Peripherally Inserted Central Catheter Placement
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Peripherally inserted central catheters (PICCs) have become an increasingly popular alternative to traditional percutaneous central venous lines. They require little or no sedation, can be placed at the bedside using minimal equipment, can be maintained at home, and, in the right patient population, offer lower rates of infection and other complications than traditional percutaneous central lines. This chapter details a method for selecting appropriate patients, determining the risks and benefits of a PICC for a given patient, and preparing for, placing, and evaluating complications of a PICC. Ultrasound guidance, the modified Seldinger technique, and direct cannulation are described.
KeywordsPeripherally inserted central catheter PICC Ultrasound Central venous catheter Infection Thrombus Seldinger
Peripherally inserted central catheters (PICCs) have become an increasingly popular alternative to traditional percutaneous central venous lines . They require little or no sedation, can be placed at the bedside using minimal equipment, can be maintained at home, and, in the right patient population, offer lower rates of infection and other complications than traditional percutaneous central lines. This chapter describes the terminology, equipment, and techniques for the placement of PICCs. Additionally, risks, benefits, complications, and troubleshooting are discussed.
Peripherally Inserted Central Catheter (PICC)
A wire placed within the lumen of the PICC during insertion to provide additional stiffness and make advancing of the PICC through the vessels easier.
A wire placed within the vessel that the PICC can be advanced over into the central circulation.
A sheath that is inserted into a peripheral vein, either over a needle or a dilator, through which a PICC can be inserted into the vein.
Long-Term IV Access
The most common indication for a PICC is the need for IV access for >7 days, but <3 months. If access is needed for <7 days, a peripheral intravenous catheter (PIV) or percutaneous central venous line (CVL) may be preferable. If access is needed for longer than 3 months, a tunneled CVL or implantable port may be considered. PICCs can remain functional for more than a year if properly cared for, but the long-term risks and convenience issues should be a consideration in choosing access for very long-term needs.
Use of Vesicant Medications
The need to administer medications not well tolerated in a peripheral vessel, such as vasoactive agents, some antibiotics, and chemotherapies, even if for <7 days, may be an indication for a PICC.
Difficult IV Access
This is more controversial, but patients who have had repeated PIV failures or unsuccessful attempts, those who need repeated bloodwork, or those who, based on history, have had difficulties maintaining IV access during past hospital admissions may all benefit from PICC placement, as the deeper peripheral vessels used for PICC insertion are often less vulnerable to the conditions that can make PIV access difficult, such as dehydration, obesity, poor nutrition, etc.
In many centers, plasmapheresis can now be successfully performed using two PICCs that have a stiffened lumen suitable for high pressure injection.
The presence of a venous thrombosis in any of the vessels through which the PICC will pass, such as the basilica vein, subclavian vein, or superior vena cava, is a contraindication to PICC placement. Even if the catheter can be passed beyond the thrombus, the presence of the PICC will increase the risk of both propagation of the thrombus and embolus .
End-Stage Renal Disease
PICCs are generally avoided in patients that are likely to need ongoing hemodialysis because any thrombus resulting from the PICC is likely to impede the formation of fistulas used for chronic dialysis.
Anticipated Need for Fluid Resuscitation or Rapid Medication Infusion
Because the lumen of a PICC is long and often narrow, the resistance to flow is higher than in a PIV or most percutaneously inserted CVLs. This makes them an inappropriate choice for rapid fluid resuscitation, massive transfusion protocols, or any other circumstance in which rapid infusion of medications (particularly high-volume medications) is indicated or likely to be needed. If no other access is available, existing PICCs can be used for these purposes, but the rate of infusion will be limited to roughly 1 l/h or slower in smaller lumen PICCs.
