WHO PLACES PICCs?
At UCDMC, RN’s that have vascular access certification can place PICCs. All RN's at PICC services are certified (UCDMC). Many NICU RN’s have vascular access certification and insert their own PICCs.
Placement is a non-emergent, sterile procedure. Patient consent is required. Sedation is also required in some cases. This requires coordination with the whole health care team to improve the patient experience.
APPROPRIATE INDICATIONS FOR PICCs
To choose an appropriate vascular access device, many factors come into play. A few things providers must consider:
- Will duration of therapy be longer than 14 days? For Treatment 6-14 days, consider an ultrasound-guided peripheral catheter or midline catheter (2016).
- What type of infusates are being used? TPN, vesicants, chemotherapy, many antibiotics, vasopressors, pH <5 or >9, >500 mOsm are examples of non-peripherally compatible solutions (2016).
- Does the patient require frequent phlebotomy? A PICC is indicated if lab draws occurs every 8 hrs or more, for a duration of at least 6 days (2016).
- Single lumen PICCs are preferred unless there is a specific indication for another lumen. Use a smaller gauge PICC with fewer lumen to reduce risk of deep vein thrombosis (DVT) (Grove and Pevec, 2000). Measure vein size to establish appropriate size of less than 45% of vein diameter (Sharp et al., 2015).
CONTRAINDICATIONS FOR PICCs
- Is the patient hemodynamically unstable or critical requiring cardiac monitoring and vasopressors?
- Consider the patient's history. For patients with history of thrombosis, hypercoagulability, or decreased venous blood flow to the extremities, consider alternatives (2016).
- Consider the insertion location. Does the patient have trauma or burns to both arms? There is increase risk for thrombosis and infection in these cases.
- Does the patient have renal failure stage IIIb or greater Chronic Kidney Disease (CKD)? Is the patient a potential or current dialysis patient? In patients with CKD (GFR less than 45 mL/ min, creatinine greater than 3.0, those on dialysis or with stage 3b CKD or greater) peripheral access with PICCs is considered inappropriate and should be preceded by nephrology consultation. (Hoggard et al, 2008)
Why are PICCs contraindicated for potential or current dialysis patients with CKD?
In patients with CKD, preservation of the integrity of peripheral and central veins is of vital importance for hemodialysis access. Cannulation of veins and insertion of venous access devices have potential to injure the veins and thereby incite phlebitis, sclerosis, stenosis or thrombosis. The creation of a high quality arteriovenous fistula (AVF) may become difficult or impossible in the presence of prior venous injury (Hoggard et al, 2008).
What can providers do? What are some alternatives?
Providers can use guidelines backed by evidence-based practice to determine appropriateness when choosing vascular access devices (VADs). Some alternatives for these patients are:
- Place a small-caliber tunneled catheter in the right internal jugular vein in lieu of a PICC, as the diameter of the internal jugular vein is greater than that of the subclavian vein and no arm veins are disrupted. (Shinagrev and Allon 2012).
- If there is no alternative to using a PICC in a CKD patient, there are two available measures that may reduce the potential harm. First, using a smaller diameter PICC may reduce the risk of venous injury (2012).
- Second, preferential use of the brachial vein may minimize the injury to the target vessel, as most AVFs are created using the cephalic or basilic veins (2012).