Use of Peripherally Inserted Central Catheters as an Alternative to Central Catheters in...

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doi: 10.4037/ccn2011911 2011;31:70-75Crit Care Nurse Christi DeLemos, Judy Abi-Nader and Paul T. AkinsCatheters in Neurocritical Care UnitsUse of Peripherally Inserted Central Catheters As an Alternative to Central

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70 CriticalCareNurse Vol 31, No. 2, APRIL 2011 www.ccnonline.org

complications associated with pre-existing advanced or unstable car-diac disease. Traditionally, centralvenous catheters (CVCs) have beenplaced for intravenous access andfor monitoring central venous pres-sure (CVP). CVP monitoring providesinformation about fluid balance butmay be affected by systemic vascu-lar resistance.1 Placement of CVCsor pulmonary artery catheters isassociated with procedural riskssuch as insertional injury leading topneumothorax or arterial punctureand with catheter-related infection.2

In 2000, Black et al3 hypothe-sized that peripherally inserted cen-tral catheters (PICCs) could be asreliable as CVCs for measuring CVPwhen the PICCs were coupled withcontinuous infusion to overcomethe inherent higher resistance of thesmall-lumen vessels of an extremity.Data from 77 paired CVP measure-ments obtained with indwellingCVCs and PICCs indicated that thedifferences in CVC and PICC meas-urements were clinically insignificant.A follow-up study4 on use of PICCs

care units (ICUs) to administertherapy and to obtain blood fortests. A subset of patients also ben-efits from hemodynamic monitor-ing, particularly patients withmoderate to severe subarachnoidhemorrhage, traumatic braininjury, or central nervous system

Reliable central venousaccess has become anessential tool in themanagement of patientsin neurological intensive

©2011 American Association of Critical-Care Nurses doi: 11.4037/ccn2011911

BACKGROUND Patients in neurological critical care units often have lengthy staysthat require extended vascular access and invasive hemodynamic monitoring. The tradi -tional approach for these patients has relied heavily on central venous and pulmonaryartery catheters. The aim of this study was to evaluate peripherally inserted centralcatheters as an alternative to central venous catheters in neurocritical care settings.

METHODS Data on 35 patients who had peripherally inserted central cathetersrather than central venous or pulmonary artery catheters for intravascular access andmonitoring were collected from a prospective registry of neurological critical careadmissions. These data were cross-referenced with information from hospital-baseddata registries for peripherally inserted central catheters and subarachnoid hemorrhage.

RESULTS Complete data were available on 33 patients with Hunt-Hess gradeIV-V aneurysmal subarachnoid hemorrhage. Catheters remained in place a total of 649days (mean, 19 days; range, 4-64 days). One patient (3%) had deep vein thrombosis inan upper extremity. In 2 patients, central venous pressure measured with a peripher-ally inserted catheter was higher than pressure measured concurrently with a cen-tral venous catheter. None of the 33 patients had a central catheter bloodstreaminfection or persistent insertion-related complications.

CONCLUSIONS Use of peripherally inserted central catheters rather than centralvenous catheters or pulmonary artery catheters in the neurocritical care unitreduced procedural and infection risk without compromising patient management.(Critical Care Nurse. 2011;31:70-75)

Use of Peripherally InsertedCentral Catheters As an Alternative to Central Cathetersin Neurocritical Care UnitsChristi DeLemos, RN, MS, ACNP-BCJudy Abi-Nader, RN, MSPaul T. Akins, MD, PhD

Feature



for measurement of CVP in an opera-tive situation confirmed that PICCsare a reliable alternative to tradi-tional CVCs for CVP measurement.

For CVP monitoring, a catheterlumen of 20 gauge or larger is rec-ommended. The Power PICC (BardAccess Systems, Inc, Salt Lake City,Utah) is preferred for patients withsubarachnoid hemorrhage becausethese patients often have computedtomography (CT) angiography, andthis catheter is approved for powerinjection of CT contrast agents.

