To PICC or not to PICC:
for hospitalized patients
“MAGIC” Guidelines for choosing appropriate IV access
Georgia McIntosh, MD
DGIM Grand Rounds
VCUHealth
Feb 1, 2016
Learning Objectives
• Gain an appreciation for proposed guidelines regarding PICC line
placement
• Distinguish between different types of IV access and why one may be
used as opposed to another
• Recognize strategies to reduce infection and DVT risk in pts with PICC
lines
• Appreciate circumstances when we may divert from the guidelines
and how to remedy that
• National survey looking at hospitalist experience, practice patterns,
and knowledge regarding PICC lines
• Feb- March, 2013
• Response rate 18% (2112 surveys emailed out, 381 returned)
• 86% stated PICC placed solely for venous access in hospitalized pt
• 82% reported having cared for a pt who specifically asked for a PICC
• 57% stated they had at least once forgotten that their pt had a PICC
• April- Sept 2013
• Multicenter survey looking at rates that interns, residents, general
medicine attendings, hospitalists and subspecialists know which of
their patients have PICC vs TLC
• Conducted face-to-face interviews with hospitalized pts and their
providers at 3 academic med centers
• Hypothesized that providers who are most proximal to their patients
(interns and hospitalists) would be more likely to identify which of
their patients had CVC
• Also hypothesized those who insert CVCs or those who consciously
debate on the type of access more likely to be aware
• Conducted face-to-face interviews with hospitalized pts and their
providers at 3 academic med centers
“As of this morning, does your patient have a PICC or TLC in the neck, chest or
groin?”
• Total patients 990
• 21% have TLC or PICCs
o 21% of clinicians did not know of the presence of PICCs or TLC with
unawareness of PICCS being greater
o 5.6% of providers stated pt had CVC when they had none
o Teaching physicians and hospitalists were more unaware of the presence
of TLC than were interns, residents or APP
Chopra V.. Ann Int Med, 2015
Objectives of MAGIC
• Develop a list of appropriate indications for use of PICCS in relation to
other venous access
• Define appropriateness of practices associated with the insertion and
care of PICCS
• Determine appropriate practices for treatment and prevention of
PICC complications
• Rate the appropriateness of peripheral IV catheter use in situations
that prompt PICC placement
Chopra V. Ann Int Med, 2015
RAND Corporation/University of California Los
Angeles Appropriateness Method
• Developed in 1980s
• RAND/UCLA method developed to enable measurement of overuse of
medical and surgical procedures
• Procedure considered appropriate when ”expected health benefits
exceed negative consequences” by a sufficiently wide margin such
that the procedure is worth doing, exclusive of cost.”
• Applied to coronary angiography, surgical procedures, urinary
catheters in hospitalized pts, etc.
Chopra V. Ann Int Med, 2015
RAND/UCLA Method
• Systematically review and synthesize available literature
• Articles gathered from Nov 12, 2012-July 1, 2013
• Medline via OVID, EMBASE, BIOSIS, Cochrane Central Register of
Controlled trials via Ovid
• Excluded pediatrics
• Excluded catheters not comparable with PICCS (arterial catheters, HD
catheters)
RAND/UCLA Method
Specialists from :
Vascular access nursing
Hospital-based medicine
Internal medicine
Infectious disease
Critical care
Nephrology
Hematology
Oncology
Pharmacy
Surgery
Interventional Radiology
Patient
RAND/UCLA Method: Rating Process
• Scenarios and indications conducted over 2 rounds
• Instructed not to consider cost
• Rate appropriateness by considering benefit-harm ratio on a scale of 1-9
• 1= harms outweigh benefits
• 9= benefits outweigh harm
• 5= benefits equal harm
• Each panelist rated every scenario twice in a 2-round, modified Delphi
process
• 665 scenarios reviewed with 391 unique indications for PICCS and related
vascular access devices
Chopra V. Ann Int Med, 2015
Appropriateness of PICC insertion
in Hospitalized Medical Patients
Scenario 1
My 41 yo patient is afraid of needles and asks for a PICC line to be
placed for blood draws. He is here for cellulitis of the leg that he
sustained after scraping his shin on the sidewalk. He has no PMHx and
his expected LOS is 5 days.
Based on the guidelines, this is an acceptable indication.
1. True
2. False
Scenario 1
My 41 yo patient is afraid of needles and asks for a PICC line to be
placed for blood draws. He is here for cellulitis of the leg that he
sustained after scraping his shin on the sidewalk. He has no PMHx and
his expected LOS is 5 days.
Based on the guidelines, this is an acceptable indication.
1. True
2. False
Appropriateness of PICC insertion in
Hospitalized Medical Patients
• PICC inappropriate use if < 5 days
• Midline most appropriate to use for 6-14 days
• PICC appropriate if use > 15 days
• Use of tunneled catheter and implanted ports appropriate only if
duration > 31 days
• PICC appropriate for infusion of irritants or vesicants (TPN, chemo) for
any duration of time
• If skilled operators available, recommend nontunneled CVC when
expected duration of use is 14 days or fewer
Choosing Wisely- SGIM
Don’t place, or leave in place, peripherally inserted central catheters
for patient or provider convenience.
