Use of Peripherally Inserted Central Catheters As an Alternative to Central Catheters in Neurocritical Care Units

Christi DeLemos, Judy Abi-Nader and Paul T. Akins

Crit Care Nurse 2011;31:70-75 doi: 10.4037/ccn2011911
2011 American Association of Critical-Care Nurses Published online http://www.cconline.org Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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Critical Care Nurse is the official peer-reviewed clinical journal of the American Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2011 by AACN. All rights reserved.

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Feature

Use of Peripherally Inserted Central Catheters As an Alternative to Central Catheters in Neurocritical Care Units
Christi DeLemos, RN, MS, ACNP-BC Judy Abi-Nader, RN, MS Paul T. Akins, MD, PhD
BACKGROUND Patients in neurological critical care units often have lengthy stays that require extended vascular access and invasive hemodynamic monitoring. The traditional approach for these patients has relied heavily on central venous and pulmonary artery catheters. The aim of this study was to evaluate peripherally inserted central catheters as an alternative to central venous catheters in neurocritical care settings. METHODS Data on 35 patients who had peripherally inserted central catheters rather than central venous or pulmonary artery catheters for intravascular access and monitoring were collected from a prospective registry of neurological critical care admissions. These data were cross-referenced with information from hospital-based data registries for peripherally inserted central catheters and subarachnoid hemorrhage. RESULTS Complete data were available on 33 patients with Hunt-Hess grade IV-V aneurysmal subarachnoid hemorrhage. Catheters remained in place a total of 649 days (mean, 19 days; range, 4-64 days). One patient (3%) had deep vein thrombosis in an upper extremity. In 2 patients, central venous pressure measured with a peripherally inserted catheter was higher than pressure measured concurrently with a central venous catheter. None of the 33 patients had a central catheter bloodstream infection or persistent insertion-related complications. CONCLUSIONS Use of peripherally inserted central catheters rather than central venous catheters or pulmonary artery catheters in the neurocritical care unit reduced procedural and infection risk without compromising patient management. (Critical Care Nurse. 2011;31:70-75)

eliable central venous access has become an essential tool in the management of patients in neurological intensive

2011 American Association of CriticalCare Nurses doi: 11.4037/ccn2011911

care units (ICUs) to administer therapy and to obtain blood for tests. A subset of patients also benefits from hemodynamic monitoring, particularly patients with moderate to severe subarachnoid hemorrhage, traumatic brain injury, or central nervous system

complications associated with preexisting advanced or unstable cardiac disease. Traditionally, central venous catheters (CVCs) have been placed for intravenous access and for monitoring central venous pressure (CVP). CVP monitoring provides information about fluid balance but may be affected by systemic vascular resistance.1 Placement of CVCs or pulmonary artery catheters is associated with procedural risks such as insertional injury leading to pneumothorax or arterial puncture and with catheter-related infection.2 In 2000, Black et al3 hypothesized that peripherally inserted central catheters (PICCs) could be as reliable as CVCs for measuring CVP when the PICCs were coupled with continuous infusion to overcome the inherent higher resistance of the small-lumen vessels of an extremity. Data from 77 paired CVP measurements obtained with indwelling CVCs and PICCs indicated that the differences in CVC and PICC measurements were clinically insignificant. A follow-up study4 on use of PICCs

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for measurement of CVP in an operative situation confirmed that PICCs are a reliable alternative to traditional CVCs for CVP measurement. For CVP monitoring, a catheter lumen of 20 gauge or larger is recommended. The Power PICC (Bard Access Systems, Inc, Salt Lake City, Utah) is preferred for patients with subarachnoid hemorrhage because these patients often have computed tomography (CT) angiography, and this catheter is approved for power injection of CT contrast agents. Relatively little has been reported about the prolonged use of PICCs in adult neurosurgical intensive care patients. PICCs are an effective tool in outpatients for long-term parenteral nutrition, prolonged administration of antibiotics, and administration of chemotherapeutic agents, but whether or not PICCs will be a safe and reliable alternative device for long-term delivery of intravenous therapy and nutritional formulas and for measurement of CVP in neurointensive care patients is unclear. When triple-lumen PICCs were approved by the Food and Drug Administration5 in October 2005, Kaiser Permanente Sacramento Medical Center, Sacramento, California, largely switched to these

peripherally placed catheters for the added benefits of CVP monitoring in addition to reliable vascular access. Subsequent development of PICCs (eg, Power PICC) that can safely withstand high flow-rate injections for CT imaging (eg, CT angiography) made the devices more useful than before. At the time of the study reported here, several devices were approved by the Food and Drug Administration for use, including the single- and dual-lumen Poly Per-Q-Cath PICC, 5F and 6F duallumen Power PICC, and 6F triplelumen Poly Per-Q-Cath2 (all Bard Access Systems, Inc). We report our experience with the transition to using PICCs for CVP monitoring and reliable vascular access without the risks of traditionally placed CVCs.