Relatively little has been reportedabout the prolonged use of PICCsin adult neurosurgical intensivecare patients. PICCs are an effectivetool in outpatients for long-termparenteral nutrition, prolongedadministration of antibiotics, andadministration of chemotherapeuticagents, but whether or not PICCswill be a safe and reliable alternativedevice for long-term delivery ofintravenous therapy and nutritionalformulas and for measurement ofCVP in neurointensive care patientsis unclear.

When triple-lumen PICCs wereapproved by the Food and DrugAdministration5 in October 2005,Kaiser Permanente SacramentoMedical Center, Sacramento, Cali-fornia, largely switched to these

peripherally placed catheters for theadded benefits of CVP monitoringin addition to reliable vascular access.Subsequent development of PICCs(eg, Power PICC) that can safelywithstand high flow-rate injectionsfor CT imaging (eg, CT angiography)made the devices more useful thanbefore. At the time of the studyreported here, several devices wereapproved by the Food and DrugAdministration for use, includingthe single- and dual-lumen PolyPer-Q-Cath PICC, 5F and 6F dual-lumen Power PICC, and 6F triple-lumen Poly Per-Q-Cath2 (all BardAccess Systems, Inc).

We report our experience withthe transition to using PICCs forCVP monitoring and reliable vascu-lar access without the risks of tradi-tionally placed CVCs.

MethodsThe study was a prospective

descriptive study of the first 35patients in whom PICCs were usedas an alternative to CVCs for long-term venous access and CVP moni-toring in a neurological ICU. Thestudy was approved by the appro-priate institutional review board.Data were collected from a prospec-tive registry of neurological ICUadmissions at the medical center.

In order to identify patients who hadundergone PICC placement, admis-sion data were cross-referenced with aregistry of PICC insertions main-tained by the hospital PICC nursingstaff. Data from electronic and papercharts were reviewed by using a stan-dardized data collection tool withspecific queries for complicationsassociated with insertion of a centralcatheter, catheter-related blood-stream infection as defined by guide-lines of the Centers for DiseaseControl and Prevention,6 arrhyth-mias associated with placement of acatheter, extremity thrombosis ipsi-lateral to the catheter, accuracy ofCVP measure if a second centralcatheter was present, unexpectedadverse effects, duration of treat-ment, and functional outcome.

DevicesDevices approved for use in the

study included the 6F triple-lumenPer-Q-Cath, 4F Per-Q-Cath, Solo 5Ftriple-lumen Power PICC, Solo 5Fdual-lumen Power PICC, and Solo 4Fsingle-lumen Power PICC. Catheterselection for each patient was basedon recommended guidelines for appro-priate catheter gauge, vessel lumendiameter, and catheter availability.

PlacementAll PICCs were placed by a spe-

cialized team of experienced nurseswho used sterile technique. For bed-side insertion, ultrasound for veinlocalization and the modifiedSeldinger technique were used. Beforeinsertion, patients were assessed,including history of insertion of cen-tral catheters, presence of a pace-maker, history of mastectomy, anddiameter of the vein to be used foraccess. Triple-lumen PICCs were

Christi DeLemos is a nurse practitioner in the Department of Neurological Surgery at theUniversity of California, Davis.

Judy Abi-Nader is a registered nurse who works with the peripherally inserted centralcatheter team at Kaiser Sacramento Neurocritical Care in Sacramento, California.

Paul T. Akins is a doctorally prepared neurointensivist at Kaiser Sacramento Neurocriti-cal Care in Sacramento, California.

Authors

Corresponding author: Christi DeLemos, RN, MS, ACNP-BC, Department of Neurological Surgery, School of Medi-cine, 4860 Y St, Ste 3740 ACC, Sacramento, CA 95817 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

www.ccnonline.org CriticalCareNurse Vol 31, No. 2, APRIL 2011 71



placed in veins with a diameter of0.5 cm or larger. Placement in thecephalic veins was avoided becauseof the high risk for thrombosis.7-11

The brachial or basilic vein wasselected on the basis of the suitabil-ity of the site.

