J Clin Monit Comput (2012) 26:85–90 DOI 10.1007/s10877-012-9337-1
Peripherally inserted central catheters are equivalent to centrally inserted catheters in intensive care unit patients for central venous pressure monitoring Heath E. Latham • Scott T. Rawson • Timothy T. Dwyer • Chirag C. Patel • Jo A. Wick • Steven Q. Simpson
Received: 16 August 2011 / Accepted: 12 January 2012 / Published online: 31 January 2012 Ó Springer Science+Business Media, LLC 2012
Abstract To determine the equivalency of pressure measurements from peripherally inserted central catheters (PICCs) versus centrally inserted central venous catheters (CVCs) in vitro as well as in vivo. The in vitro study was performed in a clinical laboratory. Static pressure measurements from PICCs and CVCs were obtained in vitro over a physiologic range of 5–25 mmHg. Triple and dual lumen PICCs were directly compared to CVC controls. Dynamic pressure waveforms were recorded to simulate physiologic intravascular pressure variation. The in vivo study was executed in the medical intensive care unit (MICU) of a tertiary-level academic medical center. Data was collected from ten adult patients with both a PICC and a CVC in place for on-going clinical care. Measurements of central venous pressure (CVP) were recorded simultaneously from PICCs and CVCs. Duplicate measurements were taken after a stable waveform was recorded. For the in vitro study, a total of 540 pressure measurements were recorded. The average bias determined by Bland–Altman plot was 0 mmHg for the 5Fr PICC and 0.071 mmHg for the 6Fr PICC. The correlation coefficient for both catheters was 1.0 (P \ 0.001). Dynamic pressure waveforms revealed equivalent amplitude. During the in vivo trial, 70
H. E. Latham (&) S. T. Rawson T. T. Dwyer C. C. Patel S. Q. Simpson Division of Pulmonary and Critical Care Medicine, The University of Kansas Medical Center, 3901 Rainbow Blvd, MS 3007, Kansas City, KS 66160, USA e-mail:
[email protected] J. A. Wick Department of Biostatistics, The University of Kansas Medical Center, 3901 Rainbow Blvd, MS 1026, Kansas City, KS 66160, USA
CVP measurements were collected. The paired CVP measurements were found to be highly reliable across subjects (r = 0.99, P \ 0.0001). No significance in the average difference in CVP measurement (PICC–CVC) was determined by the Wilcoxon Signed Rank test (S = 1, P = 0.93). In conclusion, PICCs are equivalent to CVCs when measuring static and dynamic pressure in vitro and CVP in ICU patients. Keywords Intravenous catheters Central venous pressure CVP Sepsis Peripherally inserted central catheters Hemodynamic monitoring
1 Introduction With a mortality rate of 20–60%, sepsis is the most common cause of death in intensive care unit (ICU) patients [1–3]. The economic burden related to the treatment of patients with sepsis in United States hospitals is substantial. Estimated in-hospital costs associated with the treatment of sepsis have been reported at $8.1 billion per year [4]. Early goal directed therapy (EGDT) reduces mortality and significantly decreases associated healthcare costs related to the treatment of patients with severe sepsis or septic shock [5–7]. Achieving a target central venous pressure (CVP) of 8–12 mm Hg is well published as a central component of EGDT, and central line insertion is recommended in the Surviving Sepsis Campaign guidelines as a means for general assessment of patient volume status and an objective guide to fluid resuscitation efforts [6, 8]. In addition, CVP monitoring can guide resuscitation in the various etiologies of hypovolemic shock. In United States hospitals, McGee and colleagues estimate that approximately 5 million central venous catheters
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(CVCs) are placed [9]. These intravenous catheters provide access for central venous delivery of medications, fluids, nutrition, and allow for hemodynamic monitoring of patients in the intensive care unit. Insertion of CVCs is associated with an increased risk for procedural complications, including pneumothorax, hemothorax, nerve injury, and significant bleeding from arterial puncture [9– 11]. Despite these risks, CVCs are currently the standard of care for monitoring central venous pressure. Peripherally inserted central catheters (PICCs) are an alternative method of achieving central venous access. Peripherally inserted central catheters are used for many of the same purposes as CVCs, and are commonly inserted at the bedside by specially trained nurses. Patient comfort during insertion, low cost, and