PICC Line Complications: Why More Care Is Not Always Better.

Although peripherally inserted central catheters (PICC) have an important role in hospital care,  abuse of overuse can increase the risk of patient harm.  That abuse can come as an inappropriate  request for placement from patients, families, nurses or doctors.   PICC lines can  provide safe and appropriate intravenous access for critically ill patients who require vasoactive medications and total parenteral nutrition (TPN).  They are generally considered safer and and have fewer complications than the subclavian or jugular central venous catheters.  When inserted by the appropriately trained team of radiologists or nurses,  they can provide safe IV  access for days, weeks or months at a time with proper care using protectors and covers.    They may even improve patient satisfaction in the hospital by reducing patient discomfort with laboratory draws and decreasing local skin irritation from noxious pharmaceuticals.

When elderly ladies and drug addicts present with poor veins, PICC lines can maintain safe and adequate IV access should these patients experience acute decompensation or critical illness during their hospitalization.   However, these central lines can come with their own complications.  I have had my share of patients return to the hospital with sepsis and shock from their PICC line,   including  endocarditis complications.  Nephrologists hate them because the veins around the catheter often clot, leading to fewer choices for arteriovenous fistulas in end stage renal failure.  They can also cause upper extremity deep venous thrombosis that may require  treatment with long term anticoagulants and the associated risk of that therapy as well.   They can cause heart arrhythmias if placed in atrial or ventricular positions.  Less commonly, PICC lines can, dislodge, coil, fracture or have problems leaking at the site of entrance.  With proper technique, PICC placement teams can safely avoid arteries and nerves in the antecubital area of insertion, although these are also potential  complicating issues as well.  As with any invasive procedure, the risks of this procedure should not be minimized. Convenience catheters should be banned, but I fear their use will only increase in this era of keeping patients happy.

Because Medicare pays hospitals based on high marks from patient satisfaction surveys, I suspect convenience catheters represent an increasingly real and present danger to patient safety.   Some patients ask for PICC lines by name.    While they  may have been told no a few years, the risk of a bad patient experience may cause some physician and nurse teams to cave to their request in the interest of patient satisfaction.    Some patients will even go so far as to demand a PICC line on admission before allowing any nurse or lab technician to draw blood.  Healthcare providers are placed in a quandary when appropriate care with the  denial of a PICC line request  increases the risk of a poor patient experience and bad satisfaction scores.  For doctors and nurses with compensation tied to their patient experience surveys,  agreeing to unnecessary PICC lines in the interest of good scores may be placing their patients at risk of deadly complications when PICC lines are ordered for convenience.  

More care is not always better care.  In fact, some specialty societies are even recommending PICC lines not be placed if the patient's expected hospital stay is less than 48 hours.   One less common complication of a PICC line is when the catheter curls up on itself and creates a loop and gets knotted.  I've seen that before.   Normally the line can simply be pulled out of the body with a quick tug.  In that case, it required a surgical cut down of the axillary vein.  In a constant desire to make our lives simpler, often the risks can outweigh the benefits.  And this medical ecard reminds patients that PICC line does not stand for patient initiated convenience catheter.

"Dear Patient, PICC line does not stand for Patient Initiated Convenience Catheter (just so you know)."

PICC line stands for ecard humor photo


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