The What and Why of PICCs
Since the late 1970s and 1980s , PICCs have grown in popularity primarily based on the ease of insertion facilitated by specially trained nurses and teams . A PICC is a longer catheter , typically 35-55cm , with the terminal tip in the superior or inferior vena cava or caval atrial junction . The French sizes of PICCs are 2Fr up to 7Fr in single , double , or triple lumens . Evidence points to increasing complications of thrombosis and infection with larger sizes . Recommendations of MAGIC emphasize the use of single lumen PICCs as a default and multiple lumens only when there is a specific indication for the additional access ports . The MAGIC guide also recommends consideration for establishing a policy to designate the reason or indication for a centrally positioned catheter and PICC .
Placement of PICCs reached all-time highs in the early 2000s , with questions arising pointing to over-usage for the sake of convenience . With multiple publications indicating concerns over the serious complications associated with PICCs and other central catheters , greater awareness was achieved and scrutiny over indications for PICC and central catheter placement was initiated ( Liem 2012 ). The publication of MAGIC followed other evidence by Chopra and associates on higher-than-expected incidence of thrombosis and infections with PICCs ( Chopra 2012 ). With MAGIC providing better clarity on indications for central catheters and PICCs , prescribers have moderated placement requests with a better understanding of risk associated with PICCs and central lines , while balancing for IV access in difficult access patients with ultrasound guided peripheral and midline insertions .
When is it Best to Use PICCs ?
Indications for PICC placement , designated by MAGIC , discourage the use of PICCs for therapies five days or less , or solely for difficult access patients , opting instead to focus on infusion requirements for five to 30 days or more . Other indications for PICCs include the need for infusions of irritating or vesicant medications or solutions and frequent blood draws . Once placed , PICCs can remain in place as long as clinically necessary , to the end of therapy , or when complications occur requiring removal . Risk of infection is ever present for all IV devices , and while PICCs have a generally higher rate of infection than peripheral and midline catheters , the incidence of infection is less than or equal to all other central catheters ( PICCs 0-2.1 / 1,000 catheter days ). Subcutaneously implanted ports carry the distinction of having lowest central venous access device infection rate . PICCs are best to use when there is a clear indication of need for a centrally placed catheter , and when there are trained inserters available for placement .
Consideration for the choice of an IV device with the lowest risk may include midline catheters and PICCs . One way to ensure risk reduction is to establish a policy for regularly scheduled education and training with a plan for competency assessment of inserters and those accessing IV devices . The use of the central line bundle checklist for inserters and placing emphasis on disinfection practices for those who access and manage these devices can help to ensure lower rates of infection for intravenous catheters . Observation and audits of dressings for adherence and scheduled dressing changes can also reduce risk of infection with these catheters . Establishing vascular access committees to identify gaps in practice that put patients at risk can lead to effective quality improvement initiatives , thus eliminating the gaps and going a long way toward improving outcomes with all vascular access devices . Application of each of these methods can contribute to better device selection and risk reduction with these intravenous catheters that have become essential for the delivery of medical treatment to patients ( Simonov 2015 ).
Nancy Moureau , RN , PhD , CRNI , CPUI , VA-BC , is the chief executive officer at PICC Excellence , Inc ., a research member of the Alliance for Vascular Access Teaching and Research ( AVATAR ) Group , and an adjunct associate professor at Griffith University in Brisbane , Australia .
References :
1 . Chopra V , Flanders SA , Saint S et al ( 2015a ) The Michigan Appropriateness Guide for Intravenous Catheters ( MAGIC ): Results from a Multispecialty Panel Using the RAND / UCLA Appropriateness Method . Ann Intern Med . 163 ( 6 Suppl ): S1-40 . doi : 10.7326 / M15-0744 .
2 . Chopra V , Anand S , Krein SL , Chenoweth C , Saint S . Bloodstream infection , venous thrombosis , and peripherally inserted central catheters : reappraising the evidence . Am Journal Med . 2012 Aug 1 ; 125 ( 8 ): 733-41 .
3 . Gorski L , Hadaway L , Hagle M , Broadhurst D , Clare S , Kleidon T , Meyer B , Nickel B , Rowley S , Sharpe E , Alexander M . ( 2021 ). Infusion Therapy Standards of Practice , 8th Edition . J Infusion Nursing . 44 ( suppl 1 ): S1-S224 .
https :// doi : 10.1097 / NAN . 0000000000000396
4 . Liem TK , Yanit KE , Moseley SE , Landry GJ , DeLoughery TG , Rumwell CA , Mitchell EL , Moneta GL . Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis . J Vascular Surg . 2012 Mar 1 ; 55 ( 3 ): 761-7 .
5 . Moureau N , Chopra V . Indications for peripheral , midline , and central catheters : summary of the Michigan appropriateness guide for intravenous catheters recommendations . J Association for Vascular Access . 2016 ; 21 ( 3 ): 140-8 .
7 . O ’ Grady NP , Alexander M , Burns LA , Dellinger EP , Garland J , Heard SO , Lipsett PA , Masur H , Mermel LA , Pearson ML , Raad II . Guidelines for the prevention of intravascular catheter-related infections . Clin Infect Dis . 2011 May 1 ; 52 ( 9 ): e162-93 .
8 . Prasanna N , Yamane D , Haridasa N , Davison D , Sparks A , Hawkins K . Safety and efficacy of vasopressor administration through midline catheters . J Critical Care . 2021 Feb 1 ; 61:1-4 .
9 . Simonov M , Pittiruti M , Rickard CM , Chopra V . Navigating venous access : A guide for hospitalists . J Hosp Med . 2015 Jul 1 ; 10 ( 7 ): 471-8 .
10 . Swaminathan L , Flanders S , Horowitz J , Zhang Q , O ’ Malley M , Chopra V . 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 1 ; 182 ( 1 ): 50-8 .
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Consideration for the choice of an IV device with the lowest risk may include midline catheters and PICCs .
One way to ensure risk reduction is to establish a policy for regularly scheduled education and training with a plan for competency assessment of inserters and those accessing IV devices .”