less serious procedure-related complications are factors that have resulted in a dramatic increase in the number of PICCs being placed [12, 13]. As many as 2.5 million PICCs are placed each year in the United States, with an expected annual growth rate of 10–20% [14]. This trend toward PICC insertion can also be seen in ICU patients [15]. We have previously shown that in an in vitro setting, static and dynamic pressure measurements using a standard pressure transducer system can be obtained from both CVCs and modern PICCs that support radiographic contrast media (high pressure) infusion [16]. However, in vivo, equivalency of CVP readings from both types of catheters is both limited and discordant. In a study by McLemore et al. [17], there was no significant difference in CVP measurements obtained intraoperatively by PICCs compared to CVCs in five patients undergoing elective abdominal aortic aneurysm repair. Black et al. [18] compared CVP measurements, in a mixed ICU population, from PICCs to CVCs in vivo, and concluded that, although CVP recordings from PICCs were higher when compared to CVCs, the difference was not clinically significant. The PICCs used in these studies are unlikely to be used in today’s hospitalized patient as they are not approved for high pressure infusions. The objective of this study was to evaluate the equivalency of pressure measurements from dual and triple lumen PICCs versus standard triple lumen CVCs in vitro as well as in vivo. The Bard PowerPICC used for this study has one lumen designated for high pressure injection. Our previous study utilized the Angiodynamics PICC, in which both lumens are approved for high pressure infusion. Therefore, this catheter allowed us to compare high pressure lumens to standard pressure lumens which have not been evaluated in previous studies. Based on unpublished observational data in our ICU patients, we hypothesized that CVP measurements would be equivalent, regardless of central venous catheter or lumen type.
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2 Methods and materials 2.1 In vitro study We used an inverted T-device (Fig. 1), as previously described, to generate controlled pressures via a column of water that allowed simultaneous pressure measurements from five dual and five triple lumen Bard PowerPICCs (Bard Access Systems Inc, Salt Lake City, UT, USA) and Arrow 7Fr triple lumen CVC controls (Arrow MultiLumen 7Fr, 20 cm; Teleflex Inc. Reading, PA, USA) [16]. Dual lumen PICCs were 5Fr in diameter with 18 gauge lumens. The triple lumen PICC was 6Fr in diameter with two 19 gauge lumens and a 17 gauge lumen. All PICCs were 55 cm in length. The Arrow CVC control was 20 cm in length with two 18 gauge lumens and a 16 gauge distal port. The column was calibrated over a range of 5–25 mmHg and measurements were taken at 5, 8, 10, 15, 20, and 25 mmHg. We chose this pressure range because it encompasses pressures most commonly recorded in our ICU patients. A PICC and a CVC were inserted on either side of the pressure column. The column of water was then filled with distilled water. Free air was evacuated from the system. TruWave pressure transducers (Edwards Lifesciences LLC, Irvine, CA, USA) were attached to the port of each catheter. Free air was removed from the pressure transduction tubing by flushing the system. An Agilent Technologies (Andover, MA, USA) model V24C monitor was used to provide visual display of simultaneous pressure measurements. The pressure transducer for the PICC and CVC control were mounted level with each other at the base of the column of water and zeroed to atmospheric pressure. The column of water was sequentially filled to each precalibrated pressure level. Pressure measurements from 5Fr dual lumen PICCs (n = 5), 6Fr triple lumen PICCs (n = 5), and standard triple lumen CVC controls (n = 5) were compared. Successive and simultaneous measurements of static pressures were recorded from both
Fig. 1 Inverted T-device. The device generates controlled pressures via a column of water. The PICC and CVC were inserted into the device opposite of each other with the catheter tips at the base of the column of water, allowing simultaneous measurements from the PICC and control catheter. Care was taken to avoid excessive external compression or bending of the catheters at the insertion points
