As a PICC RN, I was trained that placing a PICC into a pt with an active blood stream infection was not preferred...that it is best to treat infection for 24-48 hours with appropriate antibiotic, then place a PICC if needed for long term tx.
Recently our PICC team has been asked to insert PICCs into acutely ill pts with in the initial hours of presentation with sepsis. Our ICU staff wants a CVC line to monitor CVC pressures. According to past practice/education, we would ask for doctor to place jugular or subclavian CVC til infection under control, then replace with PICC if long term access needed.
Is this still best practice? What are most placed doing for sepsis? Is there research based evidence to guide us for the best CVCs to place in this group of patients? If PICCs are appropriate, is there any recommendations as to if/when it needs exchanged after a period of time?
Any comments/ literature would be appreciated. Thanks, Deb G
In my opinion, there is no evidence for your practice and it causes 2 catheter insertions. Subclavian/jugular insertion sites offer much greater risk of CLABSI associated with skin microbes in the neck and upper chest as compared to the skin of the forearm. No guidelines, recommendations, or standards have established that one must wait a certain period of time to insert a new PICC when BSI is present. It comes down to a risk vs benefit assessment for each patient. What ABX is prescribed? pH and osmolarity? Risk with peripheral infusion? I don't understand the rationale for placing a subclavian or jugular first, then changing later to a PICC in the presence of BSI. So if delay any CVAD insertion (PICC is a CVAD) is indicated, then the peripheral route is all you have left and you must compare these risk of peripheral vs central infusion. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
My experience has been that most septic patients are also in shock and thus vasoconstricting their peripheral veins making veins much to small for safe PICC placement. If on a rare occasion a newly admitted patient with shock has a vein big enough for a PICC them I place an antibiotic coated/impregnated line that will protect the PICC form the patients infection while limiting the number of central lines the patient needs and providing reliable venous access for the much needed meds.
Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]
null
Cheryl Kelley RN BSN, VA-BC
Please refer to the Infectious Disease Society of America's document: Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. This is a great article and will provide you (and your physicians) with much guidance.
http://cid.oxfordjournals.org/content/49/1/1.long
Cheryl Kelley RN BSN, VA-BC
In addition to the IDSA guidelines that Cheryl posted, there is another recent report:
1. Daneman N, Downing M, Zagorski BM. How Long Should Peripherally Inserted Central Catheterization Be Delayed in the Context of Recently Documented Bloodstream Infection? Journal of Vascular and Interventional Radiology. 2012;23(1):123-125.
The overall risk of BSI relapse was low at 3 out of 348 or 0.9% and was lowest when at least 3 days was allowed between positive BC report and PICC insertion. You have to weigh all factors. What has been prescribed to treat the BSI? What are the risk of peripheral infusion for 2-3 days? What does the patient's peripheral veins look like? If vancomycin, can you give it safely via peripheral veins for 3 days? This decision is a patient-specific one based on the facts for each patient. I have been searching for more information on this for an APIC project and the IDSA document and this study is all I can find. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Both are central lines so both would have the same risks
kathy