We investigated the safety and feasibility of ultrasound-guided peripherally inserted central venous catheter (PICC) placements performed by intensive care medical trainees in comparison to PICC placements performed by intensivists.
This was a retrospective and observational study of adult patients who underwent PICC placement and were admitted to the intensive care unit (ICU) between July 2013 and March 2018. Ultrasound-guided PICC was performed at the bedside by an intensivist or intensive care medical trainee if intrahospital transport was inappropriate. The primary endpoint was PICC-induced complications. The secondary endpoint was initial success of PICC.
A total of 209 patients underwent PICC placement during the study period. There were no significant differences in age, sex, body mass index, comorbidities, causes of ICU admission, or severity scores between the trainee-led PICC and intensivist-led PICC groups. Difficult venous access (42.6%) and requirement for central line infusion (39.2%) were the most common reasons for PICC placement. The basilic vein (62.2%) was the most common target vein among patients who underwent PICC. There were no significant differences in complications between the two groups (
Ultrasound-guided PICC placement by an intensive care medical trainee may be safe and feasible compared to PICC placement by an intensivist.
Peripherally inserted central venous catheters (PICCs) are commonly used as an alternative to central venous catheters in critically ill patients [
A subspecialty training program was recently established in the field of intensive care medicine in Korea [
This was a retrospective and observational study of adult patients admitted to the intensive care units (ICUs) at Samsung Medical Center between July 2013 and March 2018. This study was approved by the Institutional Review Board of Samsung Medical Center (SMC 2018-09-011). The requirement for informed consent was waived due to its retrospective nature.
Adult patients who underwent ultrasound-guided PICC performed by an intensive care medical trainee or an intensivist during their ICU stay were included in the study. Of these patients, patients younger than 18 years of age, those with insufficient medical records, and those discharged before 14 days after PICC placement were excluded. A total of 209 patients with PICC placement were analyzed in this study (
We retrospectively reviewed all placements of PICCs in the ICU during the study period. The illness severity on ICU admission was estimated by the Simplified Acute Physiology Score 3 (SAPS 3) and Sequential Organ Failure Assessment (SOFA) systems. Central line-associated bloodstream infections (CLABSIs) were defined as an infection resulting from the same bacteria as confirmed by line and blood cultures [
In this study, the primary outcome was PICC-induced complications. The secondary outcome was initial success of central line placement.
An intensivist determined the PICC placement in critically ill patients. The ultrasound-guided PICC was preferred at the bedside for patients with hemodynamic instability, on mechanical ventilation, or those who were critically ill. In this study, all PICCs were inserted as an elective procedure. Indications for placement of PICC included the need for a central line for parenteral nutrition, infusion of drugs requiring a central line, need for frequent blood sampling, or difficult venous access [
All data are presented as mean±standard deviation for continuous variables and numbers (percentages) for categorical variables. We compared data using Student’s
A total of 209 patients underwent PICC placements during their ICU stay. The mean age of the patients with PICC was 59.3±15.9 years. Of 209 patients, 116 (55.5%) were males. Hypertension (54.5%) and malignancies (53.6%) were the most common comorbidities among patients who underwent PICC placement. Respiratory failure (27.3%) and sepsis (23.4%) were the most common causes of ICU admission. There were no significant differences in age, gender, body mass index, comorbidities, causes of ICU admission, or severity scores of illness on ICU admission between the two groups (
Difficult venous access (42.6%) and requirement for central line infusion (39.2%) were the most common reasons for PICC placement. Almost all patients (92.8%) used a mechanical ventilator and 70 patients (33.5%) had hemodynamic instability. Renal replacement therapy was more frequently used in the trainee group compared to the intensivist group. The basilic vein (62.2%) and the brachial vein (20.6%) were the most common target veins among patients who underwent PICC placement. Activated partial thromboplastin time was prolonged in the trainee-led PICC group compared to the intensivist-led PICC group. There were no significant differences in reasons for PICC placement, use of anticoagulant and antiplatelet agent, insertional veins, platelet count, and international normalized ratio between the two groups (
There were no significant differences in complication between the two groups (
In this study, we investigated the safety and feasibility of ultrasound-guided PICC placement performed by intensive care medical trainees compared to PICC placements performed by intensivists. We report multiple major findings in this study. First, there were no significant differences in complications associated with PICC insertion between the two groups. In addition, there were no insertional injuries and severe bleeding in both groups. The incidence rates of CLABSI and symptomatic PICC-related venous thrombosis were low in patients with PICC. Second, the rate of initial success and procedural time were similar between the two groups. In addition, the procedure times of trainees decreased after three or four procedures. Third, PICC placement was performed in patients with intrahospital transport risks due to mechanical ventilator or hemodynamic instability. Fourthly, difficult venous access and requirement for central line infusion were the most common reasons for PICC placement. Overall, we show that ultrasound-guided PICC placement is a well-established procedure and easy to learn by an intensive care medical trainee.
