PICC Line for pressors?

[DrMetal]

Barring anatomical abnormalities or trauma to the neck....in what instances would you prefer a PICC line (vs. a R.IJ central line) for the delivery of pressors?

Also, if you use that PICC line for pressors (say for 5 days), can you then still use the same PICC line for IV antibiotics?

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[CCM-MD]

Barring anatomical abnormalities or trauma to the neck....in what instances would you prefer a PICC line (vs. a R.IJ central line) for the delivery of pressors?

Also, if you use that PICC line for pressors (say for 5 days), can you then still use the same PICC line for IV antibiotics?

With regards to neck trauma/anatomical issues - the IJ isn’t the only site available for a CVC. Usually can get a line in SOMEWHERE - but I have had 1-2 cases where our vascular surgeons and IR docs weren’t able to get a line in either - including a picc. This situation is rare. The optimal site is also variable depending on who you talk to - subclavians have least infection and most mechanical complications - femorals have most infection - IJ is in the middle. Where I did residency we did mostly IJs, in fellowship we did a mix of IJ/subclavians - subclavians were preferred.

With regards to PICCs for pressors, if someone already has one, I see no problem using it. Why subject them to another central line when we already have a “peripherally inserted central catheter”? In the same way I have no problem using port-a-caths for pressors. Unless they need a CVC for other reasons.

The logistics of placing PICCs for acutely ill patients are also problematic, most of the hospitals I have had the chance to work at have either picc nurses do it at bedside or IR docs/midlevels putting these in under fluoro - and they are usually extremely busy. It would be hard to squeeze in sick patients who often need access right away.

The other part is the number of lumens. PICCs usually have one or two. A real CVC is usually triple or quad lumen. Another thing to consider is the length of the line - PICCs are much longer catheters in length compared to CVCs. If you are trying to resuscitate someone quickly, it’s generally much faster to give it through a CVC/cordis than a PICC.

Putting in PICCs for the purposes of vasopressors is not my practice. I have seen it being done and I don’t think there is great literature for or against it. There is a paper that just came out relating to this which concluded that “Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate.” (Link below)

Peripherally Inserted Central Catheters in the ICU: A... : Critical Care Medicine

 

[DrMetal]

“Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate.” (Link below)

Peripherally Inserted Central Catheters in the ICU: A... : Critical Care Medicine

Thank you! My thoughts exactly. And thank you for the reference.

 

[BigRedBeta]

That reference is interesting, but I have to wonder what they identify as "not appropriate" criteria.

If you are trying to resuscitate someone quickly, it’s generally much faster to give it through a CVC/cordis than a PICC.

I would point out that if you are in the active resuscitation stages, two large bore PIVs is going to be orders of magnitude faster than a CVL or cordis. That length of the catheter affects your resistance far more than the differences in diameter.

As a Peds intensivist, a PICC line is certainly better tolerated in toddlers than an IJ or femoral line. I've never been in a children's hospital where subclavians are done by anyone other than surgeons.

As for my preference, it comes down to stability, availability, and managing patient workflow. If they're stable enough to get by on peripheral (diluted) norepi at 0.1mcg/kg/min, for an hour, and the PICC team will be there soon and I've got 2 other patients crashing and a family meeting scheduled, then I'll go with the PICC. If the doses are rapidly escalating and PICC team isn't immediately on their way, then of course I'm getting set up 5 minutes ago.

 

[deleted171991]

That reference is interesting, but I have to wonder what they identify as "not appropriate" criteria.


I would point out that if you are in the active resuscitation stages, two large bore PIVs is going to be orders of magnitude faster than a CVL or cordis. That length of the catheter affects your resistance far more than the differences in diameter.

In adults, the 8.5F Cordis will beat two 16G catheters. (See here: POTD Trauma Tuesday! Cordis vs Two 16 Gauge Peripheral IVs – EM Blog).

The reason for that is that the resistance to laminar flow through a catheter is inversely proportional to the 4th power of its radius (and hence its diameter), while being directly proportional to its length. The radius is MUCH more important than the length. Here's that equation: Hagen–Poiseuille equation - Wikipedia (the resistance would be deltaP over Q).

There is also the matter of tolerating high infusion pressures (both for the catheter and the vein), where a Cordis in a central vein will again be better than many combinations of 2 peripheral lines, when coupled with a Belmont.

