PICC Insertion Procedure Information
What is a peripherally inserted central catheter?
A peripherally inserted central catheter, often called a “PICC line,” is a long, very thin, flexible tube that is usually placed into one of the large veins in the arm, often just above or just below the elbow. This tube is threaded into a large vein above the right side of the heart.
Why are PICC lines used?
A PICC line is used to administer intravenous (IV) medicines or fluids. Because the tube is so small and flexible, the line can last several weeks to months, which means fewer needle pokes and less pain. The PICC line can be flushed and capped off when not in use. When it is time to administer medicine, the medicine is connected to the PICC line and disconnected again when the medicine is finished.
Who inserts the PICC?
At St. Joseph Hospital PICCs are inserted using ultrasound and fluoroscopic guidance. The imaging guidance provides safe and accurate placement of the PICC. The following individuals are qualified to insert a PICC:
- A board-certified interventional radiologist with training in vascular interventional procedures.
- Qualified and specially trained radiology nurses.
- Physician Assistants
How is the procedure performed?
The procedure is performed in a radiology special procedure room or at the bedside after written informed consent is obtained. The procedure takes about an hour.
- The patient lies on their back on a fluoroscopic procedure table or in a hospital bed, with the arm chosen for insertion resting on an arm board support, perpendicular to the 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 the patient may feel mainly a pressure sensation when the area is being worked on.
- Under ultrasound guidance venipuncture is performed with a thin needle.
- A thin safety guide wire 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 catheter is advanced over the wire into the vein.
- The PICC with an indwelling guide wire is inserted through the sheath catheter into the vena cava.
- The internal catheter length is measured and recorded, the indwelling guide wire removed, and a connector assembly and injection cap are attached.
- The catheter is tested and then flushed with sterile normal saline 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 catheter tip position is reconfirmed and the catheter is secured with an adhesive securing device.
- An anti-microbial “patch” is placed at the catheter entry site and a clear adhesive dressing is placed over the securing device and patch.
What are the contraindications for the procedure?
An alternative vein/arm may be preferred 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
- Permanent dialysis access
- Auxiliary lymph node dissection
- Local dermatitis
- Burn injury
- Infection in or near the region of the planned insertion site
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% 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 are uncommon; 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 arm position 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 guide wires 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 three 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?
- Patients are given a post-procedure instruction sheet in the event of a complication 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 dressing becomes soaked with blood, patients should have the nurse change the dressing. Patients must keep the dressing and the external tubing dry.
- If patients shower, they should cover the dressing and external tubing with a waterproof material such as plastic wrap secured with tape.
- The entry site should not be submerged under water.
- If the dressing gets wet, the nurse should change it as soon as possible.
- Strenuous exercise should be done with caution to protect the PICC and only if permitted by the patient’s doctor.
- Flushing instructions should be followed carefully.
- Patients should not arrange the external catheter with any kinks or twists.
- Patients should report any obstruction of flow, leakage of fluid, drainage at entry site, soft tissue swelling or pain to the nurse, primary physician or physician who ordered the placement of the PICC line.