Central venous pressure measurements: Peripherally inserted catheters versus centrally inserted catheters

Ian H. Black, MD; Sandralee A. Blosser, MD, FCCM; W. Bosseau Murray, MB, ChB, FFA (RCS)(Eng.), MD

Objective: To determine whether central venous pressure measurements taken from a peripherally inserted central catheter (PICC) correlate with those from a centrally inserted central catheter (CICC). Design: A pilot bench study followed by a prospective, nonblinded, clinical comparison. Setting: A 16-bed medical coronary intensive care unit and a 30-bed surgical intensive care unit at a university hospital. Patients: Seven surgical intensive care unit patients and ve medical coronary intensive care unit patients. Interventions: During the bench study, a simple manometer system was set up to test the catheters. During the clinical study, measurements of central venous pressure were recorded from patients who had an indwelling CICC and PICC concomitantly. Positions of the catheter tips in the chest were veried by radiography. Paired central venous pressure measurements were taken from 19-gauge dual-lumen PICCs and from 7-Fr, 16-gauge, 18-gauge, and pulmonary artery catheter CICCs, all with continuous pressure infusion devices. Measurements and Main Results: Bench work showed that

PICCs, because of their longer length and narrower lumen, have a higher inherent resistance, which can be overcome with a continuous infusion device. During the clinical study, three to 12 paired, digital, central venous pressure measurements were recorded from each of 12 patients for a total of 77 data pairs. Measurements were recorded at end-expiration. Mean central venous pressure from the CICCs was 11 7 mm Hg, and from the PICCs was 12 7 mm Hg. PICC pressure versus CICC pressure 0.99) for all data pairs. Analysis by repeated correlated (r measures showed PICC central venous pressure more than CICC central venous pressure by 1.0 3.2 mm Hg (p 0.02). Conclusions: PICCs can be used to measure central venous pressure and to follow trends in a clinical setting when used with a pressure infusion device to overcome the natural resistance of the PICC. Central venous pressure recorded via PICCs is slightly higher, but the difference is clinically insignicant. (Crit Care Med 2000; 28:38333836) KEY WORDS: central venous pressure; central venous catheterization; peripheral catheterization; indwelling catheters

centrally inserted central catheter (CICC) is commonly placed in the internal jugular or subclavian vein of intensive care unit (ICU) patients. This catheter provides iv access for delivery of uids, medications, and nutrition, and a direct way to measure central venous pressure. Insertion of a CICC has a known morbidity and mortality (15). As an alternative, ICU patients may undergo insertion of peripherally inserted central catheters (PICCs) for longer term iv access. PICCs are placed in the cephalic or basilic vein and are advanced until the tip resides in a

From the Pennsylvania State University College of Medicine (Dr. Black) and the Departments of Anesthesia (Drs. Blosser and Murray), Surgery (Dr. Blosser), and Medicine (Dr. Blosser), Pennsylvania State University College of Medicine, Hershey, PA. Address requests for reprints to: Sandralee Blosser, MD, Section of Trauma and Critical Care Surgery, Pennsylvania State University College of Medicine, The Milton S. Hershey Medical Center, PO Box 850, Hershey, PA 17033-0850. Copyright 2000 by Lippincott Williams & Wilkins

central vein. Placement and use of percutaneous and surgically implanted CICCs carry inherent risks and costs that may not be associated with PICCs (6 12). If central venous pressure measurements from PICCs correlated with those from CICCs, placement of some CICCs may be avoided. In the manufacturers guidelines (13) there is currently no recommendation for the use of PICCs to measure central venous pressure. There is the perception that the catheter is too pliable, the catheter is too long, and the lumen is too narrow to transmit pressures accurately. Our hypothesis is that PICCs can measure central venous pressure as reliably as CICCs, but only when coupled with a continuous infusion device. We hypothesized that in vivo the characteristics of the catheter would have minimal effect on the transmission of the mean pressure column, and subsequently the central venous pressure measurement would be accurate. The increased pliability of the PICC should make it an inferior tool to

