Peripherally inserted central lines: does the material make a difference?
Myron Yaster MD and Mark Schreiner MD
Today’s PAAD by Ulman et al.1 is one of particular interest to me. One of the worst parts of being a pediatric intern in the 1970s was having to start IVs and drawing blood. There were no IV teams and nurses didn’t place IVs or draw blood specimens either…it was outside the scope of their practice. Further, at the time, the smallest gauge IV catheters were 22 g…anything smaller required using 25 g butterflies and it didn’t take a genius to figure out that those lasted less than 24 hours… And then sometime later, a miracle occurred, namely the introduction of long-lasting silicone central lines that were placed by surgeons for patients who required long-term IV access. Initially, these central lines were placed in the internal jugular or subclavian veins. Later, they were placed peripherally and a new age dawned. Who placed these peripherally inserted central catheters? Radiologists and later by skilled infusion care nurses were responsible for placement.
I wondered why couldn’t we as pediatric anesthesiologists offer this service as well? In the early 2000s, a team of my colleagues at Johns Hopkins led by Dr. Deboral Schwengel, decided to study this question. They published a study that demonstrated that peripherally inserted central lines (PICCs) could be inserted by anesthesiologists during various initial pediatric surgeries in patients requiring more than 4 days of hospital postoperative care, especially if frequent blood sampling or IV access was required.2 Although relatively easy to do since the kids were already anesthetized, the idea that anesthesiologists could do this failed because it interfered with the already established normal processes of managing these catheters. For example, what type of catheter was being inserted? Who was going to follow these patients? Who was going to be responsible for their removal, etc.? Practically we had to abandon the idea. At CHOP and Hopkins, the IV team, who were responsible for PICC line placement, were reluctant to follow patients whose lines were placed in the OR and we (MS) too had to abandon the practice.
Perhaps because of these experiences, I’ve remained interested in this topic, particularly in the differences in the materials used in making PICCs. The material used in the Schwengel study was silicone. Today, most PICCs are made of polyurethane, a much stiffer material than silicone and much easier to place. Indeed, polyurethane is the predominate material used in making the central lines we use when we place internal jugular central catheters in the OR. Ulman et al. wondered if device failure due to infectious, thrombotic, and catheter occlusion events could be affected by the material PICC lines were made of. Myron Yaster MD
Original article
Ullman AJ, August D, Kleidon TM, Walker RM, Marsh N, Bulmer AC, Pearch B, Runnegar N, Leema J, Lee-Archer P, Biles C, Gibson V, Royle R, Southam K, Byrnes J, Chopra V, Coulthard A, Mollee P, Rickard CM, Harris PNA, Ware RS. A Comparison of Peripherally Inserted Central Catheter Materials. N Engl J Med. 2025 Jan 9;392(2):161-172. doi: 10.1056/NEJMoa2406815. PMID: 39778170.
In a recent PAAD (December 12, 2024 “Medical device regulation” https://ronlitman.substack.com/p/medical-device-regulation ) discussed some of the issues with new devices approved using the 510(k) approval process. This study highlights another issue; what is the utility/efficacy/value of the new iteration of a device compared to predicate device(s). Devices approved via this pathway have not undergone clinical trials and so clinicians must make decisions often based on hype instead of data. The investigators in this study addressed this issue directly by testing whether or not newer materials – hydrophobic catheters or catheters embedded with chlorhexidine coated – offered any advantage regarding failure rate or complications compared to plain polyurethane catheters.
The investigators noted that “Over the past decade, there has been greater recognition and response to the infectious, thrombotic, and mechanical complications associated with their use.3 An influx of products, practices, and technological advances has been introduced by manufacturers to reduce the risk of such complications.4 The development of technological innovations embedded within the PICC is a solution for reducing harm.”1
“Most conventional PICCs are made of polyurethane. Advances in material technology have introduced coatings and altered surfaces with purported antithrombotic and antiinfective properties to be used with polyurethane PICCs. Hydrophobic catheter materials are commonly used in other contexts (e.g., oil spills) but are a relatively new health care technology. Fluorinated hydrophobic materials, such as the BioFlo PICC (Spectrum Vascular), inhibit platelet adhesion and suppress protein procoagulant conformation. Antiinfective materials such as antibiotics or antiseptics have been well studied and chlorhexidine-coated PICCs have been introduced to clinical practice (Arrowg+ard Blue Advance, Teleflex).”1
The study was designed as a superiority clinical trial designed to determine if the “risk of device failure due to complications would be lower with two technological innovations (hydrophobic and chlorhexidine PICCs) than with standard polyurethane PICC.”1 The study enrolled 178 children (mean age 12) and 920 adults (mean age 57) who had a vein sufficient to insert a 4.0 French catheter. Since newer catheters are undoubtably going to be more expensive, it is vital that they should prove superior to justify the added cost. Theoretically, they should reduce either embolic complications or reduce infections, but in practice did they?
The trial failed to demonstrate the superiority of either the hydrophobic PICC or the chlorhexidine PICC comparedwith a standard polyurethane PICC. The polyurethane catheters were associated with a slightly greater incidence of adverse events but these didn’t result in a higher incidence of PICC failure. In fact, the lowest incidence of device failure was in the group assigned to the standard polyurethane catheter. Based on this trial, it is hard to justify the use of either of the newer iterations of PICC.
https://www.nejm.org/doi/full/10.1056/NEJMoa2406815
Ah, the value of data! What do you think? What kind of PICCs are being used in your practice. Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Ullman AJ, August D, Kleidon TM, et al. A Comparison of Peripherally Inserted Central Catheter Materials. The New England journal of medicine 2025;392(2):161-172. (In eng). DOI: 10.1056/NEJMoa2406815.
2. Schwengel DA, McGready J, Berenholtz SM, Kozlowski LJ, Nichols DG, Yaster M. Peripherally inserted central catheters: a randomized, controlled, prospective trial in pediatric surgical patients. AnesthAnalg 2004;99(4):1038-43, table.
3. Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. BMJ quality & safety 2022;31(1):23-30. (In eng). DOI: 10.1136/bmjqs-2021-013015.
4. Schults JA, Kleidon T, Charles K, Young ER, Ullman AJ. Peripherally inserted central catheter design and material for reducing catheter failure and complications. The Cochrane database of systematic reviews 2024;6(6):Cd013366. (In eng). DOI: 10.1002/14651858.CD013366.pub2.