In the intensive care unit, a peripherally inserted central catheter (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulopathies or at high risk of infection. The purpose of this research was to assess the feasibility of bedside ultrasound (US)-guided PICC placement by critical care fellows on intensive care units.
All bedside US-PICCs inserted by critical care fellows from July 2013 to September 2015 were retrospectively reviewed focusing on the rate of successful insertion, complications of insertion, or during maintenance.
A total of 177 US-guided PICCs were inserted in 163 patients and included in the analysis. The median age was 62 years (IQR 50–70 years) and 104 cases (58.8%) were male. There were 172 cases (90.4%) of PICCs inserted in the upper arm. Anticoagulant therapy was used in 26 patients (14.7%) and 8 patients (5.2%) had severe coagulopathies. The median procedural time was 30 minutes (IQR 19–45 minutes). Insertion success rate was 93.2%, and there were no major complications during insertions except for malposition (12.1%). Catheters remained in place for a total of 3,878 days (median 16 days: IQR 8–31 days). There was only 1 case (0.6%) of catheter-related bloodstream infection, and 2 cases (1.2%) of symptomatic venous thromboembolism.
Bedside US-guided placement of PICCs by critical care fellows is safe and feasible. The success rate of the procedure was “acceptable,” and was not associated with significant risks of infectious and non-infectious complications, even in patients with coagulopathies.
The use of a peripherally inserted central catheter (PICC) has many advantages in the intensive care unit (ICU) setting because insertion of this device is low risk, even in patients with altered coagulation and/or difficult neck anatomy [
From the early 1990s, PICCs have been used in clinical practice and the majority of placement procedures have been performed by interventional radiologists with the assistance of either contrast venography or fluoroscopy. However, the incidence of adverse events in critically ill patients remains high and constitutes a significant risk during intra-hospital transport [
Given the paucity of contemporary data on PICC placement specifically by critical care fellows in the ICU, a retrospective cohort review of the experience regarding bedside ultrasound (US)-guided PICC placement by critical care fellows in ICU patients was performed.
All bedside US-guided PICCs inserted by intensivists in patients admitted to ICU at the Samsung Medical Center (1,961-bed, university-affiliated, tertiary referral hospital in Seoul, Korea), from July 2013 to September 2015 were retrospectively reviewed. PICC were inserted in patients who were recovering from their acute illness but who still required venous access for > 2 weeks. According to hospital polices, indications for the use of PICC were: (1) need for a central line for non-peripherally compatible infusates (parenteral nutrition, and/or infusion of drugs that require a central line (pH < 5 or > 9, osmolarity > 500 mOsm/L, drugs associated with endothelial damage), and/ or: (2) need for infusion of peripherally compatible infusate > 2 weeks, and/or: (3) need for patients with difficult venous access, and/or: (4) need for frequent blood sampling (> 3 times/day). In some cases, in acutely ill patients, when a CVC insertion was not appropriate or a PICC placement was felt necessary by the critical care fellows, PICCs were used.
All procedures were performed by skilled critical care fellows who had previously inserted > 50 cases of CVCs. Prior to the clinical use of PICC, fellows followed a bedside US-guided PICC training program. The training component consisted of didactic lecture about basic concept and information of PICC and a skills laboratory. The skills laboratory was performed in the Division of education and human resources. The Clinical simulation team was at the Samsung Medical Center and used vascular access gel phantoms. After training was completed, fellows entered a competency period that required 5 successful US-guided PICCs to be placed under direct supervision of an experienced operator.
The type of PICCs selected by critical care fellows was dependent on the patient’s condition. A Scale 5 French Dual-Lumen Turbo-Ject Power-Injectable PICC (Cook, Bloomington, MN, USA) or Scale 6 French Dual-Lumen Vaxcel PICC with PASV Valve (Navilyst, Marlborough, MA, USA) was used.
All PICCs were inserted using real-time ultrasound to guide the puncture as recommended by current UK guidelines [
A diagnosis of CRBSI was made when the same organism was recovered from peripheral blood culture, and from direct culture of the catheter tip, or by the differential time to positivity method (a positive blood culture from the catheter ≤ 120 minutes prior to a positive peripheral blood culture). Diagnosis of catheter-related thrombosis was determined by US examination (compression ultrasonography and duplex Doppler), performed only when clinically indicated by signs and symptoms suggesting venous occlusion (such as edema of the arm, PICC malfunction, unexplained local pain). Catheter-related central venous thrombosis was defined as the presence (to any extent) of thrombosis in the subclavian vein (SCV), internal jugular vein, or brachiocephalic vein or in the superior vena cava on the side of PICC insertion.
