Peripherally inserted central catheter

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Typical PICC line with a double lumen. PICC line.jpg
Typical PICC line with a double lumen.

A peripherally inserted central catheter (PICC or PICC line), less commonly called a percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period of time (e.g., for long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition) or for administration of substances that should not be done peripherally (e.g., antihypotensive agents a.k.a. pressors). It is a catheter that enters the body through the skin (percutaneously) at a peripheral site, extends to the superior vena cava (a central venous trunk), and stays in place (dwells within the veins) for days, weeks or even months.

Contents

First described in 1975, [1] it is an alternative to central venous catheters in major veins such as the subclavian vein, the internal jugular vein or the femoral vein. Subclavian and jugular line placements may result in pneumothorax (air in the pleural space of lung), while PICC lines have no such issue because of the method of placement.

Medical uses

A PICC (upper arm) and IV line (elbow area) inserted prior to chemotherapy. PICC Line and IV Placement.jpg
A PICC (upper arm) and IV line (elbow area) inserted prior to chemotherapy.

Generally, PICC lines are considered when a person is expected to need more than two weeks of intravenous therapy. [2] A PICC line can remain inserted for an extended period of time compared to other forms of central IV access, ranging from seven days up to several months as long as the line remains viable. [3] They are utilized in both the hospital and community settings. They are commonly used in people receiving total parenteral nutrition (TPN), chemotherapy, or long term medications such as antibiotics. They may also be used to obtain a blood sample if the lumen is of sufficient size (at least 4 French gauge).

To help prevent the line from becoming clogged, the line should be regularly flushed with normal saline, and "locked" by filling it with heparin or normal saline when not in use.

Contraindications

A PICC line may not be inserted in a part of the body which is burned or has a local infection. Damage to the skin and surrounding tissue from radiation may also prevent the placement of a PICC line. [4]

Risks and complications

As with any intravenous line, there is the risk for sepsis – a severe bloodstream infection that can be life-threatening. The majority of infections associated with PICC lines occur after a median duration of use of 10 days, and during an intensive care unit stay. [5] Adhering to strict infection control procedures, including aseptic technique, when inserting or using a PICC line will reduce the risk of an infection. [6] There is also a risk of blood clots. [2] The use of heparin to maintain a PICC line is not universal, as heparin locks have been associated with complications, including heparin-induced thrombocytopaenia. [7]

Other complications may include catheter occlusion, phlebitis and bleeding. Urokinase or low-dose tissue plasminogen activator (tPA) may be required to break down obstructions, depending on the type and severity of the occlusion. A blood pressure reading can not be taken on an arm with a PICC line inserted. [8]

Technique

Chest X-ray showing tip of PICC line in the superior vena cava. Arrows provided to highlight the PICC line. PICC line-correct position-with annotation.jpg
Chest X-ray showing tip of PICC line in the superior vena cava. Arrows provided to highlight the PICC line.
Illustration of fully inserted PICC Blausen 0193 Catheter PICC.png
Illustration of fully inserted PICC

A PICC is inserted in a peripheral vein such as the cephalic vein, basilic vein or brachial vein in the arm, and then threaded through the veins toward the heart, until the end of the catheter rests in the proximal superior vena cava or cavoatrial junction. They must be inserted by a trained medical professional, including a physician, but also any trained medical professional such as a specially trained registered nurse. [5] An ultrasound or chest X-ray, or the use of fluoroscopy, can be used during insertion and to confirm placement. The insertion is a sterile procedure, but does not need to be performed in a completely sterile environment like an operating room.

Selection of vein and catheter

A PICC line is an invasive medical procedure, and may require local or general anesthesia during the placement. The basilic vein is an appropriate size, but is not preferred in children due to its depth and surrounding tissue. On the other hand, the cephalic vein may be used, though in some people it will not be possible to advance the line to the desired location through the cephalic vein. The brachial vein is large enough for a PICC line, but is also located close to other features such as the brachial artery and plexus. Imaging is commonly used to evaluate the length and path of the potential veins before the practitioner selects the most appropriate vein. [5] The catheter size for PICC lines is generally measured in French gauge, and may range from 2 to 6. The number of lumens may vary from one to three, allowing for concurrent administration of different medications which cannot be mixed. Catheters are also manufactured from multiple materials, including silicone and polyurethane. The insertable portion of a PICC varies from 25 to 60 cm in length, which is sufficient to reach the desired end position in most cases. Some catheters are designed to be trimmed to the required length before insertion whereas others are simply inserted to the needed depth with the excess remaining outside the body. Catheters are supplied with a guidewire. This wire is provided to stiffen the (otherwise very flexible) line so it can be more easily threaded through the veins, and is removed after insertion. Some PICC lines are manufactured with an antimicrobial coating intended to reduce the chance of an infection from the line, but these are not yet in widespread use. [5]

Insertion

While an operating room is not required for the insertion of a PICC line, it is important to maintain a sterile environment surrounding the insertion site. This involves cleaning the skin around the site, as well as the use of a sterile gown, gloves, and drape to reduce the risk of environmental contamination. After the skin is prepared, an incision is made and a device called an "introducer" is inserted into the vein. The catheter is cut to the desired length if required, and filled with saline for the duration of the insertion. The PICC line is inserted via the introducer device, and threaded through the veins to the desired end location. [5] Fluoroscopy or echocardiographic guidance may be used to monitor the tip position during insertion.

