Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC

Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 19 September 2025 V1 Latest version Share on Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC Authors : Sudipto Bhattacharya 0000-0001-6215-7204 , Nita Radhakrishnan 0000-0002-7941-5641 [email protected] , Hari Gaire , Aditi Tulsiyan , Anuj Singh , Deeksha Bhalla , Dinesh Pal , and Priyanshi Tyagi Authors Info & Affiliations https://doi.org/10.22541/au.175827796.63777628/v1 268 views 130 downloads Contents Abstract Introduction Methods Data collection and statistical analysis Results Conclusion References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Peripherally inserted central catheters (PICCs) provide a cost-effective and less invasive alternative to tunneled catheters and ports in pediatric hematology oncology and bone marrow transplantation (BMT), especially in low- and middle-income countries (LMICs). Prospective data on PICC outcomes from such settings remain limited. Methods: This prospective observational study was conducted at a tertiary pediatric hospital in India between August 2024 to 2025. Children aged 1–18 years undergoing PICC insertion for chemotherapy or BMT were enrolled. Blind (landmark-based) and ultrasound-guided (USG) insertions were performed by trained fellows or radiologists. Standardized insertion protocols, care bundles, and salvage strategies were applied. Complications, removals, and catheter survival were recorded. Kaplan–Meier survival analysis defined removal for complication as the event, with elective removals or ongoing lines censored. Results: A total of 123 PICCs were placed in 12 months, of which blind insertions (n=82, 66.1%) and USG-guided insertions (n=41, 33.9%) had similar first-attempt success rates (>75%). Median dwell time was 200 days (IQR 75–321). A total of 46 lines experienced one of the pre-determined complications. 14 lines (10.5%) were removed for complications, yielding a removal rate of 0.58 per 1000 catheter-days. Kaplan–Meier analysis showed high line survival, with no difference by insertion technique or age. Relapsed ALL patients were more likely to undergo USG-guided insertions (p=0.006). Conclusions: PICCs are safe, durable and feasible in pediatric hematology oncology and BMT patients in LMICs. Blind insertions by trained staff are comparable to USG-guided procedures, while avoiding additional costs, anesthesia, and operating theatre use. Type of article: Original Article Titl e : Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC Author list: Sudipto Bhattacharya, Nita Radhakrishnan, Hari Gaire, Aditi Tulsiyan, Anuj Singh, Deeksha Bhalla, Dinesh Pal, Priyanshi Tyagi Sudipto Bhattacharya Fellow, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida Email: [email protected] ORCID: 0000-0001-6215-7204 Nita Radhakrishnan Additional Professor and Head, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida, Delhi NCR Email: [email protected] : 0000-0002-7941-5641 Hari Gaire Fellow, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida, 201303 Email: [email protected] ORCID: 0000-0002-7685-6345 Aditi Tulsiyan Fellow, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida Email: [email protected] ORCID: 0009-0003-6117-9497 Anuj Singh Assistant Professor, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida, Delhi NCR Email: [email protected] ORCID: 0009-0007-5935-235X Deeksha Bhalla Assistant Professor, Department of Radiodiagnosis, Post Graduate Institute of Child Health, Noida, 201303 (Currently, Consultant, Kailash Hospital, Noida) Email: [email protected] ORCID: 0000-0003-0478-6859 Dinesh Pal Senior Nursing Officer, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida Email: [email protected] Priyanshi Tyagi Senior Nursing Officer, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida Email: [email protected] Running title: Cancer predisposition syndromes; Pediatric cancer; Phenotype-directed recognition; Genetic testing; Treatment modification Affiliate Institution: Post Graduate Institute of Child Health, Noida, India Corresponding author’s name and contact information (e-mail address, mailing address, phone number, fax number) Nita Radhakrishnan Additional Professor, Department of Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida, Delhi NCR Email: [email protected] Phone number: +91 9999041524 Fax number: +91-120-2455552 Author contribution: All authors contributed to patient care, were involved in preparing the manuscript and its revisions. Conflict of interest: No conflict of interest Ethics approved statement: Study protocol number: 2024-14-IM-59, Institute: Post Graduate Institute of Child Health, Noida Acknowledgements: We thank the support received from CanKids Kidscan a patient organisation for childhood cancer which has supported the