A peripherally inserted central catheter (PICC) or PIC line, is a form of intravenous access that can be used for a prolonged period of time. It is also called a percutaneous indwelling central catheter. Peripherally inserted central catheters are used to obtain central venous access. For example peripherally inserted central catheter may be used for long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition) or for the administration of substances that should not be done peripherally.
PICC can be used for a longer period than central venous catheters and have lower a lower risk of complications.
They became available in 1975 but gained popularity in the 1980s, and their use has grown steadily since then.
PICC 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 or weeks.
It is used for administering fluids, drugs, and withdrawal of blood samples.
Difference Between Central and Peripheral Venous Access
A central venous access device is one where the tip o the device [the end point where the delivery in the circulation is done] must terminate either in the superior vena cava or the inferior vena cava, or the proximal right atrium.
Central venous catheters are inserted through central veins like jugular, subclavian vein etc. PICC is actually inserted in peripheral vein like a vein in the arm or saphenous vein [in children]. But the tip reaches the above-mentioned points and thus become a central catheter.
A peripherally inserted catheter or device where the tip terminates below the level of the diaphragm for lower extremity insertion, or proximal to the superior vena cava for upper extremity insertion, is technically a peripheral catheter.
The central devices [central lines or PICC] are preferred over the peripheral catheters for infusions that would continue for prolonged durations or when the infusate is viscous or irritant.
In central catheter, the blood flow around the catheter tip is high which provides immediate dilution of the infusate and helps protect the vessel walls from chemical irritation by the prescribed therapy.
PICCs are indicated for short-term infusions for patients with limited venous access and for therapies that will continue over long periods of time.
Examples of Infusates that are irritants or vesicants are acyclovir, Amphotericin B, Partial parenteral nutrition, Dopamine, Sodium nitroprusside etc.
Most chemotherapeutic agents are irritants.
Dwell time is the maximum expected duration considered appropriate for a given type of device.
Nontunneled percutaneous central venous catheters are generally considered appropriate only for short-term use. They are associated with higher risk of infection compared with peripherally inserted central catheter, implanted ports, and tunneled catheters.
There is no established dwell time for peripherally inserted central catheter. But if the therapy is expected to last longer than 1 year, a more permanent type of central access device should be considered, such as a tunneled catheter or implanted port.
Procedure of Insertion of Peripherally Iinserted Central Catheter
Sterile precautions are used throughout the procedure.
Peel-away Cannula Technique
The access is established by inserting the cannula and stylet into a palpable vein in or near the antecubital fossa. The stylet is removed and the catheter is inserted through the cannula.
After the catheter has been positioned, the cannula is then pulled back and peeled away from the catheter. This technique requires accessible veins at or near the antecubital fossa.
Peel-away cannula technique is associated with higher incidence of thrombophlebitis
Modified Seldinger Technique
A vein is accessed with a regular hypodermic needle, an intravenous cannula, or an echogenic needle. A guide wire is threaded into the needle or cannula several centimeters.
The needle or cannula is removed, leaving the guidewire in place. The guide wire is not advanced past the shoulder. An introducer sheath with dilator is inserted over the guide wire. The guide wire and dilator are removed, and the catheter is advanced through the introducer sheath. After the catheter is inserted, the sheath is pulled back and peeled away.
Ultrasound can be used to locate and help access the vein.
Confirmation of Position
Distal tip position can be confirmed by chest x-ray immediately after insertion and prior to device use.
Care and Maintenance
After placement, a dressing is applied over a small gauze pad.
The initial dressing is removed after 24 hours and replaced with a transparent dressing only. Gauze dressing if used need to be changed every 48 hours. lA transparent dressing alone can be left in place longer and can be changed on weekly basis.
Flushing protocols vary. Some advise instillation of heparin solution when the catheter is not in use. However, some catheters are closed on one end by pressure-sensitive valves, and can be flushed with normal saline only.
All flushing should be done with 10-cc or larger syringes. Smaller syringes produce excessive flushing force that can damage the catheter.
Contraindications for Peripherally Inserted Central Catheter
Lack of peripheral access
When there is peripheral access, the PICC should either be placed under fluoroscopy or with ultrasound and modified-Seldinger technique. These procedures use a type of central catheter than bedside PICC.