Removal

In most cases the removal of a PICC is a simple procedure. Generally, the catheter line can be safely and quickly removed by a trained nurse, even in the patient's own home, in a matter of minutes. After removal, the insertion site is normally bandaged with sterile gauze and kept dry for a few days, during which the wound can close and begin healing. Usually, a smaller adhesive bandage can be placed over the wound site after the gauze is removed if the wound is slow to heal. The tip of the catheter is sent for microscopy culture and sensitivity (MCS) if the patient is systemically unwell at the time of removal of the PICC. In certain units, it is sent as routine investigation.

See also

Related Research Articles

<span class="mw-page-title-main">Central venous catheter</span> A tubular device placed in a large vein used to administer medicines

A central venous catheter (CVC), also known as a central line (c-line), central venous line, or central venous access catheter, is a catheter placed into a large vein. It is a form of venous access. Placement of larger catheters in more centrally located veins is often needed in critically ill patients, or in those requiring prolonged intravenous therapies, for more reliable vascular access. These catheters are commonly placed in veins in the neck, chest, groin, or through veins in the arms.

<span class="mw-page-title-main">Intravenous therapy</span> Medication administered into a vein

Intravenous therapy is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrients for those who cannot, or will not—due to reduced mental states or otherwise—consume food or water by mouth. It may also be used to administer medications or other medical therapy such as blood products or electrolytes to correct electrolyte imbalances. Attempts at providing intravenous therapy have been recorded as early as the 1400s, but the practice did not become widespread until the 1900s after the development of techniques for safe, effective use.

<span class="mw-page-title-main">Catheter</span> Medical tubes inserted in the body to extract or administer substances

In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Catheters are manufactured for specific applications, such as cardiovascular, urological, gastrointestinal, neurovascular and ophthalmic procedures. The process of inserting a catheter is catheterization.

<span class="mw-page-title-main">Cannula</span> Tube surgically implanted in the body

A cannula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces of a trocar needle thus extending the effective needle length by at least half the length of the original needle. Its size mainly ranges from 14 to 26 gauge. Different-sized cannula have different colours as coded.

<span class="mw-page-title-main">Dialysis catheter</span>

A dialysis catheter is a catheter used for exchanging blood to and from a hemodialysis machine and a patient.

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

<span class="mw-page-title-main">Pulmonary artery catheter</span> Catheter for insertion into a pulmonary artery

A pulmonary artery catheter (PAC), also known as a Swan-Ganz catheter or right heart catheter, is a balloon-tipped catheter that is inserted into a pulmonary artery in a procedure known as pulmonary artery catheterization or right heart catheterization. Pulmonary artery catheterization is a useful measure of the overall function of the heart particularly in those with complications from heart failure, heart attack, arrythmias or pulmonary embolism. It is also a good measure for those needing intravenous fluid therapy, for instance post heart surgery, shock, and severe burns. The procedure can also be used to measure pressures in the heart chambers.

<span class="mw-page-title-main">Hickman line</span> Central venous catheter

A Hickman line is a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood for analysis. Some types are used mainly for the purpose of apheresis or dialysis. They have also been used in total parenteral nutrition (TPN). Hickman lines may remain in place for extended periods and are used when long-term intravenous access is required.

<span class="mw-page-title-main">Cubital fossa</span> The human elbow pit

The cubital fossa,chelidon, grivet or elbow pit, is the area on the anterior side of the upper part between the arm and forearm of a human or other hormid animals. It lies anteriorly to the elbow when in standard anatomical position.

Vascular access refers to a rapid, direct method of introducing or removing devices or chemicals from the bloodstream. In hemodialysis, vascular access is used to remove the patient's blood so that it can be filtered through the dialyzer. Three primary methods are used to gain access to the blood: an intravenous catheter, an arteriovenous fistula (AV) or a synthetic graft. In the latter two, needles are used to puncture the graft or fistula each time dialysis is performed.

Venous cutdown is an emergency procedure in which the vein is exposed surgically and then a cannula is inserted into the vein under direct vision. It is used for venous access in cases of trauma, and hypovolemic shock when the use of a peripheral venous catheter is either difficult or impossible. The great saphenous vein is most commonly used. This procedure has fallen out of favor with the development of safer techniques for central venous catheterization such as the Seldinger technique, the modified Seldinger technique, intraosseous infusion, as well as the use of ultrasound guidance for placement of central venous catheters without using the cutdown technique.

<span class="mw-page-title-main">Groshong line</span>

A Groshong line is a type of intravenous catheter used for central venous access. It can be tunneled or non-tunneled.

