Makindo Medical Notes

Related Subjects: | Malnutrition Universal Screening Tool (MUST) | Body Mass Index (BMI) | Central Venous Catheters (CVC)

💡 Key Point: A PICC line provides long-term central venous access via a peripheral vein, usually in the upper arm, with the catheter tip resting in the superior vena cava (SVC). They are ideal for prolonged IV therapy and can be managed safely in an outpatient setting.

🧠 Introduction

• A Peripherally Inserted Central Catheter (PICC) is a thin, flexible tube inserted into a large arm vein (typically the basilic, brachial, or cephalic vein).
• The catheter tip sits in the SVC at the cavo-atrial junction, allowing secure central access for long-term therapy.
• PICC lines can remain in place for up to 12 months if functioning and infection-free.
• They are increasingly used in hospitals, oncology units, and the community for safe prolonged infusion therapy.

⚠️ Precautions

• 👩‍⚕️ Only trained clinicians or supervised trainees should insert PICCs.
• 🧴 Full aseptic non-touch technique (ANTT) is mandatory to reduce infection risk.
• 🩸 Review anticoagulation status and platelet count before insertion.
• Use ultrasound guidance to identify a patent, non-thrombosed vein.

🎯 Indications

• 💊 Long-term administration of antibiotics, chemotherapy, or IV fluids.
• 🥣 Total parenteral nutrition (TPN) requiring reliable venous access.
• Frequent blood sampling in patients with difficult peripheral veins.
• Delivery of irritant drugs that must not extravasate (e.g. inotropes, calcium, vancomycin).

💪 Benefits of PICC Line

• 🚫 Eliminates pneumothorax risk (unlike subclavian or jugular central lines).
• 🕒 Suitable for medium- to long-term therapy (weeks to months).
• 🦠 Lower infection and sepsis rates than femoral or subclavian catheters.
• 🏠 Can be used safely in the outpatient or community setting.

⚕️ Potential Complications

• 🩸 Local venous thrombosis: Swelling, pain, or erythema of the arm.
• 🦠 Line infection / Sepsis: Fever, discharge, or erythema at the insertion site.
• ⚡ Nerve injury or bleeding during insertion.
• 🚫 Catheter occlusion or fibrin sheath formation → may require thrombolytic instillation (e.g. urokinase).
• 💔 Tip malposition: May cause arrhythmias if advanced into right atrium.

🧴 PICC Line Care Instructions

• 🧼 Always wash hands before handling the line. Keep dressing clean and dry.
• 🩹 Change dressings only if trained; use sterile, transparent dressings.
• 🚨 Report redness, pain, discharge, fever, or swelling — possible infection.
• 💧 Flushing: Before and after use, scrub the hub with alcohol, then flush with 10 mL 0.9 % NaCl using a push-pause technique to clear the line.
• 🔒 Clamp the line when not in use. Most modern systems are saline-only (no heparin required).
• 💪 Encourage gentle arm movement to promote venous return; avoid BP cuffs or tight sleeves on that arm.

🪡 Insertion Procedure (Overview)

1. Explain and obtain informed consent. Perform safety checks and apply PPE.
2. Position the patient comfortably, arm extended and supported.
3. Ultrasound-scan to identify a suitable vein (basilic preferred for diameter and straight path).
4. Prepare skin with 2 % chlorhexidine in 70 % alcohol using circular motion; allow to dry fully.
5. Using full asepsis, puncture the vein and insert the guidewire under ultrasound visualisation.
6. Advance the catheter over the guidewire (Seldinger technique) to the measured length.
7. Secure with a sterile adhesive anchoring device — avoid sutures to reduce infection.
8. Apply sterile transparent dressing; label with date and inserter initials.
9. Confirm tip position with a chest X-ray or ECG-guided confirmation (P-wave change technique).

📋 Post-Insertion Care

• Confirm catheter tip at the SVC–RA junction (CXR or ECG).
• Document procedure details: vein used, lot number, catheter length, and any complications.
• Do not use until placement is confirmed.
• Educate patient on line care, flushing schedule, and signs of infection or thrombosis.

📈 Clinical Pearls

• 💡 Tip too short → poor flow, risk of thrombosis; tip too long → arrhythmias or cardiac perforation.
• 🫧 Always remove air from syringes before connection to prevent air embolism.
• 🕰️ Replace dressing every 7 days (or sooner if soiled or loose).
• 🧊 Warm saline flushes help clear sluggish lines.

📚 References

• NICE CG139 – Infection Prevention in IV Therapy
• RCN IV Therapy Guidance (2023 update)
• INS Standards of Practice for Infusion Therapy (2022)