Below is a list of some frequently asked questions, but please feel free to contact us if you need additional information. We are always pleased to assist you.
What is a PICC or PIC line?
PICC stands for "Peripherally Inserted Central venous Catheter." This intravenous catheter is inserted through the skin, into a vein in the arm, in the region above the elbow and below the shoulder. This is a peripheral insertion. The catheter is a long, thin tube that is advanced into the body in the veins until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart.
Why did my doctor order a PICC insertion?
The purpose of the PICC insertion procedure is to insert an intravenous catheter that can be used for intravenous therapy either for a long period, typically 2-6 weeks, or for a short period in the patient with veins that are difficult to access. Typical IV therapies administered through the PICC include antibiotics, total parenteral nutrition, blood products, immunoglobulins, or chemotherapy. You may be discharged to a rehabilitation facility or to home with home care nursing arranged for completion of intravenous therapy with the PICC.
What is so special about your PICC insertion at HSS?
Procedures are performed by radiologists that have been trained to safely use ionizing radiation, ultrasound and interventional vascular procedures; qualified and specially trained radiology nurses; and radiology nurse practitioners. Also PICC catheters come in single lumen (channel) or double lumen types. One type of PICC commonly used at HSS has a patented Groshong valve, which offers the advantage of not requiring a blood thinner to be mixed with the saline flushes. The final position of the PICC is confirmed on a chest x-ray by the radiologist at the time of the procedure. When leaving HSS, you are provided with an information book, phone number and a beeper number for contact if you have any questions or concerns about the PICC line once you have returned home.
Who inserts the PICC?
At HSS, board certified radiologists that have been trained in vascular interventional procedures, qualified and specially trained radiology nurses, and radiology nurse practitioners insert PICCs using ultrasound and fluoroscopic guidance. The imaging guidance provides safe and accurate placement of the PICC.
How is the procedure performed?
After written informed consent is obtained, the procedure is performed in a radiology special procedure room and takes about an hour. You lie on your back on a fluoroscopic procedure table with the arm chosen for insertion resting on an arm board support, perpendicular to your body. A tourniquet is tightened around the arm just below the shoulder. Using ultrasound, the vein for venipuncture is selected. The rest of the procedure is performed under sterile conditions. Lidocaine 1% is injected at the skin surface for local anesthesia and may sting and burn for a few seconds but after that a pressure sensation is mainly felt when the area is being worked on.
Under ultrasound guidance venipuncture is performed with a thin needle. A thin safety guidewire with a coiled, floppy safety tip is inserted through the needle and into the vein. The tourniquet is then loosened and the puncture site is enlarged slightly with a scalpel. The needle is removed and the catheter is advanced over the wire into the vein. The PICC, with an indwelling guidewire, is inserted through the sheath catheter into the vena cava. The external catheter length is measured and recorded, the indwelling guidewire removed, a two piece connector assembly attached to the end of the external catheter, and an injection cap attached to the connector assembly. The catheter is tested and flushed with sterile, normal saline, once at this point and again at the end of the procedure. Some catheters require additional flushes with sterile heparinized saline, a solution with a dilute blood thinner. The peel away sheath catheter is then removed, catheter tip position reconfirmed, and the catheter secured at the entry site with a suture wing and 2 sutures. Local anesthetic is used for placement of the sutures. Iodophor-PVP ointment is placed over the entry and suture sites, followed by sterile gauze and a sterile clear plastic adhesive dressing. The upper arm circumference is measured.
What must I do to prepare for the procedure?
Prior to the procedure, inform the radiologist and technologist of any allergies or anticoagulant therapies such as Coumadin or Heparin. A blood test including a PT, PTT, INR and documentation of an INR of 2.0 or less on the day of the procedure is required.
What are the contraindications for the procedure?
Patients on anticoagulant therapy who have an INR blood test result greater than 2.0 cannot undergo the procedure. An upper extremity vein cannot be used for a PICC insertion if there is a history of any of the following in the region of that upper extremity: vascular surgery, radiation therapy, venous thrombosis, or axillary lymph node dissection. In addition, local dermatitis, cellulitis, burn injury, abscess, or infection in or near the region of planned insertion site are contraindications for using that extremity for the procedure.
What are the risks/possible complications?
The risk of introduction of infection is low (approximately 2%). Bleeding is usually minimal and very easy to control. Injury of local structures is uncommon with the use of ultrasound and fluoroscopic guidance. Clotting of blood in the vein around the catheter or at the wall of the vein occurs approximately 20-40 percent of the time but is usually in such small amounts that it is not clinically evident and not clinically significant. More extensive venous thrombosis is much less common. Pulmonary embolus as a complication of this procedure is not common. Allergic reactions to the local anesthetic, latex, sterile preparation solutions, flushing solutions, or iodinated contrast agents (rarely used) are uncommon and patients are questioned about allergies prior to the procedure. Pain is expected during the injection of the local anesthetic. Discomfort or pain may occur related to being positioned on the table during the procedure. Adherence of the catheter within the venous system at the time of removal is rare when the catheter is indwelling for periods of a few months or less. Breakage of materials such as guidewires or catheters during the procedure is rare.
What are the alternatives to the procedure?
Long term intravenous therapy can be performed with other central venous catheters (e.g. tunneled catheters or buried port catheters). Compared to the PICC, insertion of these catheters is more invasive and removal is more complicated. IV therapy can be performed with peripheral IV catheters but these have to be replaced at least every 3 days and veins become increasingly difficult to catheterize over time. Oral antibiotic therapy is an alternative in some cases, but oral antibiotics may not be effective against certain types of infection or against infections in certain locations. Inadequate treatment of an infection could result in further spread or increasing severity of the infection.
What can I expect after the procedure?
You will be given a catheter information book with measurements and with phone numbers and a beeper number to call in the event of an emergency related to the PICC. Mild soreness is expected at the entry site during the day of and for one or two days after the procedure. There may be bleeding at the entry site, especially on the first and second day. If the gauze becomes soaked with blood, have your nurse change the dressing. You must keep the dressing and the external tubing dry. If you shower, cover the dressing and external tubing with a waterproof material such as plastic wrap secured with tape or a commercially available waterproof cast cover. Do not submerge the entry site under water. If the dressing gets wet, have your nurse change it as soon as possible. Strenuous exercise should be done with caution to protect the PICC and only if permitted by your doctor. Be sure that flushing instructions are followed carefully. The PICC should be flushed before and immediately after each use. Do not arrange the external catheter with any hairpin turns, kinks, or twists. Be aware that the sutures remain in until it is time to remove the PICC and that PICC removal is a simple procedure in almost all cases. Report any obstruction of flow, leakage of fluid, drainage at entry site or suture sites, soft tissue swelling, or pain to your nurse. If your nurse is not available, call the numbers listed in your PICC booklet.
Will I need other tests?
At the end of the procedure, a fluoroscopic chest film is taken to document final position of the catheter tip.