The only things that will beat a 8.5F Cordis will be two peripheral 14G catheters (good luck placing those in most patients) or a RIC line (which is also easier to place than a Cordis).

Flow rates of various vascular catheters

It may be different in Peds, where a smaller Cordis may be similar to some large PIVs.

 

[turkeyjerky]

With regard to the whole "2 large bore PIVs" thing, I heard about this in school and residency but the only times I've ever seen it achieved are in young trauma patients who present w/o established shock and in pre-op patients.

I feel like the most common indication for a PICC is that the doctor is too lazy/busy to put in a central line. Peds is obviously slightly different than adults, although again I think it's mostly logistics and technical expertise (non surgical residents don't learn how to put in CVCs because all the patients preferentially get PICCs)

 

[CCM-MD]

(non surgical residents don't learn how to put in CVCs because all the patients preferentially get PICCs)

I can’t speak for every single “non-surgical” residency but I was a “non-surgical” resident once (IM) and did plenty of CVCs in residency during - mostly in ICU months. My colleagues (those who were interested) did plenty also.

 

[NITRAS]

With regard to the whole "2 large bore PIVs" thing, I heard about this in school and residency but the only times I've ever seen it achieved are in young trauma patients who present w/o established shock and in pre-op patients.

I feel like the most common indication for a PICC is that the doctor is too lazy/busy to put in a central line. Peds is obviously slightly different than adults, although again I think it's mostly logistics and technical expertise (non surgical residents don't learn how to put in CVCs because all the patients preferentially get PICCs)

If your attendings insist on 2 large bore IV's, it gets done. You really need two IV's with the extended infusion Abx now anyways. Central lines other than PICCs are usually avoided on the floor at the current institution if possible.

As an aside, having really good IR placed picc and midlines/extended dwell catheters makes your nurses lose proficiency in placing IV's.

 

[SpacemanSpifff]

I can’t speak for every single “non-surgical” residency but I was a “non-surgical” resident once (IM) and did plenty of CVCs in residency during - mostly in ICU months. My colleagues (those who were interested) did plenty also.

I think s/he meant in pediatrics

 

[turkeyjerky]

If your attendings insist on 2 large bore IV's, it gets done. You really need two IV's with the extended infusion Abx now anyways. Central lines other than PICCs are usually avoided on the floor at the current institution if possible.

As an aside, having really good IR placed picc and midlines/extended dwell catheters makes your nurses lose proficiency in placing IV's.

I've been out of residency for about 5 years now (hard to update my status for some reason). There's a big difference between two IVs, which typically can be accomplished, and two large bore IVs, which is a technically difficult feat to accomplish.

 

[alpinism]

There's no excuse for not having 2 large bore IVs in resuscitation patients.

Its very easy to insert a 14G into the IJ with US guidance.

Hell I could put one in each IJ in under 2 minutes.

 

[thegenius]

There's no excuse for not having 2 large bore IVs in resuscitation patients.

Its very easy to insert a 14G into the IJ with US guidance.

Hell I could put one in each IJ in under 2 minutes.

Do you only use the long IVs when putting them into the IJ? And how often to the IVs dislodge or infiltrate? I'm sure it's rare...but when I see the IJ 2-3 cm deep on ultrasound, I would want my long PIV to be at least twice the length, no?

 

[alpinism]

Do you only use the long IVs when putting them into the IJ? And how often to the IVs dislodge or infiltrate? I'm sure it's rare...but when I see the IJ 2-3 cm deep on ultrasound, I would want my long PIV to be at least twice the length, no?

We've got 2 inch needles that are used for USIVs.

Haven't had any issues yet even in obese patients with thick necks. At least in my experience if you can get the last 0.5 inches in the vein it works just fine. That being said in those situations I'll make sure the IV is secured with a large tegaderm and tape since they're easier to dislodge. So far I've only had them come out in agitated patients thrashing around.

Also if you don't have access to the long IVs you can always just open the central line kit and use the angiocath which is 3 inches and works like a charm.

 

[deleted547339]

With regards to neck trauma/anatomical issues - the IJ isn’t the only site available for a CVC. Usually can get a line in SOMEWHERE - but I have had 1-2 cases where our vascular surgeons and IR docs weren’t able to get a line in either - including a picc. This situation is rare. The optimal site is also variable depending on who you talk to - subclavians have least infection and most mechanical complications - femorals have most infection - IJ is in the middle. Where I did residency we did mostly IJs, in fellowship we did a mix of IJ/subclavians - subclavians were preferred.