In order to identify patients who had undergone PICC placement, admission data were cross-referenced with a registry of PICC insertions maintained by the hospital PICC nursing staff. Data from electronic and paper charts were reviewed by using a standardized data collection tool with specific queries for complications associated with insertion of a central catheter, catheter-related bloodstream infection as defined by guidelines of the Centers for Disease Control and Prevention,6 arrhythmias associated with placement of a catheter, extremity thrombosis ipsilateral to the catheter, accuracy of CVP measure if a second central catheter was present, unexpected adverse effects, duration of treatment, and functional outcome.
Devices

Methods
The study was a prospective descriptive study of the first 35 patients in whom PICCs were used as an alternative to CVCs for longterm venous access and CVP monitoring in a neurological ICU. The study was approved by the appropriate institutional review board. Data were collected from a prospective registry of neurological ICU admissions at the medical center.

Devices approved for use in the study included the 6F triple-lumen Per-Q-Cath, 4F Per-Q-Cath, Solo 5F triple-lumen Power PICC, Solo 5F dual-lumen Power PICC, and Solo 4F single-lumen Power PICC. Catheter selection for each patient was based on recommended guidelines for appropriate catheter gauge, vessel lumen diameter, and catheter availability.
Placement

Authors
Christi DeLemos is a nurse practitioner in the Department of Neurological Surgery at the University of California, Davis. Judy Abi-Nader is a registered nurse who works with the peripherally inserted central catheter team at Kaiser Sacramento Neurocritical Care in Sacramento, California. Paul T. Akins is a doctorally prepared neurointensivist at Kaiser Sacramento Neurocritical Care in Sacramento, California.
Corresponding author: Christi DeLemos, RN, MS, ACNP-BC, Department of Neurological Surgery, School of Medicine, 4860 Y St, Ste 3740 ACC, Sacramento, CA 95817 (e-mail: christi.delemos@ucdmc.ucdavis.edu). 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, reprints@aacn.org.

All PICCs were placed by a specialized team of experienced nurses who used sterile technique. For bedside insertion, ultrasound for vein localization and the modified Seldinger technique were used. Before insertion, patients were assessed, including history of insertion of central catheters, presence of a pacemaker, history of mastectomy, and diameter of the vein to be used for access. Triple-lumen PICCs were

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placed in veins with a diameter of 0.5 cm or larger. Placement in the cephalic veins was avoided because of the high risk for thrombosis.7-11 The brachial or basilic vein was selected on the basis of the suitability of the site. Maximal barrier precautions were used. The insertion site was cleansed with a 2% chlorhexidine gluconate 70% isopropol alcohol solution (ChloraPrep, Enturia, Inc, Leawood, Kansas) and allowed to dry. An antibiotic-impregnated disk (Biopatch, Ethicon, Inc, Somerville, NJ) was placed directly over the site after insertion of the catheter. The catheter was secured by using a stabilizing device (Statlock, Bard Medical Division, Covington, Georgia), and an occlusive dressing was applied. After 24 hours the site was redressed by using a new antibiotic-impregnated disk and a transparent dressing.
Data Collection and Analysis

All data collection was done according to the guidelines of the institutional review board. Study data were collated, patient identities were removed in accordance with guidelines of the Health Insurance Portability and Accountability Act, and the resultant information was entered into an Excel spreadsheet for data analysis. Descriptive statistics were calculated by using standard formulas.

