Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

Background and aims: Total parenteral nutrition (TPN) is typically delivere d through catheters inserted into the superior vena cava (SVC) via a subcla vian or internal jugular vein approach. A peripherally-inserted central ven ous catheter (PICC), utilizing a cephalic or basilic venous approach, may p rovide a safe alternative to the standard catheter approach and, because no n-physician providers can insert the PICC, may introduce a potential cost-s avings to health care institutions. We sought to determine if PICC lines ar e safer and more cost-effective than the standard central venous catheter a pproach for hospitalized patients who require TPN. Methods: One hundred and two hospitalized patients (age range, 18-88 years) who required TPN were prospectively randomized to receive therapy via a ce ntrally-inserted subclavian catheter (n = 51) or a peripherally-inserted PI CC line (n = 51). The primary end-point was the development of a complicati on requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of ea ch catheter was also studied. Results: Complication-free delivery rate (without the need to remove or rep lace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P < 0.05). The overall infection rate was 4.9 per 1000 catheter days and w as similar for each catheter type (P = 0.68). PICC lines were associated wi th higher rates of clinically-evident thrombophlebitis (P < 0.01), difficul t insertion attempts (P < 0.05), and malposition on insertion (P < 0.05). N o catheter complications resulted in significant long-term morbity or morta lity. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P = 0.18), dislodgement (P = 0.12), o r line occlusion (P = 0.25). After standardizing costs for each hospital, t he direct institutional costs for insertion and maintenance of PICC lines ( US$22.32 +/- 2.74 per day) was greater than that for subclavian lines (US$1 6.20 +/- 2.96 per day; P < 0.05). Conclusion: PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard sub clavian approach for central venous access in hospitalized patients who req uire TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the cathete r. (C) 2000 Harcourt Publishers Ltd.