cost of PICC lines for majority of the cancer patients. Word count Main text file: 3473 wordsAbstract: 250 wordsTables: 1Figure: 0 Declaration of interest: The authors have no relevant financial or non-financial interests to disclose Funding declaration: There was no funding for this work. Title: Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC Background: Peripherally inserted central catheters (PICCs) provide a cost-effective and less invasive alternative to tunneled catheters and ports in pediatric hematology oncology and bone marrow transplantation (BMT), especially in low- and middle-income countries (LMICs). Prospective data on PICC outcomes from such settings remain limited. Methods: This prospective observational study was conducted at a tertiary pediatric hospital in India between August 2024 to 2025. Children aged 1–18 years undergoing PICC insertion for chemotherapy or BMT were enrolled. Blind (landmark-based) and ultrasound-guided (USG) insertions were performed by trained fellows or radiologists. Standardized insertion protocols, care bundles, and salvage strategies were applied. Complications, removals, and catheter survival were recorded. Kaplan–Meier survival analysis defined removal for complication as the event, with elective removals or ongoing lines censored. Results: A total of 123 PICCs were placed in 12 months, of which blind insertions (n=82, 66.1%) and USG-guided insertions (n=41, 33.9%) had similar first-attempt success rates (>75%). Median dwell time was 200 days (IQR 75–321). A total of 46 lines experienced one of the pre-determined complications. 14 lines (10.5%) were removed for complications, yielding a removal rate of 0.58 per 1000 catheter-days. Kaplan–Meier analysis showed high line survival, with no difference by insertion technique or age. Relapsed ALL patients were more likely to undergo USG-guided insertions (p=0.006). Conclusions: PICCs are safe, durable and feasible in pediatric hematology oncology and BMT patients in LMICs. Blind insertions by trained staff are comparable to USG-guided procedures, while avoiding additional costs, anesthesia, and operating theatre use. Prospective Outcomes of PICC Lines in Pediatric Hematology Oncology and BMT: Insights from an LMIC Introduction Central venous access is indispensable in pediatric hematology oncology and bone marrow transplantation (BMT), where patients require prolonged intravenous therapy, including chemotherapy, antibiotics, nutrition, and supportive care [1, 2]. Traditionally, tunneled central venous catheters such as Hickman lines or implantable ports have been widely used in high-income countries; however, these devices are costly, require operating theatre facilities, often making them less feasible in resource-limited settings [3,4]. Peripherally inserted central catheters (PICCs) have emerged as a reliable alternative, offering bedside placement, reduced need for anesthesia, and lower upfront cost [5]. PICCs are particularly advantageous in children undergoing intensive chemotherapy or BMT, as they can be placed with minimal infrastructure and provide stable long-term venous access. Despite these benefits, concerns remain about complications such as infection, thrombosis, occlusion, and fracture, which may lead to unplanned removals and treatment interruptions [6,7]. Most published prospective studies on PICCs originate from high-income countries, where complication rates are relatively low owing to robust care bundles and infection-prevention protocols [8-10]. In contrast, literature from low- and middle-income countries (LMICs), including India, remains sparse and is often retrospective, with underreporting of complications and limited follow-up. There is therefore a pressing need for prospective real-world data from LMIC centers to understand the safety, feasibility, and outcomes of PICC use in this clinical scenario. This prospective study addresses this gap by systematically evaluating PICC insertions over a one-year period in a pediatric hematology oncology and BMT center in India. In particular, we compare blind (landmark-based) versus ultrasound-guided insertions, analyze complication patterns, and assess catheter survival. Methods Study design and setting This was a prospective observational study conducted in the Department of Pediatric Hematology-Oncology, PGICH, Noida, between August 2024 to 2025 (12 months). Children aged 1–18 years undergoing PICC insertion for chemotherapy or BMT were consecutively enrolled. Blind (landmark-based) and USG-guided insertions were performed. The study was approved by the institutional ethics committee and written informed consent was obtained from parents or guardians for all participants. PICC line insertion Blind procedures were undertaken by fellows and residents in the department using