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Nearly one-quarter of patients receiving a peripheral-inserted central catheter (PICC) during their stay in hospital have advanced chronic renal failure (CKD), a large sample of Michigan hospital patients has found. However, the use of PICC should be avoided in these patients in order to preserve future vascular access, and is actually contraindicated in the recommendations, the authors point out.
"Vascular access is essential for patients with chronic kidney disease, who may need a renal replacement therapy," said David Paje, MD, MPH, University School of Medicine. of Michigan, Ann Harbor, in an article published online June 4 Annals of Internal Medicine.
"[Yet] Despite the recommendations against the use of PICC in patients with kidney disease, we found that this practice was common and inconsistent with the recommendations, "he added.
An arterio-venous fistula (AVF) is the preferred choice for long-term hemodialysis and is more likely to succeed if the veins have not already been compromised by the insertion of an arteriovenous fistula (AVF). a vascular catheter such as a PICC, explain Paje and his colleagues.
And in an accompanying editorial, Marcia Silver, MD, Case Western Reserve University School of Medicine at MetroHealth Medical Center in Cleveland, Ohio, reminds the reader that the mortality rate of patients receiving dialysis via a catheter is between 1.6 and 2.5 times that of dialysis. patients with internal access and without catheter.
"The higher rate of catheter use in American hemodialysis patients probably explains the higher mortality observed compared to that of other countries," Silver notes.
Such statistics have resulted in the "Fistula First, Catheter Last" campaign among those whose main objective is to reduce the use of catheters and to increase the use of indigenous venous fistulas in the United States. United, she noted.
Although these campaigns have led to a substantial improvement in the use of native venous fistulas in prevalent hemodialysis patients, national rates of catheter use by hemodialysis patients have hardly changed, says Silver. The latest report of the United States Renal Data System (J Vasc Surg. 2008; 48: 2S-25S) still shows that up to 80% of incident dialysis patients are dialyzed via a catheter.
"PICCs damage the veins needed for vascular access for dialysis [and] they reduce success rates for creating the preferred types of vascular access, "she notes.And" the guidelines recommended avoiding PICCs in patients with chronic renal failure. " stage 3b or worse. [CKD]and the complication rates are high, "says Silver.
She described the Paje study and her colleagues as "extraordinary, with so many files examined by qualified data badyzers", and the results "reaffirm previous observations that too little attention has been paid to recommendations for protection of the veins of patients with nephropathy, "she says. recommending a number of "vein saving" strategies that could easily be used.
Nearly one-third of ICU MRC patients had PICCs placed
In their study, Paje and his coauthors used patient-level data from a multi-institutional quality collaborative effort to evaluate the setting up of PICC in patients with chronic renal failure (MC). ) of Stage 3b or greater, defined as an estimated glomerular filtration rate of less than 45 ml / min / 1.73m2.
Data were badyzed from November 2013 to September 2016 in 52 hospitals participating in the Michigan Medicine Safety Consortium.
"The primary endpoint was the percentage of patients with eGFR less than 45 mL / min / 1.73 m2 (stage 3b or higher) among all the patients who received PICC ", note the researchers.
During the study interval, 20,545 patients were placed in a PICC during their stay in the hospital, of which 23.1% had stage 3b CKD. or more.
More patients with chronic kidney disease in the intensive care unit (ICU) had PICCs implanted at 32.1%, compared with 18.9% in services. The researchers noted that older patients were much more likely to receive a PICC both in the ICU and in the service than younger patients.
However, 3.4% of hemodialysis patients also received PICC during their stay in the hospital.
PICC were removed in two-thirds of patients with chronic kidney disease before discharge from the hospital and nearly 30% of them had it in place for 5 days or less – an interval when Other venous access devices are considered more appropriate, stress the investigators.
And most often, patients with chronic kidney disease received a PICC of 5 or more French, and multi-lumen PICCs were placed more frequently than single-light PICCs, both in ICU patients and in patients with chronic cerebral palsy. Services.
In ICU, 30.9% of patients receiving PICC had eGFR less than 45 mL / min / 1.73 m2; the corresponding percentage in neighborhoods was 19.3%.
And in patients with eGFR less than 45 mL / min / 1.73 m2, multiclear PICCs were placed more frequently than single-light PICCs.
"Our findings raise the question of why the use of PICC is so prevalent in patients with chronic kidney disease," say Paje and his coauthors.
They suggest a number of possible explanations and argue that "the lack of development … of" security systems "- especially for the doctors who order these devices and the vascular access nurses who most often insert PICCs – could have led to an inadvertent placement. "
Hospitals should leverage nurses and nephrologists to improve care
The most common complication badociated with the use of PICC in patients with chronic kidney disease was catheter occlusion; ICU patients had higher catheter occlusion rates of 14.8%, compared to those in the department, by 9.3%.
However, major complications, including thromboembolism and venous infection, were not uncommon.
In patients with eGFR less than 45 mL / min / 1.73 m2The number of PICC placements varied considerably between the consortium hospitals (interquartile range, 23.7% to 37.8% in intensive care units and 12.8% to 23.7% in services).
And as the authors have already observed, most PICCs placed in patients with chronic kidney disease were multi-lumen devices, "many of them having no documented indication suggesting a real need for the device."
"Thus," they add, "not only are PICCs potentially used inappropriately in patients with CKD, but the choice of providers with respect to device features can further increase the risk of adverse events." ", they stress.
The American Society of Nephrology recommends clinicians to consult a nephrologist before placing a PICC in patients with stage 3 to 5 coronary insufficiency – a recommendation that most hospitals participating in the study could have followed, knowing that 90% of them had a nephrologist among their workforce. contributed to IPCC-based decisions, investigators pointed out.
Silver also points out in his editorial that nurses admitting patients to the hospital "had the habit of identifying people with RCM who needed venous protection". But in the 1980s, "we have doubled the number of patients in most US hospital nurses, and the commitment to this problem has subsequently decreased."
Paje and colleagues also point to this aspect of care, noting: "Vascular access nurses are well placed to play this role and, in this study, they were less likely to place PICCs in patients with nephropathy."
"Giving vascular access teams led by nurses the means to define clinical needs in terms of access, to take into account the patient's clinical profile and to make recommendations for the choice of the appropriate device can help improve decision-making, "they write.
And the earlier orientation of patients at risk of progression from chronic nephropathy to nephrology also results in less frequent use of the catheter, Silver says. However, many are still referred late or become "fast starts" to dialysis. "The risk stratification tools could help select those who need a recommendation," she says.
Strategies to protect veins include "blue bracelets"
Silver then recommends a number of vein protection strategies. First, the avoidance of PICC in patients with chronic kidney disease for whom short tunnel internal jugular catheters could serve as an alternative.
Second, the use of a pediatric tube for phlebotomy needs would be helpful for everyone.
And "electronic medical records should include tools to identify patients who need backup vein techniques," Silver suggests.
In addition, "blue bracelets (blue for veins) marked" SAVE ARM VEINS " [should be worn to] Remind patients and staff to use a vein-saving technique, "she says.
Finally, data from Paje and colleagues remind the medical community that any strategy for vein protection depends on decisions made by non-nephrologists treating patients with chronic kidney disease, she notes.
"Therefore, the education and commitment of the general medical community are of paramount importance for further progress," Silver concludes.
Paje and Silver have not reported any relevant financial relationship.
Ann Intern Med. Posted online 4 June 2019. Abstract, Editorial
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