Critically ill patients often need central venous access using either a central venous catheter or PICC due to various reasons such as parenteral nutrition, long-term antibiotic therapy, frequent blood sampling, and difficult venous access [
In the past, PICC was only inserted by an interventional radiologist in the interventional radiology suite under fluoroscopic guidance PICC placements have been also performed by interventional radiologists [
Ultrasound for vein localization and the modified Seldinger technique have been used for safe placement of PICCs at bedside [
This study had several limitations. This study was a retrospective review of medical records. An intensivist determined the placement of the PICC rather than following a protocol-based plan [
In conclusion, ultrasound-guided PICC placement by an intensive care medical trainee may be safe and more feasible compared to PICC placement by an intensivist. Therefore, ultrasound-guided PICC placement can be performed at the bedside by an intensive care medical trainee for critically ill patients if intrahospital transport is contraindicated.
No potential conflict of interest relevant to this article.
Conceptualization: YL, JAR, and YMS. Data curation & Formal analysis: YL, JAR, YOK, and EG. Visualization & Writing–original draft: YL, JAR, and YMS. Writing–review editing: YL, JAR, YOK, EG, and YMS.
We would like to thank the nursing director of the neurosurgery intensive care unit, Hye Jung Kim, who gave excellent advice and fruitful discussions. We would also like to thank all nurses of intensive care unit at Samsung Medical Center.
Study flow chart. PICC, peripherally inserted central catheter; ICU, intensive care unit.
(A) Target veins and procedure of the ultrasound-guided insertion of the peripherally inserted central catheter (PICC). Target veins were accessed by ultrasound. The cephalic vein is not shown in this ultrasound image. (B) The optimal length of the inserted PICC is measured from the site of insertion through the humeral head to the sternal notch, and down to the 3rd intercostal space. (C) The PICC is being inserted with the ultrasound-guided method in the intensive care unit (Eunmi Gil). (D) Finally, the PICC insertion is completed.
The procedure times of (A) intensive medical trainees and (B) intensivists according to procedure number. (A) Although the procedure times of intensive medical trainees were decreased after three or four procedures, (B) those of intensivist according to procedure number were similar.
Baseline characteristics
Characteristic | Insertion by intensivist (n=95) | Insertion by trainee (n=114) | |
---|---|---|---|
Age (yr) | 58.4±15.6 | 60.1±16.2 | 0.444 |
Male sex | 52 (54.7) | 64 (56.1) | 0.949 |
BMI (kg/m2) | 23.3±4.5 | 22.5±4.5 | 0.222 |
Obese (BMI >30 kg/m2) | 6 (6.4) | 4 (3.8) | 0.522 |
Comorbidities | |||
Hypertension | 55 (57.9) | 59 (51.8) | 0.454 |
Malignancy | 53 (55.8) | 59 (51.8) | 0.658 |
Diabetes mellitus | 36 (37.9) | 45 (39.5) | 0.928 |
Chronic kidney disease | 22 (23.2) | 26 (22.8) | 0.999 |
Chronic liver disease | 7 (7.4) | 16 (14.0) | 0.190 |
Ischemic heart disease | 7 (7.4) | 13 (11.4) | 0.452 |
Cause of ICU admission | 0.242 | ||
Respiratory failure | 24 (25.3) | 33 (28.9) | |
Sepsis | 21 (22.1) | 28 (24.6) | |
Cardiovascular problems | 20 (21.1) | 28 (24.6) | |
Neurological abnormalities | 27 (28.4) | 18 (15.8) | |
Other | 3 (3.2) | 7 (6.1) | |
SOFA score | 7.7±4.5 | 8.5±4.1 | 0.267 |
SAPS 3 | 36.1±14.6 | 10.6±15.0 | 0.059 |
Values are presented as mean±standard deviation or number (%).
