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Safety versus
Problems of TPN Administration via PICC lines
In some hospital settings,
PICCs have has become the preferred alternative over
central venous lines inserted in the neck region for
administration of total parenteral nutrition therapy
(TPN). This is due to three main factors: cost-effectiveness,
ease of insertion and a significantly small incidence
of major complications.
Cost-effectiveness has
become vital in these days of managed healthcare. As
physician reimbursements for central line placements
and PICC have steadily declined, specially trained and
certified nursing teams have now been delivering effective
PICC placement services beginning with insertion through
to continuing care and education after the lines have
been placed. The cost effectiveness is proven through
numerous studies(1).
Ease of insertion compared
to subclavian or internal jugular placements not only
means greater cost-effectiveness in terms of the hours
saved in trying to secure intravenous access, but also
making the procedure much more tolerable for patients.
With PICC lines, the failure rate is significantly lower.
There is significantly less tissue trauma and complication
risks are substantially lower. In addition, risk for
infection is greatly decreased related to the mere placement
of the line - neck versus upper arm for PICC lines.
Major central venous
complications include a hemothorax, pneumothorax, cardiac
tamponade, or rupture of blood vessels which are not
typically present in PICC line placement. In addition,
there are fewer migrations of catheter tips compared
to central catheterization. With decreased complications,
patients in a sub-acute setting, who are much likely
to be conscious and eager to be discharged, experience
much less anxiety. It also makes monitoring easy which
is very advantageous use in a domestic setting.
The only drawback of
PICC in comparison to central lines appear to be venous
thrombophlebitis (10-30%)(1) and line occlusion. These
complications may result in declotting an occluded line,
which is highly successful and non-invasive, restarting
lines at more frequent intervals, or in rare instances,
conversion to central catheterization. In addition,
PICCs may also be difficult to insert in certain patients,
for example, those with very poor venous access, gross
obesity or exhaustion of viable veins due to repeated
cannulation. However, placements of other types of lines
are subject to the same difficulties.
Weighing risks versus
benefits, a PICC is most suitable for the administration
of TPN in the vast majority of cases. With improved
biomaterials and better topical and systemic anticoagulation
management, the use of PICC is likely to become more
widespread in the coming years.
References
(1) Cowl CT, Winstock J V et al (2000) Complications
and cost associated with parenteral nutrition delivered
to hospitalized patients through either subclavian or
peripherally-inserted central catheters Clinical Nutrition,
Volume 19, Issue 4, August 2000, Pages 237-243
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