basilic, brachial or cephalic veins, while USG-guided procedures were performed by interventional radiologist or fellows under direct ultrasonographic visualization. All procedures followed strict aseptic precautions and tip position was confirmed radiographically. The insertion by fellows/residents was done under short sedation (Midazolam, Ketamine) in the procedure room of the hematology-oncology ward, usually along with other planned procedures such as bone marrow evaluation or lumbar puncture and the position was confirmed by portable X-ray. In patients where interventional radiologist was involved, it was done in the fluoroscopy room of radiology department with similar sedation. The catheter tip was positioned at the cavo-atrial junction , corresponding to the distal superior vena cava just above the right atrium, as confirmed on chest radiography. Older children who opted against sedation, where given local anesthesia at the puncture site prior to insertion of the dilator. A silicone 4 Fr single-lumen Groshong catheter with a pressure-sensitive three-way valve at the tip that opens inward for aspiration, outward for infusion, and remains closed at baseline, thereby reducing the need for heparin flushing and lowering thrombotic and infection risks was used to the study. After appropriate sedation and aseptic preparation of the site, a 22G cannula was used to puncture the cephalic or basilic vein. The arm was positioned to maximize vein straightness (slight abduction and extension). The right arm was preferred because its venous anatomy provides a straighter course to the superior vena cava, facilitating smoother advancement and stable positioning of the catheter; if unsuccessful, the left arm was used. Inadvertent entry of the catheter into the neck veins was minimized by positioning the child with the ear approximated to the ipsilateral acromion during insertion, thereby achieving unilateral jugular vein occlusion. This maneuver reduced the likelihood of guidewire or catheter getting deviated into the neck veins at insertion. Once venous access was achieved with the 22G cannula, a sterilized guidewire (maintained under aseptic conditions in the ward) was introduced to facilitate catheter advancement. Only after successful guidewire placement was the sealed cover of the PICC line opened, and the 4 Fr single-lumen Groshong catheter was advanced as per standard practice. This approach was adopted to avoid unnecessary wastage of new PICC lines in cases where cannulation or guidewire passage was unsuccessful. Following insertion of the catheter as per the calculated length (distance from site of insertion to acromion to suprasternal notch plus 1 cm), the line was secured using a StatLock™ device (Bard, BD, USA) and covered with a sterile dressing. Pressure dressing was applied for first application to reduce chance of bleeding from the entry site; after 24 hours, it was changed to standard dressing with sterile gauze and Micropore™ tape. Since transparent dressings often became loose in the local humid conditions and with patient sweating, it was not preferred. Catheter placement was confirmed radiographically after insertion. Ultrasound-guided insertions were performed by radiologists or trained fellows with real-time imaging guidance to puncture the target vein and advance the catheter. Distance of insertion was recorded in patient file for later reference. Lines were removed either electively after therapy completion or urgently for uncontrolled complication by nurses or fellows. PICC line care bundle Following insertion, all catheters were maintained according to standardized care bundles. The catheters were routinely used for administration of chemotherapy, blood and blood product transfusions (including stem cell infusions), parenteral nutrition, inotropes, and other intravenous medications as clinically indicated. All PICCs were maintained according to standard care bundles, which included flushing with normal saline (0.9% sodium chloride) before and after medication administration or blood sampling, and at least weekly when not in use. A pulsatile push–pause technique using ≥10 mL syringes was employed to minimize intraluminal deposits. Flushing was always completed under aseptic conditions, with positive pressure applied on withdrawal to prevent blood reflux and catheter occlusion. Line dressings were performed weekly in discharged patients, and twice weekly (Monday and Thursday) for inpatients; children undergoing BMT received daily flushes. For BMT patients, the adapter was changed daily, and a three-lumen adapter was used with the hub kept covered to prevent contamination from skin flora. Standard infection-prevention bundles were followed for each access, including hand hygiene, aseptic hub scrubbing, and sterile technique during medication