PICC insertion is a sterile procedure. Appropriate handwashing, gowning, and other PPE should be donned as per institutional policy, and a “time out” should be used in the manner dictated by your institution. The patient should be supine with the head of the bed or gurney elevated approximately 30° for an upper limb insertion or flat for a lower limb insertion. If using an upper limb insertion location, the arm should be extended away from the patient and externally rotated to expose the surface of the intended insertion area. It may be necessary to use a soft restraint to assist the patient in maintaining this position. Identify and mark the point on the skin where you intend to insert your needle or PIV. Measure from this point to the axilla and then to the sternal notch. If measuring from the left, add 2 cm to this measurement. Record this measurement, as it will be the rough guide for trimming the PICC. If you intend to use a sterile tourniquet, the entire limb should now be cleaned with your sterile scrub. A sterile drape should be placed under the arm, and the tourniquet can now be loosely placed proximal to the intended insertion site. If an assistant will be utilized to tie and release the tourniquet, it should be loosely placed proximal to the intended insertion site, and then the insertion site should be cleaned with your sterile scrub. The insertion site should then be draped. Often, a clear plastic sterile fenestrated drape with adhesive on the side contacting the patient is placed over the insertion site. This may then be supplemented with sterile towels or whole body drapes, depending on your preference and institutional policy. Assemble your remaining equipment on a sterile field and place your ultrasound probe in a sterile sleeve (if using).
14.3.1 Placement of the PICC
Choosing a PICC
PICCs are available in a variety or diameters, lengths, and lumen options. They range from single lumen 1.9FR 30 cm catheters appropriate for neonates and very small babies to 6FR quad lumen 90 cm catheters for use in large adults, requiring multiple incompatible medications. There are specially designated PICCs that are certified as able to withstand the pressure created by power injectors used in radiologic procedures or plasmapheresis. PICCs with diameters of 3FR or less are often unreliable for blood return and may not be suitable if blood sampling is an indication for the PICC. In general, the smallest catheter with the fewest lumens that will meet indicated needs of the patient should be used. Increasing catheter size is associated with increased risk of thrombosis, and increased number of lumens is associated with increased infection risk. However, smaller catheters are more prone to damage, may be harder to advance through large vessels, and may not return blood reliably. In all cases, the risks and benefits of each size should be considered.
PICCs are most commonly inserted into either the cephalic, median basilic, or brachial veins of the arm. However, the saphenous vein (in young children who are preambulatory), popliteal vein, external jugular vein, forearm veins, and axillary vein have all been used when other options are not available. The median basilic or brachial veins are generally preferred to the cephalic vein as the tight turn and narrowing that occurs as the cephalic vein joins the axillary vein is a frequent site for phlebitis and thrombus formation. However, the cephalic vein is easier to locate (typically in the antecubital fossa) and palpate, so may be the preferred site if ultrasound guidance is not available.
A device to trim the PICC to the desired length.
If using the direct insertion technique, an obturator wire and a cannulating needle with a tear-away sheath.
If using the modified Seldinger technique, a needle or PIV for accessing the peripheral vessel, a guidewire, and a vein dilator (with or without a tear-away introducer sheath).
A sterile ultrasound sleeve and gel (if using ultrasound).
A tourniquet (sterile if it will be on the field, can be nonsterile if an assistant will be tying the tourniquet outside the sterile field).
Sterile drapes (whole body if required by your institution).
Sterile prep (such a chlorhexidine) for cleaning insertion site.
Tape measure (sterile) to measure from insertion site to intended tip location to aid in trimming PICC to desired length.
Sterile flushes (saline or heparin containing, based on institutional policy).
Caps for each lumen of the PICC (ensure caps are compatible with IV tubing system used at your institution).
Suture material, scissors, or scalpel for cutting material and needle driver if the PICC is to be sutured in place.
A securement device, such as a StatLock device, if the PICC will not be sutured in place.
Ultrasound device for identifying peripheral vessel, guiding insertion, and (with experience) identification of PICC tip location. Several commercially available devices exist to aid in tracking the path and tip location of the PICC, often using a magnetic portion of the obturator wire and a sensor that is placed on the chest of the patient. In the operating room or radiology suite, fluoroscopy may be available for visualizing the advancement of either the guidewire or the PICC into the desired location.
Many adults and older children will tolerate this procedure with only local anesthesia. However, for many young children (and their parents) or older patients with cognitive impairment, this procedure may be both technically difficult (due to movement and crying, which can increase intrathoracic pressure and lead to more internal jugular malposition) and traumatizing to the patient. Therefore, it may be appropriate to offer anxiolysis or moderate sedation to patients undergoing PICC placement, based on the available expertise, personnel, and policies of your institution.
Once preparations are complete and all equipment is available, you can begin the insertion. There are two basic techniques for inserting a PICC—the direct introducer technique and the microintroducer (or modified Seldinger) technique. Each will be discussed separately.
