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PICCs are not for all patients.

Peripherally Inserted Central Catheters (PICC) were first introduced in the mid 1970's and their use has steadily increased since. PICCs are used in all healthcare settings for the intravenous administration of antibiotics, pain medicine, chemotherapy, nutrition, or for the drawing of blood samples. While they serve an important medical purpose, a PICC is not appropriate for all patients. Patients who have elevated serum creatinine and/or decreased eGFR are at risk for developing chronic kidney disease and may need permanent arteriovenous access for future dialysis. For these patients PICCs have the potential to significantly decrease their chance for survival by limiting the sites available for atriovenous (AV) fistula placement. The AV fistula is the preferred form of vascular access for hemodialysis, delivering superior patency with lower morbidity, hospitalization, and cost compared to synthetic grafts or venous catheters.

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Healthcare practioners should be aware of the potential complications of PICCs and limit the use of PICCs to patients with normal serum creatinine and GFR unless PICC placement is approved by a nephrologist. The nephrologist should decide whether the patient's abnormal creatinine/GFR are transient or whether the patient has kidney disease and has the potential to need future dialysis.

Every patient has only four superficial upper extremity veins, the cephalic and the basilic vein in each arm. These two veins join together to form the subclavian vein then the Superior Vena Cava. PICCs are most often inserted in the basilic vein, then advanced so the distal tip of the PICC rests in the Superior Vena Cava. Vein damage anywhere along the length of the catheter, from the insertion site to the Superior Vena Cava, may make the entire extremity useless for future placement of an AV fistula for permanent dialysis access. Vein damage may be caused by many factors and it may take only a short time to render a vein useless for hemodialysis access. Medications infused through the PICC may cause chemical irritation to the venous endothelium or the catheter itself may cause venous irritation. However, the most frequent complications of PICC's are thrombosis formation and venous stenosis. These complications occur much more often than health care practioners realize because a patient may be asymptomatic but still develop enough venous stenosis or thrombosis to damage veins and render the entire arm useless for AV fistula placement.

A study conducted by Saad and Vesely found that 23.3% of studied patients developed venous thrombosis after initial PICC placement. This percentage increased to 38% for patients who underwent multiple PICC insertions. Central venous stenosis developed in 4.8% of study participants and 2.7% had central venous occlusion. (1) Even partial impairment of blood flow by thrombosis or stenosis in an extremity will greatly decrease the patient's chance of receiving a fistula.

The Renal Network recommends that patients with an eGFR of less than 43 mL/min or a serum creatinine level of greater than 2.0 mg/dL should not have a PICC line placed (2) The Fistula First Organization recommends the use of a small bore central catheter (SBCC) in the internal jugular vessel instead of a PICC for high risk patients since SBCCs can last longer than PICC lines, can be easily replaced, and have fewer complications for the period of time needed. (3)

Patients with kidney disease also need to have their forearm veins protected from venipuncture and IV placement. Only hand veins should be used unless emergency IV access is needed. The following principals should be followed for patients with kidney disease:

* Veins in both arms that could be used for hemodialysis vascular access MUST be preserved.

* Venipuncture or IV placement could damage these veins so they can't be used for hemodialysis access.

* Subclavian vein catheterization can cause central venous stenosis, which can make it impossible to use that side of the body for hemodialysis access--cutting the patient's access choices in half. (4)

The first step in preserving peripheral veins of patients who have or are at risk for kidney disease is the early identification of these patients. Some patients may not know they have early kidney disease. Review the patient's serum creatinine and/ or eGFR. If either laboratory result is abnormal consult a nephrologist before placing the PICC. This simple step may extend your patient's life. PICC's are not appropriate for all patients.

This material was prepared by HealthInsight, the Medicare Quality Improvement Organization for Nevada and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-NV-2010-7.3-062

Liz Gorka RN, BSN, CCRN

HealthInsight Project Coordinator

(Endnotes)

(1) Saad, T.F., & Vesely, T.M. (2004). Venous access for patients with chronic kidney disease. Journal of Vascular and Interventional Radiology, 15 (10), 1041-1045.

(2) The Renal Network. (n.d.) Reducing the use of PICC lines in chronic kidney disease patients. Retrieved from http://fistula.memberpath.com/LinkClick.aspx?fileticket =RJer8gKUewY%3d&tabid=205

(3) AV Fistula First Breakthrough Initiative Coalition. (2009.) Recommendations for the Minimal Use of PICC Lines. Retrieved from http://www.fistulafirst.org/LinkClick. aspx?fileticket= eCnazlnICg%3D&tabid=72

(4) AV Fistula First Breakthrough Initiative Coalition. (2009) Vein preservation and hemodialysis fistula protection. Retrieved from http://www.fistulafirst.org/LinkClick.asp x?fileticket=VETldogeiwY%3d&tabid=205

Liz is currently a Project Coordinator for HealthInsight, the Medicare Quality Improvement Organization for the state of Nevada. As the hospital liaison, Liz works with acute care facilities to ensure that quality improvement projects are developed and implemented within the context of the Centers for Medicare & Medicaid Services contract. Liz also provides educational support and research on evidenced based best practices to facilities to assist in the improvement of CMS quality measures.

Liz has over 28 years experience as a Registered Nurse including Emergency, Critical Care, Staff Education and Quality Improvement. Liz is currently working toward her Master's Degree in Nursing.
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Author:Gorka, Liz
Publication:Nevada RNformation
Date:Nov 1, 2010
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