PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC)

• Peripheral central catheter (PICC): inserted into cephalic or basilic vein (usually above the antecubital fossa) extends to SVC
• PICC lines can remain in place from 3 months–1 yr (longer if clinically required)
• for long chemotherapy regimens, extended antibiotic regimens or total parenteral nutrition
• or for administration of substances that should not be done peripherally

• Presence of device-related infection, bacteria, or if septicaemia is known/suspected
• Patient’s body size insufficient to accommodate size of implanted device
• Patient is known/suspected to be allergic to materials contained in the device
• Local tissue factors and/past treatment will prevent proper device stabilisation and/or access
• Presence of upper extremity/subclavian thrombosis
• Profound thrombocytopenia
• Implanted cardiac pacemaker or ICD on side of planned insertion if insertion of ICD or pacemaker within 3 months
• Patients that may require future dialysis fistulas forming 

Danger of serious morbidity

• Do not attempt insertion unless you are fully trained
• use whichever line you have been trained to use
• If not competent in procedure, organise supervision and training by a clinician experienced in the procedure

BARD Power PICC

• BARD Power PICC insertion set
• Select suitable PICC line, single/dual
• Skin prep: chlorhexidine gluconate 2% and isopropyl alcohol 70% cleaning solution
• if chlorhexidine sensitivity suspected, povidone-iodine 10% aqueous solution
• Topical anaesthetic cream or lidocaine hydrochloride 1% or 2% 10 mL ampoule
• Sterile gloves
• Tourniquet
• Flush solution: sodium chloride 0.9% 20 mL
• Ultrasound device, sterile Ultrasound probe cover and sterile gel

BARD Groshong single lumen/Vygon PICC

• Vascular access pack
• Select suitable PICC line, single/dual
• Skin prep: 2% chlorhexidine gluconate and 70% isopropyl alcohol cleaning solution
• if chlorhexidine sensitivity suspected, povidone-iodine 10% aqueous solution
• Sterile gloves
• Tourniquet
• Flush solution: sodium chloride 0.9% 10 mL
• 2 × 10 mL syringe
• Needle free connection device
• Sterile semi-permeable transparent dressing (Tegaderm^®)
• Sterile ultrasound probe cover and sterile gel
• Ultrasound device 

Local anaesthetic

If clinically indicated that patient requires local anaesthetic

• Topical anaesthetic cream OR
• Lidocaine hydrochloride 1% or 2% 10 mL ampoule
• 1 × 22G orange needle
• 5 mL syringe
• 1 drawing up blunt needle

• If not competent in procedure, organise supervision by a clinician experienced in the procedure

Consent

• Explain procedure and reassure patient
• Obtain verbal consent and document it in patient’s notes 

Preparation

• Check patient’s notes for
• clinical indication for line insertion
• previous line insertions – some veins can be particularly difficult and patient can often provide guidance
• Assess whether patient will need sedation and arrange appropriate person to administer
• rarely, patients with needle phobia will need general anaesthetic
• Apply topical anaesthetic cream to specified veins at 3 different sites at least 20 min before starting procedure or if using lidocaine hydrochloride 1% or 2% infiltrated over the insertion site
• median basilic vein is usually best (avoid femoral if possible due to higher infection risk)
• If necessary, shave patient’s arm to avoid hair plucking when dressing removed
• Gather all necessary equipment including a spare line (unopened) 

Position of patient

• Position patient seated in chair or lying with his/her arm stretched out on utility drape supported by table or bed
• Ensure patient in position and comfortable, and lighting optimal
• Measure the distance for the insertion point to the cavo-atrial junction

Sterile technique

• Wash hands and put on sterile gloves
• Place patient’s arm on a sterile drape
• Clean patient’s skin thoroughly in area of planned insertion for at least 30 seconds and allow to dry for 30 seconds with:
• chlorhexidine gluconate 2% and isopropyl alcohol 70% cleaning solution
• if chlorhexidine sensitivity suspected, povidone-iodine 10% aqueous solution
• Drape patient’s arm with fenestrated drape over insertion site sterile sheet to expose only chosen vein
• cover surrounding areas to provide working room and a flat surface on which to rest guidewire

Insertion

• If required, cut PICC to correct length
• Ask assistant to apply tourniquet
• Image vein using ultrasound device or visualise and palpate the vein
• Insert using Seldinger technique
• Cannulate target vein with either needle provided
• Feed guidewire into vein through cannula sheath and remove sheath leaving wire in situ
• Use scalpel to make a small cut alongside of the guidewire, to facilitate access for the introducer sheath
• Insert introducer sheath over the guidewire, to increase size of access to the vein
• Withdraw dilator and guidewire, leaving introducer sheath in place
• Slowly advance PICC into the introducer sheath
• Before advancing PICC past introducer sheath lay patient flat and rotate their head towards you, asking them to place their chin on their shoulder
• to prevent PICC entering the jugular vein
• Advance catheter to pre-measured length
• Separate introducer sheath
• Apply gentle pressure and slowly withdraw internal guidewire
• removing the guidewire too fast can damage the catheter
• Aspirate blood from the catheter and flush catheter with sodium chloride 0.9% 20 mL using a pulsed technique
• Apply steri-strips to insertion site to facilitate healing of the scalpel cut
• Secure PICC with fixation method of choice

Check position

• Verify position of the PICC radiologically and ensure tip positioned at lower third of the SVC

• Use an ANTT technique when accessing the system or for dressing changes
• Document insertion and all interventions in patient notes

BARD and Vygons PICC

• Flush after each use with sodium chloride 0.9% 20 ml with a 20 ml syringe
• using a pulsed, push-pause technique
• Change dressings and needle free connection device every 7 days (sooner if visibly soiled or coming away)
• Maintain aseptic technique for accessing system and dressing changes. Before accessing system, disinfect hub and ports with disinfectant compatible with catheter (e.g. alcohol or povidone-iodine)
• Assess site at least daily for any signs of infection. If signs of infection are present, remove line
• Assess need for device daily and remove as soon as possible