title: Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters.
abstract: OBJECTIVE
  Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach 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 centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied.
  
  
  RESULTS
  Complication-free delivery rate (without the need to remove or replace 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 was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the 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$16.20+/-2.96 per day;P<0.05).
  
  
  CONCLUSIONS
  PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.
authors.affiliation: Department of Internal Medicine, Mayo Clinic and Mayo Medical School, Rochester, Minnesota 55905, USA.
authors.forename: C T
authors.initials: CT
authors.lastname: Cowl
authors.forename: J V
authors.initials: JV
authors.lastname: Weinstock
authors.forename: A
authors.initials: A
authors.lastname: Al-Jurf
authors.forename: K
authors.initials: K
authors.lastname: Ephgrave
authors.forename: J A
authors.initials: JA
authors.lastname: Murray
authors.forename: K
authors.initials: K
authors.lastname: Dillon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation*; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D010289:Parenteral Nutrition, Total / Q000009:adverse effects* / Q000191:economics* / Q000295:instrumentation; D011446:Prospective Studies; D013924:Thrombophlebitis / Q000209:etiology