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Annals for Hospitalists Inpatient Notes - Choosing a Central Line in the ICUWhat's New and What's True?

A 60-year-old man with a history of diabetes, hyperlipidemia, and prostate cancer is seen in the emergency department for 5 days of fever and purulent sputum. Vital signs are temperature 39.1o C, heart rate 110 beats/min, respiratory rate 22 breaths/min, SpO2 91% on 3 L/min of oxygen, and blood pressure 70/30 mm Hg. Serum lactate is 5 mmol/L. A chest radiograph shows a right lower lobe infiltrate. Bedside ultrasonography finds a hyperdynamic left ventricle and inferior vena cava variation. Cultures are obtained, antibiotics are initiated, and the patient receives 30 mL/kg of intravenous fluids. His heart rate subsequently decreases to 100 beats/min, and SpO2 is 96% on 3 L/min of oxygen; however, blood pressure remains low at 80/40 mm Hg. Repeated measurement of serum lactate is 4 mmol/L. The decision is made to initiate central venous access and admit the patient to the intensive care unit (ICU). He has one 18-gauge peripheral intravenous catheter in place, with other good peripheral targets available. What is the best choice of central venous access for this patient? Fifty to 80% of critically ill patients require central venous access at some point during the hospital stay (1). Over the past decade, decisions regarding such access have become more complicated, as peripherally inserted central venous catheters (PICCs) have emerged as an alternative to traditional central venous catheters (CVCs). Further, additional information that links specific catheter characteristics (e.g., number of lumens and gauge) with complications has become available. This has led to substantial variation among facilities in the types of devices used (2). What Are Current Best Practices for Vascular Access in the ICU? Recent publications offer new guidance for decision making regarding vascular access in the ICU. In 2015, the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provided an extensive set of recommendations on intravenous access in hospitalized patients across multiple settings (3). Based on current evidence, we consider the following principles when initiating vascular access in the ICU. 1. In hemodynamically unstable patients, where the anticipated duration of central venous access is less than 15 days, CVCs are recommended over PICCs (3). Two main factors drive this recommendation: higher rates of venous thromboembolism (VTE) with PICCs than with CVCs (3), and a theoretical advantage of CVCs being able to be placed more quickly in urgent situations. Rapid PICC insertion is not available at every facility, so CVCs are generally more appropriate for hypotensive patients. However, further research is needed to better guide the choice of central access devices in this population. 2. In patients with comorbid risk factors for VTE, traditional CVCs are preferred over PICCs. Specific risk factors include cancer and a history of VTE. This recommendation is based on evidence noting a significantly higher risk for VTE with PICCs than with CVCs (3). 3. Each lumen matters. Although multilumen devices may be more versatile, each additional lumen increases risk for central line-associated bloodstream infection (CLABSI). Compared with single-lumen devices, double-lumen devices have an adjusted odds ratio (aOR) for CLABSI of 4 and triple lumen devices have an aOR of 6 (4). 4. Catheter size is important. Evidence shows that a higher ratio of catheter-to-vein diameter is an important VTE risk factor (3). The greater obstructive effect of larger catheters leads to venous stasis and increased VTE incidence. Notably, the diameter of the catheter (that is, gauge) does not always correlate with the number of lumens. 5. Established, evidence-based practices are fundamental to the safe use of central access devices. These practices (including use of bundles, insertion precautions, and aggressive early removal of devices) must be rigorously implemented and maintained (5). The Case, Continued Here is how we would approach the question of central venous access in the critically ill patient above. First, we would determine which devices are accessible and whether appropriately trained staff are available to place them. Both CVCs and PICCs are obtainable at our institutions, and we have staff readily available to place either type. Ideally, all hospitals would maintain the capability to place either of these lines, although we recognize that that may not currently be feasible in every facility. Next, we would consider patient-specific factors. For the patient described here, we would select a traditional CVC because he is hemodynamically unstable, has a history of cancer, and has an elevated risk for VTE and the anticipated duration of catheter placement is less than 15 days. If the patient did not have cancer, the decision would be less clear. Without the additional VTE risk factor, the advantage of a CVC over a PICC line is less certain. Although we would still choose a CVC based on current guidelines, more data from head-to-head comparisons of the 2 devices are needed to establish the optimal approach. Finally, we would critically evaluate the necessary characteristics of the device. In this case, the patient has a large-bore peripheral intravenous catheter and good targets for more, if needed. His oxygen requirement is also improving, decreasing the probability of the need for intubation, sedation, or neuromuscular blockade. Therefore, we would place a double-lumen CVC, in either the internal jugular or the subclavian vein, using ultrasound guidance and following evidence-based bundles. We would choose a CVC in the 4-French range to reduce risk for VTE. We recommend that hospitals stock an appropriate variety of catheters (that is, gauge and number of lumens) to optimize decision making. Summary As choices expand, determining the optimal central venous access for a given patient is becoming more complex. Attention to emerging data helps us to select the safest option for each patient, based on available literature. Nevertheless, many of our decisions about vascular access still lack strong evidence to guide them. A focused research agenda in this area is necessary and vital to ensure that intensive care practitioners make informed choices, leading to optimized vascular access outcomes for our patients.