or transfusion administration. StatLock was changed 4-6 weekly or if found to be loose. If exit site skin irritation was noted, the StatLock position was changed. Considering the challenges with nursing care including frequent staff rotations, high attrition rates, and the presence of newly trained nurses, it was difficult to maintain a pool of dedicated personnel for line care. To ensure safety, only senior nurses who had completed in-house training were permitted to perform PICC handling or dressings, and lines were not accessed in other areas such as the emergency department or radiology suite where untrained staff might be involved. Pre-defined complications and management The pre-defined complications were catheter-related bloodstream infection (CRBSI), exit-site infection, occlusion, thrombosis, fracture, or dislodgement. 1. Catheter-related bloodstream infection (CRBSI) could not be formally diagnosed in this study, as paired cultures and differential time-to-positivity (DTP) were not feasible in all. Therefore, all positive blood cultures were documented in the study. All episodes were managed as febrile neutropenia with positive blood culture. Line removal was undertaken in the presence of Candida isolation, recurrent infections with the same or different organisms, or hemodynamic instability. Where feasible, attempts were made to salvage the line using antibiotic lock therapy for 5–7 days, during which a temporary peripheral cannula was used to maintain intravenous access [11,12,13] 2. For exit site infection, rotation of StatLock site with local or systemic antibiotics were given. Occlusion was categorized as unilateral or bilateral. In cases of bilateral occlusion, a three-way technique was employed to instill heparin (1:10,000) daily until the line reopened. For unilateral occlusion, typically due to valve thrombus at the catheter tip, the Valsalva maneuver along with heparin instillation was used. Thrombolytic agents are expensive and were not used for this indication. 3. Catheter related thrombosis was suspected in case of features of deep vein thrombosis in the ipsilateral arm and was confirmed by ultrasound Doppler. 4. Line fracture was managed according to the site of disruption. If the fracture occurred distally, the damaged segment was cut, and the adapter was refixed under sterile precautions. In contrast, proximal fractures involving the intravascular portion of the catheter necessitated complete removal of the line. 5. Line displacement, whether proximal migration into subclavian or axillary veins or distal migration into the right atrium or ventricle, was minimized by securing the catheter with a StatLock™ device and adhesive dressing, careful patient positioning, and routine line checks; if migration occurred, the catheter was either repositioned under aseptic precautions or removed if secure placement could not be restored. Proximal migrations were usually removed. Line removal for infection was guided by Infectious Diseases Society of America (IDSA) guidelines [13]; line was removed in the presence of Staphylococcus aureus bacteremia, candidemia, persistent bacteremia or fungemia despite 48–72 hours of appropriate antimicrobial therapy, tunnel or exit-site infection, or hemodynamic instability not controlled with systemic treatment. Salvage with systemic antibiotics and antibiotic locks was attempted in stable patients with single-episode bacteremia [13]. Data collection and statistical analysis Data were recorded prospectively on a structured proforma and entered into a secure database. Collected variables included demographic data (age, sex), diagnosis, indication for PICC (e.g., high-dose methotrexate block, induction chemotherapy, BMT conditioning), insertion technique (blind versus USG-guided), operator grade (fellow/radiologist), number of puncture attempts, catheter details (size, single versus multi-lumen), dates of insertion and removal, complications (type and date), interventions (salvage attempts), and reason for removal (planned versus unplanned) and date of removal. Data was entered in Microsoft Excel and statistical analysis was performed using SPSS 17.0. For statistical analyses, categorical variables are presented as counts and percentages and continuous variables as mean (standard deviation) or median (interquartile range) as appropriate. Chi-square/Fisher’s exact tests compared groups, and odds ratios (OR) with 95% confidence intervals (CI) were calculated for 2×2 tables. Kaplan–Meier survival analysis was used to estimate catheter survival, with removal for complication defined as the event and elective removals or continuing lines censored at the last follow-up date (15 September 2025). Survival curves were compared between groups (blind vs ultrasound-guided insertions, and across age categories) using