How to evaluate Peripherally Inserted Central Catheter (PICC) line placement?

Evaluation of PICC Line Placement

PICC line placement should be evaluated using radiographic verification to confirm proper catheter tip position in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium. 1

Initial Verification of PICC Placement

• Radiographic verification (typically chest X-ray) is appropriate after blind bedside PICC placement or when a patient is admitted with an existing PICC 2, 1
• Radiographic verification may be unnecessary when PICCs are placed with electrocardiographic guidance, provided that proficiency with this technology has been demonstrated and adequate tracings (such as P-wave deflections) are observed 2
• Ultrasound can be used to confirm PICC tip position after placement and could be considered a complement to conventional radiography 2

Optimal Catheter Tip Position

• The catheter tip should ideally 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
• Contrary to some older recommendations, the right atrium is considered an appropriate position for the PICC tip and does not warrant adjustment 2
• Adjustment of the PICC is appropriate when the tip is positioned in the upper or middle one third of the superior vena cava or in the right ventricle 2
• Repositioning the PICC tip simply because it resides in the right atrium is rated as inappropriate in the absence of contraindications 2

Assessment for Complications

• Regular assessment of the insertion site for signs of infection, thrombosis, or mechanical failure is essential 3
• Common complications to monitor include:
  • Occlusion (7% incidence) 4
  • Catheter rupture (1.6% incidence) 4
  • Accidental withdrawal (2.4% incidence) 4
  • Infection (3.1% incidence) 4
  • Venous thrombosis (2.4-37.5% incidence, depending on anticoagulation use) 4, 5
• Catheter malposition, migration, and line fracture are additional complications that require radiological evaluation 6

Management of PICC Line Complications

• For catheter migration, advancement of migrated PICCs is inappropriate regardless of how far the PICC was dislodged 2
• Guidewire exchange of the PICC is appropriate when the catheter is dislodged, provided there are no signs of local or systemic infection 2
• For PICC-related venous thrombosis, options include:
  • Conventional treatment with line removal followed by anticoagulation 7
  • Direct thrombolysis with urokinase using the lumen of the PICC line 7
• Prophylactic anticoagulation may reduce the incidence of PICC-associated thrombosis (22.9% with anticoagulation vs. 61.9% without) 5

Best Practices for PICC Maintenance

• Use clear, transparent dressings that permit site examination 3
• Weekly or more frequent changes of wet, loose, or soiled dressings is appropriate 2
• Normal saline rather than heparin is appropriate to maintain catheter patency and prevent lumen occlusion 2, 3
• Never use syringes smaller than 10 mL for flushing to avoid excessive pressure that could damage the catheter 3
• Never forcefully flush a catheter that is meeting resistance 3

Special Considerations

• Right-sided access is preferred over left-sided to reduce thrombosis risk 1
• Default use of single-lumen devices when there is no documented rationale for multilumen PICCs is appropriate to reduce complications 2
• Collaboration with pharmacists or vascular access operators before ordering a PICC is appropriate to clarify device needs 2
• PICC lines should be removed when they have not been used for any clinical purpose for 48 hours or longer, or when the patient no longer has a clinical indication for a PICC 3