In our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we challenged the view widely held by clinicians that PICC (peripherally inserted central catheter) lines are safer than the more traditional central lines. The potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. True, the most feared complications of those central line insertions (pneumothorax for the subclavian line, carotid arterial puncture for the jugular line) are not seen with PICC insertions but a host of serious potential complications are associated with PICC’s. We noted studies done by Chopra and colleagues (Chopra 2013a) that showed PICCs were associated with a more than two-fold increased risk of deep vein thrombosis. (OR 2.55) and another (Chopra 2013b) that found no significant difference in CLABSI rate between the CVC and PICC groups.
Now yet another study from Chopra and colleagues (Chopra 2014) has characterized some of the factors associated with PICC-associated bloodstream infections. They retrospectively reviewed data on 966 PICC lines in 747 patients over a 3-year period. The indications for PICC insertion were: long-term antibiotic administration (52%), venous access (21%), total parenteral nutrition (16%), and chemotherapy (11%).
Overall, 6% of PICC lines were associated with bloodstream infection, with an infection rate of 2.16 per 1000 catheter days. The median time to infection was 10 days.
While multiple factors correlated with bloodstream infection on bivariate analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection on multivariable analysis. Most notably the hazard ratio for bloodstream infections increased over 4 times with double lumen catheters and over 8 times with triple lumen catheters.
The authors also found a significant association between time to infection and the number of catheter lumens, i.e. the higher the number of lumens the shorter the time to infection.
The authors question the use of PICC lines at all in critically ill or immune-suppressed patients. The authors suggest potential approaches to limit use of multiple lumen catheters, such as limiting their availability or enhancing the physician decision making process for these. They also strongly recommend use of interventions to limit the duration of PICC lines, such as reminders, automatic stop orders, electronic surveillance for PICC presence, etc.
Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet 2013; 382(9889): 311-325
Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013; 34(9): 908-918
Chopra V, Ratz D, Kuhn L, et al. PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors. American Journal of Medicine 2014; 127(4): 319–328
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