2017-02-06

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The Use of PICCs Within Critical Care

Lynn Hadaway, M.Ed., RN-BC, CRNI

Disclosure

• Lynn Hadaway is a paid consultant for BBraun of Canada, Ltd

• Development and delivery of thispresentation was commissioned by B Braunof Canada, Ltd

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Disclosures

• Speaker and/or consultant for:– 3M– Atrion Corp– B Braun Medical, Inc– B Braun of Canada,

Ltd– Bard Access Systems– Baxter– BD Medical– Covidien/Medtronic

– Elcam– Excelsior– Fresinius Kabi– Gayco Healthcare– LineGard Medical– Lippincott Williams

Wilkins– Terumo– VATA– Velano Vascular

Learning Objectives

• Identify the current standards and guidelines applicable to PICC insertion and management.

• Describe the clinical considerations for PICCs used in critical care.

• Analyze PICC complications associated with critical care patients.

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Standards and Guidelines

• CDC– Prevention of Intravascular Catheter-Related Infections,

2011– https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

• Safer Healthcare Now– Preventing Central Line Infections, 2012– www.saferhealthcarenow.ca

• Canadian Vascular Access Association– Occlusion Management Guideline for Central Venous

Access Devices, 2013– http://cvaa.info/PUBLICATIONS/OcclusionManagementGuideline(O

MG)/tabid/229/Default.aspx

Standards and Guidelines

• Department of Health, England

– Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England, 2013

– https://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf

• Society for Healthcare Epidemiology of America (SHEA)

– Strategies to Prevent Central Line-Associated , 2014 Update

– http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10312269&fulltextType=RA&fileId=S0899823X00193870

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Standards and Guidelines

• Canadian Hemodialysis Access Coordinators Network

– Nursing Recommendations for the Management of Vascular Access in Adult Hemodialysis Patients: 2015 Update

– http://www.cannt.ca/files/CANNT-VA%20Guidelines-2016Jan4-NP.pdf

• Infusion Nurses Society

– Infusion Therapy Standards of Practice, 2016– https://www.ins1.org/Store/ProductDetails.aspx?productId=241097

Clinical Considerations

• Vascular Access Planning (Gorski, 2016)– Preservation of peripheral veins!!

– Most appropriate VAD selection• Collaborative process among the interprofessional

team, the patient, and caregivers

• Least invasive device, Smallest outer diameter, Fewest number of lumens needed for prescribed therapy

– PICCs are NOT an infection prevention strategy!

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Clinical Considerations

• Hemodynamically UNstable patients– Recommendations from the MAGIC study

• Centrally inserted central catheter (CICC) for therapy of 14 days or less

• PICC for 15 days or more, but CICC is preferred

• PICCs preferred in critical patient with coagulopathies or sepsis (Chopra, 2015)

Clinical Considerations

• Avoid PICCs in – Stage 4 or 5 Chronic Kidney Disease

– Patients with abnormal creatinine or eGFR (CANNT, 2016)

• Use with caution in oncology and critical care patients– Risk of venous thrombosis and infection (Gorski, 2016)

• PICC outer diameter should consume 45% or less of vein diameter (Gorski, 2016)

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Clinical Considerations

• Mid-upper arm circumference (Gorski, 2016)– Before inserting PICC for baseline

– When clinically indicated

– Measure 10 cm above antecubital fossa

• Presence of pacemaker (Gorski, 2016)– Place PICC on opposite side, if possible

– Evaluate pacemaker function before and after PICC insertion

Clinical Considerations

• Ultrasound guidance for vein selection and insertion

• Maximum barriers– Full body drape

– Long sleeve gown

– Gloves

– Hair and face cover

• Alcoholic chlorhexidine skin antiseptic

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Clinical Considerations

• Tip location for all Central VADs– Location with greatest safety profile is

cavoatrial junction (CAJ)

– Body movement will mean PICC tip moving into right atrium

Clinical Considerations

• Confirmation of location– Post procedure

chest radiograph

• ECG by p wave

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Clinical Considerations

• Power injectable– For contrast injection in CT

– Maximum pressure = 325 psi

• Engineered stabilization device – Not tape or sutures

• Chlorhexidine dressing

Clinical Considerations

• VAD Removal (Gorski, 2016)– Daily assessment of need

– Immediate removal when VAD is no longer needed for the plan of care

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PICC Complications

• Critical care patients– Mechanical problems

– Bloodstream infection

– Vein thrombosis

PICC Complications

• Mechanical problems– Tip malposition (Gorski, 2016)