With regards to PICCs for pressors, if someone already has one, I see no problem using it. Why subject them to another central line when we already have a “peripherally inserted central catheter”? In the same way I have no problem using port-a-caths for pressors. Unless they need a CVC for other reasons.

The logistics of placing PICCs for acutely ill patients are also problematic, most of the hospitals I have had the chance to work at have either picc nurses do it at bedside or IR docs/midlevels putting these in under fluoro - and they are usually extremely busy. It would be hard to squeeze in sick patients who often need access right away.

The other part is the number of lumens. PICCs usually have one or two. A real CVC is usually triple or quad lumen. Another thing to consider is the length of the line - PICCs are much longer catheters in length compared to CVCs. If you are trying to resuscitate someone quickly, it’s generally much faster to give it through a CVC/cordis than a PICC.

Putting in PICCs for the purposes of vasopressors is not my practice. I have seen it being done and I don’t think there is great literature for or against it. There is a paper that just came out relating to this which concluded that “Peripherally inserted central catheter use in the ICU is highly variable, associated with complications and often not appropriate.” (Link below)

Peripherally Inserted Central Catheters in the ICU: A... : Critical Care Medicine

Stop teaching this. Fem lines aren’t dirty. The Parienti paper has been out for several years now.

 

[deleted547339]

In adults, the 8.5F Cordis will beat two 16G catheters. (See here: POTD Trauma Tuesday! Cordis vs Two 16 Gauge Peripheral IVs – EM Blog).

The reason for that is that the resistance to laminar flow through a catheter is inversely proportional to the 4th power of its radius (and hence its diameter), while being directly proportional to its length. The radius is MUCH more important than the length. Here's that equation: Hagen–Poiseuille equation - Wikipedia (the resistance would be deltaP over Q).

There is also the matter of tolerating high infusion pressures (both for the catheter and the vein), where a Cordis in a central vein will again be better than many combinations of 2 peripheral lines, when coupled with a Belmont.

The only things that will beat a 8.5F Cordis will be two peripheral 14G catheters (good luck placing those in most patients) or a RIC line (which is also easier to place than a Cordis).

Flow rates of various vascular catheters

It may be different in Peds, where a smaller Cordis may be similar to some large PIVs.

I do love me a good RIC line....seems like the only people I know who do them are the anesthesiologists who do livers.

 

[deleted171991]

I do love me a good RIC line....seems like the only people I know who do them are the anesthesiologists who do livers.

I too have only seen them in the same context.

 

[TXEMC344]

I too have only seen them in the same context.

And why do you think that is?

 

[Fox800]

I do love me a good RIC line....seems like the only people I know who do them are the anesthesiologists who do livers.

We have them, but they collect dust and never get used. Perfect patient being the 18-20 year old guy dying of penetrating trauma that comes in with two 18/20 gauges from EMS. Upsize it to a RIC.

 

[jthedestroyr]

We have them, but they collect dust and never get used. Perfect patient being the 18-20 year old guy dying of penetrating trauma that comes in with two 18/20 gauges from EMS. Upsize it to a RIC.

^^ this.

Did this the other day in exact case although gsw with existing 20g put in from OSH. While the surgeons were prepping field we just upsized the OSH 20g to RIC then had amazing access.

Sometimes you can place them in liver patients, but they often have terrible veins and RIC doesnt upsize well on them from the handful of livers I've done I've noticed this.

 

[chessknt]

I've used rics many times in the cirrhotic ugib. Only if I hey have a preexisting good piv though otherwise I just get a cordis

 

[Hamhock]

peripheral IJ upgraded to a RIC in unstable resus?

HH

 

[RNthenDoc]

Just an RN/MS1, but my rules were always 2 PIV as standard for ICU, add in a cordis or CVL if crashing, and if they are “headed that way” but we have time, we get a PICC.

I’ve almost exclusively seen triple lumen PICCs in the adult ICU, but sometimes a double lumen. On the triple there is usually one lumen that is half the bore diameter, and the other two are quarter. You can usually fit everything you need through 3 lumens and a couple peripherals.

My medic buddies infuse pressers peripherally all the time; I think that’s more of a monitoring issue than anything else in the short term.

 

[deleted875186]

The discussion about flow rates in the ICU with peripheral versus introducer CVC usually is not practically important. Every ICU I’ve been in, the nurses will put all blouses on a pump at max rate, which is still too slow for someone with very brisk bleeding. Just the other week I saw someone “being resuscitated” trying to give boluses through a TLC in the femoral, while the perfect 16G IV in the AC had propofol hooked up and was neglected.

