Overview of Peripherally Inserted Central Catheter (PICC) Line Placement
Peripherally inserted central catheters or PICCs, as they are more commonly known, are devices used to create a pathway into the central veins of your body. This pathway is often required for administering medication or providing nutrition over a long timeframe. PICCs are widely used because they offer a safer and cheaper alternative to another type of catheter – the central venous catheters (CVCs) – which are placed in the jugular vein.
The key benefits of PICCs include a lower risk of complications during the procedure, less maintenance cost, easy use in outpatient settings (where you don’t need to be admitted to the hospital), and a lower chance of developing bloodstream infections related to the catheter.
The advancements in neonatal care (care for newborn babies) have significantly boosted the survival rates of very low and extremely low birthweight infants. PICCs are beneficial for these small, fragile babies because they allow for safe delivery of necessary nutrition. By avoiding the repeated need for inserting needles or other catheters, PICCs also help save valuable medical resources.
A PICC, which is around 50 cm to 60 cm in length and can have up to 3 lumens (channels), can be inserted at the patient’s bedside by certain medical providers or a radiologist. Sometimes, the inserting radiologist would use fluoroscopic guidance, a kind of imaging technique, to make sure that the procedure is safe and the catheter is placed correctly. It is usually placed into a vein in the arm and is located close to where the large vein of your body (vena cava) meets one of the heart’s chambers (atria).
With appropriate care, PICCs can remain in place, being used for several months before they need to be removed.
Anatomy and Physiology of Peripherally Inserted Central Catheter (PICC) Line Placement
The basilic vein in your right arm is often used to put in a Peripherally Inserted Central Catheter (PICC) due to its size and the fact that it’s close to your skin. This vein usually runs from the middle of your upper arm to your underarm. It starts from the network of veins on the back of your hand and then merges with a larger vein to form the axillary vein. This becomes the subclavian vein near your first rib, which eventually leads to a large vein in your chest called the brachiocephalic vein. The right and left brachiocephalic veins come together to form the superior vena cava. The right basilic vein provides the easiest path to the superior vena cava because it isn’t twisted and it doesn’t have a lot of valves.
If doctors can’t access or find your basilic vein for some reason, they might try to find your right brachial vein. But this comes with a higher risk of accidentally puncturing an artery since the brachial artery is close by. The cephalic vein, on the other hand, can also be used if needed. If your right upper arm isn’t suitable for some reason, perhaps due to an infection, injury, or blockage, then a left-sided approach could be tried.
In newborn babies, veins in the head and neck, such as the ones near the temples and behind the ears, can be used to place a PICC line. If necessary, they could also use the saphenous vein in the lower leg.
Why do People Need Peripherally Inserted Central Catheter (PICC) Line Placement
If you’re needing medicine through a vein for a long time (anywhere from a couple of weeks to a few months), your doctor might use a PICC line. PICC stands for peripherally inserted central catheter, it’s a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart. This is done because PICC lines have a lower risk of causing infections.
There are several reasons a PICC line might be used:
- If you’re having very strong and irritating medicines like chemotherapy.
- If you’re unable to eat and need to get nutrition through your veins (called total parenteral nutrition or TPN).
- If you need long-term administration of medicines like antibiotics or antifungals.
- If your healthcare provider needs to check on the treatment’s progress by measuring central venous pressure or by taking blood samples over and over.
- If it’s hard to insert a needle in your veins because they are small or not easy to locate, which would reduce how often you get poked with a needle.
- If you need multiple blood transfusions.
- If you’re a newborn baby and the doctor wants to stop using an umbilical catheter while still being able to give medicines/nutrition through a main vein.
- If your central veins are not shaped normally or are hard to reach.
If you have difficult vein anatomy, the doctor might use a method called fluoroscopy to place the PICC line. Fluoroscopy is like an X-ray “movie” – it provides real-time moving images of your veins, helping the doctor put the PICC line in the right place.
When a Person Should Avoid Peripherally Inserted Central Catheter (PICC) Line Placement
There aren’t any strict rules against having a PICC (which stands for Peripherally Inserted Central Catheter, a type of long, thin tube that’s put into a large vein in your arm and used to give medications or fluids) put in place. But there are some instances or conditions when it’s not a good idea. These include:
– Skin infections
– History of blood clots in the vein where the PICC would be inserted
– Injury or burns at the spot where it would be put in
– Active infection in the bloodstream
– Allergies to the substances used to make objects visible on X-rays, or high levels of creatinine (a waste product) in the blood, if the doctor uses a special X-ray called venography to guide the PICC placement
– Previous breast cancer surgery with lymph node removal on the side where the PICC would be put in
Also, if a patient has a chronic kidney disease or requires blood dialysis (a treatment that performs some of the functions of a healthy kidney), or is expected to need dialysis in the future, a PICC might increase the chance of blood clots that could stop the veins in the arms from working.
