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Noncentral PICC tip locations may be dangerous

Tuesday March 26, 2013
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Noncentral tip locations for peripherally inserted central venous catheters are associated with nearly quadruple the risk of complications compared with central PICC tip locations, according to a study.

Clinicians sometimes forgo threading close to the heart and leave the PICC line in a peripheral vein in the arm or leg instead — a choice dictated by the ease and speed of placement or a childís overall condition or anatomy, researchers noted.

The findings, published March 18 on the website of JAMA Pediatrics (formerly the Archives of Pediatrics & Adolescent Medicine), suggest leaving the device in a non-central vein should be done only as a last resort, the researchers said. "Clinicians should carefully weigh the ease and speed of non-central vein placement against the higher complication risk that our study found goes with it," Aaron Milstone, MD, MHS, a senior investigator on the study and pediatric infectious disease specialist with the Johns Hopkins Childrenís Center, said in a news release.

Non-central, smaller veins, especially those in the arm, are narrower, thinner and more prone to injury than major vessels near the heart, the researchers noted. Thus, a catheter can easily damage the protective coating on the walls of such veins and encourage the formation of blood clots that, in the worst-case scenario, can dislodge and travel to the lungs or heart, causing a pulmonary embolism or heart damage.

Conducted among more than 1,800 pediatric patients hospitalized at Johns Hopkins over six years, the study found that non-central PICC tip lines accounted for a mere 16% of central lines, but 44% of all complications that led to catheter removal.

Children in the study cumulatively underwent more than 2,500 catheter insertions, of which more than 500 — one in five — had to be removed due to complications. Three-quarters of problems stemmed from mechanical malfunction such as device breakage or dislodgement, clot formation or blood vessel inflammation. The rest were due to infection, which traditionally has been the greatest worry with PICC lines. Vein location, however, played no role in infection risk, the research showed.

Despite the higher risks seen with non-centrally positioned catheters, overall complication rates dropped significantly over the six-year study period, a trend that should get a further boost from emerging technologies, the investigators said. "We are already adopting new technologies that render PICC placement near the heart easier, safer and faster, and which will drive complication rates further down," said Leslie Gosey, RN, MS, lead of the pediatric catheter-insertion team at Johns Hopkins.

The study was funded by the National Institute of Allergy and Infectious Diseases and the National Institute of Nursing Research. The study abstract is available at http://archpedi.jamanetwork.com/article.aspx?articleid=1669324.


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