monitor the central venous pressure waveform, but a better tool to measure the average central venous pressure, because the central venous pressure represents an idealized dampened average measurement of pressure uctuations. Regarding the idea that the length and the radius of the lumen make PICCs an unsuitable tool to measure central venous pressure, we refer to Poiseuilles law, which states p 8 lV/ r4t

where p is the pressure drop, is the viscosity coefcient, l is the length, V/t is the ow, and r is the radius. This law predicts that the pressure drop that occurs across the length of a catheter in a closed system is a constant with constant ow, if laminar ow exists and if the effects of surface tension are equal throughout the length of the catheter. The components of the resistance in the PICC are lumen diameter, length, and surface tension. The high surface tension in a small-diameter tube, such as a PICC,
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invalidates Poiseuilles law by causing the surface tension to be an inconstant force. The surface tension creates a high initial resistance to ow. We theorized that the variable initial surface tension could be overcome by a constant ow device that would overcome the difculty to initiate ow. This is analogous to the two coefcients of friction in mechanics in which greater energy is needed to initiate movement of an object whereas less energy maintains the object at a constant velocity. Laminar ow could be assumed if the ow rates of the constant ow device are kept well below the maximum rate of ow of normal saline for the PICCs diameter (approximately 47 mL/min). To investigate our hypothesis, we performed a two-part study. The rst part was a laboratory test of our theory, and the second part was a comparison of PICC and CICC pressures in patients in the ICU.

MATERIALS AND METHODS

Laboratory Experiments. Before beginning the clinical portion of the study, bench studies were performed. The goal was to answer the following questions: Does a PICC equilibrate fully when used as a simple manometer tube (U-tube), and how long does it take to reach nal equilibration? Does a PICC generate a constant back-pressure with a constant infusion device? In addition, how long does a standard central venous pressure monitoring system take to equilibrate when used as a simple manometer? The times taken to reach equilibration and the remaining pressure differences were measured for a19-gauge lumen of a dual-lumen PICC, which is 60 cm long (Bard Access Devices, Salt Lake City, UT). These measurements were repeated for each CICC: a singlelumen infusion catheter (SLIC; Arrow International, Reading, PA), which is 7 Fr and 20 cm in length (actual measurement, 22 cm to the hub); 16-gauge and 18-gauge ports of a triple-lumen 20-cm catheter, which measures 34 cm to the end of the attached tubing (Arrow International); and the proximal injectate (central venous pressure) port of the pulmonary artery (PA) catheter, which measures 135 cm in length (SwanGanz; Baxter Healthcare Corporation, Irvine, CA). Each catheter was used as one limb in a simple U-tube manometer, with 16-gauge pressure tubing as the other limb. Pressure differences (i.e., differences in the height of the uid columns) in the limbs of the U-tube were created, with a stopcock preventing communication between the two limbs of the manometer. The time taken to reach nal equilibration was measured as well as the pressure differences remaining after all movement stopped. By tapping the tubes (both limbs and

mounting board), attempts were made to enhance (accelerate) pressure equilibration. A pressure infusion device (typically used to ush an arterial or CICC line with a ow of 3 mL/hr of saline) was connected to a PICC line that was open to the atmosphere (i.e., no back-pressure). The back-pressure generated by the resistance of the PICC line to the ow of 3 mL/hr was measured. Patient Selection. The clinical portion of the study was a prospective, nonblinded comparison performed between October 1997 and December 1998. It was done in a 16-bed medical coronary ICU and a 30-bed surgical ICU at the Milton S. Hershey Medical Center of the Penn State Geisinger Health System. Inclusion criteria were adult patients who had PICC and CICC catheters in place concomitantly, catheter tip placement in the chest conrmed by radiography, and a consent form signed by the patient or the patients representative. The institutional review board of the Pennsylvania State University College of Medicine approved this study and the consent form. Clinical Central Venous Pressure Measurements. All measurements were taken from PICCs and from CICCs that were already in place for clinical care. The most recent portable anteroposterior chest radiograph on each patient was viewed to verify that the catheter tips were in blood vessels in the chest. Transducers, which use a continuous infusion device of heparinized saline at 3 mL/hr, were leveled to the height of the right atrium. Saline-lled, 16-gauge pressure tubing (Baxter Healthcare, Deereld, IL) was connected to the CICC, the PICC, and the pressure transducer with a three-way stopcock. Each patient lay in the supine position with their arms at their sides. The three-way stopcock was turned to place the PICC or CICC in line with the transducer. Measurements were taken in rapid succession, with each measurement taken after the catheter was briey ushed each time with heparinized saline and after the waveform had equilibrated. All central venous pressure measurements were recorded as the digital mean using the Hewlett Packard 600 monitor (Palo Alto, CA) or the Marquette 7030 monitor (Milwaukee, WI), depending on the patients ICU location. The digital mean was timed for endexpiration by impedance plethysmography and by chest palpation. Three to 12 paired central venous pressure measurements were taken for each patient. Statistical Methods. Results are reported as mean SD. A weighted Pearsons correlation coefcient for repeated measures, which paired data to measure the strength and the direction of the relationship between PICC and CICC, was calculated by using a method developed by Chinchilli et al. (14). SAS version 7 software (SAS Institute, Cary, NC) was used to carry out all of the analyses. A p value 0.05 was considered signicant.