All relevant data was collected and information, including the patient’s age and disease, indication for PICC insertion, Sequential Organ Failure Assessment (SOFA) score on the insertion day, procedure time, duration of the dwell time for the device, incidence of complications at insertion or during maintenance, and cause of removal. All data were analyzed by standard descriptive statistics. Values were reported as the median with IQR.
During the study period, 172 PICCs in 159 patients were inserted in the ICU by 17 critical care fellows. The median age was 63 years (IQR 50.25–70.75 years) and 102 cases (59.3%) were male. The median ICU length of stay was 15 days (IQR 8–26.5 days) and the median SOFA score was 8 (IQR 5–11). Therapeutic anticoagulation was performed in 25 patients (14.5%) during the procedure. There were 11 (6.4%) patients with thrombocytopenia < 2,000 platelets/μL and 17 patients (9.9%) had a prolonged prothrombin time international normalized ratio > 2. Amongst them, 7 patients (4.1%) had severe coagulopathies (2 patients with thrombocytopenia < 10,000 platelets/μL and 5 patients with a prolonged prothrombin time international normalized ratio > 5). There were 75 patients (43.6%) who had a tracheostomy and 16 patients (9.3%) were supported by extracorporeal membrane oxygenation (
Difficult venous access (52.9%) was the most common indication for the PICC placement. In 5 cases of active fluid resuscitation, PICCs were placed due to failed peripheral venous access and insertion of CVCs were inappropriate. Out of the 5 cases, 3 cases were due to severe coagulopathies and 2 cases were due to local conditions at the CVC insertion sites. The median procedure time was 30 minutes (IQR 18.5–44.75 minutes). The right upper arm (59.3%) was the most commonly used access point. Most of the catheters were inserted via the basilic or brachial veins (71.5%) and the cephalic vein cannulation rate was 22.4%. Power-injectable PICCs were inserted in 155 cases (90.1%) and the insertion success rate was 93.0% (
During the study period, there were no significant complications such as perforation of the intracranial veins, perforation of central veins, arrhythmias requiring intervention, hemorrhage or hematoma which requires transfusion, or arterial injury. The only immediate post procedural complication was malposition in 20 cases (12.5%;
Catheters remained in place a total of 3,810 days (median 16 days: IQR, 8–31 days). There was 1 case in the ICU of CRBSI where a PICC remained in place for 58 days. Extend-spectrum beta-lactamase Klebsiella pneumoniae was cultured from both peripheral and central blood cultures with positive time sensitivity, and the same organism was grown in the catheter tip culture. Symptomatic catheter-related central venous thrombosis occurred in 2 patients in the ICU. A patient with an arm swelling revealed SCV thrombosis, and another patient who showed sudden desaturation revealed SCV to SVC thrombosis with pulmonary embolism. PICCs were removed after thrombosis was diagnosed, and patients were treated with anticoagulants. There were 7 cases of catheter removal due to malfunction and 10 cases of dislodgements or accidental removals of the device (
There were a total of 177 PICC which were inserted by critical care fellows. The patients’ median age was 62 years old, median SOFA score was 8, and median ICU length of stay was 15 days. These results show a high success rate (93.2%) of PICC placement, and there were no major complications. Even though the malposition rate after PICC placement was 12.1%, many cases (
The first clinical experience with PICCs in an ICU was reported in 1996 [
The PICC placement is a relatively simple procedure. However, in critically ill patients, intra-hospital transport for example to the interventional radiology center could result in harm. In addition, the injection of iodinated contrast medium could worsen renal insufficiency. Consequently, most critically ill patients who need central lines for > 2 weeks maintain CVCs, and frequently change the insertion site. Standard CVC insertion has a higher risk of immediate complication such as hemothorax, pneumothorax, or insertion site hematoma compared with PICC insertion and sometimes it could be lethal for critically ill patients [
In case of ICU patients, PICC placement may be more difficult compared with outpatients because many of them had been treated with positive pressure ventilation, edematous extremities, and had very poor peripheral veins in case of chronic illness, and many of them could not hold a position. Consequently, the risk of failure or malposition was higher compared with non-ICU patients. In this study, failed attempt rate was 6.8% and the catheter tip malposition rate was 12.1% when a chest X-ray was performed to check PICC placement. Other studies show less than 3% of cases were due to malposition ensuring the catheter tip position with medical devices during PICC placement [
Our study had several limitations. Firstly, there may be a potential risk of confounding variables because the study was not a randomized controlled trial. In addition, 1 physician placed > 1/3 of PICCs in the study, and the success rate may not be repeated by multiple operators. Another limitation of the study was the blind technique of catheter tip location. The catheter tip position was verified with a post-procedural chest X-ray, without fluoroscopy or an electrocardiography. This results in a relatively high rate of malposition compared with previous studies using a real time catheter tip position. Considering the results of this preliminary retrospective study, further prospective, controlled, randomized trials comparing the clinical outcome of CVCs with PICCs in ICU patients are warranted. In addition, consideration should be given to the establishment of procedural training in PICC placement for critical care fellows.
