![PICC line](https://upload.wikimedia.org/wikipedia/commons/4/49/PICC_line.jpg)
A peripherally inserted central catheter (PICC or PIC line), less commonly called a percutaneous indwelling central catheter, is a form of
intravenous
Intravenous therapy (abbreviated as IV 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 nutrie ...
access that can be used for a prolonged period of time (e.g., for long
chemotherapy
Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemotherap ...
regimens, extended
antibiotic therapy, or
total parenteral nutrition
Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding companies. The person receives a nutritional mix ...
) or for administration of substances that should not be done peripherally (e.g.,
antihypotensive agent
An antihypotensive agent, also known as a vasopressor agent or simply vasopressor, or pressor, is any substance, whether endogenous or a medication, that tends to raise low blood pressure. Some antihypotensive drugs act as vasoconstrictors to i ...
s a.k.a. pressors). It is a
catheter
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. Cath ...
that enters the body through the skin (percutaneously) at a
peripheral
A peripheral or peripheral device is an auxiliary device used to put information into and get information out of a computer. The term ''peripheral device'' refers to all hardware components that are attached to a computer and are controlled by the ...
site, extends to the
superior vena cava
The superior vena cava (SVC) is the superior of the two venae cavae, the great venous trunks that return deoxygenated blood from the systemic circulation to the right atrium of the heart. It is a large-diameter (24 mm) short length vein th ...
(a central venous trunk), and stays in place (dwells within the
vein
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
s) for days, weeks or even months.
First described in 1975, it is an alternative to
central venous catheter
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 central ...
s in major
veins
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
such as the
subclavian vein
The subclavian vein is a paired large vein, one on either side of the body, that is responsible for draining blood from the upper extremities, allowing this blood to return to the heart. The left subclavian vein plays a key role in the absorption ...
, the
internal jugular vein
The internal jugular vein is a paired jugular vein that collects blood from the brain and the superficial parts of the face and neck. This vein runs in the carotid sheath with the common carotid artery and vagus nerve.
It begins in the posteri ...
or the
femoral vein
In the human body, the femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor hiatus (an opening in the adductor magnus muscle) as the continuation of the popliteal vein. It ends at th ...
. Subclavian and jugular line placements may result in
pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
(air in the pleural space of lung), while PICC lines have no such issue because of the method of placement.
Medical uses
![PICC Line and IV Placement](https://upload.wikimedia.org/wikipedia/commons/f/f1/PICC_Line_and_IV_Placement.jpg)
Generally, PICC lines are considered when a person is expected to need more than two weeks of intravenous therapy.
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. They are utilized in both the hospital and community settings. They are commonly used in people receiving total
parenteral nutrition
Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding companies. The person receives a nutritional mix ...
(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
Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the treatm ...
or
normal saline
Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein it ...
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.
Risks and complications
As with any intravenous line, there is the risk for
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
– 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
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
stay.
Adhering to strict infection control procedures, including
aseptic technique
Asepsis is the state of being free from disease-causing micro-organisms (such as pathogenic bacteria, viruses, pathogenic fungi, and parasites). There are two categories of asepsis: medical and surgical. The modern day notion of asepsis is deriv ...
, when inserting or using a PICC line will reduce the risk of an infection. There is also a risk of
blood clots
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cr ...
.
[ The use of heparin to maintain a PICC line is not universal, as heparin locks have been associated with complications, including heparin-induced ]thrombocytopaenia
Thrombocytopenia is a condition characterized by abnormally low levels of platelets, also known as thrombocytes, in the blood. It is the most common coagulation disorder among intensive care patients and is seen in a fifth of medical patients an ...
.