the log-rank test. A p-value of <0.05 was considered statistically significant. Analyses were performed using Python and custom scripts for Kaplan–Meier estimation. Results Cohort characteristics and indications. During the study period of 12 months, 123 PICC lines were inserted in the department in 124 children. The cohort had a mean age of 7.1 years (range 1.2–17.8 years). Diagnoses included acute lymphoblastic leukemia (ALL, n=49), relapsed ALL (n=12), acute myeloid leukemia, aplastic anemia, lymphomas, and various solid tumors. Indications for PICC insertion were diverse and included high-dose methotrexate administration in ALL, induction or consolidation for AML, relapsed ALL/AML chemotherapy, conditioning for BMT, immunosuppression or BMT for aplastic anemia, and rarely poor peripheral venous access in standard risk ALL. Insertion technique and operator Of the 123 insertions, 82 (66.1%) were performed using a blind landmark-based technique and 41 (33.9%) were performed under ultrasound guidance. Blind insertions were largely performed by pediatric hematology/oncology fellows or senior residents, while USG-guided insertions were predominantly carried out by interventional radiologist or fellows trained in USG. First-attempt success exceeded 75% overall; most insertions were achieved within one or two puncture attempts. Complications and management. The median dwell time of PICC lines in our cohort was 200 days (IQR 75–321), with a mean of 207 days and a maximum of 581 days, indicating that most lines could be maintained for several months without removal. A total of 46 lines (37.4%) experienced at least one complication during the observed period (total 49 complications). Positive blood cultures were documented in 38 of 124 patients (30.6%) during the study period. Since paired cultures and differential time-to-positivity could not be performed, these episodes were classified as presumed central line–associated bloodstream infections (CLABSI) rather than confirmed catheter-related bloodstream infections (CRBSI). Only 10 (8%) required line removal for positive culture, while the remaining 28 were successfully managed with conservative measures, including antibiotics and line lock protocols. This corresponds to a removal rate of 0.42 per 1000 catheter-days attributable to culture positivity. Exit-site infection was documented in 2 cases: one required removal. Mechanical complications were uncommon: 5-line occlusions (1 removal), one catheter fracture, and 1 accidental removal. Overall unplanned removals due to complications occurred in 14 patients (11.3%), while 109 lines (88.6%) were removed electively at therapy completion. Table 1 summarizes the overall characteristics of the cohort, including the number of lines inserted, distribution of blind versus ultrasound-guided procedures, age and operator profiles, and the spectrum of complications encountered. Statistical comparisons When outcomes were compared between blind and ultrasound-guided insertions, a significant difference was observed in the age distribution, with younger children more often undergoing blind insertions (<5 years: Blind 27 vs USG 25; 5–9 years: Blind 39 vs USG 9; 10–14 years: Blind 11 vs USG 6; 15–18 years: Blind 5 vs USG 2; p = 0.021). Indications for line placement, including BMT (Blind 21 vs USG 8), high-dose chemotherapy (Blind 61 vs USG 31), and immunosuppressive therapy (Blind 0 vs USG 2), showed no significant difference between the two groups (p = 0.095). Analysis restricted to patients with ALL versus relapsed ALL demonstrated that children with relapsed ALL were significantly more likely to undergo USG-guided insertions (ALL: Blind 38 vs USG 12; Relapsed ALL: Blind 4 vs USG 9; p = 0.006). During the study period, there were a total of 49 complications, corresponding to a rate of 2.04 per 1000 catheter-days . Of these, 14 complications required line removal, giving a removal rate of 0.58 per 1000 catheter-days. Complication rates did not differ significantly between blind and USG-guided insertions (p = 0.45), with an odds ratio of 0.69 (95% CI 0.32–1.48). Similarly, removal rates were not significantly different between blind and USG-guided techniques (Chi-square p = 0.29), with an odds ratio of 0.47 (95% CI 0.15–1.43). Removal analyzed by age group also showed no significant association (Chi-square p = 0.64). Kaplan–Meier analysis demonstrated high complication-free survival for the cohort; the median time to first complication was not reached during follow-up, indicating that more than half of PICCs remained complication-free through the study period. Survival curves stratified by technique (blind versus USG) overlapped substantially, reflecting similar durability of lines regardless of insertion method. Age-stratified curves likewise showed good line