RESULTS
Laboratory Experiments. When the PICC was used as part of the simple manometer, and when the two limbs were allowed to communicate, an initial narrowing of the pressure difference occurred, but the average of 14 trials showed a remaining pressure difference of 1.5 0.6 mm Hg. The PICC could take between 2 and 60 mins to equilibrate (passively), and the pressure differences could occur in either limb. Tapping the system did not accelerate the pressure equilibration. Our bench work showed (average, 33 measurements) that a continuous infusion device, with a ow of 3 mL/hr of saline, generated a constant back-pressure of 3.5 0.3 mm Hg (minimum, 2.7 mm Hg; maximum, 3.8 mm Hg) through a PICC open to the atmosphere. Conversely, when the CICCs were tested, the SLIC equilibrated in 3.5 0.2 secs with a remaining pressure difference of 0.8 0.1 mm Hg. The 16-gauge port of a triple-lumen catheter equilibrated in 8.3 1.0 secs with a remaining pressure difference of 2.1 0.1 mm Hg, and the 18-gauge port equilibrated in 14.1 1.2 secs with a remaining pressure difference of 1.7 0.1 mm Hg. The central venous pressure port of the PA catheter equilibrated in 22.3 1.8 seconds with a pressure of 1.5 0.1 mm Hg. The average of ve tests was calculated for each of the CICCs. Because equilibration in these catheters was rapid (secs) a continuous infusion device was unnecessary, although it was present in all CICCs in the clinical portion of the study. Clinical Study. Data were collected from 12 patients. Clinical measurements were taken from 19-gauge dual-lumen PICCs and from CICCs that were 7 Fr, 16 gauge, 18 gauge, or the PA catheter central venous pressure injectate port. One patient had a 7-Fr SLIC, eight patients had a 16-gauge catheter, two patients had an 18-gauge catheter, and one patient had the central venous pressure port of the PA catheter. All patients had the tip of the PICC positioned in the superior vena cava conrmed by chest radiography, except for Patient 8, who had the PICC positioned in the left subclavian vein. The tips of the CICCs were in the superior vena cava. The twelve patients generated 77 paired data sets (Fig. 1 presents the means of each patients central venous pressures). The mean CICC pressure was
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11 7 mm Hg, whereas the PICC was 12 7 mm Hg (p NS). Figure 2 shows the correlation between PICC and CICC measurements for data pairs (r 0.99). The mean difference (PICC CICC) for the data set is signicantly different (p 0.02) from zero. The mean difference between all individual data pairs demonstrated the PICC central venous pressure was more than the CICC central venous pressure by 1 3.2 mm Hg (p 0.02). Two patients were found to have extremely high, superphysiologic PICC pressures with shallow slopes, indicative of occluded catheters (a shallow slope was a slower than expected equilibration in

pressure after ushing the device). Data from one patient was used after the PICC obstruction was removed by thrombolysis and the slope returned to normal. No data were collected from the second patient because the catheter remained occluded, and the patient was not included in the analysis.