Maximal barrier precautionswere used. The insertion site wascleansed with a 2% chlorhexidinegluconate 70% isopropol alcoholsolution (ChloraPrep, Enturia, Inc,Leawood, Kansas) and allowed todry. An antibiotic-impregnated disk(Biopatch, Ethicon, Inc, Somerville,NJ) was placed directly over the siteafter insertion of the catheter. Thecatheter was secured by using a sta-bilizing device (Statlock, Bard Med-ical Division, Covington, Georgia),and an occlusive dressing was applied.After 24 hours the site was redressedby using a new antibiotic-impregnateddisk and a transparent dressing.

Data Collection and AnalysisAll data collection was done

according to the guidelines of theinstitutional review board. Studydata were collated, patient identitieswere removed in accordance withguidelines of the Health InsurancePortability and Accountability Act,and the resultant information wasentered into an Excel spreadsheetfor data analysis. Descriptive statis-tics were calculated by using stan-dard formulas.

ResultsA total of 35 patients were

enrolled in the study during a 20-month period. Of these, 2 wereexcluded because of incompletedata. The final sample consisted of33 patients. Most of the patientshad intracranial bleeding such as

subarachnoidhemorrhage,intracranialhemorrhage,or subduralhematoma(Table 1).Mean durationof PICC accesswas 19 days.Cathetersremained inplace a total of649 catheterdays. Allpatients in thestudy received subcutaneousheparin as prophylaxis for deep veinthrombosis (DVT) within 48 hoursof admission to the ICU unless severethrombocytopenia or excessivebleeding prohibited use of the drug.

One patient experienced anupper extremity DVT resulting incatheter removal (Table 2). Thispatient was an obese woman withHunt Hess grade V subarachnoidhemorrhage and minimal upperextremity movement with traceextensor posturing to pain only. Theupper extremity edema resolvedwithout further treatment, andlong-term anticoagulation was notrequired. The PICC was removed

unintentionally by 1 patient as aresult of the patient’s cognitiveimpairment. Because of persistentfever of unknown source, 3 patientshad PICCs removed to excludecatheter-related bloodstream infec-tion. Cultures of blood samples orspecimens obtained from the cathetertip were negative for microorgan-isms for all 3 patients.

Among the patients with PICCs,11 also had a second central catheterpresent for comparison of accuracyof CVP measurements. The centralcatheters were placed emergently foracute management at the time ofadmission to the ICU. The PICC nurs-ing staff does not provide 24-hour

Table 1 Demographics of the 33 patients in the study

Characteristic

Male sexAge, mean (SD), ySubarachnoid hemorrhageEncephalopathyIntracerebral hemorrhageOtherSubdural hematomaLength of stay, mean (SD), dDischarge to homeDischarge to skilled nursing facilityDischarge to rehabilitation centerDiedDays with peripherally inserted

central catheter, mean (SD)

Valuea

11 (37)62 (16.5)15 (45)

7 (21)6 (18)3 (9)2 (6)

25.6 (12.8)15 (45)9 (27)4 (12)5 (15)19 (6)

a Values are No. (%) of patients unless otherwise indicated.

Table 2 Comparison of complications between peripherally inserted centralcatheter and central venous catheter

a Data from Taylor and Palaqiri.2

Central venous cathetera

10-15

2.9 per 1000 catheter days (subcla-vian < internal jugular < femoral)

2-20 (subclavian < internal jugular< femoral)

Peripherally inserted central catheter

0

0

3

Results

Insertional injury

Bloodstream infection

Catheter-associated deepvein thrombosis

% of cases




on-call personnel to establish intra-venous access, so the PICCs wereplaced by hospital day 3 electively.

Observations were made whenCVCs and PICCs were placed con-currently. Overall accuracy of CVPmonitoring in the entire sample of33 patients cannot be reportedbecause only a subset of patientswas monitored by using both meth-ods. Erroneous measurements weredetected for 2 PICCs. No injuriesrelated to insertion of a PICC orcentral catheters occurred.

Two patients had spontaneousnonsustained ventricular tachycar-dia after a PICC insertion (Figure 1).In both instances, the tachycardiaceased when the catheters wererepositioned.

