PICC Insertion

A peripherally Inserted Central Catheter (PICC) is a thin, soft plastic tube that is used for giving intravenous fluids and medications. It is inserted through a peripheral vein, preferably in the upper arm, and advanced until the tip of the catheter reaches a large vein above the heart. A PICC line stays in place for as long as needed and up to one year if properly maintained. However, a PICC is not appropriate for all patients and hence proper patient selection is essential.


Veins Used for Insertion: A PICC is generally inserted into the veins in the upper arm above the elbow. Although they are peripheral veins, they are deeper and larger than the peripheral arms located beneath the elbow. The veins which are used include the basilic vein, cephalic vein and brachial vein. The catheter is inserted into one of these veins and advanced until it reaches the Superior Vena Cava (SVC), one of the largest veins in the body. If necessary, other large veins, for example in the legs, are utilized if no other alternatives exist.


Who Inserts a PICC Line?:

A PICC line insertion can be an inpatient or outpatient procedure and is performed by trained and qualified health care professionals such as radiologists, physician assistants, radiology assistants, or certified registered nurses. A line can be inserted in one of three ways:

1) by feeling a vessel in the lower part of the arm followed by chest x-ray to confirm tip placement;

2) by ultrasound equipment to visualize a large vessel in the upper arm followed by a chest x-ray to confirm tip placement all done at the bedside; or

3) using ultrasound to visualize the vessel then utilizing fluoroscopy for a real-time image while advancing the catheter. Specially trained registered nurse performs the first two methods and a radiologist, nurse practitioner, or physician's assistant inserts the line with fluoroscopy. After the insertion, the PICC is secured to the skin with an anchoring devised and dressed with a sterile dressing.


Technique Used to Insert:

There are two techniques used to insert a PICC. They are the Peel-Away Cannula Technique and the Modified-Seldinger Technique.


The Peel-Away Cannula Technique:

The steps involved in this technique, which rarely uses ultrasound and is performed by feel only, are as follows:

  1. 1. A cannula with a stylet is inserted into a vein near the elbow.
  2. 2. The stylet is removed.
  3. 3. The PICC catheter is advanced through the cannula into the vein.
  4. 4. The cannula is then pulled back and peeled away from the catheter.
  5. 5. The catheter is advanced further into the vein under fluoroscopy until it reaches its terminating point.
  6. 6. The position of the tip is confirmed with fluoroscopy.


The Modified Seldinger Technique:

The steps involved in this technique, which uses ultrasound guidance to visualize the vessels in the upper part of the are, include the following:

  1. 1. A regular gauge hypodermic needle or an intravenous cannula is inserted in to a vein.
  2. 2. A guide wire is passed several centimeters into the needle/cannula.
  3. 3. The needle/cannula is removed leaving the guide wire in place. The guide wire is not advanced past the shoulder.
  4. 4. An introducer sheath with a dilator is introduced over the guide wire after a small incision is made on the skin near the wire.
  5. 5. The guide wire and dilator are removed. " The catheter is advanced through the introducer sheath.
  6. 6. The introducer is then pulled back and removed.
  7. 7. The position of the tip of the catheter is confirmed with fluoroscopy or a chest x-ray.


After Insertion:

After inserting the PICC and the procedure is complete, the catheter is secured with an anchoring devise to insure it remains in place and does not migrate out from the insertion site. It is then sterilely dressed to protect the site from infection. It can be used immediately following confirmation of the catheter tip placement.


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