survival across groups, and no age cohort experienced an excess of early complications that reduced survival below 50% during the available follow-up. Discussion This prospective study provides pragmatic, real-world evidence supporting the use of PICC lines for venous access in pediatric hematology oncology and BMT in a resource-limited setting. The data indicate that PICCs can be inserted safely and maintained with acceptable complication rates and high salvageability when standardized care bundles are strictly implemented [3,10]. The primary finding was that blind landmark-based insertions comprised the majority of procedures and achieved outcomes comparable to ultrasound-guided insertions. The absence of a statistically significant difference in complication rates or line survival between techniques suggests that, when performed by trained pediatric hematology/oncology staff following clear protocols, blind PICC insertion is a valid option and USG-guidance could be reserved for patients with difficult access. This has important implications for LMICs, where access to routine ultrasound guidance and interventional radiology support may be limited or costly. Performing safe PICC insertions at bedside by trained fellows reduces the need for operating theatre time, avoids anaesthesia-associated costs and risks in many cases, and shortens time to vascular access in patients where treatment cannot be delayed. PICCs are particularly advantageous for administration of high-dose chemotherapy, including methotrexate, where prolonged infusion, aggressive hydration, and repeated blood sampling are required. Reliable central access simplifies patient management, reduces repeated painful peripheral cannulations, and allows timely delivery of supportive care such as transfusions and broad-spectrum antibiotics when needed. Comparison with alternative devices merits consideration. Tunneled central venous catheters (e.g., Hickman lines) and fully implantable ports provide advantages including lower external infection risk and greater durability for very long-term therapy. However, they require surgical placement, often under general anaesthesia, add substantial cost, and are associated with their own complication profiles. Ports are costly to procure and insert, and their maintenance requires expertise that may not be widely available in many LMIC centers. In our cohort, single-lumen PICCs were adequate for most treatment regimens with care not to use simultaneous incompatible infusions [14,15]. The blood culture positivity rates observed in this cohort was higher than some reports from high-income countries but aligns with other series from LMICs. The majority of infections in our cohort were managed successfully without catheter removal using antibiotics. Antimicrobial lock therapy was used in 2 patients to salvage the line; standardized salvage protocols can help preserve vascular access when clinically appropriate. Our infection-related removal rate of 0.42 per 1000 catheter-days compares favorably with most published series and is at the lower end of reported ranges. Direct numeric comparisons are difficult because studies differ in important ways as some report all infectious events (CLABSI surveillance definitions) while others report only microbiologically confirmed catheter-related bloodstream infections (CRBSI), follow different salvage protocols, and have variable patient mixes (for example, high proportions of BMT or relapsed patients increase infection risk). The relatively low removal rate in our cohort likely reflects several factors: strict line-care bundles and prompt salvage attempts (including antibiotic locks), a conservative threshold for removal unless there was Candida, recurrent infection, or hemodynamic instability, and the use of censored survival analysis that counts only removals-for-infection as events. The additional challenge in our program especially from the infection standpoint was the availability of adequately trained nursing staff. High attrition rates, frequent rotations, and the presence of newly recruited nurses limited the feasibility of maintaining a dedicated team for central line care. To mitigate this, only senior nurses who had completed formal training were allowed to perform line dressings, and the PICCs were not accessed in areas such as the emergency department or imaging suites where untrained staff were present. This constraint, common in many low- and middle-income countries, underscores the importance of structured training, supervision, and task restriction to safeguard line care and minimize complications, even in resource-limited environments [16]. Economic considerations are central to device selection in LMIC settings. The direct cost of a single-lumen PICC (device and insertion) is substantially lower