When is a central line preferred over a Peripherally Inserted Central Catheter (PICC) line?

When to Choose a Central Line Over a PICC Line

Central lines are preferred over PICC lines when immediate access is needed for hemodynamically unstable patients, when vasopressors are required, when hemodialysis access is needed, or when treatment duration exceeds 3 months. 1

Key Indications for Central Line Placement

Hemodynamic Considerations

• Central lines are preferred for hemodynamically unstable patients requiring invasive monitoring or immediate central access 1
• Urgent requests for PICC placement in hemodynamically unstable patients are considered inappropriate 1
• CVCs are preferred over PICCs in patients actively receiving vasopressors 1

Duration of Treatment

• For infusion therapy expected to last less than 6 days, peripheral IV catheters are preferred over both central lines and PICCs 1
• For therapy lasting 6-14 days in stable patients, midline catheters are often more appropriate than either central lines or PICCs 1
• For long-term access exceeding 3 months, tunneled central catheters or implanted ports are preferred over PICCs 1

Type of Infusate

• Both central lines and PICCs are appropriate for irritant or vesicant medications that require central venous access 1
• For parenteral nutrition with high osmolarity solutions, the catheter tip should be placed in the lower third of the SVC or upper right atrium, which can be achieved with either central lines or PICCs 1

Special Patient Populations

Renal Patients

• Central lines are strongly preferred over PICCs in patients with chronic kidney disease stage 3 or worse 1
• The National Kidney Foundation Disease Outcomes Quality Initiative (NKF-KDOQI) recommends avoiding PICCs in patients at risk for future hemodialysis vascular access 1
• For hemodialysis access of >3 weeks duration, tunneled cuffed central venous catheters are the method of choice 1

Critical Care Patients

• In critically ill patients, central lines are preferred for proposed treatment durations of 6-14 days 1
• PICCs are appropriate in critical care only when the proposed duration of treatment is 15 or more days 1
• In patients with coagulopathies (such as DIC or sepsis), PICCs may be preferred over central lines due to lower insertion complication risks 1

Oncology Patients

• For chemotherapy lasting less than 3 months, PICCs may be appropriate, though panelists have disagreed on this due to thrombosis risk 1
• For long-term chemotherapy (>6 months), implanted ports are preferred over both PICCs and traditional central lines 1
• Ports have been shown to have the lowest reported rates of catheter-related bloodstream infections compared to tunneled or non-tunneled CVCs 1

Complication Considerations

Infection Risk

• Recent evidence suggests midlines have lower rates of bloodstream infection compared to PICCs for short-term use (1.6% vs 0.4%) 2
• Ports have the lowest reported rates of catheter-related bloodstream infections for long-term use 1
• Subclavian insertion of central lines is associated with lower frequency of catheter-related infections compared to jugular insertion 1

Thrombosis Risk

• PICCs are associated with higher risk of deep vein thrombosis compared to central lines 3
• Recent data shows PICCs may have lower DVT risk than midlines in time-to-event models (hazard ratio, 0.53) 2
• For patients with recent PICC-related DVT who absolutely require central access, central lines should be considered 4

Mechanical Complications

• Midlines have lower rates of occlusion compared to PICCs (2.1% vs 7.0%) 2
• PICCs have higher rates of accidental withdrawal (8.9%) compared to tunneled central lines 5
• Central lines placed in the subclavian vein have approximately 10 times lower risk of mechanical complications and thrombosis compared to femoral access 1

Practical Considerations

Urgent Access Needs

• Central lines provide immediate access and can be placed at the bedside in emergency situations 1
• PICCs typically require more time for placement and verification of position 1
• In emergency situations requiring central access, central lines are preferred over PICCs 1

Monitoring Capabilities

• Both PICCs and central lines can be used for central venous pressure monitoring with similar accuracy 6
• For patients requiring frequent hemodynamic monitoring, central lines may be preferred due to more reliable access 1

Patient Mobility and Self-Care

• PICCs may not be suitable for patients receiving home parenteral nutrition who are self-caring because the PICC effectively disables one arm 1
• For patients requiring long-term frequent or continuous access, a tunneled CVC is preferable to a port 1

In summary, while PICCs offer advantages in certain scenarios, central lines remain the preferred option for hemodynamically unstable patients, those requiring vasopressors, patients with renal disease, and those needing very long-term access. The decision should be based on the specific clinical scenario, expected duration of treatment, and patient-specific factors.