (I)

  • Other factors (II)

(2) Identify catheter-related risk factors––

  • Catheter-to-vessel ratio prior to insertion no more than 45% ratio (II)

  • Place small-diameter catheters (I)

  • Catheter tip location (A/P)

(3) Identify operator risk factors––

  • Use a bundled approach for PICC insertion (II)

  • Consider tunnelling PICCs (III)

  • Use ultrasound for accurate insertion (V)

  • Use electrocardiography for PICC tip location (III)

(4) Risk assessment of patients with PICC––

  • When choosing and inserting a PICC (I)

(5) Consider the use of a risk scoring system––

  • The Caprini Risk Assessment Model (IV)

  • The Michigan Risk Score (IV)

(6) Monitor for signs and symptoms––

  • Measuring arm circumference (IV)

(7) Pharmacologic preventative measures for PICC-related thrombosis

  • Not to use as preference (WG)

  • Not using parenteral thromboprophylaxis (low)

  • Not using oral thromboprophylaxis (low)

  • Guided by individual patient risk (I)

(8) Non-pharmacological preventative measures for PICC-related thrombosis

  • Flush with saline as preference (WG)

–

  • Handgrip exercise (III)

(9) Diagnose and confirm PICC-related thrombosis––Doppler ultrasound as preference (II)
(10) Remove the PICC against––

  • Do not remove when the catheter is correctly positioned, functional and necessary for infusion therapy (I)

(11) Treatment after diagnosis––

  • Anticoagulant medication for at least 3 months after diagnosis (IV)

(12) Medical personnel training––

  • Ensure that the selected Vascular access device (VAD) is inserted by staff with specific training, using vascular visualisation (II)

(11) Treatment after diagnosis

  • Use LMWHs for a minimum of 3 months (guidance)

––
(12) Medical personnel training––

  • Establishing education and training systems (A, 1)

  • · Establishing Credentialing process (B, 2)

CCC-IUA 2020CMA 2018IITC-CNA 2022
(1) Identify patient risk factors

  • Patients with catheterisation (WG)

  • Malignant tumours, chemotherapy and surgery (WG)

––
(2) Identify catheter-related risk factors

  • The smallest external diameter (WG)

  • Catheter tip location (WG)

––
(3) Identify operator risk factors

  • Repeated puncture and withdrawal of catheter (WG)

  • Non-standard rushed, sealing tube operation can increase the risk (WG)

––
(4) Risk assessment of patients with PICC–

  • VTE risk assessment with a central venous catheter (2B)

–
(5) Consider use of a risk scoring system–

  • The Khorana score model (1B)

–
(6) Monitor for signs and symptoms–––
(7) Pharmacologic preventative measures for PICC-related thrombosis–

  • Not use for low-risk patients (2B)

  • Use LMWH or LDUH as preference for medium and high risk (2 B)

–
(8) Non-pharmacological preventative measures for PICC-related thrombosis

  • Handgrip exercise (WG)

  • Providing appropriate and adequate nursing care (WG)

–

  • Non-pharmacological measures (V, B)

  • Providing appropriate and adequate nursing care (II, A)

(9) Diagnose and confirm PICC-related thrombosis

  • Doppler ultrasound as preference (WG)

–

  • Doppler ultrasound as preference (I, A)

  • Not to routine use Doppler ultrasound (IV, D)

(10) Remove the PICC against––

  • Extractions consider the actual situation (II, B)

(11) Treatment after diagnosis––

  • Routine anticoagulation before removal (IV, B)

  • Further assessed for appropriate interventions (I, A)

(12) Medical personnel training

  • Establishing education and training systems (WG)

––
ITAC-CME 2022ESMO 2015ISCCM 2020
(1) Identify patient risk factors–––
(2) Identify catheter-related risk factors

  • Catheter tip location (grade 1B)

–

  • Catheter tip location (A, 2)

(3) Identify operator risk factors–

  • Assess knowledge and compliance (A, 1)

(4) Risk assessment of patients with PICC–––
(5) Consider use of a risk scoring system–––
(6) Monitor for signs and symptoms–––
(7) Pharmacologic preventative measures for PICC-related thrombosis

  • Not to use as preference (grade 1A)

––
(8) Non-pharmacological preventative measures for PICC-related thrombosis–

  • Flushing with saline as preference (I, C)

  • Providing appropriate and adequate nursing care (B, 2)

(9) Diagnose and confirm PICC-related thrombosis–

  • Doppler ultrasound as preference (III, A)

  • Doppler ultrasound as preference (B, 2)

(10) Remove the PICC against––

  • No need to extubate (A, 2)

  • *Refer to Appendix 6 for the recommendations from each CPG that informed in Table 4 and Appendix 7 for an explanation of the different evidence levels.

  • ASCO, American Society of Clinical Oncology; ASH, American Society of Haematology; CCC-IUA, Chinese Chapter Congress of the International Union of Angiology; CMA, China Medical Association; CPGs, clinical practice guidelines; ESMO, European Society for Medical Oncology; IITC-CNA, Intravenous Infusion Therapy Committee of Chinese Nursing Association; INS, Infusion Nursing Society; ISCCM, Indian Society of Critical Care Medicine; ITAC-CME, International Initiative on Thrombosis and Cancer; LMWH, low molecular weight heparin; PICC, Peripherally Inserted Central Catheter; VTE, venous thromboembolism.