In the face of concerns about inappropriate use and the resulting potential for complications, the correct choice of catheter is key. As some studies indicate^2-9, it is not only the choice of material that is important, but also the number of lumens, which can be linked to risk of infection, thrombosis and occlusion of the catheter.

To reduce the risk of complications, the guidelines recommend the use of the PICC with the lowest possible number of lumens according to the clinical need^10-11.

In practice, this recommendation is difficult to implement because there is variation in the choice of the number of lumens in the PICC, and often this choice consists of “two are better than one just in case, it will not be necessary^12-13“

 

 

 

 

However, the choice of device may in some cases be due to the limited information defining the appropriate indications for use of the single-lumen (Figure 1) versus the multi-lumen PICC¹⁴ .

A recent study, for example, found considerable variation in the use of the PICC, indications for use and associated complications in a sample of 10 hospitals¹⁵. These findings have prompted a greater focus on ensuring appropriate use of the PICC in hospitalised patients, including recommendations on the “appropriate choice of vascular access type^16-17“.

 

 

OBSTRUCTION/OCCLUSION

Double and triple-lumen PICCs (Figure 2) are associated with an increase in occlusion. Depending on the clinical situation, preference should be given to single-lumen devices as outlined in clinical practice guidelines^16-19.

The literature describes occlusion rates in PICCs and links them to the number of lumens selected, reporting occlusion rates ranging from 7% to 34%, with fibrin sheath formation being a common cause of mechanical occlusion²⁰.

 

Barrier et al²¹ examined the frequency and types of complications in PICCs placed in paediatric patients receiving antimicrobial agents, noting that the most common complication was occlusion. The analysis showed that patients with double-lumen PICCs experienced higher complication rates compared to those with a single-lumen device.

Bowe-Geddes and Nichols²² described the care and maintenance of the PICC and the identification and management of complications, identifying three major causes of thrombus formation (known as Virchow’s triad):

• vessel wall injury
• stasis/obstruction
• hypercoagulability

The authors suggested that the external diameter of the PICC may contribute to vessel wall injury if the vessel is not large enough to accommodate the catheter.

UPPER EXTREMITY VENOUS THROMBOSIS (UEVT)

Not all occlusions lead to upper extremity venous thrombosis (UEVT), and thrombotic occlusions can be treated with antithrombotic agents, while UEVT is treated symptomatically or with catheter removal. Anticoagulation can be initiated, preventing further complications. The number of lumens and the size of the catheter have been described as risk factors for thrombus formation²¹.

Zochios et al²² concluded that larger, multi-lumen PICCs demonstrated a higher incidence of thrombosis due to turbulence and restricted blood flow.

Yi et al²³ examined predictive risk factors for thrombus formation in patients with PICCs using ultrasound. Other statistically significant risk factors were noted, however the authors concluded that the number of lumens was not a factor in the development of thrombosis.

Other researchers determined that a larger external diameter of the catheter increases the risk of venous thrombosis. Grove and Pevec²⁴ reviewed the records of 678 patients with PICCs. Thrombosis rates were statistically higher in the larger diameter catheters (p = 0.001).

INFECTION

Guidelines from the Centers for Disease Control and Prevention (CDC)¹⁶ and a randomised clinical trial²⁵ indicated that when comparing multi-lumen central catheters (CVCs) with single-lumen central catheters, the former showed a higher incidence of infections.

The problem was also assessed by means of a meta-analysis²⁶ and a review investigating both colonization rate and catheter-related bloodstream infection (CRBSI) in multi-lumen and single-lumen CVCs. The meta-analysis showed that multi-lumen CVCs are not an independent variable for higher colonization or the occurrence of CRBSI. The review showed that findings from five randomised studies²⁷ documented that for every twenty single-lumen CVCs placed, a CRBSI would be avoided that would have occurred if multi-lumen CVCs had been placed.

When a multi-lumen CVC is placed, it is recommended that a single lumen is used for parenteral nutrition (TPN). This is because if emulsions of nutrients, pharmacological agents or any parenteral infusion with a different pH come into contact, there is a higher risk of precipitates and, therefore, infectious complications. In addition, parenteral nutrition bags containing lipids should be infused through the larger lumen to reduce the risk of lumen obstruction^18-28. Although further studies are needed in this regard, preference is currently given to single-lumen CVCs, except if patient care and requirements necessitate a multi-lumen CVC¹⁷.

COSTS

In the study by Ratz et al²⁹ it was observed that for every 5 % increase in the use of single-lumen PICCs, 0.5 CRBSIs and 0.5 PICC-related deep vein thrombosis events were prevented.

At the same time, a saving of $23,500 was made, with an increase in single-lumen PICC use from 25 % to 50 % resulting in annual savings of $119,283 (95 % CI, $74,030 – $184,170).

Regardless of the baseline prevalence, the use of single-lumen PICCs would be associated with a cost saving of approximately 10%.

Summary:

The scientific evidence that has studied PICC-related complications clearly shows that the number of lumens DOES matter and is a determining factor in the potential development of further complications.

1. The size of the catheter (Fr) should be as small as possible to allow for smooth administration of the prescribed treatment, according to:

–          3 Fr for paediatric patients.

–          4-5 Fr single-lumen:  patients in need of intravenous access, chemotherapy and long-term antibiotherapy.

–          4-5 Fr double-lumen: for parenteral nutrition (TPN), multiple infusions requiring simultaneous infusion, incompatible drugs and intensive care patients.

–          6 Fr triple-lumen: for certain patients in intensive care and patients undergoing bone marrow transplants (BMT).

1. The greater the number of lumens, the greater the number of complications such as infection, occlusion and thrombosis¹⁶ and the more rigorous we must be in ensuring the permeability of the catheter, treating and managing each lumen individually²⁴.
2. With regard to catheter size, it has been found that a smaller size indicates a greater risk of mechanical complications³¹ and a greater probability of obstruction, with thrombosis being the most common complication related to larger catheters³⁰.

The number of lumens in the PICC is associated with thrombotic and infectious complications. Since the multi-lumen PICC is NOT necessary in all patients, we must limit its use in order to reduce patient morbidity and cost of care, and eliminate the associated complications.

 

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