Direct Introducer Technique
This technique uses a needle with a tear-away sheath over it. The previously placed tourniquet is tied to enlarge the target blood vessel. The needle is inserted directly into an appropriate vessel until blood return is observed. The sheath is then advanced over the needle to its full depth. The needle is then removed, leaving a “tunnel” between the sheath opening and the vessel. Once inserted, this sheath can be capped briefly and the tourniquet should be removed. The distance between the intended insertion point (marked previously) and the actual insertion site should then be measured using your sterile measuring tape. This distance should be added or subtracted from your original measurement from intended insertion point to intended tip location. The PICC can now be trimmed to this length. Once trimmed, the PICC should be flushed with saline- or a heparin-containing solution (based on institutional policy) and an obturator wire inserted into the PICC. The obturator should terminate 1–2 cm short of the tip of the PICC to reduce the chance of vessel perforation and allow the softer PICC tip to direct the PICC towards central vessels during advancement. Once the obturator is inserted, the cap can be removed from the tear-away sheath. The PICC tip is then inserted through the sheath into the peripheral vein and slowly advanced until the PICC hub reaches the sheath. To help ensure the PICC tracks towards the central circulation, you may ask the patient to turn his or her head towards the site of insertion (or have an assistant position the patient if the patient is sedated). If ultrasound or other tracking devices are available, they can be used to determine the location of the PICC tip. Once the PICC has been inserted, the two handles of the introducer are pulled apart, and the “tear-away” sheath is torn into two pieces and removed. The PICC can then be secured to the patient using either an adhesive securement device or suturing, the wire removed, the PICC flushed, and a sterile dressing applied.
Microintroducer (Modified Seldinger) Technique
If fluoroscopy is available, a vein dilator can be used without an introducer sheath to dilate the tunnel between the skin and the target vein to the appropriate size for the PICC to be inserted (usually 0.5FR greater than the PICC diameter). The vein dilator is advanced over the wire in a “corkscrew” manner until it reaches the vein. The dilator is then removed.
Some PICCs are stiff enough to advance into the central circulation without an obturator wire. In this circumstance, a vein dilator without introducer sheath can be used, identically to the way it is described above.
In most cases, the PICC will require an obturator wire to provide sufficient stiffness to allow the tip to be advanced centrally. In these cases, special vein dilators are available that have a tear-away introducer sheath over them. The dilator is inserted under the skin and into the vein over the wire as above. However, once the vein is dilated, the dilator is detached from the tear-away introducer and removed, along with the guidewire. This leaves the introducer as a “tunnel” between the skin and the vein. This introducer should then be capped to stop blood flow.
The distance between the actual insertion point and the intended insertion point should be measured, and this distance is either added or subtracted from the original measurement from intended insertion point to desired tip location. The PICC should then be trimmed to this length, and if the introducer sheath method was used, an obturator wire is inserted. The tip of the wire should be 1–2 cm short of the PICC tip to allow for a flexible portion of the tip to help guide the catheter through vessel junctions and also to reduce the risk of perforating a vessel with the obturator wire. Once the PICC is trimmed and the obturator wire is inserted, the cap can be removed from the introducer sheath.
The PICC is then advanced through the sheath, into the vein, and is slowly introduced until the hub of the catheter touches the distal end of the introducer sheath. The two tabs of the introducer sheath can then be grasped and pulled apart. This will tear the introducer in two, allowing for it to be removed. The obturator wire can now be removed from the PICC.
If an introducer sheath was not used, the PICC is trimmed as outlined above, flushed, and then inserted over the guidewire until the hub reaches the skin. The guidewire is then removed.
The PICC is then anchored to the skin using either sutures or an adhesive securement device. Each lumen is aspirated to confirm blood return and then flushed with either saline-or a heparin-containing solution (based on individual institutional policy). The PICC insertion site is then dressed with a sterile dressing.
Use of Ultrasound
Many experienced PICC inserters will use ultrasound visualization of the internal jugular vein, subclavian vein, and SVC to visualize the PICC after insertion and prior to securing the PICC. However, this is not considered sufficient confirmation of tip location and a radiograph is still required. If the PICC is inserted under fluoroscopic guidance, a saved fluoroscopic image of the final tip location is generally considered sufficient confirmation of tip location.
