This makes a great decision analysis question! if the oral delivery route is not an option (e.g. surgical patient) I would presume the answer is "yes." Is there any data associating venous access with improved or worsened outcomes?
Daniel - there is lots of data regarding risks associated with PICC insertion - from DVT all the way to BSI and the spectrum of mechanical problems. The issue is also related to not just the oral route, but simply in the need to draw labs for example in patients with complex needs. Are PICCs the best way to go?
Vineet - I hear ya! Indeed, I think CER is necessary (PICC vs XXX). Jeff Fletcher at Michigan just published a study regarding the risk of DVT in neurosurgical ICU patients who received either a PICC or a CVC. PICCs were associated with a significantly increased risk. At Michigan, every PICC in a patient with a Creatinine > 1.5 (or AKI/CKD documented in their chart) has to run through nephrology so our process sounds similar to yours....
Vineet-I agree there's lots of data regarding DVTs and infections (i.e. the harm of having a PICC placed). What I'm wondering is there any data associated with not having the PICC placed e.g. delay in antibiotic delivery or oral versus intravenous rehydration? A. Gawande retells a story in one of his books where intravenous access was lost in a child resulting in a bad outcome from unidentified severe dehydration not sufficiently supplemented by oral rehydration. I can't recall similar data from an adult hospitalized population. I was approaching your question from a PICC vs no intravenous access as opposed to say PICC vs central line access. I wonder from a labs standpoint what impact some point of care devices can have. I"m told many can do some tests off of a pinprick (? from a patient point of view if that's better than a routine blood draw).
Daniel-interesting thought. I see where you are going now with the decision analysis. I suspect we need more data on alternatives to drive the markov/modeling process. There are other options for venous access in those with hard to locate periph veins, for instance --prolines, midlines come to mind (no issues with venous scarring or stenosis so our nephrologists love them). The alternative forms of lab draws is an intersting aspect as well -- good stuff!
I am from another prospective. Taking care of a lot of premies with multiple medical problems without appropriate enteral intake for weeks or even months. Regardless of potential complications we have to provide a PICC unless the patient can reach full feeds in one week. Judging from nutritional support the benefit outweighs the risk most of the time. We spend a lot of time to prevent line infection. Also, we can easily run out of peripheral vein in a few days so PICC line becomes a must-to-have. I have been asked 3 AM in the unit to place a PICC line after the nurse told me she has attempted 20 times. So we would rather to have it early than late, at least in very premature infants.
Agree with you completely. When it comes to neonatea and primies, hard to generalize. This was specifically targeted for adults who new venous access. But I suppose the tpn issue would also hol true for adults. What about using a standard CVC though? Is this not an option for primies?
The standard CVC is too big for most micropremies. Usually we place PICC throught periphearl veins after sterile preparation of the insertion site. The size of PICC can be #24 or #27. Umbilical line usually will be taken out by day 7. We do not have big veins for the regular CVC.
Interesting info - is the data regarding infectious and venous thrombotic complications suggestive of harm with this practice? It seems as if you see more benefit than downsides.