What are the technical steps for Ultrasound (USG) guided Peripherally Inserted Central Catheter (PICC) line insertion?

Technical Steps for Ultrasound-Guided PICC Line Insertion

Follow a systematic six-step approach for ultrasound-guided PICC line insertion that includes pre-procedural vein assessment, confirmation of patency, real-time needle guidance, and sequential verification of needle, wire, and catheter positioning. 1

Pre-Procedural Preparation

Equipment and Sterile Technique

• Maintain strict aseptic technique including maximal sterile barriers: hat, mask, sterile gloves, sterile body gown, large sterile drape covering the puncture site, sterile ultrasound probe cover with sterile gel 1
• Use a high-frequency linear ultrasound probe for optimal vessel visualization 2
• Position yourself so the insertion site, needle, and ultrasound screen are all within your line of sight during the procedure 1

Patient Positioning

• Position the patient in Trendelenburg (head-down) position to increase venous filling and cross-sectional lumen of the target vein 1, 2
• Minimize head rotation during internal jugular vein access to reduce arterial-venous overlap 2

Step 1: Identify Anatomy and Localize the Target Vein

• Perform this assessment BEFORE prepping and draping to account for anatomic variability 1
• Use both short-axis (transverse) and long-axis (longitudinal) views to identify the vein and its relationship to the adjacent artery 1
• Check for anatomic variations of vessels, which occur in a significant proportion of patients 2
• Identify hypoplastic veins or underfilling due to hypovolemia 1
• Use color Doppler imaging and Doppler flow measurements to definitively differentiate venous from arterial vessels 1

Common Pitfall: The left cephalic vein has a significantly higher failure rate compared to other veins; consider right-arm access through the basilic or brachial vein for higher success rates 3

Step 2: Confirm Vein Patency

• Apply pressure with the ultrasound probe to test vein compressibility, confirming patency and excluding venous thrombosis 1
• Caveat: In patients with systolic arterial pressure <60 mmHg, the artery may also be compressible, potentially causing confusion 1

Step 3: Real-Time Ultrasound Guidance for Vein Puncture

Single-Operator Technique

• Hold the ultrasound probe with your nondominant hand while advancing the needle with your dominant hand 1
• This allows optimal alignment of the ultrasound plane with the needle direction 1
• Constantly identify the needle tip during the entire approach to and puncture of the vein 1
• Use either short-axis/out-of-plane view OR long-axis/in-plane view for needle visualization 1

Step 4: Confirm Needle Position in the Vein

• Use real-time ultrasound to confirm the needle tip is placed centrally in the vein before advancing the guidewire 1
• Verify positioning in both short-axis and long-axis views 1
• Critical Safety Step: Verify venous (not arterial) placement using ultrasound, manometry, or pressure waveform analysis to avoid arterial dilation or cannulation 2

Step 5: Confirm Guidewire Position in the Vein

• After wire advancement, confirm correct guidewire position using both short-axis and long-axis ultrasound views 1
• If the complete guidewire cannot be located in the procedural field, order chest radiography to check for wire retention in the vascular system 2

Step 6: Confirm Catheter Position in the Vein

• After placing the PICC over the guidewire, visualize correct catheter position using ultrasound in both short-axis and long-axis views 1
• The most common locations of catheter advancement obstacles are the subclavian vein (28.8%), axillary vein (24.3%), and brachiocephalic vein (19.3%) 3
• Problem-solving methods for malpositioned catheters include guidewire assistance (74.7%), venographic guidance (13.8%), and fluoroscopic guidance (11.5%) 3

Post-Procedural Verification

• Obtain chest radiography for final confirmation of central tip position, as bedside ultrasound confirmation by novice users has limited accuracy (positive predictive value 43%) 4
• If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and immediately consult vascular surgery or interventional radiology 2

Key Success Factor: The technique achieves 100% success rates when performed systematically with ultrasound guidance, compared to variable success with blind bedside insertions 5, 6