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peripherally-inserted central catheter (PICC)

Implanted right atrial catheter Classification: - Gershon catheter most common type Indications: 1) aggressive chemotherapy 2) prolonged antibiotic treatment 3) parenteral hyperalimentation 4) *frequent blood draws for >= 6 days 5) infusions or palliative care at end of life [4] Contraindications: - chronic kidney disease stage 3b or higher [9] - current or impending hemodialysis - not for rapid infusion of blood products [1] - avoid use in otherwise healthy children with infections if they can switch to an oral antibiotic [6] Procedure: - catheter threaded into the superior vena cava. - placement check by chest X-ray. Use of catheter. [2] - initial dressing change within 24 hours with transparent dressing - transparent dressing change a) routine weekly change b) change MWF for TPN & immunocompromised patients - catheter flush with 10 mL of saline* - prior to & after each blood draw & IV infusion - blood draws: a) draw back until blood obtained in syringe. b) raw blood into new syringe*. c) flush with 20 mL of saline#. * Volume in PICC about 2 mL. # heparin used for flush in other types of catheter(s) Complications: - upper-extremity deep venous thrombosis (DVT)* (RR=10.5) - lower-extremity deep venous thrombosis (RR=1.48) [3] - not associated with increased risk of pulmonary embolism [3] - association between number of lumens in PICC lines & risk for complications, including intravenous catheter-associated infections, venous thromboembolism, & catheter occlusions - PICCs placed before or after hemodialysis initiation diminish likelihood of successful transition to a working graft or fistula [1,8] - for short-term indications, midline catheters associated with lower risk of bloodstream infection & occlusion compared with PICCs [10] - major PICC-related complications occur in 15% of patients: - occlusion in 10% - central line-associated bloodstream infections in 2.5% - deep venous thrombosis (DVT) in 3.6% - pulmonary embolism in 0.6% [11] - single lumen PICCs have less risk of venous thromboembolism & central line-associated bloodstream infections than multilumen PICCs [12] - major PICC-related complications occur most frequently in cancer patients with - ovarian cancer (26%) - uterine cancer (19%) - pancreatic cancer (18%) - brain cancer (17%) [11] * more common with PICCs than with other central venous catheters [3]; 10 fold increased risk [3] Management: - for use up to 1 year [1] - single lumen PICC line safest [7]

Related

catheter-related infection

Specific

peripherally-inserted central venous catheter with subcutaneous port

General

central venous catheter

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2013, 2015, 2018.
  2. WLA VAMC PICC line nursing
  3. Journal Watch. June 6, 2013 Massachusetts Medical Society http://www.jwatch.org - Chopra V et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: A systematic review and meta-analysis. Lancet 2013 May 20 PMID: 23697825
  4. Chopra V et al The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;163(6_Supplement):S1-S40. Sept 15, 2015 PMID: 26369828 http://annals.org/article.aspx?articleid=2436759
  5. Greene MT et al. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med 2015 Sep; 128:986 PMID: 25940453
  6. American Academy of Pediatrics - Committee on Infectious Diseases and the Pediatric Infectious Diseases Society. Choosing Wisely. November 12, 2018 http://www.choosingwisely.org/societies/american-academy-of-pediatrics-committee-on-infectious-diseases-and-the-pediatric-infectious-diseases-society/
  7. Bozaan D, Skicki D, Brancaccio A et al. Less lumens-less risk: A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. J Hosp Med 2019 Jan 8; 14:42 PMID: 30379146 https://www.journalofhospitalmedicine.com/jhospmed/article/177747/hospital-medicine/less-lumens-less-risk-pilot-intervention-increase-use
  8. McGill RL, Ruthazer R, Meyer KB, Miskulin DC, Weiner DE. Peripherally Inserted Central Catheters and Hemodialysis Outcomes. Clin J Am Soc Nephrol. 2016 Aug 8;11(8):1434-40. PMID: 27340280 Free PMC Article
  9. Paje D, Rogers MAM, Conlon A et al. Use of peripherally inserted central catheters in patients with advanced chronic kidney disease: A prospective cohort study. Ann Intern Med 2019 Jun 4 PMID: 31158846 https://annals.org/aim/article-abstract/2735181/use-peripherally-inserted-central-catheters-patients-advanced-chronic-kidney-disease?doi=10.7326%2fM18-2937
  10. Swaminathan L, Flanders S, Horowitz J et al. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: A multicenter study. JAMA Intern Med 2022 Jan; 182:50-58. PMID: 34842905 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2786212
  11. Mitbander UB et al. Patterns of use and outcomes of peripherally inserted central catheters in hospitalized patients with solid tumors: A multicenter study. Cancer 2022 Oct; 128:3681 PMID: 35943390 https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.34410
  12. Bredenberg E et al. Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis. J Hosp Med 2023 Jun; 18:483. PMID: 37052429 https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13093