Since its development in the 1970s1, the PICC catheter has become a commonly used venous access in adult and child patients because it is long-lasting, easy and quick to insert and has few complications.
In the face of concerns about inappropriate use and the resulting potential for complications, the correct choice of catheter is key. As some studies indicate2-9, 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 need10-11.
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 necessary12-13“
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 type16-17“.
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 guidelines16-19.
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
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).
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 obstruction18-28. 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.
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%.
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.
- 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).
- 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.
- 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.
- Paolo Cotogni, Mauro Pittiruti. Focus on peripherally inserted central catheters in critically ill patients. World J Crit Care Med 2014 November 4; 3(4): 80-94.
- Gow KW, Tapper D, Hickman RO. Between the lines: the 50th anniversary of long-term central venous catheters. Am J Surg 2017;213:837-48.
- Horattas MC, Trupiano J, Hopkins S, et al. Changing concepts in long-term central venous access: catheter selection and cost savings. Am J Infect Control 2001;29:32-40.
- Chopra V, Flanders SA, Saint S. The problem with peripherally inserted central catheters. JAMA 2012;308:1527-8.
- McMahon LF, Beyth RJ, Burger A, et al. Enhancing patient-centered care: SGIM and choosing wisely. J Gen Intern Med 2014;29:432-3.
- Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 2013;382:311-25.
- Chopra V, Anand S, Krein SL, et al. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med 2012;125:733-41.
- Chopra V, O’Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013;34:908-18.
- Krein SL et al. Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf 2019;0:1-8.
- Pan L, Zhao Q, Yang X. Risk factors for venous thrombosis associated with peripherally inserted central venous catheters. Int J Clin Exp Med. 2014;7(12):5814-5819. 19.
- Herc E, Patel P, Washer LL, Conlon A, Flanders SA, Chopra V. A model to predict central-line-associated bloodstream infection among patients with peripherally inserted central catheters: The MPC score. Infect Cont Hosp Ep. 20. 2017;38(10):1155-1166.
- Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 pub- 21. lished prospective studies. Mayo Clin Proc. 2006;81(9):1159–1171.
- Smith SN, Moureau N, Vaughn VM, et al. Patterns and predictors of peripher- ally inserted central catheter occlusion: The 3P-O study. J Vasc Interv Radiol. 22. 2017;28(5):749-756.
- Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-325.
- Chopra V, Ratz D, Kuhn L, Lopus T, Lee A, Krein S. Peripherally inserted cen- tral catheter-related deep vein thrombosis: contemporary patterns and pre- 24. dictors. J Thromb Haemost. 2014;12(6):847-854. 9.
- Carter JH, Langley JM, Kuhle S, Kirkland S. Risk factors for central venous catheter-associated bloodstream infection in pediatric patients: A cohort study. Infect Control Hosp Epidemiol. 2016;37(8):939-945.
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- Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide 15. for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6 Sup- pl):S1-S40.
- Mermis JD, Strom JC, Greenwood JP, et al. Quality improvement initiative to reduce deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis. Ann Am Thorac Soc. 2014;11(9):1404- 1410.
- Tiwari MM, Hermsen ED, Charlton ME, Anderson JR, Rupp ME. Inappropriate intravascular device use: a prospective study. J Hosp Infect. 2011;78(2):128- 132.
- Chopra V, Kuhn L, Flanders SA, Saint S, Krein SL. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: results of a national survey. J Hosp Med. 2013;8(11):635-638.
- Bozaan D et al. Less Lumens-Less Risk: A Pilot Intervention to Increase the Use of Single-Lumen Peripherally Inserted Central Catheters. Journal of Hospital Medicine 2018; E1-E5.
- Chopra V, Smith S, Swaminathan L, et al. Variations in peripherally inserted central catheter use and outcomes in Michigan hospitals. JAMA Intern Med 2016;176:548-51.
- O’Grady NP et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical Infectious Diseases 2011; 52 (9): e162-e193.
- Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr.2009;28(4):365-77.
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- Barrier A, Williams DJ, Connelly M, Creech CB. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2012;31(5):519-521.
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- Baskin JL, Pui C-H, Reiss U, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. 2009;374(9684):159-169.
- Zochios V, Umar I, Simpson N, Jones N. Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients. J Vasc Access. 2014;15(5):329-337.
- Yi X-l, Chen J, Li J, et al. Risk factors associated with PICC-related upper extremity venous thrombosis in cancer patients. J Clin Nurs. 2014;23(5-6):837-843.
- Grove JR, Pevec WC. Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(7):837-840.
- Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803-810.
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- Farkas JC, Liu N, Bleriot JP, Chevret S, Goldstein FW, Carlet J. Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population. Am J Med 1992; 93: 277-282 .
- Dezfulian C, Lavelle J, Nallamothu BK, Kaufman SR, Saint S. Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis. Crit Care Med 2003; 31: 2385-2390.01.
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- Cotogni P, Pittiruti M, Barbero C, Monge T, Palmo A, Boggio Bertinet D. Catheter-related complications in cancer patients on home parenteral nutrition: a prospective study of over 51,000 catheter days. JPEN J Parenter Enteral Nutr 2013; 37: 375-383.
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