BMI, body mass index; ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment; SAPS, Simplified Acute Physiology Score.
Procedural characteristics of peripherally inserted central venous catheter line placement
Characteristic | Insertion by intensivist (n=95) | Insertion by trainee (n=114) | |
---|---|---|---|
Reason for PICC insertion | 0.799 | ||
Difficult venous access | 39 (41.1) | 50 (43.9) | |
For infusion of drugs requiring a central line | 38 (40.0) | 44 (38.6) | |
Parenteral nutrition | 13 (13.7) | 11 (9.6) | |
Frequent blood sampling | 4 (4.2) | 6 (5.3) | |
Other | 1 (1.1) | 3 (2.6) | |
Anticoagulation | 33 (34.7) | 40 (35.1) | 0.999 |
Use of antiplatelet agent | 4 (4.2) | 8 (7.0) | 0.569 |
Use of mechanical ventilator | 91 (95.8) | 103 (90.4) | 0.212 |
Use of renal replacement therapy | 32 (33.7) | 57 (50.0) | 0.025 |
Use of vasopressor or hypotension | 27 (28.4) | 43 (37.7) | 0.156 |
Insertional site | 0.654 | ||
Basilic vein | 60 (63.2) | 70 (61.4) | |
Brachial vein | 21 (22.1) | 22 (19.3) | |
Cephalic vein | 14 (14.7) | 22 (19.3) | |
Laboratory results of coagulation on the day of PICC | |||
Platelet count (×103/μL) | 191.0±128.3 | 158.5±126.2 | 0.068 |
INR | 1.4±0.9 | 1.7±1.1 | 0.154 |
aPTT (sec) | 47.4±15.4 | 52.1±16.1 | 0.049 |
Values are presented as number (%) or mean±standard deviation.
PICC, peripherally inserted central catheter; INR, international normalized ratio; aPTT, activated partial thromboplastin time.
Clinical outcomes
Characteristic | Insertion by intensivist (n=95) | Insertion by trainee (n=114) | |
---|---|---|---|
Procedural data | |||
Initial success of PICC | 87 (91.6) | 96 (84.2) | 0.108 |
Malposition & reinsertion | 8 (8.4) | 6 (5.3) | 0.363 |
Procedure time (min) | 32.3±19.9 | 37.6±20.8 | 0.076 |
Duration of using PICC (day) | 80±20.1 | 102±32.4 | 0.112 |
Complication | 5 (5.3) | 3 (2.6) | 0.473 |
CLABSI | 3 (3.2) | 2 (1.8) | 0.661 |
Symptomatic PICC-related venous thrombosis | 2 (2.1) | 1 (0.9) | 0.179 |
Insertional injury | 0 | 0 | NS |
Moderate or severe bleeding and hematoma | 0 | 0 | NS |
Cause of removal | 0.723 | ||
Unnecessary | 58 (61.1) | 77 (67.5) | |
Malfunction | 22 (23.2) | 21 (18.4) | |
Fever | 9 (9.5) | 8 (7.0) | |
Self-removal | 6 (6.3) | 8 (7.0) |
Values are presented as number (%) or mean±standard deviation.
PICC, peripherally inserted central catheter; CLABSI, central line-associated bloodstream infection; NS, not significant with