The Case

A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital for management of persistent abdominal pain and inability to tolerate oral feedings, possibly secondary to diabetic gastroparesis. The day before transfer, the patient had undergone placement of a peripherally inserted central catheter (PICC) to address his continued need for intravenous pain medications, intravenous fluids, and parenteral nutrition. An initial chest radiograph performed to evaluate the catheter reported the PICC was located in "a persistent left-sided superior vena cava." The physicians caring for the patient assumed the PICC was safe to use, and the patient began receiving nutrition and hydration through the line. He was not receiving any oral nutrition at this point.

The following day, the patient complained of headache, unilateral visual loss, and left-sided tingling and numbness. A stat noncontrast CT scan of the head revealed strokes distributed in an embolic fashion. The radiologist reviewed the chest radiograph and pointed out that the persistent left-sided superior vena cava is in fact a congenital remnant that can drain into the left atrium of the heart. A subsequent CT of the chest revealed the PICC tip was actually in the left atrium, and was therefore delivering fluid into the patient's systemic circulation. Fat emboli from the lipid emulsion infused through the PICC were the likely cause of the patient's strokes.

The patient was urgently transferred to the neurological intensive care unit. He ultimately developed increased intracranial pressure and required intubation, mechanical ventilation, and mannitol to prevent further neurologic damage. The patient was eventually stabilized and weaned off the ventilator, but his neurological deficits persisted. He required a permanent feeding tube and tracheostomy tube, remained unable to perform any activities of daily living independently, and required 24-hour care.

The Commentary

by Vineet Chopra, MD, MSc

There is little denying the prolific growth in the use of peripherally inserted central catheters (PICCs) in United States health care.(1,2) A recent survey of infection preventionists found that more than 60% of hospitals now have nurse-led PICC teams that specialize in inserting these devices and managing patients with them.(3) With the growing use of PICCs has come a realization that they may be associated with adverse events. Although the complication illustrated in this case is highly uncommon (the perfect storm of a congenital anomaly, lipophilic particle infusion, and failure to act on imaging that suggested abnormal placement), it does highlight how PICCs are far from benign. In fact, accumulating evidence suggests that these devices are associated with myriad complications, ranging from occlusion and migration to potentially life-threatening infection and thrombosis.

How best to use PICCs is an important clinical and safety question. To date, much of the evidence has focused on quantifying risk rather than defining appropriate use. For instance, several systematic reviews have found that PICCs are associated with greater rates of mechanical complications (e.g., coiling, kinking) than other central venous catheters.(4,5) Similarly, two systematic reviews suggest that rates of central line–associated bloodstream infection from these devices—which were originally assumed to be much safer than standard central catheters—parallel those of traditional central venous catheters.(6,7) More recently, a large systematic review of 62 studies published in the Lancet found that PICCs were associated with a 2.5-fold higher risk of deep vein thrombosis than central venous catheters.(8) These data have undoubtedly led to a greater appreciation of the risks associated with these devices, but have not well addressed a key clinical question: when should one use a PICC versus another device?

Given this knowledge gap, it is not surprising that reports of inappropriate use of PICCs have begun to populate the literature. For example, in a study at an academic medical center, a substantial proportion of PICCs were idle or placed in patients who already had functioning peripheral intravenous access.(9) Similarly, a study spanning a decade worth of data from a pediatric academic medical center found decreasing dwell times (or duration of catheter use), multiple insertions in the same child, and premature removals of PICCs—all of which raised concerns regarding current use patterns.(10) Fueled by an immature evidence base and financial pressures to move patients through the hospital quickly, it is possible that clinicians have lost sight of the risk–benefit equation for PICCs.(11,12) And speaking of sight, these devices have become common enough that clinicians are now desensitized, as illustrated by a recent study that found one in five inpatient providers did not know that their patient had a PICC, despite one being in place.(13)

Because clinicians make decisions regarding vascular access on a daily basis, my colleagues and I perceived an unmet need for evidence-based recommendations regarding when a PICC may be appropriate. To bridge this gap, we used the RAND/UCLA appropriateness method to convene an expert, multidisciplinary panel and developed the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).(14) Based on clinical scenarios that focus on device insertion, care, and management, MAGIC provides guidance for when use of a particular vascular device (ranging from peripheral intravenous catheters to PICCs and ports) may be appropriate, inappropriate, or uncertain. Importantly, the recommendations weigh relative risks and benefits associated with each device against factors such as proposed duration of therapy, the nature of the infusion, and patient characteristics.

When applied to this case, placement of a PICC to provide parenteral nutrition is an appropriate MAGIC indication for PICC use. However, MAGIC (and several other guidelines) (15-17) stress the importance of confirming that the PICC tip is located in the lower third of the superior vena cava (SVC), cavoatrial junction, or right atrium prior to use. This location is important, as proximal positions (e.g., middle or upper SVC) are associated with greater risk of complications, including thrombosis.(18,19) Thus, while the PICC in this case was placed for an appropriate indication, confirmation of an appropriate position did not occur and likely contributed to the harm.

Although ascertaining tip position generally falls to radiologists, frontline clinicians should remember that the chest radiographs most often used for this purpose are two-dimensional projections of landmarks that may or may not be aberrant. Indeed, the radiologist here noted a persistent left-sided SVC, a congenital abnormality that is exceedingly rare (0.3%–0.5% of the population) and even less commonly associated with shunts (90% open in the right atrium, only 10% open in the left atrium to cause paradoxical emboli).(20-22) Regardless, this abnormal location should have triggered discussions with the radiologist to understand any clinical implications. An evaluation of the PICC should have followed, assessing for abnormalities such as pulsatile blood flow, color of returning blood, or difficulty using the device. In cases in which arterial placement is a possibility, blood gas analysis may be useful.(23) Notably, growing use of electrocardiographic guidance to place PICCs may soon obviate the need for radiographic PICC tip verification, as this new technology helps guide clinicians to place PICCs near the sinoatrial node and thus the cavoatrial junction.(24) In a recent Italian study, ECG-guidance outperformed radiographic ascertainment of PICC-tip location.(25)

Regardless of these advances, the importance of acting on an abnormal imaging finding and clinically evaluating a PICC before use cannot be understated. Although PICC placement in left-sided SVC positions is uncommon, it does occur (26), making it important to develop systems and practices to confirm PICC tip position.

Take-Home Points

• The use of PICCs is on the rise in hospitals across the United States.
• Despite their many advantages, PICCs are associated with important complications, ranging from occlusion to thrombosis and infection.
• The recently introduced MAGIC guidelines offer an evidence-based approach to improve vascular access device decision-making.
• Ascertainment of tip location prior to use is a prerequisite to safe use of PICCs. PICC tip positions that do not terminate near the cavoatrial junction should prompt discussion with radiology and further clinical evaluation.

Vineet Chopra, MD, MSc Assistant Professor, Internal Medicine Division of General Medicine, Department of Medicine University of Michigan School of Medicine The Patient Safety Enhancement Program and Center for Clinical Management Research of the VA Ann Arbor Health System Ann Arbor, MI

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