The Best Intravenous Line for a Patient in the Hospital with CKD 3, 4, and 5

Lincoln Nephrology and Hypertension has a high rate of successful fistula placement in patients they serve who need kidney replacement therapy. A coordinated effort among multiple specialties, Nephrology, interventional radiology, hospital medicine, critical care medicine, vascular surgery and patient families allows for such success.

The American Society of Nephrology suggests and we agree that patients with stages 3, 4, and 5 chronic kidney disease should have central catheters placed, preferably internal jugular catheters, instead of peripheral intravenous lines if we require an IV in order to protect the arms for future fistula placement. It may seem easier to get blood peripherally, or using the arms, but in the long run, the patient will suffer. To get everyone on the same page, let’s show a graphic of the anatomy we are referring to:

Notice the location of the different lines that we can place in the hospital if a patient needs an IV.

The preferred location is the right internal jugular. Although this location may seem aggressive at first, you will do better if we place a central line when indicated. A critical care physician or an interventional radiologist can place this line if we need it. Less preferred, but better than using the arm veins, is the subclavian vein. It is central in location but is prone to narrowing or stenosis. The least favored but easiest to place IV line is a PICC line. PICC stands for a peripherally inserted central catheter. The PICC line starts in the arm and ends in the central vein. But they cause trauma and may prevent the possibility for future fistula creation.

Nephrology usually approves PICC lines at the hospitals we serve. The red stop allows for a pause in time to make sure the risk of placing a PICC outweighs the benefits of the ease of placement. If a patient does not have CKD then protecting the peripheral vessels is less important. If a patient has advanced CKD, and the plan is to place a fistula in the future, the veins need to be usable.

Left brachiocephalic AV Fistula. The blood flows from the artery in red to the vein in blue. PICC line placement can destroy the vein for the future and prevent the possibility of fistula placement.

So we request limiting blood draws and avoiding PICCs in a patient’s non-dominant arm, or either arm, to protect the patient for future access. What’s more concerning, besides the fact that there is a smaller chance that a fistula will work after placement of a PICC, a 20% lower chance, the risk of death increases when we order a PICC in this setting. If required, we ask for a PICC, but we first perform a thorough chart review and risk-benefit assessment and then give the OK.

So we suggest using a right internal jugular (right IJ) central line instead of a PICC in CKD stages 3-5 when a provider requires intravenous access for a hospitalized patient. That one wise decision may prolong your life. That said, if we can use a vein in the hand for IV access, or a simple peripheral IV, that access might be better under certain conditions.

Simple peripheral IV.

Every person is unique. The best line for you depends on the particular situation.