Our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” focused on the widespread use of PICC lines and the general lack of awareness by clinicians of their potential complications. Previous work by Vineet Chopra and colleagues at University of Michigan Health System as well as others has shown potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. Complications include CLABSI’s, deep vein thrombosis, catheter tip malpositioning, thrombophlebitis, and catheter dysfunction. Both patient-related and device-related factors are important in leading to complications of central lines and PICC lines. A subsequent study (Greene 2015) also showed an independent association between PICC lines and lower extremity venous thrombosis, though this association is much less pronounced than that for upper extremity venous thrombosis and cannot be definitely construed as causal. There may even be complications associated with removal of PICC lines, though the risk of air embolism is presumably less than that for removal of conventional central venous catheters (Dobson 2015).
It is also clear that the duration of catheter use is an important factor in leading to complications and that many times the catheters are left in place longer than necessary. But the initial decision to insert a PICC line (or, for that matter, a conventional central venous catheter) is often done without much thought. We discussed that in our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” and a followup column December 2014 “Surprise Central Lines” in which it was noted that very often that physicians were not even aware that such lines were in place in their patients.
Then in our July 2015 What’s New in the Patient Safety World column “Reducing Central Venous Catheter Use” we discussed a study showing that use of an online physician audit tool led to a substantial reduction in central venous catheter use (McDonald 2015). The tool listed several potential indications for central venous catheters or PICC’s and also allowed for input of “other” reasons. Its use resulted in a 46.6% reduction in use of CVC’s or PICC’s compared to the pre-intervention period. But the investigators still found substantial room for improvement in that a third of the CVC’s/PICC’s were used for “ease of drawing blood” or “just-in-case the patient deteriorates”.
That study highlighted a critical question: “what are the evidence-based indications for use of PICC lines (or conventional central venous catheters)?” And, once again, Michigan to the rescue. Leading experts from the University of Michigan (you’ll note most of them in our prior columns on PICC lines) along with multiple other experts have put together the Michigan Appropriateness Guide for Intravenous Catheters, also known as MAGIC (Chopra 2015). This was the result of deliberations by a multispecialty panel using the RAND/UCLA Appropriateness Method.
Along with a review of a phenomenal amount of literature, albeit of limited high-level evidence, the panel reviewed 665 scenarios related to PICC use, care and maintenance compared with that of other venous access devices. They found that of the 665 scenarios 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. They then constructed tables showing which type of venous access device is most appropriate for each of a variety of scenarios.
The appropriateness of inserting PICC lines depends upon patient characteristics, purpose of the line, nature of substance being infused, and especially on expected duration of need. They deemed use of PICC lines as appropriate for peripherally compatible infusates when treatment is expected to be 6 or more days (and for non-peripherally compatible infusates for any duration). One area that has always been controversial is use of PICC lines for ease of drawing blood. The panel ultimately concluded that use of a PICC may be appropriate in patients who need frequent blood draws with an expected duration of 6 or more days. PICC is also preferred to tunneled catheter for such frequent phlebotomies with durations of 15-30 days. PICC may be appropriate for patients receiving cyclical or episodic chemotherapy where expected duration of treatment is 3 months or more. PICC may also be appropriate for infusions or palliative treatment during end-of-life care or for delivery of peripherally compatible infusates for patients residing in skilled nursing facilities or transitioning from hospital to home, provided that the proposed duration of such use is ≥15 days. We refer you to the MAGIC document for other details.
The MAGIC has tables that can be easily referred to when a decision about use of PICC or other vascular access device is being considered. The other devices included are peripheral IV catheter, US-guided peripheral IV catheter, midline catheter, nontunneled/acute central venous catheter, tunneled catheter, and port.
The MAGIC also has recommendations regarding care and maintenance of the various catheters and management of complications.
The UM Health System also launched a comprehensive website, ImprovePICC, that offers easy access to the MAGIC recommendations and a host of valuable PICC resources (videos, slides, etc.).
Overall, this is an outstanding endeavor on a much needed resource for healthcare workers in multiple venues.
In addition to MAGIC’s discussion of catheters other than PICC lines, the New England Journal of Medicine just had a study comparing the intravascular complications of central venous catheterization by insertion site (Parienti 2015). The authors found in a randomized controlled trial that subclavian vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular vein or femoral vein catheterization.
Some of our other columns on central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
Greene MT, Flanders SA, Woller SC, et al. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities. Am J Med 2015; Published Online: May 01, 2015
Dobson P, Hansel BC. Letter to the Editor: Preventing Air Embolism with PICC Line Removal. Pa Patient Saf Advis 2015; 12(1): 48
McDonald EG, Lee TC. Reduction of Central Venous Catheter Use in Medical Inpatients Through Regular Physician Audits Using an Online Tool. JAMA Intern Med 2015; Published online May 04, 2015
Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 163(6_Supplement): S1-S40
Universitiy of Michigan Health System. Improve PICC website.
Parienti J-J, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. New Engl J Med 2015; 373(13): 1220-1229
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