PICC lines often used inappropriately in advanced CKD patients
Background: PICC insertion is associated with risk for venous thrombosis and stenosis. National guidelines recommend avoiding PICC lines in patients with CKD stage 3b (glomerular filtration rate less than 45 mL/min per 1.73 m2) in order to preserve venous integrity for future creation of arteriovenous fistula, which is the ideal vascular access for hemodialysis.
Dr. Kevin Hageman
Study design: Prospective cohort.
Setting: 52 hospitals in Michigan.
Synopsis: Data obtained from inpatients within the Michigan Hospital Medicine Safety Consortium between 2013 and 2016 showed that, of 20,545 total PICCs placed, 23% were placed in patients with a glomerular filtration rate less than 45 mL/min per 1.73 m2, and 3.2% were placed in those receiving dialysis. PICC placement in advanced CKD was more common in the ICU than in the ward setting, and placement more frequently utilized multilumen instead of single-lumen catheters. PICC-related complications were not more common in advanced CKD but were more often seen in the ICU and with multilumen PICCs. About one-quarter of PICCs were used for durations of less than 5 days.
The study is limited by lack of data in a subset of patients who had no documented GFR (2.7%) or missing covariate data (2.7%). The inability to ascertain other clinical information, such as nephrology approval of PICC, functional AV fistula or other hemodialysis access, or PICC complications after discharge further limit the findings.
Hospitalists should first decide if a PICC line is truly indicated, and if so, carefully weigh the risks and benefits of PICC placement in patients with advanced CKD.
Bottom line: PICC placement is common and often inappropriate in hospitalized patients with advanced CKD.
Citation: Paje D et al. Use of peripherally inserted central catheters in patients with advanced chronic kidney disease A prospective cohort study. Ann Intern Med. 2019 Jun 4;171:10-8.
Dr. Hageman is a hospitalist at Vanderbilt University Medical Center, Nashville, Tenn.