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ports of the dual lumen PICC, all three ports of the triple lumen PICC, and the distal port of the CVC control. This process was performed in triplicate with each PICC port after pressure adjustment of the column and appearance of a stable static waveform was observed. Additionally, dynamic waveforms from PICCs and CVCs were evaluated. Repetitive pressure pulses were applied to the column of water to produce dynamic pressure waveforms; thus, simulating physiologic intravascular pressure variations. Simultaneous pressure tracings from each catheter were then recorded at 25 mm per second on standard grid paper. Statistical analysis using direct comparison of measurement accuracy, Bland–Altman plot, correlation coefficient, and average bias were used to determine agreement between catheters and lumens. 2.2 In vivo study Local Human Subjects Committee approval was obtained prior to starting the in vivo study. After verbal consent from the patient or surrogate was obtained, simultaneous measurements of CVP were recorded from PICCs and CVCs in ICU patients (n = 10). The specifications of the catheters used for the in vivo study were the same as those described in the in vitro study. Each patient had a CVC and either a dual or triple lumen Bard PowerPICC already in place as part of ongoing medical care. Appropriate catheter placement was determined by visualization of the catheter within the chest on chest X-ray. The PICC and CVC catheter tips were required to be positioned within the SVC to qualify for study enrollment. Each patient was positioned in the semirecumbent position with their arms to the side of their body. The catheters were connected via a 3-way stopcock, high pressure tubing, and pressure transducer to a single telemetry monitoring system. Pressure transducer units were placed at the level of the right atrium, zero-calibrated to atmospheric pressure, and flushed with saline (0.9% NaCl) solution. The monitor displayed both PICC and CVC pressure tracings simultaneously, and calculated mean pressure to the nearest 1 mmHg. Measurements were taken after a stable waveform was recorded on the telemetry monitor. Absence of catheter obstruction was determined by monitoring for an appropriate pressure waveform. A square wave test was performed to verify appropriate system damping. CVP measurements were recorded in duplicate from both ports of the three patients with dual lumen PICCs, and all 3 ports of the seven patients with triple lumen PICCs. The distal port of the CVC was used as the control. Statistical analyses using Pearson’s product-moment correlation coefficient, Wilcoxon Signed Rank test, Kolmogorov–Smirnov test and Kruskal–Wallis test were utilized to determine agreement between catheters and lumens. SAS version 9.2 was used.
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3 Results 3.1 In vitro study A total of five hundred forty pressure measurements were recorded. The average bias determined by Bland–Altman plot was 0 mmHg with a standard error of 0 mmHg for the 5Fr dual lumen PICC and 0.071 mmHg with a standard error of 0 mmHg for the 6Fr triple lumen PICC. The difference range was 0 mmHg for the dual lumen PICC and 1 to -1 mmHg for the triple lumen PICC (Fig. 2). The correlation coefficient for both the dual lumen and the triple lumen PICCs was 1.0 (P value \ 0.001). Differences in measurement of dual and triple lumen PICCs versus standard triple lumen CVC controls were investigated using a general linear model controlling for the different levels of pressure, lumen, and catheter size. The estimated marginal mean difference in measurement for PICCs versus CVC controls was 0.007 (95% CI: -0.033, 0.047). No significant differences were found (P = 0.716). Dynamic pressure waveforms were plotted simultaneously between dual and triple lumen PICCs compared to CVC controls (Fig. 3). The mean pressure recording amplitude was equivalent amongst the three comparison groups. There was a small loss of fidelity of the PICC waveform, but this did not affect the mean pressure, even at 300 cycles per minute. 3.2 In vivo study A cohort of ten patients was included in the in vivo study. There were four men and six women (Table 1). Seven patients were diagnosed with severe sepsis or septic shock, one with cardiogenic shock, one with gastrointestinal
Fig. 2 Triple lumen peripherally inserted central catheter Bland– Altman Plot. The average bias determined by the plot is 0.071 mmHg with a standard error of zero. The difference range is 1 to -1 mmHg. PICC, peripherally inserted central catheter
