The Use of PICCs Within Critical Care. Lynn Hadaway, M.Ed., RN-BC, CRNI

Transcription

1 The Use of PICCs Within Critical Care Lynn Hadaway, M.Ed., RN-BC, CRNI Disclosure Lynn Hadaway is a paid consultant for B Braun of Canada, Ltd Development and delivery of this presentation was commissioned by B Braun of Canada, Ltd 1

2 Disclosures Speaker and/or consultant for: 3M AtrionCorp B Braun Medical, Inc B Braun of Canada, Ltd Bard Access Systems Baxter BD Medical Covidien/Medtronic Elcam Excelsior Fresinius Kabi Gayco Healthcare LineGard Medical Lippincott Williams Wilkins Terumo VATA Velano Vascular Learning Objectives Identify the current standards and guidelines applicable to PICC insertion and management. Describe the clinical considerations for PICCs used in critical care. Analyze PICC complications associated with critical care patients. 2

3 Standards and Guidelines CDC Prevention of Intravascular Catheter-Related Infections, Safer Healthcare Now Preventing Central Line Infections, Canadian Vascular Access Association Occlusion Management Guideline for Central Venous Access Devices, MG)/tabid/229/Default.aspx Standards and Guidelines Department of Health, England Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England, ce-based_guidelines_for_preventing_hcai_in_nhse.pdf Society for Healthcare Epidemiology of America (SHEA) Strategies to Prevent Central Line-Associated, 2014 Update ne&aid= &fulltexttype=ra&fileid=s x

4 Standards and Guidelines Canadian Hemodialysis Access Coordinators Network Nursing Recommendations for the Management of Vascular Access in Adult Hemodialysis Patients: 2015 Update NP.pdf Infusion Nurses Society Infusion Therapy Standards of Practice, Clinical Considerations Vascular Access Planning (Gorski, 2016) Preservation of peripheral veins!! Most appropriate VAD selection Collaborative process among the interprofessional team, the patient, and caregivers Least invasive device, Smallest outer diameter, Fewest number of lumens needed for prescribed therapy PICCs are NOT an infection prevention strategy! 4

5 Clinical Considerations Hemodynamically UNstable patients Recommendations from the MAGIC study Centrally inserted central catheter (CICC) for therapy of 14 days or less PICC for 15 days or more, but CICC is preferred PICCs preferred in critical patient with coagulopathies or sepsis (Chopra, 2015) Clinical Considerations Avoid PICCs in Stage 4 or 5 Chronic Kidney Disease Patients with abnormal creatinine or egfr (CANNT, 2016) Use with caution in oncology and critical care patients Risk of venous thrombosis and infection (Gorski, 2016) PICC outer diameter should consume 45% or less of vein diameter (Gorski, 2016) 5

6 Clinical Considerations Mid-upper arm circumference (Gorski, 2016) Before inserting PICC for baseline When clinically indicated Measure 10 cm above antecubital fossa Presence of pacemaker (Gorski, 2016) Place PICC on opposite side, if possible Evaluate pacemaker function before and after PICC insertion Clinical Considerations Ultrasound guidance for vein selection and insertion Maximum barriers Full body drape Long sleeve gown Gloves Hair and face cover Alcoholic chlorhexidine skin antiseptic 6

7 Clinical Considerations Tip location for all Central VADs Location with greatest safety profile is cavoatrial junction (CAJ) Body movement will mean PICC tip moving into right atrium Clinical Considerations Confirmation of location Post procedure chest radiograph ECG by p wave 7

8 Clinical Considerations Power injectable For contrast injection in CT Maximum pressure = 325 psi Engineered stabilization device Not tape or sutures Chlorhexidine dressing Clinical Considerations VAD Removal (Gorski, 2016) Daily assessment of need Immediate removal when VAD is no longer needed for the plan of care 8

9 Critical care patients Mechanical problems Bloodstream infection Vein thrombosis Mechanical problems Tip malposition (Gorski, 2016) Primary malposition occurs on insertion and corrected immediately Intracardiac by more than 2 cm from CAJ Secondary malposition occurs during dwell Also known as tip migration Original tip location high in SVC or brachiocephalic vein Changes in intrathoracic pressure Body movement neck, arm, shoulder Vein thrombosis Power injection in CT 9

