What are the guidelines for Peripherally Inserted Central Catheter (PICC) placement?

Guidelines for Peripherally Inserted Central Catheter (PICC) Placement

PICCs should be placed using ultrasound guidance, with the catheter tip positioned in the lower third of the superior vena cava or at the atrio-caval junction, and preferably using a right-sided approach to reduce thrombosis risk. 1

Indications and Device Selection

• PICCs are appropriate for medium-term venous access (up to 3 months) in both hospitalized patients and outpatient settings 1
• PICCs are indicated when venous access is needed for more than 15 days for non-irritant/non-vesicant infusions 1
• For irritant or vesicant infusions (e.g., chemotherapy, parenteral nutrition), PICCs are appropriate regardless of duration 1
• For short-term access (≤5 days), peripheral IV catheters are preferred; for 6-14 days, midline catheters are more appropriate than PICCs 1
• For long-term access (>3 months), tunneled catheters or implanted ports are preferred over PICCs 1

Pre-insertion Considerations

• Specialist consultation is appropriate before PICC placement (e.g., infectious disease for antibiotics, oncology for chemotherapy) 1
• For patients requiring prolonged antibiotic infusions, PICC placement within 2-3 days of hospital admission is appropriate in the absence of bacteremia 1
• In patients with bacteremia, PICC placement timing is uncertain and infectious disease consultation is recommended 1
• Right-sided access is preferred over left-sided to reduce thrombosis risk 1

Insertion Technique

• Ultrasound-guided venipuncture is strongly recommended for all PICC insertions to reduce complications and increase success rates 1, 2
• Preferred insertion veins include the basilic vein or brachial vein in the mid-arm 1, 2
• Placement should be performed under strict sterile conditions using chlorhexidine solutions with alcohol 1
• Avoid insertion over bruised or corded venous segments, near/over open wounds or burns, and into veins below the elbow 1
• Avoid PICC placement in a hemiparetic or immobile arm when the opposite limb is available 1
• Insertion in the dominant arm is not contraindicated, but patient preferences should be considered 1

Interventional Radiology Referral

Preferential placement by interventional radiology is appropriate when:

• A suitable target vein cannot be identified with bedside ultrasound 1
• The guidewire or catheter fails to advance during bedside placement 1
• The patient requires sedation that cannot be safely delivered at bedside 1
• The patient has bilateral mastectomy, altered chest anatomy, or superior vena cava filters 1
• The patient has permanent pacemakers or defibrillators and the contralateral arm is not amenable to insertion 1

Catheter Tip Position

• The catheter tip should be positioned in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium 1
• Position verification is required during or after the procedure 1
• Radiographic verification is appropriate after blind bedside PICC placement or when a patient is admitted with an existing PICC 1
• Routine radiographic verification is not necessary when PICCs are placed with electrocardiographic guidance (provided proficiency is demonstrated) 1
• If the PICC tip is in the upper or middle third of the superior vena cava or right ventricle, adjustment is appropriate 1
• Contrary to some recommendations, the right atrium is considered an appropriate position for the PICC tip and does not warrant adjustment 1

Complication Prevention

The risk of catheter-related infection can be reduced by:

• Using antimicrobial coated catheters (for short-term use) 1
• Using single-lumen catheters when possible 1
• Appropriate choice of insertion site 1
• Maximal barrier precautions during insertion 1
• Proper education and specific training of staff 1
• Adequate hand hygiene 1
• Using 2% chlorhexidine as skin antiseptic 1
• Appropriate dressing of the exit site 1
• Disinfection of hubs, stopcocks, and connectors 1
• Regular change of administration sets 1

Common Complications and Management

• Mechanical complications: Arrhythmia (1.5%), difficult catheter propelling (3.75%), excessive bleeding (0.3%) 3
• Post-insertion complications: Sensitizing dermatitis (8%), mechanical phlebitis (7.5%), catheter occlusion (9.5%), catheter-associated infection (3%), venous thrombosis (2%) 3
• Venous thrombosis can be treated with direct thrombolysis using the PICC lumen 4
• Most complications are "mechanical" and can be prevented with proper management 5

Special Considerations

• For home parenteral nutrition, PICCs can be used if duration is estimated to be less than six months 1
• PICCs may have a lower risk of catheter-related bloodstream infection but a higher risk of catheter-related venous thrombosis compared to other central venous catheters 1
• The time to first catheter-related complication appears to be shorter with PICCs 1

By following these evidence-based guidelines for PICC placement, healthcare providers can minimize complications and optimize patient outcomes.