Peripherally inserted central catheters (or “PICCs”) are commonly used
devices in contemporary medical practice that are associated with two
costly and potentially lethal health care-acquired complications:
central-line associated bloodstream infection (CLABSI) and venous
thromboembolism (VTE). Given the clinical and economic
consequences of these complications, placement of PICCs should be
limited to acceptable indications (long-term intravenous antibiotics,
total parenteral nutrition, chemotherapy and frequent blood draws).
PICCs should be promptly removed when acceptable indications for
their use ends.
Appropriateness of PICCs in pts
with CKD, Cancer or Critical
Illness
Scenario 2
I always consult nephrology prior to placing a PICC line in a pt
with stable CKD stage 3 who is hospitalized.
1. True
2. false
Scenario 2
I always consult nephrology prior to placing a PICC line in a pt
with stable CKD stage 3 who is hospitalized.
1. True
2. false
Appropriateness of PICCs in Patients with
CKD, Cancer or Critical Illness
• Pts with stage 1-3a CKD (GFR > 45ml/min)- follow guidelines
for general medical patients
• Pts with stage 3b- recommend consultation with
nephrologist
• If venous access required for < 5 days, recommend dorsum of hand
• If venous access required for > 5 days or infusion of non-peripherally
compatible drug is needed- tunneled small-bore central catheter
Choosing Wisely- American
Society of Nephrology
Don’t place peripherally inserted central catheters (PICC) in stage III-V
CKD patients without consulting nephrology.
Venous preservation is critical for stage III–V CKD patients.
Arteriovenous fistulas (AVF) are the best hemodialysis access, with
fewer complications and lower patient mortality, versus grafts or
catheters. Excessive venous puncture damages veins, destroying
potential AVF sites. PICC lines and subclavian vein puncture can cause
venous thrombosis and central vein stenosis. Early nephrology
consultation increases AVF use at hemodialysis initiation and may avoid
unnecessary PICC lines or central/peripheral vein puncture.
Appropriateness of PICCs in Patients with
CKD, Cancer or Critical Illness
• Pts with cancer differ from gen med pts
• Recommend PICC for nonirritant or nonvesicant chemotherapy if proposed
duration > 3 months
• Recommend interval placement of PICC with each chemotherapy treatment
• Recommend tunneled, cuffed catheters when at least 3 months of treatment
proposed or if PICC not available
• For irritant or vesicant chemo- recommend tunneled, cuffed catheter at all
time intervals
• In pts with coagulopathy, panel recommended PICCs rather than tunneled
• In pts needing frequent phlebotomy or difficult peripheral IV access, PICC
appropriate only if duration > 15 days; rec. midlines for 14 days or fewer
Appropriateness of PICCs in Patients with
CKD, Cancer or Critical Illness
• Pts with critical illness differ from gen med pts
• PICCs consistently rated inappropriate due to infection, hemodynamic
instability and thrombosis
• PICCs only appropriate for peripherally compatible infusates > 15 days
• PIVs or midlines appropriate for > 5 days but < 14 days
• Prefer CVC as inserted by skilled critical care provider unless coagulopathy
• Recommend PICCS in hemodynamically stable pts with coagulopathy
Appropriateness of PICC insertion
in special populations (sickle cell,
CF, short gut, etc)
Appropriateness of PICC insertion in special
populations (sickle cell, CF, short gut, etc)
Guidelines focus on frequency of hospitalizations
• < 5 hospitalizations per yr- PICC rated inappropriate
• > 6 hospitalizations per yr- PICC rated as appropriate
• PICCs appropriate when duration of use > 15 days
• Tunneled cuffed catheter appropriate for > 6 hospitalizations/yr
and duration > 15 days
• Ports appropriate when duration of use expected to be > 31 days
• Pts in SNF
• PICC appropriate if proposed duration > 15 days
• Midline appropriate for 6-14 days
Chopra V. Ann Int Med, 2015
Appropriateness of PICC Insertion
Practices
Scenario 3
One of your overnight admissions is a patient from an outside hospital.
Luckily, there is a PICC line already in place. There are no reports of
difficulty in using this line.
PICC lines from outside hospitals can be used immediately if there are
no reports of difficulty with accessing the line.
1. True
2. False
Scenario 3
One of your overnight admissions is a patient from an outside hospital.
Luckily, there is a PICC line already in place. There are no reports of
difficulty in using this line.
PICC lines from outside hospitals can be used immediately if there are
no reports of difficulty with accessing the line.