<span class="mw-page-title-main">Umbilical line</span>

An umbilical line is a catheter that is inserted into one of the two arteries or the vein of the umbilical cord. Generally the UAC/UVC is used in Neonatal Intensive Care Units (NICU) as it provides quick access to the central circulation of premature infants. UAC/UVC lines can be placed at the time of birth and allow medical staff to quickly infuse fluids, inotropic drugs, and blood if required. It is sometimes used in term or near-term newborns in whom the umbilical cord stump is still connected to the circulatory system. Medications, fluids, and blood can be given through this catheter and it allows monitoring of blood gasses and withdrawing of blood samples. Transumbilical catheter intervention is also a method of gaining access to the heart, for example to surgically correct a patent ductus arteriosus.

<span class="mw-page-title-main">Port (medical)</span> Small completely implantable medical appliance that is installed entirely beneath the skin

In medicine, a port is a small medical appliance that is installed beneath the skin. A catheter connects the port to a vein. Under the skin, the port has a septum through which drugs can be injected and blood samples can be drawn many times, usually with less discomfort for the patient than a more typical "needle stick".

<span class="mw-page-title-main">Peripheral venous catheter</span>

In medicine, a peripheral venous catheter, peripheral venous line, peripheral venous access catheter, or peripheral intravenous catheter, is a catheter placed into a peripheral vein for venous access to administer intravenous therapy such as medication fluids.

<span class="mw-page-title-main">Cardiac resynchronization therapy</span>

Cardiac resynchronisation therapy is the insertion of electrodes in the left and right ventricles of the heart, as well as on occasion the right atrium, to treat heart failure by coordinating the function of the left and right ventricles via a pacemaker, a small device inserted into the anterior chest wall.

<span class="mw-page-title-main">Electrophysiology study</span> Medical test to record electrical activity within the heart

A cardiac electrophysiology study is a minimally invasive procedure using catheters introduced through a vein or artery to record electrical activity from within the heart. This electrical activity is recorded when the heart is in a normal rhythm to assess the conduction system of the heart and to look for additional electrical connections, and during any abnormal heart rhythms that can be induced. EP studies are used to investigate the cause, location of origin, and best treatment for various abnormal heart rhythms, and are often followed by a catheter ablation during the same procedure.

Ambesh maneuver is a technique that involves the simple external compression of internal jugular vein in supraclavicular fossa to prevent and diagnose misplacement of the subclavian vein catheter into the internal jugular vein (IJV). The subclavian vein is a big vessel that drains the blood from the hand, forearm and the upper arm into the right side of the heart through superior vena cava. The subclavian veins lie just behind the clavicle on each side and therefore known as subclavian vein.

Venous access is any method used to access the bloodstream through the veins, either to administer intravenous therapy, parenteral nutrition, to obtain blood for analysis, or to provide an access point for blood-based treatments such as dialysis or apheresis. Access is most commonly achieved via the Seldinger technique, and guidance tools such as ultrasound and fluoroscopy can also be used to assist with visualizing access placement.

In medicine, vascular access is a means of accessing the bloodstream through the peripheral or central blood vessels in order to obtain blood or deliver medications including chemotherapy. A vascular access procedure involves insertion of a sterile plastic tube called a catheter into a blood vessel. Types of catheters can be either peripherally or centrally located. Peripheral catheters are approximately one inch (25 mm) long and are inserted into the small veins of the forearm. Central catheters are bigger and longer and are inserted into the large veins of the extremities, neck, or chest. Central venous catheters are the primary modality used for delivery of chemotherapeutic agents. The duration of central venous catheterization is dependent on the type of treatment given.

References

  1. ↑ Hoshal VL (May 1975). "Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters". Arch Surg. 110 (5): 644–6. doi:10.1001/archsurg.1975.01360110190032. PMID   805577.
  2. 1 2 Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, et al. (September 15, 2015). "The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method". Annals of Internal Medicine. 163 (6 Suppl): S1–S40. doi: 10.7326/M15-0744 . PMID   26369828.
  3. ↑ "Guidelines for the Prevention of Intravascular Catheter-Related Infections". Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Retrieved July 23, 2019.
  4. ↑ Westergaard B, Classen V, Walther-Larsen S (March 2013). "Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations: PICCs in children". Acta Anaesthesiologica Scandinavica. 57 (3): 278–287. doi:10.1111/aas.12024. PMID   23252685. S2CID   10458652.
  5. 1 2 3 4 5 Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S (April 2014). "PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors". The American Journal of Medicine. 127 (4): 319–328. doi: 10.1016/j.amjmed.2014.01.001 . PMID   24440542.
  6. ↑ Guidelines for the Prenention of Intravascular Catheter-Related Infections, Centre for Disease Control 2011; Infusion Nurses Standards, 2010).Centre for Disease Control
  7. ↑ "Safety of Catheter Lock with or Without Heparin in Implanted Central Venous Catheters - Related Studies - ClinicalTrials.gov". Archived from the original on August 1, 2013. Retrieved February 5, 2012.
  8. ↑ U Wisconsin, Preparing and Caring Archived August 4, 2013, at the Wayback Machine , accessed July 24, 2013

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