At the forefront of the medical field, the Intensive Care Unit (ICU) plays a crucial role as the last line of defense for preserving life [1][2]. Peripheral Arterial Catheters (PAC) are essential monitoring tools in the ICU and anesthesiology, widely utilized for continuous hemodynamic monitoring, blood sampling, and arterial blood gas analysis, with over 10 million catheters placed each year globally [3][4], underscoring their indispensable clinical value. However, the widespread application of PACs is accompanied by certain risks and challenges [5]. During the retention of PACs, the occurrence of Peripheral Arterial Catheter Failure (PACF) is common, defined as the inability of the catheter to achieve the expected monitoring and therapeutic functions due to complications such as kinking, absence of blood return, abnormal waveforms, catheter-related bloodstream infections, occlusion, or dislodgment [6]. Currently, the incidence of PACF remains high both domestically and internationally, ranging from 4% to 25% worldwide [7]. A secondary analysis by Jessica A. et al. [8] on 664 patients indicated a PACF incidence of 26%, with 8% attributed to catheter occlusion; additionally, a study by Yuan Cui et al. [9] confirmed a PACF incidence of 25.1% among ICU patients in China. Despite the significant impact of PACF on clinical diagnosis and treatment, research on risk prediction tools for PACF is exceedingly scarce, resulting in challenges for clinicians in early and accurate identification of high-risk patients and the formulation of personalized preventive interventions, thereby scientifically guiding PAC maintenance practices. Based on this, the present study aims to analyze the influencing factors to provide a basis for the early prevention and control of PACF in clinical settings.

The global incidence of PACF ranges from 4% to 25% [7], whereas in this study, the incidence of PACF among 240 ICU patients was 29.2%, which is slightly higher than the aforementioned studies. This discrepancy may be attributed to the median APACHE II score of 21 in the enrolled patients, indicating a higher severity of illness, as well as the presence of peripheral vascular diseases in some patients [12]. This also underscores the urgency of PACF prevention and control in critically ill patients and further validates the significant value of developing a PACF risk prediction model for clinical practice.

This study, employing a prospective cohort design, systematically analyzed the influencing factors of PACF in adult patients in the ICU of a tertiary hospital in Jingzhou for the first time. The results exhibit both consistency with existing domestic and international research and specific clinical characteristics. In terms of laboratory indicators, this study found that the median platelet count in the PACF group (158.00 × 10⁹/L) was significantly higher than that in the non-PACF group (129.50 × 10⁹/L, P = 0.025). Although platelet count did not enter the final model in the multivariate analysis (P = 0.081), this trend suggests that elevated platelet counts may increase the risk of blood coagulation. Platelet activation is a crucial early step in thrombosis formation. Clinically, for patients with significantly elevated platelet counts [13], it is essential to enhance the frequency of catheter flushing and monitor thrombotic risks, providing potential laboratory warning cues for the prevention of PACF. In terms of clinical outcomes, the median ICU length of stay in the PACF group (6.00 days) was significantly longer than that in the non-PACF group (5.00 days, P < 0.001). The catheter replacements and management of complications caused by PACF not only consume medical resources but may also delay clinical judgment due to monitoring interruptions, thereby prolonging patients’ ICU stay. This underscores the direct significance of reducing the incidence of PACF in shortening hospitalization periods and improving patient prognosis [14].

Skin edema and bruising may compromise the integrity of the puncture site barrier, increasing the risk of bleeding and infection. Elli et al. [15] emphasized in their study on residual blood flow in radial artery catheters that the integrity of the puncture site skin is fundamental to maintaining catheter function. Abnormal skin conditions can elevate the probability of bleeding around the catheter and thrombosis; therefore, clinicians should prioritize puncturing areas with good skin conditions. The strong protective effect of ultrasound-guided puncture directly validates the recommendation by Imbriaco et al. based on the guidelines from the French Society of Anesthesia and Intensive Care (SFAR) that “patients with shock, obesity, and edema require ultrasound-assisted puncture”. Furthermore, this study corroborates that even in ordinary ICU patients, ultrasound guidance can reduce the risk of PACF by 68%. This conclusion is highly consistent with the findings of Elli et al. [15], who assessed the radial artery catheter/artery ratio via ultrasound (recommended ≥ 45%) and found that ultrasound guidance could reduce vascular injury and decrease the rate of catheter occlusion. It is hypothesized that this protective effect is achieved by improving puncture accuracy and reducing the frequency of repeated punctures (in this study, the incidence of PACF in patients requiring ≥ 3 punctures was 25.71%, significantly higher than the 44.29% in those with a single successful attempt). Therefore, it is recommended to promote standardized ultrasound-guided puncture procedures in clinical practice.

With each additional day of catheter indwelling time, the risk of PACF significantly decreases. This finding appears to contradict the traditional perception that “longer indwelling time leads to higher risk”. However, in this study, patients categorized as having “long indwelling time” were primarily those with standardized catheter maintenance (e.g., maintenance frequency ≥ 3 times/day) and relatively stable conditions, rather than those with “long-term indwelling but poor management”. This discrepancy may be attributed to the standardized maintenance protocols implemented for patients with prolonged indwelling durations. This aligns with the conclusions of Watts et al. [16], who found that under the premise of standardized maintenance (such as daily flushing of the catheter ≥ 3 times and regular assessment of catheter patency), there was no significant positive correlation between the duration of radial artery catheter indwelling and the incidence of complications. This suggests that “reasonable indwelling under standardized maintenance” is more effective in reducing PACF risk than “blindly shortening indwelling time”.

The study results directly emphasize the importance of regular flushing and monitoring the patency of catheters. Giani et al. [17] also pointed out in their research on the use of midline catheters for blood gas monitoring in critically ill patients that maintenance frequency (such as the number of flushes and line checks) is a core factor affecting catheter function. The findings of this study further address the gap in domestic research, which has largely focused on catheter infections and thrombosis while paying insufficient attention to the critical aspect of “maintenance frequency”. The presence of blood residuals within the catheter is a risk factor for PACF, as blood residuals can easily lead to thrombus formation within the catheter. This is consistent with the conclusions of Ying et al. [18], whose literature review analyzed 57 cases of severe ischemia related to radial artery catheters and found that 82% of catheter blockages were due to thrombi within the lumen, with blood residuals being the primary cause of thrombus formation. Therefore, it is essential for clinical practice to strictly adhere to the operational protocols of “thoroughly flushing the catheter after blood sampling” and “timely addressing any residuals detected”. The results indicate that frequent blood sampling may increase the likelihood of blood stasis within the catheter and endothelial irritation, suggesting a need for clinical optimization of blood sampling protocols. The research by Giani et al. [17] also supports this strategy, finding that midline catheters can accurately monitor blood gas parameters, achieving an 89.2% consistency with arterial catheters, indicating that midline catheters can partially replace arterial blood sampling, thereby reducing unnecessary arterial catheter use and lowering the risk of PACF.

In conclusion, this study systematically identified and clarified the key influencing factors of peripheral arterial catheter-related complications (PACF) in ICU patients, thereby laying a solid theoretical and data foundation for the subsequent construction of a high-precision and generalizable PACF risk prediction model. However, this study employed a convenience sampling method and was conducted in a single hospital, which may introduce certain sample bias. Additionally, this research did not include some variables, such as the experience of the operators or specific maintenance protocols, which may also affect the study outcomes. Future investigations could expand the sample size through multicenter studies and incorporate a more comprehensive range of variables, providing a basis for reducing PACF incidence and improving treatment outcomes and long-term prognosis for critically ill patients.