Strike the Balance: Evolving Venous Access Practices in the Intensive Care Unit

By Nayla Ahmed, MBBS, and Alexander Niven, MD

Dr. Ahmed is with the Division of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN.

Dr. Niven is Consultant, Division of Pulmonary/Critical Care Medicine, Mayo Clinic, Rochester, MN.

Reliable vascular access plays a crucial role in the delivery of many important therapies in the intensive care unit (ICU). While peripheral venous access generally is encouraged to reduce the risk of mechanical complications and central line-associated bloodstream infections (CLABSIs), temporary central venous catheter (CVC) and peripherally inserted central catheter (PICC) use remains common in critically ill patients. This feature offers a focused review of the existing literature on PICC and temporary CVC use in the critically ill for healthcare professionals navigating this rapidly evolving field during their daily clinical activities.

Dr. Werner Forssmann is widely credited for inserting the first CVC, a urinary catheter, through his cubital vein and into his right heart in 1929. Since that time, CVC placement has evolved to become one of the most common interventions performed in the ICU. Commonly accepted indications for CVC placement include vasopressor or parenteral nutrition infusion, and “introducer sheaths” with larger lumens and shorter lengths often are used when rapid resuscitation using large volumes of blood products or fluids may be required.¹ CVCs can be inserted through the internal jugular, subclavian, or femoral vein, and routine use of bedside ultrasound guidance has significantly reduced mechanical complications, such as arterial puncture, pneumothorax, or malpositioning.² The Keystone ICU Project demonstrated that routine hand washing, use of chlorhexidine and full-barrier precautions during central line insertion, avoidance of the femoral site when possible, and early CVC removal when central access was no longer necessary resulted in significant and sustained CLABSI reductions that have informed subsequent guidelines in this area.^3,4 The 3Sites trial demonstrated subclavian vein catheterization was associated with a lower risk of CLABSI and symptomatic thrombosis, but a higher risk of pneumothorax during insertion compared to internal jugular and femoral sites.⁵

First introduced in 1975, PICCs involve line insertion through a peripheral vein into the central circulation using bedside ultrasound.⁶ PICC use has grown rapidly over the past 20 years, and there have been more than 60 studies comparing the use and complications of PICCs vs. CVCs. PICC line placement has been shown to be safe in patients of all ages, and their use has been best studied in children and patients with hematological malignancy or critical illness.⁷ In neonates and infants especially, it minimizes the need for general anesthetics, opioids, and ventilatory support during insertion, and is more cost-effective.⁸ There is the perception that PICCs have a lower rate of mechanical complications and are safe to remain in place for longer periods of time without the risk of infection because of their tunneled placement technique, making them an attractive option for patients likely to need long-term vascular access for medications or parenteral nutrition in both inpatient and outpatient settings.⁸ However, there is increasing evidence demonstrating challenges in PICC placement and use in certain populations in addition to associations with CLABSI, thrombosis, and vascular injury.⁹

Is a Central Venous Catheter Always Necessary?

While CVCs have long been the cornerstone of vascular access in the ICU, there is growing recognition that less invasive device use offers an important strategy to reduce CVC-related complications. Although the quality of current evidence is mixed, a review of 11 adult trials including 16,055 patients suggested that vasopressor administration through a peripheral intravenous catheter was safe and effective. The incidence of extravasation in this pooled cohort was 1.8%, with no episodes of tissue necrosis or limb ischemia with close observation and vasodilator treatment.¹⁰ While peripheral vasopressor administration is increasing in our clinical practice, we require large-bore peripheral intravenous catheters placed in the antecubital or similarly sized vein for a limited duration only.

It is important to emphasize the limited role that CVCs and PICCs play in initial volume resuscitation. Maximal infusion rates through 32 mm (14 g) or 30 mm (16 g) peripheral intravenous catheters have been shown to be superior to even an 8.5-F Cordis introducer, making them the preferred initial route for resuscitation in shock associated with hypovolemia.¹¹ A recent meta-analysis demonstrated higher first-time success and a shorter mean procedure time for intraosseous (IO) compared to intravenous access in hypotensive trauma patients, and short-term IO catheters have become a preferred approach for emergent resuscitation when venous access is not readily available in both prehospital and in-hospital settings.¹²

What Is the Best Approach to Central Venous Access?