• Primary malposition – occurs on insertion and corrected immediately

– Intracardiac by more than 2 cm from CAJ

• Secondary malposition – occurs during dwell– Also known as tip migration

– Original tip location high in SVC or brachiocephalic vein

– Changes in intrathoracic pressure

– Body movement – neck, arm, shoulder

– Vein thrombosis

– Power injection in CT

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PICC Complications

• Mechanical problems– Tip malposition (Gorski, 2016)

• Intravascular– Jugular

– Contralateral subclavian

– Azygos

– Small tributary veins

– Aberrant venous anatomy such as persistent left SVC

• Extravascular– Erosion of catheter tip through vein wall

– Fistula between vein and artery

– Cardiac tamponade

PICC Complications

• Mechanical problems– Tip malposition

• Withhold infusion through PICC

• Develop plan for identification of tip and repositioning or removal

• A major reason for the importance of a blood return!!

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PICC Complications

• Know signs and symptoms of malposition– No blood return

– Pulsatility of blood return

– Resistance when flushing

– Alteration in waveform when transducer is attached

– Dyshythmias

– Changes in vital signs

– Pain and/or edema in chest, shoulder, neck, back

– Complaints of hearing a running stream on ipsilateral side

– Neurological problems

PICC Complications

• Bloodstream Infection– Retrospective audit of medical records for all

hospitalized patients with PICC insertion over a 3-year period (Chopra, 2014)

• 966 PICCs, 171 (18%) in ICU patients

• 58 (6%) with PICC-associated BSI over 1156 catheter days

• 2.16 per 1000 catheter days

• Median time to infection = 10 days

• Greatest risk factors by multivariate analysis:– Hospital length of stay

– ICU status

– Number of lumens

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PICC Complications

• Bloodstream Infection– Systematic literature review and meta-analysis

in hospitalized patients (Chopra, 2013)• CLABSI rates with PICCs statistically the same as

other CICCs

• Rates for both catheters similar for critical care patients

PICC-CLABSI CICC-CLABSI

Incidence 5.2% 5.8%

# of CLABSI (# of patients)

76 (1473) 76 (1302)

Sources of Microbes

• Skin – Insertion site

– Hands of caregivers

• Hub

• Infusate

• Seeding from other infection sites

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Source of Infection - Skin

• Signs and symptoms within 1 week of catheter insertion– Skin is thought to be

most likely source

• Surface• Hair follicles

– Organisms protected by lipids

• Sebaceous ducts– No penetration of

antiseptics

Source of Infection - Hub

• Signs and symptoms after the first week of dwell time– Catheter hub is

considered most likely source

• Hub manipulation – Medication infusion

– Tubing or needleless connector changes

– Flushing

– Blood sampling

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Biofilm

• Biofilm forms in all aquatic systems, including VADs

• Structured community of bacterial cells surrounded by a self-protective matrix– Microbes cooperate

metabolically to live in a hostile environment

• Appears as a “slimy”substance

Biofilm Stages

• Planktonic (free-floating) bacteria adhere to surface

• Secrete adhesins that cause the organisms to adhere and grow biofilm

• Occurs at all flow rates• Faster flow rates

produce stronger biofilm

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Biofilm

• Mechanism for biofilm to produce BSI– Detachment of cells or

clumps

– Production of endotoxins

– Resistance of host immune system

• Body temperature elevation and chills after catheter flushing is probably due to a shower of organisms from the biofilm

Infection Prevention – Clinical Domain

• Skin– Hand hygiene– Insertion site– Skin antisepsis– Maximal barriers– Insertion technique– Antimicrobial impregnated

catheters– Engineered catheter

stabilization devices– Antimicrobial dressings

– Hub• Hand hygiene, glove use• Patency assessment• Safe injection practices• Needleless connector &

hub disinfection• Disinfection caps• Administration set

management• Flush and locking

solutions• Blood sampling • Minimize system

manipulation

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PICC Complications

• Vein Thrombosis– Damage to the vein

wall

– Two flow system• Blood flow through vein

• Fluid flow through catheter

Triad of Virchow

Vein wall changes• Catheter advancement• Tip location

Blood flow alterations• Venous stenosis• Foreign objects

Blood composition• Disease produced

changes• Genetic clotting

disorders

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Fibrin Tail or Flap

• Also called the “ball-valve effect”

