Venous Assessment Prior to Mobilization Significantly Reduced Use of Apheresis Central Venous Catheters

Introduction: Autologous stem cell transplantation (ASCT) is a treatment option for hematologic malignancies. Current techniques may include placement of an apheresis central venous catheter (aCVC), for the purpose of autologous leukapheresis (LA) (Kalantari et al, Journal Clinical Apheresis, 2012). CVCs are associated with a risk of bloodstream infections (BSI) and venous thromboembolism (Johansson et al, BMT, 1999). The aim of this analysis was to evaluate the effect of instituting formal LA venous assessment (intervention) prior to mobilization on the rate of CVC placement in patients (pts) undergoing ASCT.

Method: 254 pts divided into 2 cohorts (pre and post intervention) were retrospectively reviewed. Cohort 1 included 135 consecutive pts treated in 2012, pre-intervention. Cohort 2 included 119 consecutive pts treated in 2015-2016, post intervention. Pts in cohort 2 had a formal venous assessment performed by a LA-specialized nurse prior to mobilization. Central venous catheterization was performed if veins were deemed unsuitable for cannulation. Pts identified as having insufficient peripheral venous access (PVA) had placement of an antibiotic-coated short-term aCVC, which was either kept for the duration of ASCT or removed prior to ASCT followed by insertion of a dual-lumen PICC for ASCT. Pts who collected via PVA for LA then had planned PICC placement for the duration of ASCT. Blood cultures (BC) were obtained in pts who developed fever (temperature >100.5°F). Screening BC were not performed. Positive blood cultures were not classified as central line-associated bloodstream infections (CLABSI) unless specific criterion was met.

Results: Patient characteristics between the 2 groups were comparable in terms of age, diagnosis and gender. 52% in cohort 1 were male; 55% in cohort 2 were male (p= 0.082); 60% in cohort 1 and 70% in cohort 2 had a diagnosis of multiple myeloma (p= 0.997). Pts with an aCVC for LA were greater in cohort 1 (93% vs. 59%, p<0.0001); the proportion of PVA was significantly greater in cohort 2 (38% vs 7%, p<0.0001). 12% of male pts in cohort 1 and 53% of male pts in cohort 2 were successfully collected using PVA (p<0.001). Only 1% of patients in the entire sample required conversion from PVA to aCVC due to poor venous access. The number of PICC lines for ASCT increased from 14% to 77% across the intervention period (p<0.001), and the number of aCVC for ASCT decreased from 79% to 13% (p<0.001).

Median number of CD34+ cells collected was 12.44 x 10⁶/kg for the full sample. There were no significant differences between the 2 cohorts in terms of number of CD34+ cells. 82% of pts who had LA using PVA post intervention had planned PICC line insertion for ASCT. The incidence of positive blood cultures during the transplant period increased from 19% in the 2012 cohort, to 36.4% in the 2015-2016 cohort (p<0.0001).

Conclusion: There are no statistical differences between pts undergoing LA using PVA and aCVC in terms of number of days of apheresis and number of CD34+ cells collected. Peripheral venous access is a less invasive procedure, and is the preferred method in eligible pts. The statistically significant increase in positive blood cultures during the transplant phase may be explained by the use of non-antibiotic coated PICC lines during ASCT in cohort 2. Use of antibiotic coated PICC lines is currently being evaluated at our center. Our study demonstrates that 38% of all pts and 53% of male pts can undergo apheresis using PVA. The process of formal venous assessment by a LA-specialized nurse is recommended and can effectively predict who can complete LA using peripheral access.