Thread by @aishaikh

💥Can PICC Use be Avoided in CKD?
Tweetorial

Let’s review the following:
⚡️What is a PICC?
⚡️Indications for PICC use?
⚡️Complications associated w/
PICCs?
⚡️How can PICC use be avoided in
CKD patients?

#NKFClinicals
@RenalFellowNtwk
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💥What is a PICC?
⚡️Peripherally Inserted Central Catheter
It is a Central Vein Catheter‼️
⚡️Inserted into the peripheral veins of the upper arm
⚡️It passes thru the central veins
⚡️Tip of the PICC resides at the SVC/atrial junction or in the Right Atrium
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💥PICC use has been growing for reasons stated below👇🏽

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💥As a Clinician one much be aware of the different vascular access devices that are available for use, and the indications for their use:
⚡️PIV (peripheral IV)
⚡️Midline catheter
⚡️PICC
⚡️Tunneled & Non-tunneled CVC
⚡️Implanted Ports
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💥Choice of a Vascular Access Device depends on many factors including:

⚡️Proposed duration of IV therapy
⚡️Infusate properties
⚡️Patient factors such as presence of
kidney disease
👇🏽👇🏽👇🏽
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💥For instance, if the proposed duration of IV Rx is < 5 days & the infusate is peripheral vein compatible then a PIV would suffice
⚡️If the proposed duration of IV Rx is > 5 days but < 15 days then a Midline catheter would suffice👇🏽

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⚡️PICC is generally used when proposed duration of IV Rx is >15 days
OR
⚡️If the IV infusate is not compatible w/ peripheral vein use

⚡️PICC though inserted into a peripheral vein, is a central venous catheter)👇🏽
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💥As Nephrologists, we must be aware that it is recommended to avoid PICCs (and Midline catheters) in advanced CKD patients
(Patients with CKD stage3b or higher = eGFR < 45mls/min)👇🏽

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💥To understand why PICC use is not recommended in advanced CKD patients, one must first recognize the complications associated with PICC use👇🏽
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💥PICC-associated Central Line Associated Blood Stream Infection (CLABSI)

⚡️How does PICC-associated CLABSI rate compare to CVC-associated CLABSI rate?

⚡️It depends...whether the patient is in-patient or out-patient👇🏽

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💥PICC use & it’s association with Venous Thrombosis?

PICC use is associated with:
⚡️Peripheral Vein Thrombosis
⚡️Central Vein Thrombosis

And in some cases the venous thrombosis can be completely asymptomatic as shown in this study👇🏽

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💥PICC-associated venous thrombosis is concerning in CKD pts. because the veins that are used for PICC placement are the same veins that are used for AV access creation

⚡️Thrombosis of these veins may jeopardize future AV access creation👇🏽

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💥Obervational & Case-Control Studies show that PICC use is associated with poor AV Access outcomes in ESRD pts.👇🏽

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💥One can argue that:
⚡️This is Observational data
⚡️And these pts. had PICCs in the 1st place due to poor peripheral veins, & that AV access outcomes would be poor in this cohort regardless of a prior PICC
⚡️But this is the best data that we have...

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💥So what vascular access device should one use in pts. with advanced CKD who require prolonged IV therapy (> 5 days)?

⚡️In such patients, small-bore central vein catheter (4 or 5 F in diameter) can be placed in the IJ or EJ vein👇🏽
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💥Why is it ok to place CVC in the IJ or EJ vein but NOT a PICC line in CKD?

⚡️Because the potential loss of IJ or EJ vein is less problematic than the loss of a peripheral vein or subclavian vein which are needed for dialysis AV access function

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💥How to assess a patient with CKD who needs a vascular access device?

⚡️Assess CKD stage & risk of CKD progression (KFRE equation)👇🏽

⚡️But assessment of CKD stage alone is not enough. One must assess:
💥Pt’s Comorbidities, Life expectancy & Wishes👇🏽

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💥This is my approach in deciding which vascular access device to use in a CKD pt.👇🏽

💥Is the pt. a candidate for future dialysis & are they likely to reach ESRD?

⚡️If No: then you can use a PICC
⚡️If Yes: then use a small-bore CVC

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💥Even though guidelines suggest that PICC use must be avoided in pts w/ advanced CKD, this recent study showed that PICC use remains highly prevalent among advanced CKD pts.
(~23% pts. who had a PICC had an eGFR < 45 ml/min)👇🏽

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💥Additionally, another study showed that up to 25% Clinicians were unaware that their patients even had a PICC in place👇🏽

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💥Can PICC use be avoided in CKD pts?
⚡️Yes!

💥Clinicians must be aware of PICC use indications & it’s complications
💥Hospitals must have institutional policy to screen CKD pts. for appropriate PICC use
💥Nephrologists must be involved in this process

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