10 Mechanical problems Tip malposition (Gorski, 2016) Intravascular Jugular Contralateral subclavian Azygos Small tributary veins Aberrant venous anatomy such as persistent left SVC Extravascular Erosion of catheter tip through vein wall Fistula between vein and artery Cardiac tamponade Mechanical problems Tip malposition Withhold infusion through PICC Develop plan for identification of tip and repositioning or removal A major reason for the importance of a blood return!! 10

11 Know signs and symptoms of malposition No blood return Pulsatility of blood return Resistance when flushing Alteration in waveform when transducer is attached Dyshythmias Changes in vital signs Pain and/or edema in chest, shoulder, neck, back Complaints of hearing a running stream on ipsilateral side Neurological problems Bloodstream Infection Retrospective audit of medical records for all hospitalized patients with PICC insertion over a 3-year period (Chopra, 2014) 966 PICCs, 171 (18%) in ICU patients 58 (6%) with PICC-associated BSI over 1156 catheter days 2.16 per 1000 catheter days Median time to infection = 10 days Greatest risk factors by multivariate analysis: Hospital length of stay ICU status Number of lumens 11

12 Bloodstream Infection Systematic literature review and meta-analysis in hospitalized patients (Chopra, 2013) CLABSI rates with PICCs statistically the same as other CICCs Rates for both catheters similar for critical care patients PICC-CLABSI CICC-CLABSI Incidence 5.2% 5.8% # of CLABSI (# of patients) 76 (1473) 76 (1302) Sources of Microbes Skin Insertion site Hands of caregivers Hub Infusate Seeding from other infection sites 12

13 Source of Infection - Skin Signs and symptoms within 1 week of catheter insertion Skin is thought to be most likely source Surface Hair follicles Organisms protected by lipids Sebaceous ducts No penetration of antiseptics Source of Infection - Hub Signs and symptoms after the first week of dwell time Catheter hub is considered most likely source Hub manipulation Medication infusion Tubing or needleless connector changes Flushing Blood sampling 13

14 Biofilm Biofilm forms in all aquatic systems, including VADs Structured community of bacterial cells surrounded by a selfprotective matrix Microbes cooperate metabolically to live in a hostile environment Appears as a slimy substance Biofilm Stages Planktonic (freefloating) bacteria adhere to surface Secrete adhesins that cause the organisms to adhere and grow biofilm Occurs at all flow rates Faster flow rates produce stronger biofilm 14

15 Biofilm Mechanism for biofilm to produce BSI Detachment of cells or clumps Production of endotoxins Resistance of host immune system Body temperature elevation and chills after catheter flushing is probably due to a shower of organisms from the biofilm Infection Prevention Clinical Domain Skin Hand hygiene Insertion site Skin antisepsis Maximal barriers Insertion technique Antimicrobial impregnated catheters Engineered catheter stabilization devices Antimicrobial dressings Hub Hand hygiene, glove use Patency assessment Safe injection practices Needleless connector & hub disinfection Disinfection caps Administration set management Flush and locking solutions Blood sampling Minimize system manipulation 15

16 Vein Thrombosis Damage to the vein wall Two flow system Blood flow through vein Fluid flow through catheter Triad of Virchow Vein wall changes Catheter advancement Tip location Blood composition Disease produced changes Genetic clotting disorders Blood flow alterations Venous stenosis Foreign objects 16

17 Fibrin Tail or Flap Also called the ballvalve effect Prevents blood return from lumen Partial Fibrin Sheath Fluid flow between catheter and sheath Fluid escapes into the blood flow Prevents blood return from lumen 17

18 Complete Fibrin Sheath Fluid flow between catheter wall and fibrin sheath Prevents blood return from lumen Escapes from the vein entry site Causes infiltration or extravasation Thrombotic Vein Occlusions May block flow through catheter lumen Veno-occlusive thrombosis Occludes blood flow Fluid flow may not be affected 18