This preliminary retrospective study showed that bedside US-guided PICC placement by critical care fellows is safe and feasible in most ICU patients, even in patients with severe coagulopathies and those requiring fluid resuscitation. There were no major immediate complications except for malposition, and CRBSI, and symptomatic thrombosis was uncommon. Bedside US-guided PICC placement by critical care fellows could be considered in ICU patients who were recovering from their acute illness, but who still required venous access for > 2 weeks, and could be considered in some cases of acute illness.
Supplementary Table S1 can be found in the online version at
The authors have no conflicts of interest to declare.
Baseline characteristics.
Variable | Total ( |
---|---|
Age (y) | 63.0 (50.25–70.75) |
Gender, male | 102 (59.3) |
BMI | 22.2 (19.37–25.27) |
SOFA score | 8.0 (5.00–11.00) |
Medical ICU | 118 (68.6) |
Surgical ICU | 54 (31.4) |
ICU length of stay (d) | 15.0 (8.00–26.50) |
Platelet count ×103/μL | 113.0 (65.00–208.00) |
Platelet count ≤ 2 ×103/μL | 11 (6.4) |
PT-INR | 1.2 (1.08–1.49) |
PT-INR ≥ 2 | 17 (9.9) |
aPTT (s) | 43.7(37.00–55.10) |
Therapeutic anticoagulation | 25 (14.5) |
CRRT | 57 (33.1) |
Mechanical ventilation | 104 (60.5) |
Tracheostomy | 75 (43.6) |
ECMO | 16 (9.3) |
Vasopressor | 62 (36.0) |
Data are presented as
ICU= intensive care unit; SOFA= sequential organ failure assessment; BMI= body mass index; PT-INR= prothrombin time - international normalized ratio; aPTT= activated partial thromboplastin time; CRRT= continuous renal replacement therapy; ECMO= extracorporeal membrane oxygenator.
Procedure outcomes.
Variable | Total ( |
---|---|
Indications for PICC insertion | |
Non-peripherally compatible infusates | 81 (47.1) |
Difficult venous access | 91 (52.9) |
| |
Procedure time (min) | 30.0 (18.5–44.75) |
| |
Puncture site | |
Right upper arm | 102 (59.3) |
Left upper arm | 62 (36.0) |
| |
Puncture vessel | |
Non-cephalic vein (basilic or brachial) | 123 (71.5) |
Cephalic vein | 37 (21.5) |
| |
Power injectable PICC | 155 (90.1) |
| |
Success rate | 160 (93.0) |
| |
Failed attempt | 12 (7.0) |
Puncture fail | 10 (5.8) |
Remove due to malposition | 2 (1.2) |
Data are presented as
PICC = peripherally inserted central catheter; IQR = interquartile range.
Procedure outcome, immediate (success case).
Variable | Total ( |
---|---|
Primary malposition | 20 (12.5) |
Ipsilateral IJV | 10 (6.3) |
Ipsilateral SCV | 10 (6.3) |
| |
Catheter tip location | |
RA or SVC lower 1/3 | 70 (40.7) |
SVC mid 1/3 | 58 (33.7) |
SVC upper 1/3 | 15 (8.7) |
Axillary vein | 17 (9.9) |
Data are presented as
IJV= internal jugular vein; SCV= subclavian vein; RA= right atrium; SVC= superior vena cava.
Procedure outcomes, long-term (success case).
Variable | Total ( |
Indications for PICC insertion | ||
---|---|---|---|---|
Non-peripherally compatible infusates | Difficult venous access | |||
| ||||
( |
( | |||
Catheter indwelling time (d) | 16.0 (8.00–31.00) | 17.5 (9.00–35.25) | 14.5 (7.00–26.75) | 0.195 |
| ||||
Total catheter days | 3,810 | 2,086 | 1,724 | |
| ||||
Complications | 0.550 | |||
CRBSI | 1 (0.6; 0.26/1,000 catheter-days) | 1 (1.3) | 0 | |
Symptomatic DVT | 2 (1.3; 0.52/1,000 catheter-days) | 0 | 2 (2.4) | |
Malfunction | 7 (4.4) | 4 (5.1) | 3 (3.7) | |
Accidental removal or dislodgement | 10 (6.3) | 6 (7.7) | 4 (4.9) |
Data are presented as
PICC = peripherally inserted central catheter; IQR = interqurtile range; CRBSI= catheter related blood stream infection; DVT= deep vein thrombosis.