Central Venous Access for Total Parenteral Nutrition

Catheter Selection

For short to medium-term use (up to 3 months), PICCs are preferred due to their ease of insertion and lower risk of complications, while tunneled CVCs are recommended for long-term TPN (>3 months) due to lower complication rates and better durability, as suggested by the Clinical Nutrition guidelines 1, 2
Tunneled CVCs, such as Hickman or Broviac, are strongly recommended due to their better fixation, lower infection rates, and greater durability, with fewer replacements needed 2, 3
PICC lines offer advantages, including the ability to be inserted without general anesthesia, no direct vein manipulation, and lower risk of insertion complications, making them suitable for use by trained non-physician providers 2

High osmolarity solutions (>850 mOsm/L) require central venous access, while solutions with osmolarity ≤850 mOsm/L may be suitable for peripheral access for short-term use, as recommended by the Clinical Nutrition guidelines 1, 3
A dedicated lumen should be used exclusively for TPN, regardless of catheter type, to reduce the risk of infection and complications 2
Single-lumen catheters are preferred when possible to reduce infection risk, and if multi-lumen catheters are necessary, one lumen should be reserved exclusively for TPN 2

Ultrasound guidance should be used for insertion to reduce complications, as recommended by the Clinical Nutrition guidelines 3
Femoral vein access should be avoided for TPN due to high contamination and thrombosis risk, as suggested by the Clinical Nutrition guidelines 3
Central venous catheters, including midline catheters and PICC lines, differ in insertion depth, tip location, duration of use, and indications, with PICCs being central venous catheters that terminate in the superior vena cava, while midlines remain in peripheral veins 4

Midline catheters are non-tunneled devices with a length of 7.5 to 25 cm, inserted above the antecubital fossa in the upper arm, and terminate in the basilic or cephalic vein, short of the subclavian vein, intended for medium-term access 4, 3
PICC lines have a length of >45 cm in adults, are inserted in the upper arm peripheral veins, and terminate in the lower portion of the superior vena cava or upper portion of the right atrium, providing access to central circulation, and can be tunneled or non-tunneled 4
Midline catheters are suitable for peripherally compatible infusates (osmolarity ≤850 mOsm/L) and preferred for infusion durations of 6-14 days 4, 3, 5
PICC lines are suitable for both peripherally compatible and non-compatible infusates, preferred for infusion durations >15 days, and required for irritants or vesicants (e.g., chemotherapy, parenteral nutrition with high osmolarity) 4, 3

Patient selection and catheter choice significantly impact morbidity, mortality, and quality of life outcomes, with the Infusion Nurses Society recommending assessment of infusate characteristics and expected duration of therapy to guide catheter selection 4
The American College of Radiology recommends avoiding PICC lines in patients with chronic kidney disease who may need future hemodialysis access 5
For frequent phlebotomy (≥3/day) for >6 days, PICC lines are preferred, while for patients with self-care requirements, PICC lines may limit use of one arm, affecting patient independence 4, 3

For infusion durations ≤14 days, midline catheters are preferred, for 15-28 days, consider PICC lines, and for >28 days, PICC lines are required 4, 3
For peripherally compatible infusates, either device is appropriate, while for irritant/vesicant medications or TPN with high osmolarity, PICC lines are required 4, 3, 5
The American College of Radiology and Clinical Nutrition guidelines state that tunneled catheters are typically intended for longer-term use (>3 months) and have lower infection rates compared to non-tunneled PICCs 3, 5

Physical examination, ultrasound assessment, and reviewing procedural documentation can help determine tunneling status, while X-ray imaging can confirm catheter tip position but has limitations in distinguishing between tunneled and non-tunneled PICCs 6, 7, 3, 5
The American Society of Anesthesiologists and the European Society for Medical Oncology note that X-ray imaging has significant limitations, including the inability to visualize soft tissue tunnels, making it difficult to distinguish between tunneled and non-tunneled PICCs 6, 7
Misidentifying catheter type based on X-ray appearance alone can have significant clinical implications, with tunneled PICCs typically having lower infection rates and being intended for longer-term use 6, 3