1. Bard PowerPICC Solo2 vs. Cook Turbo-Ject: A Tale of Two PICCS
Brie Alport1 BSc Hon, Brent Burbridge1 MD, FRCPC, Hyun Lim2 PhD
1Department of Medical Imaging; College of Medicine, Saskatoon, SK
2Department of Community Health and Epidemiology; College of Medicine, Saskatoon, SK.

2. Background
A milestone in medical history was the ability to gain intravenous (IV) access allowing for the safe administration of nutrition, fluids and medications, and the ability to withdraw blood.
Safe, reliable IV access is essential for current patient management.
Peripherally inserted central catheters (PICCs) are a form of long-term intravenous access used to administer nutrition, fluids, and medications. They are inserted in the arm rather than in the subclavian or jugular vein.

3. Background
PICCs have gained popularity because they are safe and effective for patients requiring long term venous access (1, 2).
PICCs have a lower risk of infection and complication during placement and are less expensive than centrally inserted venous catheters (3).
PICCs allow for easy intravenous care and maintenance and facilitate outpatient treatment.

4. Rationale
PICC complications include problems of insertion, mechanical complications and secondary events such as sepsis, embolization.
Catheter occlusion and infection are common complications with an incidence of 7-25% (3).
PICC complications result in patient discomfort, loss of venous access and additional healthcare costs.
A variety of PICCs are available that are specifically designed to improve patient care and reduce complications.

5. Objective
To compare the complication rates of two different brands of PICCs: Cook Turbo-Ject (Cook Medical, Stouffville, ON, Canada) and the Bard PowerPICC Solo2 (Bard Canada Inc., Mississauga, ON, Canada).

6. PICC Designs
Bard PowerPicc Solo2 (Bard Canada Inc., Mississauga, ON, Canada)
Cook Turbo-Ject (Cook Medical, Stouffville, ON, Canada)
Long or short term venous access, IV therapy, power injection of contrast or central venous pressure monitoring
Kink resistant, reverse tapered design
Clamp-free 3 valve design – 2 small valves for aspiration and blood withdrawal, 1 large valve for fluid infusion
Max power injection rate is 5 ml/sec
Max pressure rate is 300 psi
One external valve for fluid infusion
External plastic clamps to prevent air aspiration
Max flow rate is 5 ml/sec
Max pressure rate is 325 psi

7. Methods
A prospective clinical trial was conducted at the Royal University Hospital Surgical ward 5000.
PICCs were implanted at the RUH Medical Imaging Department by an Interventional Radiologist.
Two brands of PICC lines were used in this study: Cook Turbo-Ject and the Bard PowerPicc Solo2.
PICC incidents, complications, and corrective actions were recorded using a standardized data collection form.

8. Methods
Data collection included: number of catheter days, primary and secondary diagnosis, age, patient gender and details of technical placement of the PICC.
Descriptive statistics were used to summarize the data. Between group comparisons of categorical variables were performed with chi-square testing. Two group comparisons of continuous variables were tested with Student’s t-test (2- tailed). Analysis was carried out with SAS statistical software version 9.2 (The SAS Institute Inc., Cary, NC, USA).
Statistical significance was set at P< 0.05.

9. Demographics
Table 1: Patients’ baseline characteristics (n; % and mean ±SE)
Patients
PICC brand
p-value
Bard (n=25)
Cook (n=28)
Female
15 (65.2%)
18 (66.7%)
0.914
Age
56.2 (±4.7)
61.7 (±3.7)
0.358
Diabetes Yes No
7 (31.8%)
15 (68.2%)
5 (18.5%)
22 (81.5%)
0.331
Primary Diagnosis
Neoplastic GI
Infection
Other*
4 (18.2%)
8 (36.4%)
2 (9.1%)
11 (42.3%)
7 (26.9%)
6 (23.1%)
2 (7.7%)
0.346
* Includes respiratory (n=1), Genitourinary (n=2), metabolic (n=1) and coagulation disorders
(n=0).
Note unavailable data: diabetes – Bard (n=3), Cook (n=1); Primary diagnosis – Bard (n=3),
Cook (n=2).

10. Technical Placement of PICC
Table 2: Technical placement of PICC
PICC placement
PICC brand
p-value
Bard (n=25)
Cook (n=28)
Reason for Insertion
TPN
Others*
21 (84.0%)
4 (16.0%)
20 (71.4%)
8 (28.6%)
0.275
Method of Insertion
Ultrasound
Fluoroscopy
0 (0.0%)
19 (100.0%)
2 (7.4%)
25 (92.6%)
0.225
* Includes antibiotics (n=2), IV access (n=8) and chemotherapy (n=2).
Note unavailable data: Method of insertion – Bard (n=6), Cook (n=1).