If you are able to visualize or palpate an appropriate vessel but cannot cannulate it, consider the following: once an unsuccessful attempt to cannulate a vessel has been made, further attempts should be made proximal to the original site, so as to avoid cannulating a hematoma or advancing a wire through the previous insertion site. While many kits come with 20 g or larger needles or insertion catheters, many of the guidewires used will fit comfortably through a 22 g (or in some cases 24 g) PIV catheter. If you are unsuccessful using the supplied needle or PIV catheter, you can try cannulating the vessel with a smaller needle or catheter. Just be sure to confirm that your guidewire will pass through the needle or catheter you select first. If you are using ultrasound guidance and a transverse view of the vessel without success, consider using a longitudinal view of the vessel. While more technically difficult to hold during insertion, this view does allow visualization of valves, any displacement of the vessel wall by the needle, and any stenosis of the vessel at the point of attempted insertion.
If you have cannulated the vessel and inserted the PICC into the vessel but are unable to advance the PICC centrally, consider the following: advance the PICC slowly and steadily. Rapid advancement generates substantial heat through friction within the vessel, which can prompt vasospasm. If you encounter vasospasm, stop your advancement and wait a few minutes before attempting further advancement. If you encounter difficulties at the expected location of the axilla or subclavian veins, try extending the arm up and away from the patient. This sometimes helps align the vessels at the junction of the axillary and subclavian veins, allowing for passage. If this is unsuccessful, have an assistant try gently pressing on the clavicle or placing his/her hands between the shoulder blades and lifting. Some patients have a significant deflection of their subclavian vein under the clavicle which can prevent the advancement of the PICC. If repeated attempts to advance the PICC are unsuccessful, particularly in a patient who has had previous PICCs or CVLs, a thrombus or stenosis may exist. In that case, you can either try a different limb for insertion or refer to interventional radiology, where a dye study can confirm the patency of the vessels.
The two most common malpositions of the PICC tip are in the internal jugular (IJ) vein (either ipsilateral or contralateral) and the contralateral subclavian vein. You can reduce the chance of IJ malposition during insertion by having the patient turn his/her head towards the insertion site during advancement and by having him or her take a deep breath during the last few centimeters of advancement. If the PICC tip is identified in the IJ prior to termination of the procedure (such as with ultrasound), the PICC can be retracted until out of the IJ and then reinserted. If the PICC tip migrates into the IJ or the malposition is identified after termination of the procedure, the following can be attempted to reposition the PICC. Obtain a 10 cc syringe with saline and attach it to the hub of the largest lumen of the PICC. Extend the patient’s arm to 90° from the body and then raise the arm above the patient’s head. This should retract the PICC tip a few centimeters. Then, flush the PICC in a rapid and pulsatile manner. This creates a “jet” of saline at the tip which can propel the PICC down into the SVC (visualize a firehose when the firefighter lets go of it and it whips around). Before you have finished flushing, drop the arm to the patient’s side. This should readvance the PICC by several centimeters and ideally help guide it back into the SVC. If the PICC tip is located in the contralateral subclavian vein and the procedure has not been terminated, retract the tip to the ipsilateral subclavian vein, raise the head of the bed (if possible), and readvance. If the malposition is identified after the procedure has terminated (or the tip migration is identified on subsequent radiograph), the only practical solution is to retract the PICC until the tip rests just over the junction of the subclavian vein, IJ, and SVC. While not an ideal location, this is less likely to promote thrombosis than leaving the tip in a contralateral subclavian location.
14.4.1 Removal of the PICC
PICCs can be removed by trained nurses, either in the hospital or long-term care facility, during a clinic visit or at home for patients receiving home nursing care. To remove the PICC, the dressing is removed, the securement device (if used) or sutures are removed, and the PICC is slowly retracted until the entire PICC is removed. Prior to removal, you should confirm the length of the PICC from the insertion note (as PICCs can be trimmed to many lengths), and after removal you should confirm the PICC tip is at least as long as the recorded insertion length. The PICC may be longer than at the time of insertion, particularly if it has been indwelling for an extended period of time, as the material is designed to increase in flexibility when exposed to body heat, and adherence to vessel walls can then “stretch” the PICC. However, if the PICC measures shorter than the recorded length at insertion, the possibility that a portion of the PICC has been retained exists. This should prompt immediate referral to an interventional radiologist for further imaging and possible retrieval of retained PICC.
Once the PICC is removed, the insertion site can be dressed with an adhesive bandage. Some providers cover the insertion site with an antibiotic- or betadine-impregnated ointment prior to application of the adhesive bandage.