19 Asymptomatic vein thrombosis Reported to be as high as 62% of PICCs Symptomatic vein thrombosis Ranges from 3% to 20% of PICCs Diagnostic tests only with signs and symptoms = many missed thromboses 72% with thrombosis found in patients with 5 Fr double lumen PICCs (Zochios, 2014) Vein Thrombosis Rates higher in ICU 13.91% in critical care patients 6.67% in cancer patients (Chopra, 2014) Neurological ICU 8.4% symptomatic PICC-related thrombosis (Zochios, 2014) Medical ICU study no significant differences in thrombosis or BSI between PICC and CICC (Nolan, 2016) 19

20 Vein Thrombosis Bigger is NOT better with PICCs! 4 Fr with 0.4% symptomatic thrombosis vs 8.8% with 6 Fr PICCs Single lumen = 0.6% Double lumen = 2.9% Triple lumen = 8.8% (Zochios, 2014) PICC should consume less than 45% of vein lumen (Sharp, 2013) 4 Fr PICC requires a minimum vein diameter of 4 cm Pulmonary embolism Occurs in 1.3% of all PICCs 15% of PICCs with symptomatic thrombosis (Zochios, 2014) Lower extremity deep vein thrombosis reported in 9/966 PICCs (1%) (Chopra, 2014) 20

21 Thrombotic Risk factors Suboptimal tip locations Mechanical ventilation Increases pulmonary coagulopathy leading to systemic coagulopathy Immobility in ICU End-stage renal disease Sepsis Platelet transfusion Use of vasopressors (Zochios, 2014) Clinical Signs and Symptoms (Gorski, 2016) Pain, edema in arm, shoulder, neck or chest Erythema in extremity Engorged superficial veins of extremity, shoulder, neck or chest Difficulty with neck or extremity movement 21

22 Vein Thrombosis Diagnosis (Gorski, 2016) Color-flow Doppler ultrasound preferred Not invasive, no radiation exposure Venography with contrast, CT, or MRI may be needed for viewing veins obscured by clavicle or ribs Do not remove a CVAD in the presence of CVADassociated vein thrombosis when the catheter is correctly positioned at the cavoatrial junction, is functioning correctly with a blood return, and has no evidence of any infection. The decision to remove the CVAD should also consider the severity of DVT related symptoms, presence of contraindications for systemic anticoagulation, and the continued need for infusion therapy requiring a CVAD. INS VAD Removal Standard 44 Based on Kearon,

23 Take Away Messages PICCs are not the best choice for many critical care patients Use with caution! Use smaller PICCs with fewer lumens May not be possible with critical care infusion needs Careful attention to tip location at or close to cavoatrial junction! Rigorously employ ALL infection prevention techniques Questions 23

24 References Sharp R, Gordon A, Mikocka-Walus A, et al. Vein measurement by peripherally inserted central catheter nurses using ultrasound: a reliability study. Journal of the Association for Vascular Access. 2013;18(4): Gorski L, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D. Infusion Therapy Standards of Practice. Journal of Infusion Nursing. 2016;39(1S):159. Chopra V, Flanders SA, Saint S, Woller S, O'Grady NP, N S. The Michigan appropriateness guidel for intravenous catheers (MAGIC). 2015;in press. Chopra V, Ratz D, Kuhn L, Lopus T, Lee A, Krein S. Peripherally inserted central catheter related deep vein thrombosis: contemporary patterns and predictors. Journal of Thrombosis and Haemostasis. 2014;12(6): References Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet. 2013;382(9889): Chopra V, O'Horo JC, Rogers MA, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34(9): Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S. PICC-associated bloodstream infections: prevalence, patterns, and predictors. Am J Med. 2014;127(4):

25 References Zochios V, Umar I, Simpson N, Jones N. Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients. The journal of vascular access. 2014;15(5): Nolan ME, Yadav H, Cawcutt KA, Cartin-Ceba R. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Journal of critical care. 2016;31(1): Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST Journal. 2012;141(2_suppl):e419S-e494S. 25