 

[vector2]

The discussion about flow rates in the ICU with peripheral versus introducer CVC usually is not practically important. Every ICU I’ve been in, the nurses will put all blouses on a pump at max rate, which is still too slow for someone with very brisk bleeding. Just the other week I saw someone “being resuscitated” trying to give boluses through a TLC in the femoral, while the perfect 16G IV in the AC had propofol hooked up and was neglected.

Not to mention ICU nurses have an unbreakable aversion to taking off the luer lock adapter from a large bore catheter or line. Those stupid adapters will turn your 16g into a 20g.

 

[drmwvr]

We have them, but they collect dust and never get used. Perfect patient being the 18-20 year old guy dying of penetrating trauma that comes in with two 18/20 gauges from EMS. Upsize it to a RIC.

Excellent for ruptured AAA crashing to the OR from the helipad as well. Usually a couple of 20's from the sending hospital and easy to do while the surgeons are trying to place an occlusion balloon.

 

[anbuitachi]

^^ this.

Did this the other day in exact case although gsw with existing 20g put in from OSH. While the surgeons were prepping field we just upsized the OSH 20g to RIC then had amazing access.

Sometimes you can place them in liver patients, but they often have terrible veins and RIC doesnt upsize well on them from the handful of livers I've done I've noticed this.

Liver patients have great veins.. high output

 

[engineeredout]

Don't have RIC catheters where I'm at.

Problem with the standard Arrow 8.5Fr introducers is how flimsy they can be and how easily kinked they can get when sandwiched between a large neck or pannus. I've dropped double lumen dialysis catheters in these patients, which although yes they are longer, they are still two very large bore lines meant for high flow rates, and work beautifully with a level 1. Just reassure your nurses when they start losing their **** that it is okay to access this particular dialysis line.

 

[drmwvr]

Don't have RIC catheters where I'm at.

Problem with the standard Arrow 8.5Fr introducers is how flimsy they can be and how easily kinked they can get when sandwiched between a large neck or pannus. I've dropped double lumen dialysis catheters in these patients, which although yes they are longer, they are still two very large bore lines meant for high flow rates, and work beautifully with a level 1. Just reassure your nurses when they start losing their **** that it is okay to access this particular dialysis line.

Fine and well...no RIC? It's a primal PIV for pete's sake. The VA has RIC's for the love of God...you don't need a stack 6 feet tall, but they are cheap and they save lives when a neck line isn't practical in the moment...get some....

 

[engineeredout]

Fine and well...no RIC? It's a primal PIV for pete's sake. The VA has RIC's for the love of God...you don't need a stack 6 feet tall, but they are cheap and they save lives when a neck line isn't practical in the moment...get some....

Decisions beyond my pay grade...

 

[fakin' the funk]

I would point out that if you are in the active resuscitation stages, two large bore PIVs is going to be orders of magnitude faster than a CVL or cordis. That length of the catheter affects your resistance far more than the differences in diameter.

This is the dumbest **** that I hear over and over. Catheter dimensions are never ever the rate limiting step in fluid or product administration. It's always always the availability of fluid or blood. Since you're infusing under pressure (right? Otherwise there's DEFINITELY no difference) there is the issue of dislodgement and extravasation of peripherals. Give me a 9fr over 2 14s any day whether were Belmonting or not.

 

[lymphocyte]

UpToDate quotes a thrombosis rate > 10% in critically ill patients. I also think the evidence supports vaso-active agents for a limited period of time in a well-placed PIVC. Therefore, I really don't really see the use in PICC lines for this reason (unless a patient is very coagulopathic).

The real travesty are the new triple or even quad lumen PICCs, which seem like they'd be even more thrombosis prone.

 

[jdh71]

UpToDate quotes a thrombosis rate > 10% in critically ill patients. I also think the evidence supports vaso-active agents for a limited period of time in a well-placed PIVC. Therefore, I really don't really see the use in PICC lines for this reason (unless a patient is very coagulopathic).

The real travesty are the new triple or even quad lumen PICCs, which seem like they'd be even more thrombosis prone.

Double lumen PICCs seem ok from a DVT perspective. Though I don't put them in just so I can use pressor.

(I don't know what crazy person ever puts in a single lumen PICC)