Peripherally Inserted Central Catheter (PICC Line)

 

What is a PICC line (or PIC line)?

PICC stands for "peripherally inserted central 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. This tube may have one or two openings, called lumens, that are used to deliver medication.

After written informed patient consent is obtained, the procedure is performed in a radiology interventional procedure room and takes about an hour.

What is a PICC line used for?

The purpose of the PICC insertion procedure is to provide medicinal therapy and fluids through an intravenous catheter.

Who orders a PICC line?

A PICC must be ordered by your primary physician or surgeon or their consulting colleague.

How long can a PICC line stay in?

The benefit of a PICC is that the catheter can remain for a long period, typically two to six weeks, over which a course of medication such as antibiotics can be delivered. The patient may be discharged to a rehabilitation facility or to their home with home care nursing arranged for the completion of intravenous therapy with the PICC in place. The PICC can also be used for short intervals in a patient with difficult vein access. In some instancies a PICC is used.

Typical intravenous (IV) therapies administered through a PICC include:

  • Antibiotics
  • Total parenteral nutrition (vitamins, minerals, electrolytes, proteins, carbohydrates, etc.)
  • Blood products
  • Immunoglobulins
  • Chemotherapy

What is so special about a PICC insertion at HSS?

PICC insertion procedures are performed by HSS radiologists and qualified and specially trained radiology nurses, radiology physician assistants and radiology nurse practitioners trained to safely use ionizing radiation, ultrasound and interventional vascular procedures.

To ensure safe and accurate PICC placement, PICC lines are inserted using either ultrasound or fluoroscopic imaging guidance. The final position of the PICC is confirmed by the radiologist on a chest X-ray obtained at the time of the procedure. When leaving HSS, the patient is provided with an information book, phone number and a pager number for contact to address any questions or concerns about the PICC.

The PICC lines commonly used at HSS has a patented Groshong valve, which offers an advantage of not requiring a blood thinner to be mixed with the saline flushes. PICC catheters come in single lumen (channel) or double lumen types.

Who inserts the PICC line?

At HSS, PICC lines are inserted by:

  • board certified radiologists trained in vascular interventional procedures
  • qualified and specially trained radiology nurses
  • radiology physician assistants
  • radiology nurse practitioners

How is the PICC procedure performed?

The patient is advised to lie on their back on a procedure table with the arm chosen for insertion resting on an arm board support. A tourniquet is placed around the arm just below the shoulder. The vein for the PICC access is selected using ultrasound. Under sterile conditions, lidocaine 1%, a common local anesthetic, is injected at the skin surface. Local anesthesia may sting or burn for a few seconds but after that becomes numb, so only a pressure sensation is felt when the PICC is being inserted.

Under ultrasound guidance, a thin needle is used to enter the vein. A thin safety guidewire with a floppy safety tip is inserted through the needle, into the vein, and the tourniquet is loosened. The needle is then removed and the catheter is advanced through the vein over the guide wire to the superior vena cava. The indwelling guide wire is removed and an injection cap is attached to the catheter hub.

The catheter is tested for blood return and then flushed with sterile, normal saline. A final chest X-ray is performed to confirm catheter tip position. The catheter is secured at the entry site with a suture wing and 2 sutures. The insertion site is cleaned with an alcohol-based solution. Sterile gauze is applied and covered with clear plastic adhesive dressing, and the upper arm circumference is measured to be used as a baseline.

How do you prepare for a PICC procedure?

Prior to the procedure, information on medications like anticoagulant therapies such as Coumadin or Heparin is required. A blood test to check for potential bleeding complications may be requested.

What are the contraindications for the PICC procedure?

A key contraindication is that patients on anticoagulant therapy who have an INR blood test result greater than 2.0 cannot undergo the procedure. In addition, certain conditions may affect which veins are safe for the insertion site.

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:

  • major shoulder surgery
  • vascular surgery
  • radiation therapy
  • venous thrombosis
  • axillary lymph node dissection

Similarly, a vein should not be used for a PICC insertion in any place on the body where the skin has a local dermatitis, cellulitis, burn injury, abscess or infection.

What are the risks or possible complications of having a PICC line?

Although rare, the risks associated with the PICC line procedure can include infection, bleeding, blood clot, increased venous thrombosis, pulmonary embolus, breakage of instrumentation during the procedure.

  • Introduction of infection: Risk is low (approximately 2%).
  • Bleeding: Risk is usually minimal and very easy to control.
  • Clotting of blood in the vein around the catheter or at the wall of the vein: Risk is approximately 20% to 40% of the time but is usually so minimal that it is not clinically evident or significant.
  • Increased venous thrombosis: Risk is extremely rare.
  • Pulmonary embolus: Risk is not common.
  • Allergic reactions to the local anesthetic, latex, sterile preparation solutions, flushing solutions or (rarely used) iodinated contrast agents: Risk is uncommon and patients are questioned about allergies prior to the procedure. Appropriate precautions are then taken.
  • Breakage of materials such as guide wire or catheters during the procedure: Risk is extremely rare.

Pain can be expected during the injection of the local anesthetic and discomfort, or pain, may occur related to table positioning during the procedure. Adherence of the catheter within the venous system at the time of removal can occur when the catheter has been in dwelling for a long periods of time, although this is a rare occurrence

What are the alternatives to the PICC procedure?

Oral antibiotic therapy is an alternative in some cases, but may not be effective against certain types of infection or against infections in certain locations. Inadequate treatment of an infection could result in the further spreading or increasing severity of the infection.

Intravenous (IV) therapy can be performed with peripheral IV catheters, but these have to be replaced at least every three days and the veins typically become increasingly difficult to catheterize over time. Long-term IV therapy can be performed with other central venous catheters (for example, tunneled catheters or buried port catheters). Compared to the PICC, insertion of these catheter types is more invasive and their removal can be more complicated.

What should I expect after a PICC procedure?

Mild soreness can be expected at the entry site for one to two days after the procedure. There may be bleeding at the entry site, especially on the first or second day. If the gauze becomes soaked with blood, a nurse should be told to change the dressing. It is important to keep the dressing and the external tubing dry. If showering, 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 a nurse change it as soon as possible.

Strenuous exercise should be done with caution to protect the PICC and only if permitted by your physician. The PICC should be flushed before and immediately after each use and flushing instructions must be followed carefully. Do not allow the external catheter to have hairpin turns, kinks, or twists, and be aware that the sutures should remain in until the PICC is removed.

Patients are given a catheter information book with phone numbers and a pager number to call in the event of a question or emergency related to the PICC. They should report any of the following to a nurse:

  • obstruction of flow
  • leakage of fluid
  • drainage at entry site or suture sites
  • soft-tissue swelling
  • pain

If a nurse is unavailable, call the numbers listed in your PICC booklet.

PICC removal is a simple procedure in almost all cases.

Possible follow-up tests

At the end of the procedure, a fluoroscopic chest film is taken to document final position of the catheter tip.

Authors

Department of Radiology and Imaging
Hospital for Special Surgery

Reviewed by Teresita Leynes and Helene Pavlov, MD, FACR

     

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