Other complications may include catheter occlusion, phlebitis
Phlebitis (or Venitis) is inflammation of a vein, usually in the legs. It most commonly occurs in superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called thrombophlebitis or superficial thrombophlebitis. Unlike ...
and bleeding
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
. Urokinase
Urokinase, also known as urokinase-type plasminogen activator (uPA), is a serine protease present in humans and other animals. The human urokinase protein was discovered, but not named, by McFarlane and Pilling in 1947. Urokinase was originally i ...
or low-dose tissue plasminogen activator
Tissue plasminogen activator (abbreviated tPA or PLAT) is a protein involved in the breakdown of blood clots. It is a serine protease () found on endothelial cells, the cells that line the blood vessels. As an enzyme, it catalyzes the conversion ...
(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.U Wisconsin, Preparing and Caring
, accessed July 24, 2013
Technique
![Blausen 0193 Catheter PICC](https://upload.wikimedia.org/wikipedia/commons/f/f1/Blausen_0193_Catheter_PICC.png)
A PICC is inserted in a
peripheral vein
The peripheral vascular system is the part of the circulatory system that consists of the veins and arteries not in the chest or abdomen (i.e. in the arms, hands, legs and feet). The peripheral arteries supply oxygenated blood to the body, a ...
such as the
cephalic vein
In human anatomy, the cephalic vein is a superficial vein in the arm. It originates from the radial end of the dorsal venous network of hand, and ascends along the radial (lateral) side of the arm before emptying into the axillary vein. At the ...
,
basilic vein
The basilic vein is a large superficial vein of the upper limb that helps drain parts of the hand and forearm. It originates on the medial (ulnar) side of the dorsal venous network of the hand and travels up the base of the forearm, where its c ...
or
brachial vein
In human anatomy, the brachial veins are venae comitantes of the brachial artery in the arm proper. Because they are deep to muscle, they are considered deep veins. Their course is that of the brachial artery (in reverse): they begin where r ...
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
The superior vena cava (SVC) is the superior of the two venae cavae, the great venous trunks that return deoxygenated blood from the systemic circulation to the right atrium of the heart. It is a large-diameter (24 mm) short length vein th ...
or
cavoatrial junction. They must be inserted by a trained medical professional, including a
physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
, but also any trained medical professional such as a specially trained
registered nurse
A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to o ...
.
An
ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
or chest X-ray, or the use of
fluoroscopy
Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...
, can be used during insertion and to confirm placement. The insertion is a
sterile
Sterile or sterility may refer to:
*Asepsis, a state of being free from biological contaminants
* Sterile (archaeology), a sediment deposit which contains no evidence of human activity
*Sterilization (microbiology), any process that eliminates or ...
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
The basilic vein is a large superficial vein of the upper limb that helps drain parts of the hand and forearm. It originates on the medial (ulnar) side of the dorsal venous network of the hand and travels up the base of the forearm, where its c ...
is an appropriate size, but is not preferred in children due to its depth and surrounding tissue. On the other hand, the
cephalic vein
In human anatomy, the cephalic vein is a superficial vein in the arm. It originates from the radial end of the dorsal venous network of hand, and ascends along the radial (lateral) side of the arm before emptying into the axillary vein. At the ...
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
In human anatomy, the brachial veins are venae comitantes of the brachial artery in the arm proper. Because they are deep to muscle, they are considered deep veins. Their course is that of the brachial artery (in reverse): they begin where r ...
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.
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.
Insertion
While an operating room is not required for the insertion of a PICC line, it is important to maintain a
sterile
Sterile or sterility may refer to:
*Asepsis, a state of being free from biological contaminants
* Sterile (archaeology), a sediment deposit which contains no evidence of human activity
*Sterilization (microbiology), any process that eliminates or ...
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.
Fluoroscopy
Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...
or
electrocardiography
Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the hear ...
(ECG) 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
*
Central venous catheter
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 central ...
*
Hickman line
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. T ...
References
Further reading
* Bender, C. M., Rosenzweig, M., & Green, E. (2006). "Cancer". In S. Goldsworthy & M. A. Barry. ''Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems'' (1st Canadian ed.). Mosby: Toronto. .
External links
Description and images of PICC line insertionPICC line indications, insertion, care and complications
{{Intravenous therapy
Catheters