subarachnoid Table 1 Demographics of the 33 patients in the study hemorrhage, Valuea Characteristic intracranial 11 (37) Male sex hemorrhage, 62 (16.5) Age, mean (SD), y or subdural 15 (45) Subarachnoid hemorrhage hematoma 7 (21) Encephalopathy 6 (18) Intracerebral hemorrhage (Table 1). 3 (9) Other Mean duration 2 (6) Subdural hematoma 25.6 (12.8) Length of stay, mean (SD), d of PICC access 15 (45) Discharge to home was 19 days. 9 (27) Discharge to skilled nursing facility Catheters 4 (12) Discharge to rehabilitation center 5 (15) Died remained in 19 (6) Days with peripherally inserted place a total of central catheter, mean (SD) 649 catheter a Values are No. (%) of patients unless otherwise indicated. days. All patients in the unintentionally by 1 patient as a study received subcutaneous result of the patients cognitive heparin as prophylaxis for deep vein impairment. Because of persistent thrombosis (DVT) within 48 hours fever of unknown source, 3 patients of admission to the ICU unless severe had PICCs removed to exclude thrombocytopenia or excessive catheter-related bloodstream infecbleeding prohibited use of the drug. tion. Cultures of blood samples or One patient experienced an specimens obtained from the catheter upper extremity DVT resulting in tip were negative for microorgancatheter removal (Table 2). This isms for all 3 patients. patient was an obese woman with Among the patients with PICCs, Hunt Hess grade V subarachnoid 11 also had a second central catheter hemorrhage and minimal upper present for comparison of accuracy extremity movement with trace of CVP measurements. The central extensor posturing to pain only. The catheters were placed emergently for upper extremity edema resolved acute management at the time of without further treatment, and admission to the ICU. The PICC nurslong-term anticoagulation was not ing staff does not provide 24-hour required. The PICC was removed

Table 2 Comparison of complications between peripherally inserted central catheter and central venous catheter
% of cases Results Insertional injury Bloodstream infection Catheter-associated deep vein thrombosis
a Data

Results
A total of 35 patients were enrolled in the study during a 20-month period. Of these, 2 were excluded because of incomplete data. The final sample consisted of 33 patients. Most of the patients had intracranial bleeding such as

Peripherally inserted central catheter 0 0

Central venous cathetera 10-15 2.9 per 1000 catheter days (subclavian < internal jugular < femoral) 2-20 (subclavian < internal jugular < femoral)

from Taylor and Palaqiri.2

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on-call personnel to establish intravenous access, so the PICCs were placed by hospital day 3 electively. Observations were made when CVCs and PICCs were placed concurrently. Overall accuracy of CVP monitoring in the entire sample of 33 patients cannot be reported because only a subset of patients was monitored by using both methods. Erroneous measurements were detected for 2 PICCs. No injuries related to insertion of a PICC or central catheters occurred. Two patients had spontaneous nonsustained ventricular tachycardia after a PICC insertion (Figure 1). In both instances, the tachycardia ceased when the catheters were repositioned.

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

Case Illustration
A 78-year-old woman initially had a headache and lethargy that progressed to decerebrate posturing and coma. CT of the brain showed extensive subarachnoid hemorrhage with posterior fossa predominance and hydrocephalus. Her score on the Glasgow Coma Scale was 4

(E1VTM2), and she was grade 5 on the Hunt Hess scale. Her condition was stabilized with intubation and external ventricular drainage. Systolic blood pressure was reduced by 30 points in the left arm compared with the right arm. Findings on brain CT angiography suggested an aneurysm at the vertebrobasilar junction, and this abnormality was confirmed with catheter angiography (Figure 2A). The aneurysm was flow-related due to left subclavian steal from a severe proximal left subclavian stenosis. After 4 days, the patients neurological status improved and she could follow commands intermittently. She underwent stenting of the left subclavian stenosis, coil embolization of the distal right vertebral

artery, and occlusion of the flowrelated aneurysm with preservation of the right posterior inferior cerebellar artery. CVP monitoring with a Power PICC and minimally invasive cardiac output monitoring (Vigileo monitor, Edwards Lifesciences, Irvine, California) via either femoral artery or radial artery waveform (Figure 2B) during the patients ICU stay was used to guide fluid management and facilitated safe resolution of pulmonary vascular congestion without excessive diuresis. The patient initially had pulmonary vascular congestion with moderately elevated CVP but adequate cardiac output. Periodic surveillance CT and magnetic resonance angiography were used to monitor for vasospasm. Avoidance

PICC

AP PORTABLE

PICC Arterial catheter

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 was facilitated by placement of a peripherally inserted central catheter (PICC) for vascular access and monitoring of central venous pressure (left upper extremity) and cardiac output monitoring with a minimally invasive device. C, Anteroposterior (AP) portable chest radiograph shows pulmonary vascular congestion and confirms proper placement of PICC in the superior vena cava.

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of excessive diuresis was a clinical goal both to prevent nephropathy associated with contrast medium and to avoid dehydration, which can increase the risk for vasospasm. The patients neurological status improved gradually during a 2-month period. She was discharged to a community skilled nursing facility for subacute rehabilitation initially and then to home at 3-month office follow-up. She currently is living at home with her family. She is selfsufficient with basic activities of daily living, can walk independently within her home but not in the community, and needs assistance with instrumental activities of daily living (modified Rankin score of 3: moderate disability but able to walk).

