A Peripherally Inserted Central Catheter, or PICC line, is a thin, flexible tube used to deliver medications, fluids, or nutrition directly into the central circulation. The line is inserted into a vein in the upper arm and then threaded until the tip rests in a large vein near the heart. This method provides reliable, long-term intravenous access, often for weeks or months, avoiding the need for repeated needle sticks into smaller peripheral veins. PICC lines are commonly used for extended treatments like long-term antibiotics, certain chemotherapy regimens, or total parenteral nutrition. The device offers a safer and more comfortable alternative to traditional central lines inserted in the neck or chest.
Patient Assessment and Pre-Procedure Preparation
Before the procedure, patient assessment confirms the line’s indication and selects the optimal insertion site. Informed consent is obtained, detailing the procedure’s purpose, benefits, and risks such as infection and blood clot formation. The patient’s medical history is reviewed for allergies, current medications (especially anticoagulants), and any history of arm vein thrombosis.
The most common insertion sites are the basilic or brachial veins in the mid-upper arm, as they offer the straightest path to the central circulation. Clinicians use ultrasound imaging to accurately map the veins and measure the diameter. This ensures the selected vein is patent and large enough to maintain a proper catheter-to-vein ratio, which helps promote blood flow and reduce the risk of thrombosis. The required catheter length is measured externally from the insertion site up to the third intercostal space near the sternum.
The Sterile Insertion Procedure
PICC insertion requires a sterile technique to prevent contamination and bloodstream infection. The patient is prepped with an antiseptic solution, such as chlorhexidine, and draped with sterile barriers to isolate the insertion area. A local anesthetic, typically lidocaine, is injected at the chosen site to numb the area.
The procedure utilizes the Modified Seldinger Technique (MST), beginning with the insertion of an introducer needle into the targeted vein under real-time ultrasound guidance. Once venous access is confirmed, a soft-tipped guidewire is threaded through the needle and advanced into the vein. The introducer needle is then removed, and a coaxial dilator and peel-away sheath are threaded over the guidewire to enlarge the puncture site.
The PICC catheter is advanced over the guidewire through the peel-away sheath and into the vein, passing through the axillary and subclavian veins. Many procedures utilize an integrated intracavitary electrocardiogram (ECG) system for real-time tip confirmation. As the tip approaches the cavoatrial junction (CAJ), a distinct increase in the P-wave amplitude is observed on the ECG monitor. Once the tip is confirmed to be at the CAJ, the guidewire and the peel-away sheath are removed, leaving the PICC catheter secured.
Immediate Post-Procedure Verification and Securing
After removing the guidewire and sheath, the catheter is flushed with sterile normal saline to ensure patency and check for blood return. The final position of the catheter tip is verified immediately after insertion, often using the ECG-guided system or a post-procedure chest X-ray. The chest X-ray confirms that the tip rests in the lower third of the superior vena cava, preventing complications like cardiac arrhythmias or vessel erosion.
The catheter must be securely anchored at the exit site to prevent accidental dislodgement and migration. Modern practice favors sutureless securement devices, such as the StatLock or SecurAcath, which are more effective than traditional sutures at stabilizing the line. A sterile, transparent semipermeable dressing, sometimes impregnated with chlorhexidine, is then applied over the insertion site and the securement device. This maintains a sterile barrier and allows for visual inspection.
Long-Term Maintenance and Management
Proper maintenance of the PICC line prevents complications and ensures its long-term function. The sterile transparent dressing must be changed at least once every seven days, or immediately if it becomes soiled, damp, or loose. This dressing change requires aseptic technique, often involving a chlorhexidine-based skin disinfectant, to minimize the risk of infection at the exit site.
Routine flushing is performed to prevent blood clots within the catheter lumen and maintain patency. This involves flushing with normal saline using a pulsatile technique to clear the catheter walls of residue. If the catheter is not in use, flushing is performed at least once daily or weekly, sometimes followed by a small volume of heparin solution as a lock. Patients must cover the PICC site with an impermeable cover during showering to keep the dressing dry, and submerging the arm in water is prohibited.
Recognizing and Addressing Complications
Complications can occur despite careful insertion and maintenance, and patients must be vigilant for warning signs. One of the most common mechanical issues is catheter occlusion, signaled by an inability to infuse fluids, difficulty aspirating blood, or an infusion pump repeatedly alarming. Catheter migration, where the external length of the line changes, can be indicated by new discomfort in the chest or arm, or a gurgling sensation during flushing.
Infectious complications include local site infection and a serious bloodstream infection. A local infection presents with patient-recognizable symptoms such as increased redness, warmth, swelling, or pain at the insertion site, sometimes accompanied by pus or drainage. Deep Vein Thrombosis (DVT) is a vascular complication involving a blood clot forming in the arm vein. DVT presents as swelling, tenderness, a noticeable color change, or a feeling of heaviness in the arm. Any sign of a serious complication, such as a sudden fever, chills, or new arm swelling, requires immediate medical attention.