The purpose of the PICC insertion procedure is to provide medicinal therapy and fluids through an intravenous catheter.
PICC 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 carry blood to the heart. This tube may have one or two openings, called lumens, that are used to deliver medication.
A PICC must be ordered by your primary physician or surgeon or their consulting colleague.
The benefit of a PICC is that the catheter can remain for a long period, typically 2 to 6 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 instances, a PICC is used and can stay in for up to one year.
Typical intravenous (IV) therapies administered through a PICC include:
- Total parenteral nutrition (vitamins, minerals, electrolytes, proteins, carbohydrates, etc.)
- Blood products
- PICC insertion procedures are performed by qualified and specially trained nurses to safely use ultrasound.
- To ensure safe and accurate PICC placement, PICC lines are inserted using ultrasound. The final position of the PICC is confirmed by a chest X-ray or by 3CG technology at the time of insertion.
After written informed patient consent is obtained, 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. The insertion site is cleaned with an alcohol-based solution. 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 removed. An introducer is slipped over the guidewire, into the skin, and then into the vein. The introducer or (dilator) widens the tract for the PICC line. The guidewire is removed. The PICC is then inserted. The indwelling stylet 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 3CG or chest X-ray is used to confirm proper placement. The catheter is secured to the skin with a STAT lock. This is an adhesive-backed securing device. A bio-patch is applied around the catheter at the insertion site. This is an antimicrobial patch to help reduce the risk of infection. To finalize the site is covered with a transparent adhesive dressing.
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:
- A Contraindication is any patient with kidney disease. They would need clearance by their nephrologist before any line could be placed in their upper arm.
- If the nephrologist okays the PICC placement. The patient’s dominant arm should be used. this is to preserve the vessels of the nondominant arm for potential fistula/graft formation.
- Known blood clots in the chosen arm
- Breast cancer patient with lymph node resection
- Shoulder replacement on the chosen side could affect successful line placement
- Burns on the arm
- Known infection of the arm
The risks involved with the PICC procedure involve:
- Bleeding from site
- Nerve Damage (rare)
- Blood Vessel Damage (rare)
- Paint at site
- Muscle Damage (rare)
- 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: Risk is uncommon and patients are questioned about allergies prior to the procedure. Appropriate precautions are then taken.
- Breakage of materials such as guidewire or catheters during the procedure: Risk is extremely rare.
Adherence of the catheter within the venous system at the time of removal can occur when the catheter has been in-dwelling for long periods of time, although this is a rare occurrence
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 infection could result in further spreading or increasing the severity of the infection.
Intravenous (IV) therapy can be performed with peripheral IV catheters, but these don’t function as long as a PICC requiring multiple IV sticks, leading to increased discomfort and increased risk of infection. Long-term IV therapy can be performed with other central venous catheters (for example, tunneled catheters or implanted port-a-caths).
The patient is 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.
You should report any of the following to a nurse:
- Obstruction of flow
- The line is pulled out partially or completely
- Leakage of fluid
- Drainage at an entry site
- Soft-tissue swelling
If a nurse is unavailable, call the numbers listed in your PICC booklet.
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 dressing becomes saturated with fluid, inform your doctor so the dressing can be changed. An intact dressing is the most important way to prevent infection. 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 underwater. 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 should remain in until the PICC is removed. Lifting 10 or more pounds with the affected arm is also not recommended. Always visually inspect the dressing daily.
PICC removal is a simple procedure in almost all cases.
Call Us or your Doctor if:
- Leaking from the catheter, or the catheter is cut or cracked
- Pain, redness, numbness, or swelling near the catheter site, or in your neck, face, chest, or arm
- Trouble flushing your catheter