Clinical experience with power-injectable PICCs in intensive care patients
Mauro Pittiruti
0
1
Alberto Brutti
1
3
Davide Celentano
1
3
Massimiliano Pomponi
1
3
Daniele G Biasucci
1
3
Maria Giuseppina Annetta
1
3
Giancarlo Scoppettuolo
1
2
0
Department of Surgery, Catholic University Hospital
,
Largo F. Vito 1, 00168 Rome
,
Italy
1
See related Letter by Zampieri
2
Department of Infectious Diseases, Catholic University Hospital
,
Largo F. Vito 1, 00168 Rome
,
Italy
3
Department of Anesthesiology and Intensive Care, Catholic University Hospital
,
Largo F. Vito 1, 00168 Rome
,
Italy
Introduction: In the ICU, peripherally inserted central catheters (PICCs) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome with the use of power-injectable catheters. Methods: We retrospectively reviewed all of the power-injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results: We collected 89 power-injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related bloodstream infection. Non-infective complications during management were not clinically significant. There was one episode of symptomatic thrombosis during the stay in the ICU and one episode after transfer of a patient to a non-intensive ward. Conclusion: Power-injectable PICCs have many advantages in the ICU: they can be used as multipurpose central lines for any type of infusion including high-flow infusion, for hemodynamic monitoring, and for high-pressure injection of contrast media during radiological procedures. Their insertion is successful in 100% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infective and non-infective complications.
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Introduction
The use of peripherally inserted central catheters
(PICCs) has many theoretical advantages in the ICU
setting because these devices are associated with low-risk
insertion, even in patients with altered coagulation and/
or difficult neck anatomy [1]. PICC insertion can be
carried out with no risk of pleura-pulmonary damage and
with no clinically significant risk of local hemorrhage or
hematoma, if compared with standard central venous
catheters (CVCs) [2]. Furthermore, PICC insertion in
the upper mid-arm is characterized by an easy dressing
of the exit site, this benefit being particularly evident in
patients with tracheostomy [3]. Although the issue is
somehow controversial [4,5], PICCs are also usually
considered a device at low risk for catheter-related
bloodstream infection (CRBSI), which may be an
additional advantage in acutely ill patients [2]. PICCs can
also be used for central venous pressure monitoring [6],
specifically when using polyurethane, open-ended
catheters > 4 Fr, as long as they have no evidence of
malfunction.
Although the potential benefit of PICCs in the acutely
ill patient was proposed almost 10 years ago [7], some
technical limitations have slowed their introduction into
clinical practice in the ICU. The ICU patient usually
requires high flow rates of intravenous infusion as well
as simultaneous administration of potentially
incompatible drugs, which should ideally be delivered through
multiple-lumen catheters. Since standard PICCs are
catheters with small caliber (typically, 4 to 5 Fr) and
relevant length (30 to 40 cm on average), they are
associated with a high resistance to flow. A single-lumen 4
Fr PICC may achieve a flow rate of 2 to 3 ml/minute
(by gravity infusion) and 10 to 11 ml/minute (with
pump); the flow rates of a single-lumen 5 Fr PICC are
only slightly higher (3 to 4 ml/minute by gravity and 11
to 13 ml/minute with pump). Double-lumen PICCs have
worse performance in terms of flow, because increasing
the number of lumens reduces the lumen size and
further decreases the flow rate.
The situation changed following the recent
development of PICCs made of ultra-resistant polyurethane,
which were originally introduced for use with the
highpressure pumps (so-called power injectors) commonly
utilized for high-velocity infusion of contrast media
during computed tomography scan and other radiological
procedures. The rationale for these so-called
powerinjectable PICCs was the concern of potential
mechanical damage to standard polyurethane and silicon PICCs
when used during high-pressure injection. Power
injectors may develop pressures as high as 300 psi (silicone
catheters tolerate no more than 50 to 60 psi, and most
polyurethane catheters approximately 100 psi). Several
reports of mechanical damage to PICCs and other
devices have been described in the literature, leading to
an official warning from the US Food and Drug
Administration [8] - w (...truncated)