Discussion
We report our initial experience with the use of PICCs rather than traditional central catheters. Some patients in the sample also underwent less invasive cardiac output monitoring (Vigileo monitor); the results of that monitoring are not included here. Other researchers9 have reported few catheter-related complications such as insertional injury and catheter-related bloodstream infection with PICCs. In the year preceding our study, 3 insertion-related complications associated with central catheters occurred: 1 subclavian artery catheterization and 2 pneumothoraces. These complications had no long-term sequelae. None of our patients had catheter-related bloodstream infection. This lack of complications may be related to the use of a specialized nursing team that managed the insertion of PICCs and supervised subsequent catheter care or the length of treatment.12,13

Catheter-associated bloodstream infection may be less common with PICCs than with CVCs, and the PICCs can still be used for hemodynamic monitoring, volume replacement, phlebotomy, and administration of medications. Patel et al9 performed a retrospective review of a 4-year period in which traditional central catheters were replaced with PICCs in ICU patients to capitalize on the advances in catheter technology, reduce risks associated with catheter insertion, and provide a cost-effective alternative to central catheters. By the third intervention year, nearly two-thirds of all hemodynamic monitoring was accomplished with PICCs and the rate of catheter-related bloodstream infection had decreased by 81% (P<.001). In another large-scale study10 in which PICCs were compared with traditional CVCs in the ICU, the median time to infection was significantly longer (P=.03) with PICCs (23 days) than with traditional CVCs (13 days). Catheter-associated DVT has become a concern with increased use of PICCs.7-9,12,14 Few data are available on upper extremity DVT; most of the observational studies have focused on lower extremity DVT. In one study,11 compared with nonobese patients, obese patients had a 23-fold increase in upper extremity DVT. Other risk factors for lower extremity DVT include presence of a hypercoagulable state, recent major surgery, thrombogenic effects of cancer, and prolonged immobility.8 Use of prophylactic anticoagulants can reduce the incidence of venous thrombosis associated with PICCs.15

Neurosurgical ICU patients may be among the groups at highest risk for venous thrombotic events because of prolonged immobility due to neurological injury, underlying tumors, and early contraindications to anticoagulation therapy. The pathogenesis of upper extremity DVT may be multifactorial, related to direct endothelial trauma caused by the presence of the catheter, an underlying hypercoagulable state, and reduced venous return in paretic arms. One of the most important variables may be correct lumen-to-catheter sizing.11 The patient in our study who had DVT was an obese woman with Hunt Hess grade V aneurysm and a score of 6 on the Glasgow Coma Scale. As our experience with PICC has increased, we have learned to place PICCs in nonparetic arms and to use small, single-lumen catheters in patients at high risk for upper extremity DVT. As expected, insertion-related complications of PICCs were favorable compared with complications associated with insertion of central catheters. We had no complications related to arterial puncture or pneumothorax from PICC placement. Insertion-related complications associated with placement of central catheters decreased from 3 in the year before our study to zero with the increased use of PICCs. Two patients with nonsustained ventricular tachycardia after PICC insertion were asymptomatic, and the dysrhythmias resolved with repositioning of the catheter. Spontaneous nonsustained ventricular tachycardia due to drifting of the PICC from the superior vena cava to the right atrium or the right ventricle after

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PICC insertion has been documented in other medical centers. In our patients, the tachycardia may have been unrelated to placement of a PICC; the CVP tracing did not show a right atrial pressure waveform. We found 3 reports of PICCrelated cardiac effects: 1 case of fatal cardiac tamponade due to migration of a catheter used to infuse potassium-enriched sodium chloride,16 1 case indicating that arm position was the most significant variable influencing position of the catheter tip,17 and 1 case of atrial fibrillation related to position of the catheter tip.18 The risk of tip migration with arm abduction is greater with PICCs than with central catheters, and care must be taken to ensure positioning that avoids advancing the catheter. Advancement of the catheter tip, which can be as much as 9.5 cm,19 can be clinically relevant. The flexibility of PICC tips, which is less than that of central catheters, may be an additional variable that increases the risk for dysrhythmia and cardiac injury. CVC-associated complications are well documented, with higher rates of bloodstream infection in femoral placement sites than in other sites.20 Similar to the findings in previous studies,21 costs per vascular access device were about 10% to 15% lower for PICCs than for CVCs; the overall reductions in costs per case and morbidity were greater when the