Other situations where a PICC may not be recommended include:
– Any sort of severe bleeding or platelet disorder (platelets are cells that help your blood clot)
– If the patient is agitated
– If the patient refuses the procedure
For pregnant patients, procedures that use fluoroscopy (a type of imaging that shows a continuous X-ray image on a monitor) are usually avoided unless it’s really needed for the patient’s health. For these patients, a PICC can be placed using ultrasound instead of fluoroscopy.
Equipment used for Peripherally Inserted Central Catheter (PICC) Line Placement
A catheter is a small, flexible tube that’s used in medical treatments. There are many different types available for use, all with unique designs. They are usually made from silicone or polyurethane. These catheters also come in various sizes and may have more than one channel inside them, known as lumens, for carrying out various tasks. The tip of a catheter can be designed in three ways: end hole, staggered tip, and valve-tipped. Valve-tipped catheters are good because they stop blood from flowing backward into the catheter when it’s open.
The most common method of putting in a PICC (Peripherally Inserted Central Catheter), which is a type of catheter, is using a method called the modified Seldinger technique.
Most hospitals have special kits that contain everything needed to put the catheter in your body. These kits contain things like:
- Sterile draping material, which ensures a clean procedure space
- An ultrasound machine, used as a visual guide during the procedure
- Sterile gown, gloves, and cap – for hygiene and protection of the nurse or doctor who will perform the procedure
- Measuring tape – to measure the right length of the catheter
- Chlorhexidine solution – a type of disinfectant used to clean the skin
- Sterile saline flushes – to clean out the catheter
- Suture material – like a medical thread, which is used to secure the catheter in place
- Dressing – for covering the wound
- Local anesthetic – a medicine used to numb the area where the catheter will be inserted
- The PICC catheter, introducer needle, guidewire, dilator, and blade – all tools used to insert the catheter inside your body
- Leaded glasses and apron – protection for the doctor or nurse from radiation if used during the procedure
These supplies ensure your safety and comfort during the procedure while maintaining the highest possible hygiene levels.
Who is needed to perform Peripherally Inserted Central Catheter (PICC) Line Placement?
Doctors, qualified nurses, or physician assistants are trained to insert PICCs, which are a type of special tube used for treatments like chemotherapy or long-term antibiotics. However, a lot of hospitals and healthcare institutions have dedicated teams of nurses who specialize in PICC insertions. This means that they have extra training and focus specifically on this procedure.
Preparing for Peripherally Inserted Central Catheter (PICC) Line Placement
Before starting the procedure, the healthcare provider will discuss with the patient the advantages and potential risks involved. During the procedure, the patient’s heart activity is continuously monitored for any irregular heartbeat that may occur due to the insertion of a wire into the right atrium (a chamber of the heart).
The patient will be made to lie down flat on their back, with their arm moved outward and upward. An ultrasound tool will be used to help identify the best blood vessel to be used for the procedure.
A tape measure will be used to figure out the length of the catheter needed. This is calculated by measuring the distance from the elbow crease to the midpoint of the line that runs vertically down the chest area. This length will give a rough idea of how long the catheter should be. In some cases where a catheter is needed in the lower extremity (leg), the length is measured from where the needle will be inserted, along the path of the vein, up to just below the chest.
To keep the procedure area clean and free from any germs, an antiseptic solution will be applied. The patient will then be covered with special sterile (germ-free) sheets. A sterile covering is placed on the ultrasound tool. Medical instruments needed for the procedure will be arranged in order, in a sterile environment, for easy access. All catheter tubes are cleaned with normal saline (a salt-water solution) and sealed shut. If needed, medication to help the patient relax may be given.
How is Peripherally Inserted Central Catheter (PICC) Line Placement performed
A PICC (Peripherally Inserted Central Catheter) is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart. This procedure can be used to give treatments and medicines, over a long period of time. There are two ways to insert a PICC – with ultrasound guidance or with fluoroscopic guidance.
In an ultrasound-guided PICC placement, your arm is positioned on a board at a 45 to 90-degree angle, palm facing up. The doctor uses an ultrasound to find the best vein and then numbs the area with a mild anaesthetic. Using a needle, they puncture the vein and confirm they’re in the right place. A thin, flexible wire is then guided through the needle.
If the wire goes too far, it can cause changes in the heart’s electrical activity. If this happens, the wire is pulled back. Once the wire is in place, the needle is removed. The doctor then makes a small cut in your skin to make room for the PICC. The catheter is then guided over the wire, into the vein and up towards the heart.
The doctor then carefully removes the wire and seals the area with a dressing. It’s very important to check the catheter is in the right place before using it, so a chest X-ray is taken.
In the second method of PICC placement, fluoroscopic guidance is used. This is very similar to the ultrasound-guided method, except that instead of using ultrasound to find the vein, a special dye is used which shows up on X-ray images. The doctor can then watch on a monitor as the catheter is inserted and correctly positioned.