1. True
2. False
Appropriateness of PICC Insertion Practices
Guidelines recommend radiographic verification of PICC tip in
a pt on admission to a hospital with an existing PICC
Appropriateness of PICC Insertion Practices
When to use IR vs PICC team
• Suitable target vein for insertion cannot be identified
• Guide wire or catheter fails to advance during bedside insertion
• Patient requests sedation
• Patient with bilateral mastectomy, altered chest anatomy or SVC
filter
• IR preferable for pts with pacemakers or defibrillators if
contralateral arm not amenable to insertion
Chopra V. Ann Int Med, 2015
Scenario 4
Your patient has received a PICC line. Confirmatory x ray notes tip
extends to R atrium.
It is recommended to reposition any PICC line that extends into the R
atrium.
1. True
2. False
Scenario 4
Your patient has received a PICC line. Confirmatory x ray notes tip
extends to R atrium.
It is recommended to reposition any PICC line that extends into the R
atrium.
1. True
2. False
3. Maybe
Appropriateness of PICC Insertion Practices
• U.S. Food and Drug Administration and specialty societies
recommend CVCs terminate in the lower one third of the SVC of
cavoatrial junction
• Review of literature does not warrant this practice- MAGIC
recommends no need for repositioning for PICC that terminates in R
atrium (consensus opinion)
• Summarized evidence related to optimal tip position of a CVC
• Not enough evidence stating position of catheter in R atrium
predisposes to more arrhythmias
• Arrhythmias typically occur during insertion with guide wire during catheter
insertion or during exchange
Vesely J. Vasc Int Rad, 2003
Appropriateness of PICC
selection, care and maintenance
practices
Appropriateness of PICC selection, care and
maintenance practices
• Single lumen preferable
• No evidence to support use of “super glue” at site to prevent
oozing
• Use NS rather than heparin to flush
• Quality Improvement intervention
• Address the frequency of inappropriate venous catheter
• McGill University, May 2011-Jan 2012
• Intermountain Medical Center, Utah
• Prospective observational study 2008-2010
• Excluded pts who had multiple PICC-associated DVTs or who
experienced a hospital-acquired infection or adverse drug event
• Incidence of DVTs diagnosed by US
• Primary outcome DVT
• Secondary outcome measure - length of stay and cost
Evans R. Chest 2013
• 78% of PICCS placed by PICC
team
• 153 PICC-associated DVTs over 3
yrs
• Pairwise comparison that
controlled for a number of
patient-level characteristics
• Average LOS : DVT 25.3 days
vs 12.1 days
• Average cost: $84,221 vs
$42,100
Evans Chest 2013
Appropriateness of management
of PICC complications
• Retrospective study to eval
patterns, incidence, timing and
predictors of PICC-associated
bloodstream infections
• 2009-2012
• VA pts
• Clinical info gleaned
•
•
•
•
Indication for insertion
Number of attempts
Vein and arm of insertion
Excluded PICCS placed elsewhere
• 966 PICCS inserted in 747 unique
patients, accounting for 26,887
catheter days
• 98% males
• Median duration of PICC use 21
days
• Most placed by vasc access
nurses (85%) vs 15% by IR
• 48% single lumen
Chopra V. Am J Med, 2014
Appropriateness of management of PICC
complications
• DVT
• No need to remove PICC if:
• Type of irritant or vesicant infusion remains necessary
• Pt with poor peripheral venous access and requires frequent phlebotomy and may require
another PICC
• Patient has minimal improvement in symptoms of venous occlusion but therapeutic
anticoagulation has been provider for 72 or fewer hrs
• Only need to remove it:
• When PICC not clinically necessary
• PICC only being used for phlebotomy but peripheral veins available
• Symptoms of venous occlusion persisted despite therapeutic anticoagulation for 72 hrs or
more
• Bacteremia with objective evidence of line-related infection exist
References
• Chopra, Vineet, et al. "Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central
catheters: a Michigan survey." Journal of Hospital Medicine 8.6 (2013): 309-314.
• Chopra, Vineet, et al. "Do clinicians know which of their patients have central venous catheters?: a multicenter
observational study." Annals of internal medicine 161.8 (2014): 562-567.
•
Evans, R. Scott, et al. "Risk of symptomatic DVT associated with peripherally inserted central catheters." CHEST
Journal 138.4 (2010): 803-810.
• Chopra, Vineet, et al. "The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a
multispecialty panel using the RAND/UCLA appropriateness method." Annals of internal medicine163.6_Supplement
(2015): S1-S40.
• Vesely, Thomas M. "Central venous catheter tip position: a continuing controversy." Journal of Vascular and Interventional
Radiology 14.5 (2003): 527-534.
• O'Brien, Jeremy, et al. "Insertion of PICCs with minimum number of lumens reduces complications and costs." Journal of
the American College of Radiology 10.11 (2013): 864-868.
• Evans, R. Scott, et al. "Reduction of peripherally inserted central catheter-associated DVT." CHEST Journal 143.3 (2013):
627-633.
• Chopra, Vineet, et al. "Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising
the evidence." The American journal of medicine 125.8 (2012): 733-741.