Sacramento, 02/02/2016 /SubmitPressRelease123/
The use of peripherally inserted central catheters (PICC lines) has grown significantly in the United States over the past decade. Specialty-trained nurses using ultrasound-guided technique, under sterile conditions, place PICC lines. The line is placed with measured estimates to approximate tip placement. Not only has the use expanded in hospitals, there are private vendors that provide this service to nursing homes and home health. The use has become ‘routine’ despite significant complications related to the use of these medical devices.
Historically in the hospital setting intravenous access was managed nearly exclusively with peripheral IVs placed by nursing. Only in the setting of significant trauma or an absolute impossibility of finding a peripheral vein suitable for placing an IV would a surgeon be consulted to place a central line in the supraclavicular space (above the clavicle). To avoid supraclavicular central lines physicians and nurses would expend significant time and energy attempting to place peripheral IVs in difficult venous access patients understanding that central lines were painful, expensive, and associated with punctured lungs and hemorrhage.
Now supraclavicular central lines have been replaced by the simple and ‘routine’ PICC procedure. Unfortunately, this ‘routine’ procedure is overused and in many cases not necessary if nurses and doctors continued to attempt peripheral IV placement in the difficult venous access patient. It must be understood that the risk of PICC line placement are real and associated with significant morbidity and sometimes mortality.
The primary risk related to PICC lines is the occurrence of an upper extremity deep venous thrombosis (DVT), which may lead to pulmonary embolism. In the case of an upper extremity DVT that is PICC line related DVTs are caused by a slowing of blood around the line in the vein, platelet adherence to the line, and trauma to the vein that all of which induces blood clots to form. Clearly associated with the risk of development of an upper extremity DVT is the diameter of the catheter, distal tip location, and if there is an underlying infection. Large diameter triple lumen PICC lines carry a 20-fold risk of DVT and a misplaced catheter is associated with nearly a fifty-percent increase in risk of DVT.
Upper extremity DVTs are not as ‘benign’ as once believed. Studies indicate that pulmonary embolisms occur in approximately ten percent of those with upper extremity DVTs. Other complications include chronic edema and chronic pain. Careful consideration of which patients absolutely require a PICC line and once determined that one is medically needed, the smallest diameter catheter should be utilized. Keeping a catheter in for routine blood draws in the hospitalized patient is not prudent since this represents an unreasonable risk for central catheter blood infections as well as DVTs.
Symptoms of a DVT include pain, swelling, and warmth. A venous Doppler exam is used to diagnose a DVT. Once diagnosed, anticoagulation treatment is indicated with Coumadin for three months and the PICC line should be removed after anticoagulation has begun. Anticoagulation alone has significant risk of complications related to major bleeding that occurs in approximately three percent.
PICC lines have a useful roll in the modern management of patients who have suffered significant trauma but should only be utilized in situations where IV nutrition is required or prolonged antibiotic management in necessary. PICC lines should not be considered a routine procedure and should not be used out of convenience. Once it is determined a PICC line is necessary the lowest diameter catheter should be used that will achieve its clinical use and the line should be pulled as soon as possible.
http://journal.publications.chestnet.org/article.aspx?articleid=1086677&issueno=4&rss=1
http://onlinelibrary.wiley.com/doi/10.1111/jth.12549/full
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