For children, the procedure can be a bit different. They might need sedation, and doctors may use different veins that are more suited to smaller bodies. When inserting a PICC in a leg, the tip of the catheter should be in a large vein above the diaphragm, which is the muscle that helps you breathe.
After a PICC has been inserted, it’s important to check the area for bleeding or redness. Dressings need to be changed at least once a week, or as per hospital policy and manufacturer’s instructions. After each use, the PICC should be flushed with a saline and heparin solution to keep it clear and prevent blood clots.
Possible Complications of Peripherally Inserted Central Catheter (PICC) Line Placement
PICCs, also known as Peripherally Inserted Central Catheters, are generally placed safely, but there can be some issues during or after the procedure. Problems may occur related to how the device is placed, how it works, or infections afterwards. Most of these complications impact the blood vessels. In some cases, they might accidentally poke an artery, which can cause bleeding, temporary tightening of the blood vessels or the formation of a bulge in the blood vessel wall.
Besides damage to the arteries, nerves near the upper arm could also be impacted. On rare occasions, the catheter that is placed from the outside of the body to a large vein near the heart might cause complications like a fluid-filled sac pressing against the heart, air bubble in a blood vessel, a collapsed lung or injury to a major chest duct because of wrong placement. However, these problems can be reduced with proper ultrasound training and use of fluoroscopy, a type of medical imaging that shows a continuous X-ray image on a monitor.
On some occasions, the catheter may get blocked by either the inside or the outside. Blockages inside the catheter most frequently happens when blood clots or certain medications form a solid mass. Blockages outside the catheter usually results from the formation of a fibrin sheath, a kind of blood clot or an incorrectly positioned catheter. These issues can be problematic for patients who regularly use a PICC. A medicine that breaks down blood clots can dissolve the fibrin sheath and restore the flow. The rate of these blockages has significantly decreased with improvements in catheter design and material.
One extensive study examining 29,503 patients demonstrated that the use of PICCs comes with a higher risk of deep vein thrombosis (DVT), a condition where a blood clot forms in the deep veins of the body, than CVCs, another kind of catheter. The risk is higher in critically ill patients and those with cancer. The risk of DVT is also elevated in people with a past history of DVT, overweight, and those with other medical conditions such as diabetes. More importantly, the larger the catheter size, the higher the risk. This risk can be reduced by choosing a small-size catheter based on an appropriate catheter-to-vein ratio.
Another recent study that looked at the complications in 3,285 patients discovered that bloodstream infections and symptomatic DVT were the most common complications with PICCs. Most of the bloodstream infections were caused by a single type of bacteria, usually gram-positive. Studies have found that the infection rate from PICC-related bloodstream infections was 2.4% or 2 to 5 per 1000 catheter days. This was noted to be similar in another study on patients in Intensive Care Units (ICU) comparing PICCs with CVCs. Infections were seen less frequently in patients with a PICC who were being cared for at home.
Recent research supports the fact that PICCs carry a lower risk of infection than CVCs. When compared with a different, tunneled type of CVC for the administration of nutrition directly into the blood, the PICC was associated with a significantly lower rate of bloodstream infections. The most common way for an infection to develop is when skin organisms at the insertion site migrate into the tube, resulting in the colonization of the catheter tip. Infections can also occur if the fluid being infused or the catheter hub becomes contaminated.
What Else Should I Know About Peripherally Inserted Central Catheter (PICC) Line Placement?
Central Venous Catheters (CVCs) are special tubes – much like IV lines – that doctors use to deliver medication and fluids to people who are in the hospital, specifically those in intensive care, undergoing surgery, or receiving cancer treatment. These days, they’re often used to care for patients outside the hospital as well.
One type of CVC is the Peripherally Inserted Central Catheter (PICC), which has gained popularity over time. PICCs offer several benefits over other types of CVCs. These include the ability to safely use them outside the hospital, a reduced risk of infection in the hospital, and the possibility of keeping them in place for many months, which is great for long-term treatments and certain diagnostic tests.
Traditionally, doctors have used fluoroscopy, a technique that uses X-rays to get real-time moving images of the inside of the body, to guide the placement of PICC lines. This method helps doctors accurately position the PICC line, ensuring that it’s in the right blood vessel, and check that there are no twists or turns in the line and that it ends at the right spot inside the body. Fluoroscopy also eliminates the need for an additional chest X-ray after placing the PICC line.
However, fluoroscopic PICC placement does have some limitations. Only certain facilities can perform this procedure. In addition, patients who are very ill, like those in the intensive care unit (ICU), could have trouble moving to the radiology department where the procedure usually takes place. For these patients, doctors might need to use ultrasound guidance instead to place the PICC line at their bedside. Pregnant women might also need to avoid fluoroscopy to protect their unborn baby from excessive radiation. That being said, fluoroscopy can be especially helpful in guiding PICC placement in patients with complex anatomy. As healthcare professionals gain more experience and knowledge about this technique, it will lead to better patient outcomes by reducing the risk of infection and other complications like bleeding or injury to blood vessels.