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Fig. 3 Dynamic pressure waveforms. Dynamic pressure waveforms comparing dual and triple lumen peripherally inserted central catheters (PICC) to the standard triple lumen central venous catheter (CVC) control. There is a small loss of fidelity in the PICC waveform. However, the peaks, troughs, and means are equal at 300 cycles per minute
Table 1 Patient clinical characteristics (n = 10) n (%)
PICC–CVC Mean (SD)
P
10 (100)
0.167 (1.14)
0.93a
Male
4 (40)
-0.50 (0.71)
0.39b
Female
6 (60)
0.61 (1.20)
Sepsis
7 (70)
-0.19 (0.93)
Cardiogenic shock GI bleed
1 (10) 1 (10)
2.5 (–) 0 (–)
Respiratory failure
1 (10)
0.50 (–)
Dual lumen
3 (30)
-0.33 (0.76)
Triple lumen
7 (70)
0.38 (1.25)
Right internal jugular vein
5 (50)
-0.30 (0.76)
Left subclavian vein
2 (20)
0.83 (2.36)
Left internal jugular vein
3 (30)
0.50 (0.87)
Overall Gender
Diagnosis –
PICC type 0.92b
CVC site 0.51c
PICC peripherally inserted central catheter, CVC central venous catheter, GI gastrointestinal a
From the nonparametric Wilcoxon Signed Rank test
b
From the nonparametric Kolmogorov–Smirnov test of the equality of two distributions
c
From the nonparametric Kruskal–Wallis test of the equality of k distributions
bleed, and one with respiratory failure. Seventy percent of the patients evaluated had triple-lumen PICCs (n = 7) and the remainder of the patients had dual lumen PICCs (n = 3). All PICCs were inserted into the basilic veins of either the left or right upper extremity. A total of seventy CVP measurements were obtained. Descriptive statistics are given in Table 1. To test for significant differences between CVP measurements for PICC versus CVC, the average of all replicates was computed by catheter type and lumen (PICC or CVC) for each subject (Fig. 4). Reliability was computed using Pearson’s coefficient correlating the paired averages across subjects
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Fig. 4 Average central venous pressure by collapsed catheter type. PICC peripherally inserted central catheter, CVC central venous catheter. Each symbol is representative of results pertaining to individual study patients
(r = 0.99, P \ 0.0001). A Wilcoxon Signed Rank test was then used to test the hypothesis that the average of differences in CVP, as measured by PICC and CVC, was equal to zero. No significant difference was found (S = 1, P = 0.93). Nonparametric methods were used to test for associations with baseline demographic characteristics. None were observed (Table 1).
4 Discussion Our hypothesis was confirmed by the results of this study. In vitro and in vivo, static, dynamic, and central venous pressure measured via PICC, regardless of lumen, is equivalent to pressure measured through a standard CVC control. This is consistent with previous work performed, in vitro, on PICCs capable of high pressure infusion [16]. We found a strong degree of correlation and agreement in pressure readings between PICCs and CVCs in vitro. We previously investigated the equivalency of in vitro pressure
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measurements using Angiodynamics PICCs compared to CVC controls [16]. The results of the current study support these findings and further enhance the body of evidence that regardless of the brand of PICC or high pressure infusion capability of the lumen used, the PICC is equivalent to a CVC when measuring in vitro pressure. The strong correlation and agreement of pressure measurement that were observed in the in vitro portion of this study were confirmed when we performed a direct comparison of PICCs and CVCs in patients undergoing active resuscitation in our intensive care unit. In these patients, CVP readings obtained from either a dual or triple lumen PICC appropriately positioned in the SVC were equivalent to values obtained from CVCs. This is the second study to evaluate the utility of PICCs to measure CVP in an ICU setting. A previous study has shown in vivo equivalency of Bard PICCs compared to CVCs when measuring CVP in clinically stable ICU patients [18]. However, unlike the PICC in this study, the PICC used in Black’s study does not have high infusion rate capability, and is unlikely to be inserted in today’s ICU patient. This finding is of significant clinical importance in light of the increasing number of PICCs placed in hospitalized patients in the United States and the prevalence of severe sepsis and septic shock in ICU patients. A growing body of literature suggests that CVP is a poor predictor of cardiac output, intravascular volume, or fluid responsiveness [19]. However, EGDT is the best-evidenced approach to the resuscitation of patients with severe sepsis and septic shock, and a central component of