How do I confirm a Peripherally Inserted Central Catheter (PICC) line placement?

How to Confirm PICC Line Placement

Obtain a chest radiograph after blind bedside PICC placement to verify tip position, with the optimal location being the lower third of the superior vena cava at the cavoatrial junction or upper right atrium. 1

Immediate Post-Placement Verification

When Radiographic Confirmation is Required

• Radiographic verification is mandatory after blind bedside PICC placement or when a patient is admitted with an existing PICC line already in place 1
• Standard anteroposterior (AP) chest radiograph remains the most widely used and convenient method for confirming placement 2

When Radiographic Confirmation May Be Unnecessary

• If electrocardiographic (ECG) guidance was used during placement AND you have demonstrated proficiency with this technology AND adequate ECG tracings were observed during insertion, radiographic verification may be omitted 1
• This represents a significant advantage of ECG-guided placement, as it can eliminate radiation exposure and delays in line use 3

Optimal Catheter Tip Position on Imaging

Target Location

• 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
• Contrary to older teaching, the right atrium is an appropriate and acceptable position—do not adjust a line simply because the tip is in the right atrium 1

When Adjustment is Required

• Reposition the PICC if the tip is located in the upper or middle one-third of the superior vena cava 1
• Reposition immediately if the tip is in the right ventricle 1

Optimizing Radiographic Interpretation

Patient Positioning Matters

• Arm position is critical during radiograph acquisition—movement of the arm can cause catheter migration and lead to inaccurate assessment 2
• Consider a right posterior oblique (RPO) chest radiograph if the AP view is unclear, as this reduces superimposition of mediastinal structures and improves tip visualization (80% agreement rate vs 55% for AP views) 4

Common Pitfalls

• Be aware of significant inter-observer variability when identifying line tip position 2
• When line tip position remains unclear after standard radiograph, consider contrast injection or ultrasound for additional confirmation 2

Alternative Confirmation Methods

Ultrasound Confirmation

• Ultrasound can be used as a complement to conventional radiography to confirm PICC tip position after placement 1
• However, current evidence shows that ultrasound confirmation by novice users is not superior to chest radiograph, with only 43% positive predictive value for identifying malpositioned lines 5
• Ultrasound may have future potential with pediatric-specific technology or echogenic catheter tips 5

ECG-Guided Placement

• ECG guidance during insertion allows real-time tip positioning and may be preferable to post-placement radiographic confirmation 3
• This method can accurately measure the exact position within the venous system during the procedure itself 3

Special Considerations for Lower Extremity Access

• When PICCs are placed via the saphenous vein, obtain both supine AND lateral abdominal radiographs to ensure proper placement in the inferior vena cava 2
• The tip should be located 0.5-1 cm outside cardiac chambers in premature infants and 1-2 cm outside in larger infants 2

Post-Confirmation Assessment

• Regularly assess the insertion site for signs of infection, thrombosis, or mechanical failure after confirming initial placement 1
• Document the external catheter length at the insertion site to detect future migration 1