In the presence o upper extremity or subclavian thrombosis, peripherally inserted central catheter is inserted under fluoroscopy
End-stage renal disease
Patients with chronic renal failure and end-stage renal disease are not appropriate candidates for PICC placement as they need to preserve peripheral veins for future dialysis fistulas. Any thrombosis in upper extremity or the subclavian veins following PICC reduces the probability of successful fistula development.
Central venous line in the internal jugular vein is the preferred insertion site for these patients.
In addition, PICCs should not be used for frequent intermittent access or for blood sampling.
Complications of Peripherally Inserted Central Catheter
This may occur due to
- Alteration of the vein wall by injury, irritation, or disease process.
- Stasis, obstruction, or change in blood flow [esp when vein chosen is smaller
- Platelet aggregation due to hypercoagulability
Thrombus could be intraluminal thrombus which forms inside the catheter or mural which forms between catheter and vein wall.
Intraluminal thrombus can and can result in partial or complete occlusion of the catheter. Alteplase is a fibrinolytic agent that when instilled for 30-120 minutes and then withdrawn can dissolve this thrombus.
A mural thrombus forms between the catheter and the vein wall and it could be partial or complete. Mural thrombus restricts blood flow around the catheter. It may cause
- Swelling near and distal to the point of occlusion
- Peripheral collateral venous distention
- Periorbital edema, tearing of the eye on the affected side
- Discomfort of the shoulder or jaw on the affected side.
Fibrin build-up may form an encasing sheath to completely encase the catheter. Infusions still may be possible, but the sheath will occlude the distal opening during aspiration and prevent withdrawal of blood from the catheter.
Fibrin also may build up on a catheter without completely enclosing it and may lead to a small piece of fibrin hangings off the catheter tip [Fibrin tail] which occludes blood withdrawal.
Both the situations are known as persistent withdrawal occlusion.
Other causes of nonthrombotic occlusions are
- Medication crystallization and precipitation
- Lipid occlusions
- Mechanical occlusions
- Crimping of the catheter
- Tip against a vessel wall
Mechanical phlebitis is caused by irritation of the venous endothelium by the catheter. It is found more in PICCs inserted in the antecubital fossa than in the upper arm.
Chemical phlebitis seldom occurs with solutions infused when the leak occurs through the damaged catheter or retrograde flow when there is fibrin sheath.
This can happen when PICC is inserted or later, due to changes in intrathoracic pressure. Sometimes, the catheter can migrate.
Tip in the distal right atrium or in the right ventricle can lead to arrhythmia.
A position proximal to the superior vena cava can lead to phlebitis and thrombus formation. Proximal superior vena cava tip termination has a higher incidence of complications, including tip malposition.
Proper catheter securement is essential to help prevent catheter dislodgement or migration. Use of securement devices is safer and more effective than suturing or taping.
The catheter can get damaged by
- Improper care
- Improper securement
- Excessive pressure when flushing the device
- Use of a syringe with a barrel smaller than 10cc’s
- Lead to increased intraluminal pressure
- Contact with sharp objects
- Applying luer-locking devices too tightly
- Cracks in the catheter hub
- Entanglement of the external portion of the catheter in bed linens, clothing, or equipment etc
A damaged catheter is a contaminated catheter.
It can be tackled with one of the following options
- Short-term intervention
- Replacement using an over-the-wire modified-Seldinger procedure
- Removal and different catheter at the different site
It is marked by hypotension, lightheadedness, confusion, tachycardia, anxiety, chest pain, shortness of breath etc
Arterial Injury(during insertion)
- Bright red blood
- Pulsatile bleeding at insertion site
- Retrograde flow in IV tubing
An Arterial blood gas analysis can verify the site. Catheter needs to be removed carefully and arterial injury repaired.
Infection is suggested by fever, chills, tachycardia, fatigue, muscle aches etc. Other features are swelling at site, induration, purulent drainage at site, elevated white blood cell count etc.
It is treated by removal of catheter and antibiotics.
Removal of Peripherally Inserted Central Catheter
Removal of the catheter should be done in a center where complications could be managed.
One of the prime complications is stuck PICC which refers to the failure of the catheter to disengage, usually caused by venospasm.
Venospasm would resolve with time and it is important to stop the pull, coil the exposed portion, dress it and allow time for the venospasm to resolve. Continuing to pull against the resistance will aggravate the venospasm and PICC could break and lead to a life-threatening catheter embolus.
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