Effect of a prevention bundle for internal jugular vein malposition of peripherally inserted central catheters in children: a single-center before-after study.

BACKGROUND: Peripherally inserted central catheters (PICCs) are widely used in pediatric intensive care units, but bedside insertion without fluoroscopy often results in catheter tip malposition into the internal jugular vein (IJV). We implemented a three-component prevention bundle consisting of head rotation toward the insertion side, arm abduction, and neck ultrasonography confirmation of the guidewire, and evaluated its effect on IJV catheter malposition. METHODS: This before-after study was performed on patients aged <16 years who underwent PICC placement during the pre- and post-bundle periods. The primary analysis compared IJV catheter malposition between the pre-bundle and fully adherent post-bundle groups. Secondary analysis evaluated adherence to individual bundle components and their association with IJV catheter malposition. RESULTS: We compared 168 pre-bundle patients with 112 fully adherent post-bundle patients. The IJV catheter malposition rate decreased from 11.9% (20/168) to 6.3% (7/112). However, this reduction was not statistically significant (p = 0.15). In unadjusted analysis, full bundle adherence was associated with lower odds of malposition compared with the pre-bundle group (OR, 0.49; 95% CI, 0.20-1.21; p = 0.12). After adjustment for age and primary diagnostic category, the odds ratio decreased to 0.41 (95% CI, 0.16-1.02; p = 0.06). In multivariable analysis of the individual bundle components, head rotation was associated with lower odds of malposition (adjusted OR, 0.22; 95% CI, 0.06-0.76; p = 0.02), whereas arm abduction and neck ultrasonography were not. CONCLUSIONS: The effect of bundle implementation was limited. A simpler, more reliable bundle should be investigated.