than that of tunneled Hickman catheters or implantable ports when accounting for device price, operating theatre charges, surgical and anaesthesia fees, and peri-procedural imaging. To reduce costs, we prevented wastage of even one PICC line by using a 22G cannula and a spare sterilized guidewire initially to secure the venous access. By confirming venous entry with the guidewire before opening the PICC set, we avoided unnecessary opening of lines in cases of failed cannulation, ensuring conservation of resources and cost savings in our resource-limited context. In our cohort, 97 of 124 insertions (78.2%) were successful on the first attempt, while most of the remaining required only two attempts; the overall median number of pricks was one (range 1–5). The principal strengths of this study are its prospective design, systematic collection of real-world clinical data, and focus on an LMIC pediatric hematology oncology population. Our observed overall complication rate of 2.04 per 1000 catheter-days and removal rate of 0.58 per 1000 catheter-days are lower than those reported in many pediatric series from both high-income countries and LMICs. The dwell time noted in our study compares favorably with published literature. Our observed median of 200 days is therefore longer than that reported in most LMIC cohorts and is comparable to or better than high-performing HIC series, supporting the durability and feasibility of PICC use in pediatric hematology oncology and BMT patients in resource-constrained settings [17-20]. The limitations include a single-center setting, modest sample size that limits power for rare outcomes (e.g., catheter-related thrombosis), and a follow-up duration confined to the study period which may not capture late complications after removal. Additionally, technique allocation was not randomized and may refle selection bias; operators preferentially selected USG guidance for children with prior access difficulties or relapsed disease, which could confound direct comparisons. Nonetheless, the findings remain directly applicable to centers in similar resource contexts and reinforce the feasibility of an organized PICC program. Conclusion Peripherally inserted central catheters are a reliable, pragmatic, and cost-effective method for central venous access in pediatric oncology and bone marrow transplant patients in resource-limited settings. Blind insertions performed by trained staff in the ward, supported by robust line-care bundles and salvage protocols, provide outcomes comparable to ultrasound-guided techniques while avoiding theatre, anaesthesia and additional radiology expenses. Careful device selection, meticulous maintenance, and early recognition and management of complications are essential to optimize outcomes. Total lines inserted in 12 months 123 Technique Blind insertions USG insertions 82 41 Age wise division Age <5 Age 5-9 Age 10-14 Age 15-18 51 48 17 7 Age vs Technique <5 years 5–9 years 10–14 years 15–18 years p = 0.021 Blind 27 | USG 24 Blind 39 | USG 9 Blind 11 | USG 6 Blind 5 | USG 2 Diagnosis vs Technique ALL Relapsed ALL p = 0.006 Blind 38 | USG 11 Blind 4 | USG 9 Complications Blood stream infection Line block/ occlusion Exit site pain / infection Accidental removal Line fracture Total number (n=49) 40 5 2 1 1 Removal (n=14) 10 1 1 1 1 Complications vs Technique Blind USG p = 0.451 No complication: 54 With complication: 28 No complication: 24 With complication: 18 (some lines had >1 complication) Removal for complication vs Technique Blind insertions: USG-guided insertions: removed p = 0.292 7 removals for complication, 75 not removed 7 removals for complication, 35 not removed References 1. 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Keywords bmt pediatric hematology/oncology pediatric oncology Authors Affiliations Sudipto Bhattacharya 0000-0001-6215-7204 Department of Pediatric Hematology Oncology View all articles by this author Nita Radhakrishnan 0000-0002-7941-5641 [email protected] Department of Pediatric Hematology Oncology View all articles by this author Hari Gaire Department of Pediatric Hematology Oncology View all articles by this author Aditi Tulsiyan Department of Pediatric Hematology Oncology View all articles by this author Anuj Singh Department of Pediatric Hematology Oncology View all articles by this author Deeksha Bhalla Department of Radiodiagnosis View all articles by this author Dinesh Pal Department of Pediatric Hematology Oncology View all articles by this author Priyanshi Tyagi Department of Pediatric Hematology Oncology View all articles by this author Metrics & Citations Metrics Article Usage 268 views 130 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Sudipto Bhattacharya, Nita Radhakrishnan, Hari Gaire, et al. 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