Spotlight Case

Breakage of a PICC Line

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Source and Credits• This presentation is based on the April 2009

AHRQ WebM&M Spotlight Case– See the full article at http://webmm.ahrq.gov – CME credit is available

• Commentary by: Vesselin Dimov, MDCreighton University– Editor, AHRQ WebM&M: Robert Wachter, MD– Managing Editor: Erin Hartman, MS

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ObjectivesAt the conclusion of this educational activity, participants should be able to:

• Appreciate the incidence and consequences of PICC line breakage

• Understand the risk factors for PICC line breakage• Understand the treatment options in case of PICC line

breakage• Understand the measures to safely place a PICC line

and prevent PICC line breakage• Appreciate the guidelines to reduce risk of

complications from central venous catheters

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Case: PICC Line Breakage

Born at 27 weeks’ gestation, a premature infant had a standard, silastic, 1.9 F percutaneously inserted central venous catheter (PICC) placed on day two of life for parenteral nutrition. The PICC was inserted under sterile conditions with placement verified by X-ray. Initially, the infant was on ventilator support and NPO due to feeding intolerance and necrotizing enterocolitis surveillance. Several attempts were made to introduce feeds; however, the infant continued to have large residuals and increased abdominal girth.

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Case: PICC Line Breakage (2)

After 40 days of parenteral therapy, the antecubital site and the upper arm became red, swollen, and tender to the touch. The neonatologist opted to remove the catheter. When the RN started to remove the PICC, it broke, leaving approximately 7 cm in the patient.

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Case: PICC Line Breakage (3)

After several attempts to retrieve the remainder of the line, with X-rays to check placement, the infant was sent for surgical removal of the catheter. Cultures taken via blood and PICC reported moderate growth of Staphylococcus. The infant required an increased level of care that included ventilator support, infusion of blood products, and antibiotic treatment.

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PICC Lines Commonly Used Today• First introduced in 1975

– Alternative to tunneled catheters or port lines– Now inserted under ultrasound or fluoroscopic

guidance by interventional radiologists or PICC teams

• Several attractive features– Easier, less expensive to insert than tunneled caths– Lower complication rates

• Particularly attractive in neonates– May need fluid, frequent blood draws

See Notes for references.

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PICCs Can Cause Complications

• In retrospective series, complications included:– Wound oozing and leakage– Phlebitis– Occlusion– Infection– Breakage

• Complication rate ~5 per 1,000 catheter days– Complications usually in older (>30 days) PICCs

See Notes for reference.

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PICC Breakage is Uncommon

• One study: incidence ~ 7 per 1000 PICCs• Fractures associated with:

– Older lines (only 2/11 broke < 2 months from insert) – Evidence of difficulty flushing line, leakage, blockage

• Fractures not associated with:– Catheter size, insertion site, specific meds infused

• All fractures near entrance site• Pathophysiology of break: probably mechanical fatigue

and stress

See Notes for reference.

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Discovery and Removal

• Most fractures discovered by CXR or fluoro done pre-contrast injection

• Removal: usually percutaneously– Fragment is snared, then pulled into sheath, which

is removed– May be particularly challenging in neonates, as in

this case

Why The Fracture in This Case

• Small size of line (1.9F) in neonate• Line in place for more than 30 days

– Likely develop fibrin binding of catheter to vessel wall, increasing chance of breakage on removal

• Small syringe used for flushing creates higher pressure, increased stress on catheter

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Recommendations for Prevention

• Avoid flushing PICCs under high pressure or with small syringes

• Remove PICC as soon as no longer needed– However, strict time limit not warranted presently

• Ensure cath tip in large vessel (SVC)– Monitor frequently with CXR or ultrasound

• Develop new PICC materials or coatings• Promptly investigate leaks, difficulty flushing

12 See Notes for references.

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Take-Home Points

• Use of PICCs has become increasingly prevalent, including in pediatric inpatients

• PICC complications include:– Injury to other vessels or organs during insertion– Catheter migration or malposition with extravasation

from the malpositioned catheter– Infection– Thromboembolism– Catheter breakage– Dysfunction

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Take-Home Points (2)

• In a case series of 1650 PICCs, fracture and embolization occurred at an incidence of 6.7 in 1000 PICCs

• Duration of placement and line complication (blockage of the line or leaking at the insertion site) are associated with PICC fractures

• Caregivers should be warned against flushing PICCs with small-volume syringes or with too much pressure