Case IllustrationA 78-year-old woman initially

had a headache and lethargy thatprogressed to decerebrate posturingand coma. CT of the brain showedextensive subarachnoid hemorrhagewith posterior fossa predominanceand hydrocephalus. Her score onthe Glasgow Coma Scale was 4

(E1VTM2), and she was grade 5 onthe Hunt Hess scale. Her conditionwas stabilized with intubation andexternal ventricular drainage. Sys-tolic blood pressure was reduced by30 points in the left arm comparedwith the right arm.

Findings on brain CT angiogra-phy suggested an aneurysm at thevertebrobasilar junction, and thisabnormality was confirmed withcatheter angiography (Figure 2A).The aneurysm was flow-related dueto left subclavian steal from a severeproximal left subclavian stenosis.After 4 days, the patient’s neurolog-ical status improved and she couldfollow commands intermittently.She underwent stenting of the leftsubclavian stenosis, coil emboliza-tion of the distal right vertebral

artery, and occlusion of the flow-related aneurysm with preservationof the right posterior inferior cere-bellar artery. CVP monitoring witha Power PICC and minimally inva-sive cardiac output monitoring (Vig-ileo monitor, Edwards Lifesciences,Irvine, California) via either femoralartery or radial artery waveform(Figure 2B) during the patient’s ICUstay was used to guide fluid manage-ment and facilitated safe resolutionof pulmonary vascular congestionwithout excessive diuresis.

The patient initially had pul-monary vascular congestion withmoderately elevated CVP but ade-quate cardiac output. Periodic surveillance CT and magnetic reso-nance angiography were used tomonitor for vasospasm. Avoidance

Figure 1 Ventricular tachycardia in a patient with a Power PICC peripherally insertedcentral catheter in place. The top row is the telemetry recording; the bottom row,the central venous pressure recording.

Figure 2 Extensive subarachnoid hemorrhage with posterior fossa predominance and hydrocephalus in a 78-year-old woman. A,Digital subtraction angiography with 3-dimensional reconstruction shows left subclavian steal, a proximal left subclavian stenosis,and a flow-related, caudally projecting, bifurcating aneurysm at the vertebrobasilar junction. B, Neurocritical care management wasfacilitated by placement of a peripherally inserted central catheter (PICC) for vascular access and monitoring of central venous pres-sure (left upper extremity) and cardiac output monitoring with a minimally invasive device. C, Anteroposterior (AP) portable chestradiograph shows pulmonary vascular congestion and confirms proper placement of PICC in the superior vena cava.

A B C

PICC

PICC

PORTABLE

AP

Arterialcatheter




of excessive diuresis was a clinicalgoal both to prevent nephropathyassociated with contrast mediumand to avoid dehydration, which canincrease the risk for vasospasm.

The patient’s neurological statusimproved gradually during a 2-monthperiod. She was discharged to acommunity skilled nursing facilityfor subacute rehabilitation initiallyand then to home at 3-month officefollow-up. She currently is living athome with her family. She is self-sufficient with basic activities ofdaily living, can walk independentlywithin her home but not in the com-munity, and needs assistance withinstrumental activities of daily living(modified Rankin score of 3: moder-ate disability but able to walk).

DiscussionWe report our initial experience

with the use of PICCs rather thantraditional central catheters. Somepatients in the sample also underwentless invasive cardiac output monitor-ing (Vigileo monitor); the results ofthat monitoring are not includedhere. Other researchers9 have reportedfew catheter-related complicationssuch as insertional injury andcatheter-related bloodstream infec-tion with PICCs. In the year preced-ing our study, 3 insertion-relatedcomplications associated with cen-tral catheters occurred: 1 subclavianartery catheterization and 2 pneu-mothoraces. These complicationshad no long-term sequelae. None ofour patients had catheter-relatedbloodstream infection. This lack ofcomplications may be related to theuse of a specialized nursing teamthat managed the insertion of PICCsand supervised subsequent cathetercare or the length of treatment.12,13

Catheter-associated bloodstreaminfection may be less common withPICCs than with CVCs, and thePICCs can still be used for hemo -dynamic monitoring, volumereplacement, phlebotomy, andadministration of medications.Patel et al9 performed a retrospec-tive review of a 4-year period inwhich traditional central catheterswere replaced with PICCs in ICUpatients to capitalize on theadvances in catheter technology,reduce risks associated withcatheter insertion, and provide acost-effective alternative to centralcatheters. By the third interventionyear, nearly two-thirds of all hemo-dynamic monitoring was accom-plished with PICCs and the rate ofcatheter-related bloodstream infec-tion had decreased by 81% (P<.001).In another large-scale study10 inwhich PICCs were compared withtraditional CVCs in the ICU, themedian time to infection was signif-icantly longer (P = .03) with PICCs(23 days) than with traditionalCVCs (13 days).