While there have been multiple studies comparing the benefits and complications of various CVC approaches over the past decade, a comprehensive review has not been performed. Studies to date have focused on ease of insertion, cost-effectiveness, use for long-term access, and risk of mechanical complications, malpositioning, infection, and thrombosis.

Bedside PICC placement has been associated with less anesthetic use, greater patient comfort, and lower costs, especially since PICCs often remain in place for longer periods than CVCs. While early retrospective studies suggested that PICCs were associated with lower rates of malpositioning, pneumothorax, arterial cannulation, and CLABSI, more recent data have raised different safety concerns.¹³ Mechanical complications related to PICC placement include venous injury, sclerosis, frequent malpositioning, and, rarely, median nerve injury, all of which frequently prompt early line removal.¹⁴

In a 12-month retrospective cohort study examining the incidence of thrombosis and infections in PICCs vs. CVCs, Nolan et al found no significant differences in CLABSI incidence in the ICU but a slight, nonsignificant increase in PICC infections post-ICU transfer.¹⁵ Since then, a number of multicenter studies have suggested that the risk of PICC-associated CLABSI is either equal to or higher than the risk with CVCs. PICC-associated CLABSI risk factors include prolonged duration of use, multi-lumen catheters, parenteral nutrition, and underlying immune compromise.¹⁶ One study suggested that PICC-associated CLABSIs generally occurred after longer periods of device use than CVCs.¹⁶

PICCs have been consistently associated with increased risk of phlebitis and thrombosis compared to CVCs, presumably related to the smaller vessel size and length in which these slender lines reside for extended periods. A 2013 systematic review and meta-analysis showed PICCs were associated with a higher incidence of deep vein thrombosis (odds ratio, 2.55), especially in patients with critical illness or active malignancy.¹⁴ A retrospective analysis of PICC use in patients with neuro-oncological disease compared to other malignancies showed a trend toward increased thrombosis in patients with elevated body mass index, prior chemotherapy, or previous failed vascular access attempts.¹⁷ One trial in the pediatric oncological population showed a higher incidence of CLABSI and thrombosis in patients with PICC lines, with predisposing factors including younger patient age, femoral site, longer duration of use, prior cardiovascular surgery, and sub-optimal catheter length.

A number of line care strategies can help to reduce both PICC- and CVC-related CLABSIs.¹⁸ In addition to hand washing, a number of studies have examined the use of antimicrobial dressings containing agents such as chlorhexidine (CHG) and silver. Impregnated CVCs and PICCs containing silver, miconazole and rifampin, and a minocycline and rifampin combination also have been developed. While CHG dressings have been shown to have a slight decrease in CLABSI rates, the benefits of impregnated catheters do not sufficiently justify the cost and effort of routine use.¹⁹ Tools to provide decision support on the appropriate use of PICCs and CVCs and checklists to facilitate early removal also have helped to reduce complication rates.²⁰

Conclusions

Despite growing trends toward peripheral intravenous catheter and PICC use for indications traditionally reserved for CVCs, data supporting these practices continue to evolve. Clinical providers should thoughtfully consider the necessity of CVC placement when alternative venous access may be sufficient, especially if the need is not anticipated to be prolonged. PICCs are easier to insert, require less resources for placement, have lower mechanical complication rates during insertion, and offer a cost-effective option for prolonged venous access. However, they also have higher rates of malpositioning and phlebitis and thrombosis, especially in patients with hematological malignancies. These data limit PICC use in patients with certain conditions, such as those receiving or approaching dialysis or with active bacteremia. The incidence of CLABSI in PICCs vs. CVCs remains controversial, with the duration of device use and presence of multiple lumens the most important risk factors in both cases. Early device removal when appropriate, in addition to proper hand hygiene, sterile placement techniques, and use of CHG-impregnated dressings, are key line care bundle recommendations to reduce the risk of infection. While guideline-based recommendations are limited, there are tools that can help guide bedside vascular access discussions. Based on the current evidence, the use of central venous access and which type of catheter to choose remain highly individualized clinical decisions and should be based on the patient and clinical scenario.

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