From the Guidelines
Fluoroscopy-guided technique (FGT) is the recommended method for PICC line insertion, particularly in high-risk patients or those requiring long-term vascular access, due to its ability to provide real-time visualization and significantly reduce complications such as catheter malposition, arrhythmias, and thrombosis. The use of FGT has been shown to improve success rates and reduce complications compared to bedside technique (BST) 1. While BST can be improved through proper patient head positioning and ultrasound guidance, it still carries a higher risk of complications, especially when the internal jugular vein is accidentally accessed [@8@].
Key Considerations for PICC Insertion
- Optimal catheter tip placement should be in the lower superior vena cava or at the cavo-atrial junction to minimize complications 1.
- Emerging technologies like intracavitary ECG placement and magnetic tracking systems show promise for improving placement accuracy and patient outcomes [@7@].
- For facilities without fluoroscopy capabilities, using ultrasound guidance combined with proper patient positioning and post-procedure chest X-ray verification is essential 1.
- Patient-specific factors including anatomy, comorbidities, and expected duration of catheter use should guide the selection of insertion technique to ensure safe and effective PICC placement.
Importance of Ultrasound Guidance
The use of ultrasound guidance during PICC insertion has been shown to reduce the number of complications and improve the safety and quality of the procedure 1. A structured approach for ultrasound-guided central venous access is recommended for clinical practice, including the use of ultrasound to guide venepuncture and verify catheter tip placement 1.
Guidelines for PICC Insertion
The European Society for Clinical Nutrition and Metabolism guidelines recommend the use of ultrasound-guided venepuncture for central venous access and proper positioning of the catheter tip to minimize complications 1. The guidelines also emphasize the importance of proper education and training of staff, adequate hand washing policy, and use of maximal barrier protection during insertion to reduce the risk of catheter-related bloodstream infection 1.
From the Research
Comparison of Insertion Techniques
- The use of fluoroscopic-guided technique (FGT) versus bedside technique (BST) for peripherally inserted central catheters (PICC) placement has been compared in several studies, with FGT offering better success rates and fewer complications 2, 3.
- FGT allows for real-time visualization, which significantly reduces complications such as malposition, as shown in a study by Glauser et al. (2017) 3.
- The risk of catheter malposition with BST is a concern, and improving its accuracy by positioning the patient's head correctly is crucial, as confirmed by recent evidence [@8@].
Emerging Technologies
- Emerging technologies, such as intracavitary ECG placement and magnetic tracking, offer promising results in reducing malposition rates and enhancing patient safety, as shown in a study by Johnston et al. (2014) [@7@].
- The use of ultrasound and intracavitary electrocardiogram for tip navigation and tip location during PICC placement has been investigated, and a feasible and safe standardized protocol has been suggested 4.
- The study found that the percentage of optimal tip location was significantly higher in the ECG + US group compared to the ECG group, and the rate of malposition was obviously lower.
Patient Selection and Safety
- Patient selection is key, and for high-risk patients or those requiring long-term access, fluoroscopy-guided placement should be strongly considered, as it ensures proper positioning and reduces complications 3.
- The safety and feasibility of ultrasound-guided PICC placement performed by a neurointensivist in a neurosurgery intensive care unit have been evaluated, and the results show that it may be safe and feasible compared to fluoroscopy-guided PICC placement by interventional radiologists and CCVC placement 5.
- The study found that the initial success rate of central line placement was better in the fluoroscopy-guided PICC placement group, but there was no significant difference in procedure time between the three groups.