Catheter-associated DVT hasbecome a concern with increaseduse of PICCs.7-9,12,14 Few data areavailable on upper extremity DVT;most of the observational studieshave focused on lower extremityDVT. In one study,11 compared withnonobese patients, obese patientshad a 23-fold increase in upperextremity DVT. Other risk factorsfor lower extremity DVT includepresence of a hypercoagulable state,recent major surgery, thrombogeniceffects of cancer, and prolongedimmobility.8 Use of prophylacticanticoagulants can reduce the inci-dence of venous thrombosis associ-ated with PICCs.15

Neurosurgical ICU patients maybe among the groups at highestrisk for venous thrombotic eventsbecause of prolonged immobilitydue to neurological injury, underly-ing tumors, and early contraindica-tions to anticoagulation therapy.The pathogenesis of upper extrem-ity DVT may be multifactorial,related to direct endothelial traumacaused by the presence of thecatheter, an underlying hypercoagu-lable state, and reduced venousreturn in paretic arms. One of themost important variables may becorrect lumen-to-catheter sizing.11

The patient in our study who hadDVT was an obese woman withHunt Hess grade V aneurysm and ascore of 6 on the Glasgow ComaScale. As our experience with PICChas increased, we have learned toplace PICCs in nonparetic arms andto use small, single-lumen cathetersin patients at high risk for upperextremity DVT.

As expected, insertion-relatedcomplications of PICCs were favor-able compared with complicationsassociated with insertion of centralcatheters. We had no complicationsrelated to arterial puncture or pneu-mothorax from PICC placement.Insertion-related complicationsassociated with placement of centralcatheters decreased from 3 in theyear before our study to zero withthe increased use of PICCs. Twopatients with nonsustained ventric-ular tachycardia after PICC inser-tion were asymptomatic, and thedysrhythmias resolved with reposi-tioning of the catheter. Spontaneousnonsustained ventricular tachycar-dia due to drifting of the PICC fromthe superior vena cava to the rightatrium or the right ventricle after




PICC insertion has been docu-mented in other medical centers.In our patients, the tachycardiamay have been unrelated to place-ment of a PICC; the CVP tracingdid not show a right atrial pressurewaveform.

We found 3 reports of PICC-related cardiac effects: 1 case offatal cardiac tamponade due tomigration of a catheter used toinfuse potassium-enriched sodiumchloride,16 1 case indicating thatarm position was the most signifi-cant variable influencing positionof the catheter tip,17 and 1 case ofatrial fibrillation related to positionof the catheter tip.18 The risk of tipmigration with arm abduction isgreater with PICCs than with cen-tral catheters, and care must betaken to ensure positioning thatavoids advancing the catheter.Advancement of the catheter tip,which can be as much as 9.5 cm,19

can be clinically relevant. The flexi-bility of PICC tips, which is lessthan that of central catheters, maybe an additional variable thatincreases the risk for dysrhythmiaand cardiac injury. CVC-associatedcomplications are well documented,with higher rates of bloodstreaminfection in femoral placementsites than in other sites.20 Similarto the findings in previous studies,21

costs per vascular access devicewere about 10% to 15% lower forPICCs than for CVCs; the overallreductions in costs per case andmorbidity were greater when the

reduction in bloodstream infectionswas considered.

Two previous studies3,4 docu-mented the reliability of CVP meas-urement with PICCs, and we did notseek to directly compare CVCs withPICCs. Retrospectively, we foundthat the 2 PICCs with erroneouslyhigh CVP measurements had in-lineneedleless access caps, which wereassociated with falsely high meas-urements in the previous reports.3,4

Reliable CVP data depend on a con-tinuous, patent column of fluid trav-eling like a wave from the cathetertip to the pressure transducer. Inter-ferences such as kinks, air, or needle-less injection caps may dampen thewaveform or alter the signal.

