In the Journals

Patients with advanced CKD given peripherally inserted central catheters despite recommendations

Hospitalized patients with chronic kidney disease often received peripherally inserted central catheters, or PICCs, despite clinical guidelines that recommend against placing PICCs in those patients, according to a study recently published in Annals of Internal Medicine.

“Many studies show that PICC insertion is associated with increased risk for venous thrombosis and central vein stenosis,” David Paje, MD, MPH, from the Patient Safety Enhancement Program at the University of Michigan Medical School and the Center for Clinical Management Research in the VA Ann Arbor Healthcare System, and colleagues wrote. “Therefore, to preserve veins for hemodialysis access, national guidelines (including Choosing Wisely) recommend avoidance of PICC placement in patients with CKD.”

Researchers conducted a longitudinal study of data regarding PICC insertion from November 2013 through September 2016. The 52 hospitals included in the study were participants in the Michigan Hospital Medicine Safety Consortium. Patients were eligible for enrollment in the study if they had a PICC placed while admitted in a general medicine unit or in the ICU.

The primary outcome of the study was the percentage of patients with a GFR less than 45 mL/min/1.73m2, or stage 3b or greater CKD, who were given PICCs. The secondary outcome was the occurrence of PICC-related complications.

Among the 20,545 patients who received a PICC, 4,743 (23.1%) had an estimated GFR less than 45 mL/min/1.73 m2. Of those, 699 (3.4%) underwent home dialysis. Approximately 30.9% of patients in the ICU and 19.3% of patients in general medical units who received PICCs had an eGFR less than 45 mL/min/1.73 m2.

PICC-related complications occurred in 15.3% of patients in general medical units with an eGFR lower than 45 mL/min/1.73 m2, and in 15.2% with a score 45 mL/min/1.73 m2 or higher. In the ICU, PICC-related complications occurred in 22.4% of those with an eGFR below 45 mL/min/1.73 m2 and in 23.9% of those with an eGFR 45 mL/min/1.73 m2 or higher.

“As Paje and colleagues’ data remind us, so much of vein protection depends on decision making by non-nephrologists care for complex patients with CKD,” Marcia R. Silver, MD, of the division of nephrology and hypertension at Case Western University School of Medicine at Metrohealth Medical Center wrote in an editorial accompanying the study. “Hence, education and engagement of the general medical community are critically important to further progress.”– by Erin Michael

Disclosures: Paje and Silver report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.

Hospitalized patients with chronic kidney disease often received peripherally inserted central catheters, or PICCs, despite clinical guidelines that recommend against placing PICCs in those patients, according to a study recently published in Annals of Internal Medicine.

“Many studies show that PICC insertion is associated with increased risk for venous thrombosis and central vein stenosis,” David Paje, MD, MPH, from the Patient Safety Enhancement Program at the University of Michigan Medical School and the Center for Clinical Management Research in the VA Ann Arbor Healthcare System, and colleagues wrote. “Therefore, to preserve veins for hemodialysis access, national guidelines (including Choosing Wisely) recommend avoidance of PICC placement in patients with CKD.”

Researchers conducted a longitudinal study of data regarding PICC insertion from November 2013 through September 2016. The 52 hospitals included in the study were participants in the Michigan Hospital Medicine Safety Consortium. Patients were eligible for enrollment in the study if they had a PICC placed while admitted in a general medicine unit or in the ICU.

The primary outcome of the study was the percentage of patients with a GFR less than 45 mL/min/1.73m2, or stage 3b or greater CKD, who were given PICCs. The secondary outcome was the occurrence of PICC-related complications.

Among the 20,545 patients who received a PICC, 4,743 (23.1%) had an estimated GFR less than 45 mL/min/1.73 m2. Of those, 699 (3.4%) underwent home dialysis. Approximately 30.9% of patients in the ICU and 19.3% of patients in general medical units who received PICCs had an eGFR less than 45 mL/min/1.73 m2.

PICC-related complications occurred in 15.3% of patients in general medical units with an eGFR lower than 45 mL/min/1.73 m2, and in 15.2% with a score 45 mL/min/1.73 m2 or higher. In the ICU, PICC-related complications occurred in 22.4% of those with an eGFR below 45 mL/min/1.73 m2 and in 23.9% of those with an eGFR 45 mL/min/1.73 m2 or higher.

“As Paje and colleagues’ data remind us, so much of vein protection depends on decision making by non-nephrologists care for complex patients with CKD,” Marcia R. Silver, MD, of the division of nephrology and hypertension at Case Western University School of Medicine at Metrohealth Medical Center wrote in an editorial accompanying the study. “Hence, education and engagement of the general medical community are critically important to further progress.”– by Erin Michael

Disclosures: Paje and Silver report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.