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Peripherally inserted central venous catheter (PICC) insertion

A peripherally inserted central venous catheter serves as an alternative vascular access device in hospitalized patients. Whether it is part of de-resuscitation in transitioning from traditional central venous access or planning for long term parenteral administration, PICC devices are asset to caring for acutely ill patient. Below we review the key steps in insertion of a PICC access device and provide a 360 degree video tutorial.

Section contributors: Dr Ayush Lacoul, Dr Laz Milovanovic, Dr Darren Hudson, Dr Brian Buchanan

PICC indications/benefits

  • Patients with poor peripheral venous access
  • Monitoring of interventions
  • Central venous pressure and repeat blood sampling
  • Infusion of medications centrally (i.e pressors, chemotherapy, TPN)
  • Long term administration of medications (i.e antibiotics)
  • Can be discharged home with PICC
  • Aberrant central venous anatomy

Relative Contra-indications

  • There are NO absolute contraindications
  • Ongoing bacteremia
  • Infection at site
  • Trauma or burn to site
  • Patient refusal or lack of cooperation

Risks

  • Bleeding
  • Infection (2.4%, 2-5 per 1000 catheter days)
  • Thrombus (3%)
  • Mechanical obstruction (4%)
  • Injury to surrounding structure i.e. brachial artery, brachial nerves
  • Malposition
  • Arrhythmia (PAC, PVC) during insertion
  • Extremely rare cases, thoracic duct injury, pneumothorax and air embolus

Benefits

Key venous access landmarks

Basilic vein in the right arm is preferred in most circumstances if accessible. Right basilic vein has least torotuous route to superior vena cava. Cephalic vein next best alternative. Brachial vein can also be used *but increases the risk of arterial injury.

(R) sided basilic vein

(R) Brachial vein

  • Veins should be fully compressible (to exlude thrombus) and imaged along the entire length proximal to entry site to exclude thrombus

PICC measurments

There are many reported ways to measure for PICC line length, but we recommend this common approach. Measure the distance from the right antecubital fossa (insertion site) to the right axillary crease to the right sternal head and turn the tape measure caudal to reach the third intercostal space at the right border of the sternum. This will be the approximate measurement of the catheter for a right-sided PICC (32-42 cm). A left-sided PICC will also use the right side sternal head as a reference point, given placement of the SVC.

Cut the catheter tip at this point. The target location on the CXR post-insertion is the lower third of the SVC.

PICC insertion video tutorial

The video below provides a step-by-step instructional video on how to insert a PICC line. This video was recorded with a 360 camera. Please  use your cursor to drag the screen where the action is! If it is not working in your browser, then click the link to view it in YouTube.

Click here to view in YouTube

References

  • Johansson E, Hammarskjöld F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 2013 Jun;52(5):886-92.
  • Kwon S, Son SM, Lee SH, Kim JH, Kim H, Kim JY, Kim JI, Moon IS. Outcomes of bedside peripherally inserted central catheter placement: a retrospective study at a single institution. Acute Crit Care. 2020 Feb;35(1):31-37.
  • Maki DJ,  Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc, 81 (2006), pp. 1159-1171
  • Montanarella, M. J. (2021, August 12). Fluoroscopic Picc Line Placement. StatPearls [Internet]. Retrieved January 24, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK573064/
  • Moran J, Colbert CY, Song J, et al. Screening for novel risk factors related to peripherally inserted central catheter-associated complications. J Hosp Med2014;9:481–9.
  • Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005 Aug;128(2):489-95.
  • Ullman AJ, Marsh N, Mihala G, et al. Complications of central venous access devices: a systematic review. Pediatrics2015;136:e1331–44.
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