Although PICC infections are rare (0.75/1000 catheter days, ), they do occur. PICCs are generally considered to have a lower overall infection rate versus percutaneously inserted CVLs. However, at least one study has demonstrated that, in high-risk hospitalized patients, the infection risk is roughly equivalent (2.1/1000 catheter days) to that of percutaneously placed CVLs . This suggests that some of the association between PICCs and lower infection rates may have more to do with the types of patients who initially received PICCs rather than an innate lowering of risk due to the device or insertion site. Infection may require the removal of the device and short- or long-term courses of appropriate antibiotic therapy.
Although initially thought to be associated with lower risk of thrombosis than percutaneously placed CVLs, recent systematic reviews have indicated that PICCs may have a higher association with large vessel thrombus formation . However, there is not an associated increased risk of pulmonary embolus. The long-term clinical significance of these thrombi is unclear. In this and other studies, most of the large vessel thrombi identified were in critically ill patients, suggesting that some of the earlier studies that suggested lower thrombus risk may have reflected the patients who initially received PICCs rather than the risk associated with the device itself or insertion site. As the use of PICCs in the acute and critical care settings increase, reevaluation of the associated complications will be necessary. Symptomatic large vessel thrombus formation may require the removal of the PICC and potentially anticoagulant therapy.
Fibrin sheaths form on most long-term indwelling PICCs. This can result in non-thrombotic occlusion of the PICC, particularly with aspiration (due to a ball-valve effect of the sheath on the tip of the catheter). If clinically appropriate, this occlusion can be treated with the instillation of direct thrombolytic agents such as alteplase.
With increased use of ultrasound, insertion into deeper peripheral veins, and the increased use of the microintroducer technique, phlebitis has become a much less common complication of PICC insertion. A peripheral phlebitis not associated with thrombus will usually resolve with application of warm compresses to the affected area and use of nonsteroidal antiinflammatory medications (if clinically appropriate).
Because PICCs are generally softer and more flexible than CVLs, they are more prone to migration into unintended tip positions. The most common site of malposition is the ipsilateral internal jugular vein, although migration into the contralateral subclavian vein or migration back into the ipsilateral subclavian, axillary, or even basilica vein has been reported. Troubleshooting approaches to this malposition is addressed above, but persistent malposition may require removal or replacement of PICC.
Particularly when used in high-intensity environments, such as ICUs, PICCs can rupture. The most common site of rupture is at the catheter hub, but rupture can occur at any point. In general, this occurs when the PICC becomes occluded and pressure is exerted in an effort to instill a medication. The chance of rupture can be reduced by using only 10 cc or larger syringes for instilling medications into PICCs, as the pressure generated by larger syringes is generally insufficient to rupture the PICC wall. Ruptures of the distal catheter or hub external to the patient can sometimes be repaired using premade kits supplied by the PICC manufacturer. Internal ruptures or those close to the hub generally require the removal and replacement of the PICC.
14.5 Consideration of PICC Versus Percutaneously Placed CVL
In general, PICCs have lower reported infection rates versus percutaneously placed CVLs (0.75 versus 2.51/1000 catheter days, ). However, most studies comparing PICCs to CVLs have used data from PICCs that were indwelling for >7 days. There is no evidence that PICCs are safer for short-term use (<7 days) and in a critically ill patient who may require rapid or high-volume resuscitation, the percutaneously placed CVL may offer advantages that offset the theoretical reduction of infection rates in the short term.
Advance the guidewire and catheter slowly (1–2 cm/s) as rapid advancement generates significant heat at the point where the vessel wall is in contact. This heat can cause endothelial damage and increase the risk of thrombus formation.
If placing the PICC in an awake patient (or if an assistant is available), have him/her turn his/her head towards the side of insertion while advancing the catheter. This will slightly restrict the opening to the ipsilateral internal jugular vein and reduce the chance of malposition.
If placing a PICC in a spontaneously breathing patient, try to perform the final 10–15 cm of catheter advancement during inhalation. Intrathoracic pressure will be at its most negative during inspiration, increasing venous return to the superior vena cava and helping direct the PICC towards the atriocaval junction. Conversely, in mechanically ventilated patients, advance during exhalation or during inhalation of an unassisted breath. Intrathoracic pressure in the mechanically ventilated patient is always positive but is the least positive during exhalation. Advancing during mechanical inhalation has a higher risk of directing the PICC tip upwards towards the internal jugular vein.
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