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Researchers determine appropriate use of IV catheters

Researchers at the University of Michigan reviewed scientific literature and gathered a group of experts to create The Michigan Appropriateness Guide for Intravenous Catheters, which determines appropriate use of IV catheters in adults.

“Our panel of experts used a validated method to develop appropriate indications for peripherally inserted central catheter … use across patient populations,” Vineet Chopra, MD, assistant professor of internal medicine at the University of Michigan, and colleagues wrote. “PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCS is thus important for patient safety.”

The researchers reviewed the scientific literature to create 665 clinical scenarios of peripherally inserted central catheter (PICC) use in adult patients. The researchers gathered a group of international experts to rate these scenarios according to appropriateness.

Overall, the experts rated 253 (38%) of the scenarios as appropriate, 124 (19%) as neutral and 288 (43%) as inappropriate.

For hospitalized medical patients

For durations of use fewer than 5 days, the experts rated PICC use as inappropriate. In addition, they rated peripheral IV catheter and ultrasonography-guided peripheral IV use as appropriate when used for fewer than 5 days. For durations between 6 and 14 days, they preferred midline catheters and ultrasonography-guided peripheral IV catheter use over PICC use. For durations greater than 15 days, they preferred PICC use over midline catheter use. For durations greater than 31 days, they preferred PICC use over tunneled catheter and implanted port use.

For infusion of irritants or vesicants (eg, parenteral nutrition or chemotherapy), the experts rated PICC use as appropriate and rated midline catheter, peripheral IV catheter and ultrasonography-guided peripheral IV catheter use as inappropriate for all durations. The researchers rated tunneled, cuffed catheter use as appropriate for 15 or more days and rated implanted port use as appropriate for 31 or more days.

For patients with difficult venous access, the experts preferred ultrasonography-guided peripheral IV catheter and midline catheter use over PICC use for 14 or fewer days. They rated port and tunneled catheter use as appropriate for 31 or more days.

For frequent phlebotomy or difficult venous access, the experts rated PICC use as appropriate for 6 or more days and rated port use as inappropriate for all durations.

In the case of skilled operators being available, the experts rated central venous catheter (CVC) and nontunneled CVC use as appropriate for 14 or fewer days.

For cancer, critical illness and chronic kidney disease

For patients with cancer, the experts rated interval placement of peripheral IV catheters as appropriate when chemotherapy was necessary for fewer than 3 months. For infusion of nonirritant or nonvesicant chemotherapy, they rated PICC use as appropriate for 3 or fewer months. They preferred PICC use to tunneled, cuffed catheter use for 3 or more months. In addition, they rated ports as neutral for 3 to 6 months and rated them as appropriate for 6 or more months. For infusion of irritant or vesicant chemotherapy, they rated PICC and tunneled, cuffed catheter use as appropriate for all durations. In addition, they rated ports as neutral for 3 to 6 months and rated them as appropriate for 6 or more months. For frequent infusions, they preferred tunneled, cuffed catheter use over multilumen PICC use. For patients with coagulopathy and those with severe or prolonged thrombocytopenia, the experts preferred PICC use over tunneled, cuffed catheter use. For frequent phlebotomy or difficult peripheral venous access, they rated midline catheter use as appropriate for 14 or fewer days and rated PICC use as appropriate for 15 or more days’ duration of treatment.

For critically ill patients who are also hemodynamically unstable, the experts rated CVC use as appropriate for 14 or fewer days and rated PICC use as appropriate for 15 or more days. For hemodynamically stable patients, the experts rated CVC use as appropriate for 6 to 14 days duration of treatment. They rated CVC use as neutral for treatment lasting more than 15 days. For infusion of peripherally compatible infusates for 15 or more days, they rated PICC use as appropriate and rated peripheral IV catheter use as appropriate for 5 or fewer days. In addition, they rated midline catheter use as appropriate for 6 to 14 days.  In patients with coagulopathies, the experts preferred PICC use over CVC use.

For patients with stage 1 to 3a chronic kidney disease (CKD), the experts rated PICC use the same as they did for hospitalized medical patients. In addition, the experts recommended consultation with a nephrologist before PICC use if the severity of the disease is uncertain. For infusion of peripherally compatible infusates, the experts rated peripheral IV use as appropriate in the dorsum of the hand when venous access for 5 or fewer days was needed. For infusion of nonperipherally compatible drugs, they rated tunneled small-bore central catheter use as appropriate. For patients with stage 3b or greater CKD, the experts rated PICC and midline catheter use as inappropriate because preservation of peripheral and central veins is important for hemodialysis.

For Special Populations

For patients that require lifelong IV access and were infrequently hospitalized, the experts rated PICC use as inappropriate when the duration of treatment was 5 or fewer days and preferred midline catheter use over PICC use between 6 and 14 days. They rated PICC use as appropriate for 15 or more days. In addition, they rated tunneled, cuffed catheter and port use as inappropriate for all durations in infrequently hospitalized patients. For patients that are hospitalized six or more times per year, the experts preferred tunneled, cuffed catheter use over PICC use for 15 or more days. In addition, they rated ports as appropriate for 31 or more days for those frequently hospitalized.

For patients that live in skilled nursing facilities that required infusion of nonirritant, nonvesicant treatment or frequent phlebotomy, the experts preferred midline catheter use over PICC use between 6 and 14 days. In addition, the experts rated PICC use as appropriate for more than 15 days duration of treatment.

“The implications of this work is substantial, because it provides a potential means to quantify appropriateness, qualify existing use, and improve care of PICCs and related devices in hospitalized patients,” Chopra and colleagues wrote. “Given an international team of experts that represented multiple subspecialties and the inclusion of a patient to formulate panelist ratings, these criteria are well positioned to broadly improve the quality and safety of venous access in hospitalized adults.” – by Will Offit

Disclosures: Chopra reports receiving grants from the Society of Hospital Medicine and AHRQ during the conduct of the study. Please see the full study for a list of all other authors’ relevant financial disclosures.