I have been attending on the General Medicine Service at the
Brigham starting a few days ago. Today, the issue of whether to insert a peripherally
inserted central venous catheter (PICC line) came up on rounds. The patient is a man in his 60’s
with stage 2 CKD and quite advanced bronchiectasis, in hospital for a “wet”
bronchiectasis exacerbation responding slowly to imipenam and vancomycin. With
poor peripheral access the question came up: why don’t we insert a PICC line.
At our hospital, we have a policy that PICC lines are not
inserted in dialysis patients or those with advanced kidney disease.
A nice article by Timothy Pflederer from Morton Illinois in
the ASN’s "Kidney Daily" discusses the concerns with PICC line placement in kidney patients. The key
points that he makes are:
1. PICC lines are associated with a 23-57% of thrombosis in
the vein they are inserted
2. 7.5% of patients have some sort of central venous problem
following insertion of a PICC line.
3. Loss of peripheral and central patency markedly reduces
the access options for dialysis patients.
Pflederer recommends that PICC lines should be avoided in
patients with CKD stage 3-5. Instead, he suggests a small bore catheter
inserted into the internal jugular vein. In the end, we decided to insert a
PICC line because there were limited access options available to us and the
patient had relatively mild CKD.