reduction in bloodstream infections was considered. Two previous studies3,4 documented the reliability of CVP measurement with PICCs, and we did not seek to directly compare CVCs with PICCs. Retrospectively, we found that the 2 PICCs with erroneously high CVP measurements had in-line needleless access caps, which were associated with falsely high measurements in the previous reports.3,4 Reliable CVP data depend on a continuous, patent column of fluid traveling like a wave from the catheter tip to the pressure transducer. Interferences such as kinks, air, or needleless injection caps may dampen the waveform or alter the signal. In conclusion, patients in neurological ICUs often have lengthy stays and require extended periods of vascular access. As neurocritical care providers strive to lower complication rates related to vascular access and bloodstream infections, less invasive approaches such as use of PICCs, use of minimally invasive cardiac monitoring devices, and dedicated vascular access nursing teams will become increasingly important elements in the effort to advance patient care. CCN
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Financial Disclosures
None reported.

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To learn more about neurocritical care, read Embrace Hope: An End-of-Life Intervention to Support Neurological Critical Care Patients and Their Families in Critical Care Nurse, February 2010;30:47-58. Available at www.ccnonline.org.

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Intraoperative peripherally inserted central venous catheter central venous pressure monitoring in abdominal aortic aneurysm reconstruction. Ann Vasc Surg. 2006;20(4):577-581. 501(k) Premarket notification for k051991. Food and Drug Administration Web site. http://www .accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN /pmn.cfm?ID=18987. Accessed January 12, 2011. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332. Seeley MA, Santiago M, Shott S. Prediction tool for thrombi associated with peripherally inserted central catheters. J Infus Nurs. 2007; 30(5):280-286. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314. Patel B, Dauenahuer C, Rady M, et al. Impact of peripherally inserted central catheters on catheter-related bloodstream infections in the intensive care unit. J Patient Saf. 2007;3(3):142-148. Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high-risk short-term central venous catheters. Am J Infect Control. 2010;38(2):149-153. Grove J, Pevec W, Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(7):837-840. Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. Improved care and reduced costs for patients requiring peripherally inserted central catheters: the role of bedside ultrasound and a dedicated team. JPEN J Parenter Enteral Nutr. 2005;29(5):374-379. Fong NI, Holtzman SR, Bettmann MA, Bettis SJ. Peripherally inserted central catheters: outcome as a function of the operator. J Vasc Interv Radiol. 2001;12(6):723-729. Ong B, Gibbs I, Catchpole R, Hetherington R, Harper J. Peripherally inserted central catheters and upper extremity deep vein thrombosis. Australas Radiol. 2006;50(5):451-454. Paauw J, Borders H, Ingalls N, et al. The incidence of PICC line-associated thrombosis with and without the use of prophylactic anticoagulants. JPEN J Parenter Enteral Nutr. 2008;32:443-447. Orme R, McSwiney M, Chamberlain-Webber R. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. Br J Anaesth. 2007;99:384-388. Connolly B, Amaral J, Walsh S, Temple M, Chait P, Stephens D. Influence of arm movement on central tip location of peripherally inserted central catheters. Pediatr Radiol. 2006;36:845-850. Elsharkawy H, Lewis BS, Steiger E, Farag E. Post placement positional atrial fibrillation and peripherally inserted central catheters. Minerva Anestesiol. 2009;75(7-8):471-474. Lee DS, Kuhn J, Shaffer MJ. Migration of tips of central catheters in seated patients. Anesth Analg. 1984;63:949-952. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001; 286(6):700-707. Horattas MC, Trupiano J, Hopkins S, Pasini D, Martino C, Murty A. Changing concepts in long-term central venous access: catheter selection and cost savings. Am J Infect Control. 2001;29(1):32-40.

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Corrections
The correct doi number for Modified Insertion of a Peripherally Inserted Central Catheter: Taking the Chest Radiograph Earlier by Tian et al (Crit Care Nurse. 2011;31[2]:64-69) is doi: 10.4037/ccn2011966. The correct doi number for Use of Peripherally Inserted Central Catheters As an Alternative to Central Catheters in Neurocritical Care Units by DeLemos et al (Crit Care Nurse. 2011;31[2]: 70-75) is doi: 10.4037/ccn2011911. In the April article by Cecil and colleagues, Traumatic Brain Injury: Advanced Multimodal Neuromonitoring From Theory to Clinical Practice (Crit Care Nurse. 2011;31[2]:25-37), the threshold value for glycerol listed in Table 1 on page 28 should be 921 mg/dL. On page 31, the pink box under Tier 2 in Figure 5 should state Hypertonic saline. Lastly, on page 33, the formula for cerebral perfusion pressure is CPP = MAP - ICP. In addition, question No. 1 in CE test C112 (page 37) has been deleted from the CE test and the passing score has been revised to 9 correct answers.

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