EGDT is achieving a CVP target range of 8–12 mmHg. The ability of PICCs to measure CVP as accurately as CVCs has significant implications in the treatment of these patients by affording the clinician an alternative means to monitor CVP. This flexibility is useful, because it allows guidance for fluid resuscitation and the successful treatment of patients with severe sepsis and septic shock without exposing patients to the potential risks of CVC insertion for the purposes of CVP monitoring. The ability to monitor CVP from either a PICC or CVC also affords the clinician the ability to initiate CVP monitoring immediately, regardless of which catheter may already be present in the patient. Delayed EGDT implementation due to central venous catheter placement is not optimal and increases the risk for higher morbidity and mortality [5, 6, 8]. The successful utilization of EGDT not only decreases morbidity and mortality in these patients, but also decreases the hospital-associated costs related to their care [4]. Peripherally inserted central catheters provide an alternative means by which clinicians obtain central venous access and are associated with fewer procedure-related complications compared to CVCs [9–13, 20]. PICC insertion can be complicated by the inability to advance the wire
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or catheter past venous valves and malposition of the catheter outside of the desired superior vena cava to right atrial junction [21]. Catheters not in adequate position should not be used for hemodynamic monitoring. In addition, catheter related blood stream infections (CRBSI) and thrombosis are the most concerning complications of PICC line insertion. Several studies comparing PICC associated CRBSI to CVCs did not find an increase rate of infection with PICC [8, 12, 15, 22, 23]. The literature on PICC associated thrombosis is mixed, with several studies not finding any increased risk of thrombosis and others reporting thrombosis rates as high as 20% in critically ill patients [12, 20, 24]. These factors should be considered prior to the placement of any central line. In addition, the individual characteristics of the central catheter chosen for insertion by clinicians should be considered for each patient. The majority of the CVCs currently available are capable of high pressure infusion needed for large volume resuscitation or contrast administration. Although the PICCs used in this and our previous study has at least one lumen designated for high pressure infusion, not all PICCs have this capability. Therefore, a physician’s knowledge of the physical characteristics of the catheters available at his or her institution is imperative when selecting a central catheter for a given patient. Central venous catheters should be inserted by experienced physicians using maximal aseptic technique [25]. Procedure-related complications are more likely to occur when physicians have inserted fewer than 50 CVCs [25]. In many hospitals throughout the United States, the number of physicians with adequate CVC insertion experience is limited. Alternatively, PICC insertion is usually performed at the bedside by specially trained nurses, and in a prospective study by Barber et al., up to 75% of PICCs were successfully placed on the wards by nurses [11, 26]. Therefore, the ability to insert a PICC as an alternative means for central venous access is of great clinical importance when CVC insertion is not a practical and safe option. There are limitations to this study. It contained a limited number of study subjects, although the number of paired measurements was large enough to overcome the possibility of a Type II error. However, we have now demonstrated in two large in vitro studies that two different brands of modern PICCs accurately measure pressure when compared to CVCs [16]. The encouraging results of the in vivo arm of this study warrant further investigation in a larger patient population. In conclusion, peripherally inserted central catheters are equivalent to CVCs when measuring static and dynamic pressure in vitro and CVP in ICU patients regardless of the lumen used for hemodynamic monitoring. This study builds on the current knowledge about CVP monitoring and
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provides an alternative, but equivalent means that clinicians can utilize during early goal directed therapy for patients with severe sepsis or septic shock.
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13.
14.
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