• Prevents blood return from lumen

Partial Fibrin Sheath

• Fluid flow between catheter and sheath– Fluid escapes into

the blood flow

– Prevents blood return from lumen

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Complete Fibrin Sheath

• Fluid flow between catheter wall and fibrin sheath– Prevents blood

return from lumen

– Escapes from the vein entry site

– Causes infiltration or extravasation

Thrombotic Vein Occlusions

• May block flow through catheter lumen

• Veno-occlusive thrombosis– Occludes blood flow

– Fluid flow may not be affected

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PICC Complications

• Asymptomatic vein thrombosis– Reported to be as high as 62% of PICCs

• Symptomatic vein thrombosis– Ranges from 3% to 20% of PICCs

• Diagnostic tests only with signs and symptoms = many missed thromboses– 72% with thrombosis found in patients with 5 Fr

double lumen PICCs

– (Zochios, 2014)

PICC Complications

• Vein Thrombosis– Rates higher in ICU

• 13.91% in critical care patients

• 6.67% in cancer patients (Chopra, 2014)

– Neurological ICU• 8.4% symptomatic PICC-related thrombosis

(Zochios, 2014)

– Medical ICU study – no significant differences in thrombosis or BSI between PICC and CICC (Nolan, 2016)

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PICC Complications

• Vein Thrombosis

• Bigger is NOT better with PICCs!– 4 Fr with 0.4% symptomatic thrombosis vs 8.8% with 6

Fr PICCs• Single lumen = 0.6%

• Double lumen = 2.9%

• Triple lumen = 8.8% (Zochios, 2014)

• PICC should consume less than 45% of vein lumen (Sharp, 2013)– 4 Fr PICC requires a minimum vein diameter of 4 cm

PICC Complications

• Pulmonary embolism– Occurs in 1.3% of all PICCs

– 15% of PICCs with symptomatic thrombosis (Zochios, 2014)

• Lower extremity deep vein thrombosis reported in 9/966 PICCs (1%) (Chopra, 2014)

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PICC Complications

• Thrombotic Risk factors– Suboptimal tip locations

– Mechanical ventilation• Increases pulmonary coagulopathy leading to

systemic coagulopathy

– Immobility in ICU

– End-stage renal disease

– Sepsis

– Platelet transfusion

– Use of vasopressors (Zochios, 2014)

PICC Complications

• Clinical Signs and Symptoms (Gorski, 2016)– Pain, edema in arm, shoulder, neck or chest

– Erythema in extremity

– Engorged superficial veins of extremity, shoulder, neck or chest

– Difficulty with neck or extremity movement

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PICC Complications

• Vein Thrombosis Diagnosis (Gorski, 2016)– Color-flow Doppler ultrasound preferred

• Not invasive, no radiation exposure

– Venography with contrast, CT, or MRI may be needed for viewing veins obscured by clavicle or ribs

PICC Complications

• “Do not remove a CVAD in the presence of CVAD-associated vein thrombosis when the catheter is correctly positioned at the cavoatrial junction, is functioning correctly with a blood return, and has no evidence of any infection. The decision to remove the CVAD should also consider the severity of DVT related symptoms, presence of contraindications for systemic anticoagulation, and the continued need for infusion therapy requiring a CVAD.” – INS VAD Removal Standard 44

• Based on Kearon, 2012

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PICC Complications

• Take Away Messages– PICCs are not the best choice for many critical

care patients – Use with caution!

– Use smaller PICCs with fewer lumens• May not be possible with critical care infusion needs

– Careful attention to tip location at or close to cavoatrial junction!

– Rigorously employ ALL infection prevention techniques

Questions

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References

• Sharp R, Gordon A, Mikocka-Walus A, et al. Vein measurement by peripherally inserted central catheter nurses using ultrasound: a reliability study. Journal of the Association for Vascular Access. 2013;18(4):234-238.

• Gorski L, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D. Infusion Therapy Standards of Practice. Journal of Infusion Nursing. 2016;39(1S):159.

• Chopra V, Flanders SA, Saint S, Woller S, O'Grady NP, N S. The Michigan appropriateness guidel for intravenous catheers (MAGIC). 2015;in press.

• Chopra V, Ratz D, Kuhn L, Lopus T, Lee A, Krein S. Peripherally inserted central catheter‐related deep vein thrombosis: contemporary patterns and predictors. Journal of Thrombosis and Haemostasis. 2014;12(6):847-854.

References

• Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet. 2013;382(9889):311-325.

• Chopra V, O'Horo JC, Rogers MA, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34(9):908-918.

• Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S. PICC-associated bloodstream infections: prevalence, patterns, and predictors. Am J Med. 2014;127(4):319-328.

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References

• Zochios V, Umar I, Simpson N, Jones N. Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients. The journal of vascular access. 2014;15(5):329-337.

• Nolan ME, Yadav H, Cawcutt KA, Cartin-Ceba R. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Journal of critical care. 2016;31(1):238-242.

• Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST Journal. 2012;141(2_suppl):e419S-e494S.