DISCUSSION
The use of PICCs is increasing in hospitalized and ambulatory patients for many reasons, including reduced rates of infection, decreased risk of pneumothorax and great vessel perforation during

Figure 1. Mean central venous pressure measurements SD from the centrally inserted central catheter (CICC) and the peripherally inserted central catheter (PICC) for each patient (n 77 data sets for 12 patients). Patients without SD bars have SD 0.

Figure 2. Peripherally inserted central catheter (PICC) versus centrally inserted central catheter (CICC) measurements of central venous pressure (n 77 data pairs for 12 patients). Thirty-seven data points are not visible because of overlap with other points.

insertion, and reduced costs when compared with CICCs or surgically implanted catheters (6, 8 12). PICC use may increase further if there is condence in their ability to measure central venous pressure accurately. (In the current study there was at least one case in which the CICC was inserted solely for the purpose of central venous pressure monitoring.) The central venous pressure measurement is commonly used in conjunction with clinical signs and symptoms to guide uid therapy. It would be especially advantageous to use central venous pressure information that is readily available in patients with PICCs without additional invasive procedures. The current study shows that PICCs can measure central venous pressure as reliably as CICCs, but only when coupled with a continuous infusion device. Our initial bench work showed that PICCs, because of their longer length and narrower lumen, have a higher inherent resistance that makes them an inappropriate vehicle to measure central venous pressure without methodological modication. We used the continuous infusion device to overcome the PICCs inherent resistance. Based on this bench work of a PICC connected to a constant infusion device, we expected PICC pressures to be more than CICC pressures by 3 to 4 mm Hg. We were surprised that in the clinical study PICC pressures were greater by only 1 mm Hg. We theorize that the higher temperature in vivo compared with the ambient temperature in which the bench work was conducted may have expanded the lumens diameter and made the saline ush less viscous. Both of these effects would decrease the pressure produced by a ow of 3 mL/hr through the PICC. A higher reading of approximately 1 mm Hg is associated with the PICC measurements when the differences between the paired data points are calculated. This was statistically signicant, but clinically insignicant and not relevant. Considering the narrower lumen and greater length of the PICC, it is not unexpected that it should show a slightly higher back-pressure while attached to the continuous infusion device. It was noted that the rst PICC measurements may vary more from subsequent PICC measurements. We theorized that microthrombi may have partially occluded the PICCs, and these were swept away progressively with repeated ushing. The CICC measurements did not
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peripherally inserted central catheters provide an additional tool for assessing patients intravascular volume status, with a reported decrease in cost and risks.

entral pressure

venous mea-

surements from

have this variation, perhaps because they were attached to continuous infusion devices. The PICC catheters were not attached to continuous ow devices until the experiment was started. It is standard to use continuous infusion devices with CICCs, and continuous ow and monitoring of PICCs would minimize the impact of single outlier measurements. PICC response to ushing may also be used to assess the patency of PICC lines. After the ushing maneuver in a patent catheter, the high pressure generated by the ush device rapidly decreased to physiologic levels. The steep slope of this pressure decrease indicates a patent catheter. Although we did not examine the slopes of the PICC pressure decreases in detail, it was apparent that shallow slopes immediately after catheter ushing were indicative of line occlusion. Bench work and clinical data showed that PICCs should equilibrate rapidly after ushing. If, after ushing, the pressure did not fall in a few seconds to near-baseline levels, or the tracing remained at at an extended high (nonphysiologic) pressure, the line was totally or partially occluded.

The monitoring trace may offer a method to detect a partially kinked or occluded PICC. Central venous pressure measurements from PICCs provide an additional tool for assessing patients intravascular volume status, with a reported decrease in cost and risks (6 12). Although PICCs are associated with decreased infection rates and a decreased incidence of pneumothorax, PICCs may be associated with an increase in catheter malposition, inadvertent removal, and severed or leaking catheters, when compared with CICCs (12). Some institutions now use PICCs in favor of CICCs and surgically implanted catheters for long-term venous access (12, 15). With this additional benet of central venous pressure monitoring from PICCs, more institutions may adopt this policy. Further studies should be performed as indicated to outline the complications and cost-effectiveness of PICCs compared with CICCs.

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ACKNOWLEDGMENT
The authors thank Erik Lehman, MS, from the Department of Health Evaluation Sciences for his assistance with the statistical analysis for this study.

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