11. Technical Placement of PICC
Table 2: Technical placement of PICC (continued)
PICC placement
PICC brand
p-value
Bard (n=25)
Cook (n=28)
PICC location
Arm
Right
Left
12 (48.0%)
13 (52.0%)
16 (57.1%)
12 (42.9%)
0.506
Vein
Basilic
Brachial
Cephalic
22 (88.0%)
2 (8.0%)
1 (4.0%)
20 (71.4%)
6 (21.4%)
2 (7.1%)
0.322
Tip position*
SVC
Cavoatrial junction
20 (87.0%)
3 (13.0%)
21 (75.0%)
7 (25.0%)
0.480
Number of days inserted** (mean ± SE)
23.3 (±3.1)
23.3 (±3.3)
0.986
Total catheter days**
898
658
* Unavailable data: Tip position - Bard (n=2).
** Unavailable data: Bard (n=1), Cook (n=1)

12. PICC incidents Table 3: PICC incidents Brand of PICC p-value
Bard (n=25)
Cook (n=28)
Incident No
Yes*
12 (48%)
13 (52%)
16 (57%)
12 (43%)
0.081
Incidents experienced:
Total Incidents
Aspiration
Blood withdrawal
Flushing
Other 29 5 17 2 18 4 9 1
* 29 incidents for 13 patients in the Bard group and 18 incidents for 12
patients in the Cook group.

13. PICC complications Table 3: PICC complications Brand of PICC p-value
Bard (n=25)
Cook (n=28)
Patient Complications No
Yes*
13 (52%)**
12 (48%)
21 (75%)
7 (25%)
0.506
Complications experienced:
Total complications
PICC infection
PICC occlusion
Suture wing tear
Sutures pulled out of skin
PICC partially extracted
PICC completely extracted
Fibrin sheath
Migrations of PICC
Thrombosis
18 (20.1)***
3 (3.3)
0 (0.0)
4 (4.5)
1 (1.1)
5 (5.6)
10 (15.2)
3 (4.6)
1 (1.5)
2 (3.0)
* 18 complications from 12 patients in the Bard group and 10 complications from 7 patients in the Cook group.
** percentage for each brand of PICC.
*** # events/1000 catheter days.

14. Results A total of 53 PICCs (Bard=25, Cook=28) were implanted.
Variables in patient demographics, technical placement of the PICC, incidents and complications were analyzed independently.
Mean dwell time was 23.3 days for both groups.
Complications were evaluated by analyzing the incident and complication rates:
An incident was the initial suggestion of a problem identified by the nursing staff prior to assessment by Medical Imaging (aspiration, flushing and blood withdrawal).
Medical Imaging confirming the incident was a true complication.
Each PICC could have more than one incident and complication.

15. Results
Incident rates were 52% and 43% for Bard and Cook respectively; blood withdrawal was the most common problem in both groups.
All complications encountered were recognized risks of the procedure.
Complication rates were 48% and 25% for Bard and Cook PICCs respectively; fibrin sheath was the most common in both groups.
No significant difference was detected in patient demographics, technical placement of the PICC, incidents or complications between the groups.

16. Conclusion
Both the Cook Turbo-Ject and the Bard PowerPICC Solo 2 PICCs provide safe and effective venous access for a number of indications.
Reported PICC complication rates range from 35-65% (4, 5, 6, 7).
The Bard and Cook complication rates were 48% and 25% respectively – this difference was not statistically significant.
Choosing an appropriate brand of PICC can be determined by user preference or by the cost of the product.
Further research should be conducted to ensure appropriate PICC selection in a clinical setting that meets patient needs.

17. References
Haider G, Kumar S, Salam B, et al. Determination of complication rate of PICC lines in oncological patients. J.Pak.Med.Assoc. 59: 10: , 2009.
Chu FS, Cheng VC, Law MW, et al. Efficacy and complications in peripherally inserted central catheter insertion: a study using 4-Fr non-valved catheters and a single infusate. Australas.Radiol. 51: 5: ,
Hoffer EK, Borsa J, Santulli P, et al. Prospective randomized comparison of valved versus nonvalved peripherally inserted central vein catheters. AJR Am.J.Roentgenol. 173: 5: , 1999.
Amerasekera SS, Jones CM, Patel R, et al. Imaging of the complications of peripherally inserted central venous catheters. Clin.Radiol. 64: 8: , 2009.
Cowl CT, Weinstock JV, Al-Jurf A, et al. Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters. Clin.Nutr. 19: 4: , 2000.
Smith JR, Friedell ML, Cheatham ML, et al. Peripherally inserted central catheters revisited. Am.J.Surg. 176: 2: , 1998.
Chlebicki MP and Teo EK. Review of peripherally inserted central catheters in the Singapore acute-care hospital. Singapore Med.J. 44: 10: , 2003

18. Acknowledgments We would like to thank:
The University of Saskatchewan for financial supporting this project.
The Royal University Hospital Ward 5000 Nursing Staff and Vascular technologists for their assistance in data recording.