Intravascular catheters have been used for >100 years. The question of which vascular access modality is superior to others has yet to be answered. Peripherally inserted central catheters (PICCs) are placed in the upper arm to provide central venous access for administration of IV drugs (antibiotics or chemotherapeutics) or total parenteral nutrition (TPN). Complications are related to patient, provider, or institutional characteristics; catheter size; and clinical setting (thrombosis, emboli, infection, phlebitis, malfunction, malposition, or mechanical failure). The main advantages of PICCs compared with more traditionally placed central venous catheters (e.g., subclavian or internal jugular venous insertion sites) are some reduced complications (especially pneumothorax or hemothorax) and early patient discharge from hospital with more efficient and convenient care at home.1–3
At our institution, PICCs were incidentally placed in the antecubital veins by anesthesiologists without the use of ultrasound or specific training. A more structured service was started at our institution in the spring of 2013 at the initiative of one of the authors. This included ultrasound-guided placement of PICCs. In preparation for this service, all necessary protocols were written and publicized to practitioners. All available consultant anesthesiologists initially inserted PICCs as a shared task with shared responsibility.
After an uneventful start-up of our vascular access service, we experienced 2 serious complications. Both complications were potentially life-threatening.
Both patients gave written consent for publication of this case report. Both authors participated in the follow-up of these patients.
A female surgical patient was scheduled for postoperative central venous access for administration of TPN. Ultrasound-guided insertion of a PICC was uneventful in the right basilic vein. Placement was performed by an anesthetic trainee under the supervision of an experienced anesthesiologist. A chest radiograph was performed to confirm the position of the catheter tip. The chest radiograph after catheter placement was evaluated by the attending anesthesiologist. He accepted the position of the catheter tip in the right subclavian vein, and the patient was discharged back to the ward. Four days later, swelling was noted in the patient’s neck and above the clavicle. Computed tomography showed that a PICC had perforated the subclavian vein behind the clavicle. The TPN infusion into the subcutaneous tissues resulted in local inflammation without systemic symptoms. The problem was most likely caused by the tip of the PICC perforating the subclavian vein because of incorrect positioning, probably attributable to repeated movements of the arm.
A female surgical patient was scheduled for central venous access for administration of TPN and antibiotics. A double-lumen PICC was placed uneventfully under ultrasound guidance in the left basilic vein by an experienced anesthesiologist. On chest radiograph in the a-p orientation, the tip of the catheter was deemed acceptable in the left brachiocephalic vein. After 4 days, the patient developed fever >39°C, atrial fibrillation, and was clinically septic with increased markers of infection in the blood. With regard to the PICC, the only noteworthy fact was that the nursing staff could not aspirate blood from 1 lumen, which was thus discontinued from use. The second lumen was patent with no signs of complications. Emergency computed tomography of the chest revealed mediastinal air around the tip of the PICC. The patient was diagnosed with mediastinitis attributable to unintended continuous administration of TPN into the upper mediastinum. After diagnosis, the PICC was removed, cardiac sinus rhythm restored, and broad-spectrum antibiotics were given. The patient recovered uneventfully. A causal explanation for this complication considered incorrect positioning of the tip of the catheter pointing directly toward the vessel wall and that this position contributed to subsequent erosion of the vessel wall with dynamic motion of the mediastinum over time.
Clinical use of venous and arterial catheters often is accomplished by physicians who have not had formal training in this procedure. In addition, this often takes place when individuals have varying degrees of supervision. To our knowledge, there is no accepted worldwide formal education or accreditation process for learning this skill.
In 2013, Moureau et al.4 published training requirements for the insertion of central venous access devices. The proposed curriculum points out that the rapid evolution of vascular access devices makes specialized training and accreditation necessary to ensure provider competence.
In The Netherlands, PICCs are increasingly accepted and provided by vascular access services that are mainly staffed by radiology and anesthesia personnel. Ultrasound-guided placement is considered the “gold standard” for insertion of vascular catheters, and results in a reduction of complications.5
Locally at our hospital, the introduction of ultrasound-guided insertion of PICCs together with a protocol-driven service has led to growing interest across clinical specialties. We have experienced a rapid increase in catheter insertions, growing from 30 catheters in 2013 to 160 catheters within just 12 months. This growth came at a price, that is, placement of PICCs requires more time than first anticipated, and extra time could only be allocated by reducing the availability of anesthetists for other tasks and increasing individual workload.
Complications from the use of PICC can be severe. In our first case, perforation of the subclavian vein could have caused permanent harm to the brachial plexus by means of mechanical damage, bleeding, or the chemical side effects of TPN. Extensive bleeding would be extremely rare at this location. The second patient was lucky that she did not develop fatal intrathoracic bleeding and did survive life-threatening mediastinitis because this has a high mortality rate in itself.6 In both cases, extensive follow-up and consultation with vascular access experts confirmed that the position of both PICCs should never have been accepted when the catheters were inserted initially and that procedural mistakes probably contributed.
A significant factor contributing to complications was the circumstance that the start-up of our vascular access service was driven by 1 anesthesiologist with a specific interest in vascular access, whereas the group of providers inserting the catheters was too large to develop individual expert skills. Other issues added to the incidence of complications: workload onto a busy (anesthesia) service, time constraints, handover during out-of-office hours,7 or performance of nondedicated teams. Setting up and requiring that specialized clinical teams be responsible for placement of PICC access may be a solution with regard to quality and patient safety.8 These teams must be supported by adequate internal and external audits.9 Unfortunately, health care can still improve on human factors,10,11 like becoming complacent or losing vigilance with success.12
On analysis of the complications, it became clear that lack of competence was the most important explanation. In the absence of formal training, we decided on some immediate measures to ensure the basics of a high-quality service (Table 1).
The ideal future of PICCs in our hospital rests on the creation of a dedicated multidisciplinary vascular access team consisting of medical and nursing staff, trained and accredited, with an adequate budget.8,13 This task obviously is a difficult one in times of budget constraints and requires motivated individuals and management with long-term vision.14
In conclusion, we describe 2 serious and potentially life-threatening complications after placement of PICCs. Both complications occurred because of insufficient provider knowledge about vascular access devices. We urgently recommend the development of worldwide standards for use of indwelling catheters. In our opinion, the future of vascular access lies with specialized services and dedicated teams with formal accreditation.
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