PICC

Experts warn of serious blood clot risks from common IV devices

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Experts from the University of Michigan Health System in Michigan, US have cautioned medical practitioners on the serious risks of upper extremity deep-vein thrombosis (DVT) for hospitalized patients with peripherally-inserted central catheter (PICC) lines.

PICC lines are intravenous (IV) devices inserted in a patient’s arm to provide a means of access for medicine, nutrition and to draw blood samples. These devices are usually maintained for days to months.

Dr. Vineet Chopra and colleagues studied the records of 909 adults who received PICCs at their hospital in 2012 and 2013. The PICC lines were used for long-term IV antibiotic therapy, obtaining blood samples and for providing total parenteral nutrition (TPN) in these patients. Of the 909, 268 patients developed clots associated with PICC. [Am J Med 2015; doi:10.1016/j.amjmed.2015.01.027]

PICC- associated DVT (PICC-DVT) was more likely to occur in subjects with history of venous thromboembolism (VTE) and those who underwent surgery while the PICC was in place.

Moreover, narrower PICCs and intake of both aspirin and statins were associated with low DVT risk. However, DVT prophylaxis did not show a significant reduction in the risk of PICC-DVT. Treatment for PICC-DVT included heparin bridging, low molecular weight heparin (LMWH) only, or device removal.

Based on these findings, the authors recommended that patients with PICCs be monitored for clots and advised to continue taking aspirin and statins. More importantly, PICCs should only be used when indicated.

This recommendation was supported by another paper published recently emphasizing the importance of knowing the types of venous access devices, their indications and contraindications and the relevant anatomy involved. The authors also outlined an algorithm to help clinicians in choosing the best vascular access for each patient. [Journal of Hospital Medicine 2015;doi: 10.1002/jhm.2335]

Chopra and colleagues also published a review of best practices to help reduce DVTs and ensure proper use of PICC in hospitals. Ultrasonography was found to be more specific and sensitive in detecting PICC-DVT than clinical symptoms alone. Contrast venography may also be used in cases with unremarkable ultrasonography findings and high clinical probability. PICCs that are centrally-positioned, functional and clinically necessary should not be removed in cases of concomitant DVT. The mainstay of treatment is anticoagulation with LMWH or warfarin for at least 3 months.

Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis.

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Background

Peripherally inserted central catheters (PICCs) are associated with an increased risk of venous thromboembolism. However, the size of this risk relative to that associated with other central venous catheters (CVCs) is unknown. We did a systematic review and meta-analysis to compare the risk of venous thromboembolism associated with PICCs versus that associated with other CVCs.

Methods

We searched several databases, including Medline, Embase, Biosis, Cochrane Central Register of Controlled Trials, Conference Papers Index, and Scopus. Additional studies were identified through hand searches of bibliographies and internet searches, and we contacted study authors to obtain unpublished data. All human studies published in full text, abstract, or poster form were eligible for inclusion. All studies were of adult patients aged at least 18 years who underwent insertion of a PICC. Studies were assessed with the Newcastle—Ottawa risk of bias scale. In studies without a comparison group, the pooled frequency of venous thromboembolism was calculated for patients receiving PICCs. In studies comparing PICCs with other CVCs, summary odds ratios (ORs) were calculated with a random effects meta-analysis.

Findings

Of the 533 citations identified, 64 studies (12 with a comparison group and 52 without) including 29 503 patients met the eligibility criteria. In the non-comparison studies, the weighted frequency of PICC-related deep vein thrombosis was highest in patients who were critically ill (13·91%, 95% CI 7·68—20·14) and those with cancer (6·67%, 4·69—8·64). Our meta-analysis of 11 studies comparing the risk of deep vein thrombosis related to PICCs with that related to CVCs showed that PICCs were associated with an increased risk of deep vein thrombosis (OR 2·55, 1·54—4·23, p<0·0001) but not pulmonary embolism (no events). With the baseline PICC-related deep vein thrombosis rate of 2·7% and pooled OR of 2·55, the number needed to harm relative to CVCs was 26 (95% CI 13—71).

Interpretation

PICCs are associated with a higher risk of deep vein thrombosis than are CVCs, especially in patients who are critically ill or those with a malignancy. The decision to insert PICCs should be guided by weighing of the risk of thrombosis against the benefit provided by these devices.

Source: Lancet