Overview
Definition:
A Peripherally Inserted Central Catheter (PICC) is a long, thin, flexible tube inserted into a vein in the arm (or sometimes leg) and advanced until it reaches a large vein near the heart (superior or inferior vena cava)
It provides a secure route for long-term intravenous access for medication, fluids, or nutrition.
Epidemiology:
PICC lines are commonly used in neonates and pediatric patients requiring prolonged IV therapy, antibiotic courses, chemotherapy, or parenteral nutrition
Incidence varies by hospital and patient population, but is significant in NICUs and pediatric oncology/hematology wards.
Clinical Significance:
PICC lines are crucial for safe and effective delivery of vesicant medications, chemotherapy, and long-term antibiotics, minimizing repeated peripheral venipunctures and associated trauma, pain, and infiltration risks
Proper management and troubleshooting are vital to prevent complications and ensure optimal patient outcomes.
Indications
Prolonged Iv Therapy:
Need for intravenous therapy exceeding 7-10 days, including antibiotics, antivirals, or antifungals.
Chemotherapy Administration:
Administration of vesicant or irritant chemotherapy agents that can cause severe tissue damage if infiltrated.
Parenteral Nutrition:
Requirement for long-term parenteral nutrition when peripheral veins are inadequate or at risk of damage.
Frequent Blood Sampling:
Need for frequent or difficult blood sampling, particularly in neonates, to avoid repeated venipunctures.
Certain Medications:
Infusion of medications that are hyperosmolar or have a high pH, which can irritate peripheral veins.
Limited Peripheral Access:
Patients with poor peripheral venous access due to obesity, previous difficult access, or superficial veins.
Contraindications
Absence Of Suitable Veins:
Lack of viable peripheral veins in the intended insertion site, often due to previous trauma, burns, or sclerotherapy.
Presence Of Infection:
Active local skin infection at the insertion site or systemic infection that cannot be controlled.
Patient Factors:
Certain conditions where the risk of thrombosis or bleeding is excessively high, such as severe coagulopathy or significant arteriovenous fistulas in the extremity.
Previous Central Line Insertion:
History of previous central venous catheterization on the ipsilateral side with suspected venous occlusion or thrombosis.
Insertion Considerations And Technique
Site Selection:
Preferred sites are the antecubital fossa veins (cephalic, basilic, median cubital) or veins in the upper arm
In neonates, saphenous veins may be used
Avoid areas of cellulitis, rash, or edema.
Ultrasound Guidance:
Ultrasound-guided insertion significantly increases success rates and reduces complications like arterial puncture or nerve injury.
Vein Preparation:
Strict aseptic technique is paramount
Skin cleansing with an antiseptic solution (e.g., chlorhexidine) followed by sterile draping.
Advancement And Tip Location:
The catheter is advanced under ultrasound or fluoroscopic guidance until the tip is positioned in the superior vena cava (SVC) or at the cavoatrial junction
Confirm tip position with chest X-ray (CXR).
Securement And Dressing:
Secure the catheter using sterile dressings (e.g., transparent semipermeable membrane dressing) and sterile tape or a stabilization device
Avoid any tension on the catheter.
Troubleshooting Common Issues
Occlusion:
Causes include sluggish infusion, inability to infuse/aspirate, or particulate matter
Management: attempt gentle flushing with saline
if occluded, consider using a low-dose fibrinolytic (e.g., urokinase) as per protocol
avoid forceful flushing which can dislodge a clot.
Phlebitis:
Signs: erythema, warmth, tenderness, swelling along the vein
Management: remove the PICC line, apply warm compresses, and administer analgesics
culture catheter tip if infection is suspected.
Infiltration Extravasation:
Signs: swelling, pain, leakage at the insertion site or along the limb
Management: stop infusion immediately, disconnect syringe, remove PICC if it is the source, aspirate any remaining fluid from the catheter, and treat according to the specific infusate guidelines.
Infection:
Signs: fever, chills, erythema, purulent discharge at the insertion site, positive blood cultures
Management: remove the PICC line, obtain blood and catheter tip cultures, and initiate appropriate antibiotic therapy
If systemic infection is present, PICC removal is mandatory.
Mechanical Obstruction:
Causes: kinked catheter, thrombus formation, or malposition
Management: check for external kinks
reposition patient if catheter may be against vessel wall
consider thrombolytic therapy for suspected clot
confirm tip position with CXR if malposition is suspected.
Complications
Early Complications:
Arterial puncture during insertion
nerve injury
pneumothorax (if inserted in upper arm and subclavian entry is inadvertently involved)
air embolism
local bleeding or hematoma
catheter malposition.
Late Complications:
Catheter-related bloodstream infection (CRBSI)
deep vein thrombosis (DVT) or venous occlusion
catheter occlusion
phlebitis
skin erosion or breakdown
catheter fracture or embolism (rare).
Prevention Strategies:
Strict aseptic technique during insertion and maintenance
proper securement to prevent dislodgement
regular site assessment
appropriate flushing protocols (e.g., positive pressure flushing with saline/heparin)
patient and family education
early removal when no longer indicated.
Key Points
Exam Focus:
Understand the indications for PICC lines in critically ill neonates and children
Differentiate between peripheral IV and PICC when planning long-term access
Recognize signs and management of common PICC complications like occlusion, infection, and thrombosis.
Clinical Pearls:
Always confirm tip placement with a chest X-ray post-insertion
Use ultrasound guidance for insertion whenever possible
Maintain meticulous aseptic technique for all manipulations
Educate parents/caregivers on PICC care and warning signs.
Common Mistakes:
Using a PICC line when a peripheral IV is sufficient
Inadequate aseptic technique leading to infection
Forceful flushing of an occluded line
Delayed removal when the PICC is no longer needed
Failure to obtain proper tip confirmation with CXR.