From the Guidelines
To confirm proper placement of a peripherally inserted central catheter (PICC line), chest X-ray is the gold standard imaging method. After PICC line insertion, a chest X-ray should be obtained to verify that the catheter tip is positioned in the lower superior vena cava or at the cavoatrial junction. This imaging is essential before the line is used for medication administration or blood draws to prevent complications.
Key Points to Consider
- Alternative confirmation methods include fluoroscopy during insertion, which provides real-time visualization, or ECG-guided placement systems that detect characteristic changes in the P-wave as the catheter approaches the right atrium 1.
- Ultrasound can verify that the catheter has entered the vein initially but cannot confirm final tip position.
- For critically ill patients who cannot be transported, portable chest X-ray is appropriate.
- The imaging should be reviewed by a qualified clinician before the PICC line is used, and documentation of confirmed placement should be noted in the patient's medical record.
- Malpositioned catheters require repositioning before use to avoid complications such as vascular erosion, thrombosis, or ineffective medication delivery.
Recommendations Based on Evidence
- High osmolarity PN requires central venous access and should be delivered through a catheter whose tip is in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium 1.
- Postoperative X-ray is mandatory when the position of the tip has not been checked during the procedure, and/or when the device has been placed using a blind subclavian approach or other technique which carries the risk of pleuropulmonary damage 1.
- Ultrasound-guided venepuncture is recommended for all central venous access, as it reduces the risk of complications and improves the success rate of catheter placement 1.
From the Research
Imaging Modalities for Confirming PICC Line Placement
To confirm the placement of a peripherally inserted central catheter (PICC) line, various imaging modalities can be used. The choice of imaging modality depends on several factors, including the patient's condition, the availability of equipment, and the expertise of the healthcare provider.
Available Imaging Modalities
- Chest radiograph: This is the most widely used method for confirming PICC line placement 2. However, it may not always provide a clear view of the catheter tip, especially in patients with complex anatomy.
- Bedside ultrasound: This modality can be used to confirm PICC line placement and has been shown to be effective in reducing patient radiation exposure 3, 4. However, the quality of the image acquisition may vary, and the wire may not always be visualized.
- Electromagnetic catheter tip detection device: This device can be used to navigate the catheter into the desired central vein and confirm catheter tip position 5.
- ECG-guided technique: This technique involves observing the morphological variations of the P wave to verify the correct positioning of the PICC line tip 6.
- Fluoroscopic placement: This is considered the ideal method for confirming PICC line placement, but it is not always feasible at the bedside and can be costly 2.
Comparison of Imaging Modalities
- A study comparing the anatomical landmark technique with the ECG-guided technique found that the ECG-guided technique was more accurate and resulted in fewer suboptimal positions 6.
- Another study found that bedside ultrasound was not superior to chest radiograph for confirming PICC line placement in pediatric patients 3.
- A study evaluating the use of bedside ultrasound for confirming central venous catheter placement found that it was effective in eliminating the need for chest radiographs in most patients 4.