Advantages of ultrasound-guided peripherally inserted venous access (PICC and midline catheters) in critically ill patients

Introduction

In the critically ill, a reliable peripheral or central venous access is of paramount importance. Nonetheless, access may be difficult or may carry a significant risk of complications (pneumothorax, central line infection, etc.). Peripherally inserted venous catheters – either central (PICC) or peripheral (midline catheters (MC)) – are associated with a low risk of catheter-related bacteremia; also, using the ultrasound guidance and the microintroducer technique (UG + MIT), they can be inserted in any patient, regardless of the availability of superficial veins.

We have reviewed our experience of 56 peripherally inserted catheters in 53 patients in different ICUs (surgical ICU, trauma unit, coronary unit, neurosurgical ICU, stroke unit, pediatric ICU, etc.); all catheters were positioned at the mid-arm, in the basilic vein or in the brachial veins, using UG + MIT. We assessed the feasibility of this technique in the acutely ill and the rate of complications.

Methods and results

We inserted 16 PICC and 40 MC in patients requiring prolonged venous access (estimated >15 days); nine were septic, six had coagulopathy, 21 had tracheostomy. We used both silicone and polyurethane 4 Fr catheters. Procedures were performed by a team of trained physicians and nurses. Catheter insertion was easy in most cases, and immediate complications were few (no failure; one hematoma; no arterial or nerve injury). Late complications were: one local infection; three thrombosis (two requiring removal); four cases of damage of the external catheter (due to poor nursing or to inappropriate use of the catheter during rx procedures), all easily repaired; one dislocation; no catheter occlusion; no catheter-related bacteremia. Most catheters stayed in place for a prolonged time (range 9–65 days, median 19 days); only three were removed because of complications.

Conclusion

Our experience with PICC and MC was characterized by an extremely low rate of infective and thrombotic complications. Venous access was achieved in any patient, even with limited availability of peripheral veins. The use of US-inserted PICC and MC should be considered when central access is not advisable or is contraindicated.