In conclusion, patients in neuro-logical ICUs often have lengthystays and require extended periodsof vascular access. As neurocriticalcare providers strive to lower com-plication rates related to vascularaccess and bloodstream infections,less invasive approaches such as useof PICCs, use of minimally invasivecardiac monitoring devices, anddedicated vascular access nursingteams will become increasinglyimportant elements in the effort toadvance patient care. CCN

Financial DisclosuresNone reported.

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9. Patel B, Dauenahuer C, Rady M, et al. Impact ofperipherally inserted central catheters on cath -eter-related bloodstream infections in the inten-sive care unit. J Patient Saf. 2007;3(3):142-148.

10. Al Raiy B, Fakih MG, Bryan-Nomides N, et al.Peripherally inserted central venous cathetersin the acute care setting: a safe alternative tohigh-risk short-term central venous catheters.Am J Infect Control. 2010;38(2):149-153.

11. Grove J, Pevec W, Venous thrombosis related toperipherally inserted central catheters. J VascInterv Radiol. 2000;11(7):837-840.

12. Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. Improved care andreduced costs for patients requiring peripher-ally inserted central catheters: the role of bed-side ultrasound and a dedicated team. JPEN JParenter Enteral Nutr. 2005;29(5):374-379.

13. Fong NI, Holtzman SR, Bettmann MA, Bettis SJ.Peripherally inserted central catheters: outcomeas a function of the operator. J Vasc Interv Radiol.2001;12(6):723-729.

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15. Paauw J, Borders H, Ingalls N, et al. The incidenceof PICC line-associated thrombosis with andwithout the use of prophylactic anticoagulants.JPEN J Parenter Enteral Nutr. 2008;32:443-447.

16. Orme R, McSwiney M, Chamberlain-Webber R.Fatal cardiac tamponade as a result of a periph-erally inserted central venous catheter: a casereport and review of the literature. Br J Anaesth.2007;99:384-388.

17. Connolly B, Amaral J, Walsh S, Temple M,Chait P, Stephens D. Influence of arm move-ment on central tip location of peripherallyinserted central catheters. Pediatr Radiol.2006;36:845-850.

18. Elsharkawy H, Lewis BS, Steiger E, Farag E. Postplacement positional atrial fibrillation andperipherally inserted central catheters. MinervaAnestesiol. 2009;75(7-8):471-474.

19. Lee DS, Kuhn J, Shaffer MJ. Migration of tips ofcentral catheters in seated patients. AnesthAnalg. 1984;63:949-952.

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To learn more about neurocritical care, read“Embrace Hope: An End-of-Life Interventionto Support Neurological Critical Care Patientsand Their Families” in Critical Care Nurse,February 2010;30:47-58. Available atwww.ccnonline.org.

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Corrections

The correct doi number for “Modi-fied Insertion of a Peripherally InsertedCentral Catheter: Taking the Chest Radi-ograph Earlier” by Tian et al (Crit CareNurse. 2011;31[2]:64-69) is doi:10.4037/ccn2011966.

The correct doi number for “Use ofPeripherally Inserted Central CathetersAs an Alternative to Central Cathetersin Neurocritical Care Units” by DeLe-mos et al (Crit Care Nurse. 2011;31[2]:70-75) is doi: 10.4037/ccn2011911.

In the April article by Cecil and col-leagues, “Traumatic Brain Injury:Advanced Multimodal Neuromonitor-ing From Theory to Clinical Practice”(Crit Care Nurse. 2011;31[2]:25-37), thethreshold value for glycerol listed inTable 1 on page 28 should be 921mg/dL. On page 31, the pink box under“Tier 2” in Figure 5 should state “Hyper-tonic saline.” Lastly, on page 33, the for-mula for cerebral perfusion pressure isCPP = MAP - ICP.

In addition, question No. 1 in CEtest C112 (page 37) has been deletedfrom the CE test and the passing scorehas been revised to 9 correct answers.

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