Overview
Definition:
Peripherally Inserted Central Catheters (PICCs) are long, thin tubes inserted into a vein in the arm (usually the cephalic, basilic, or brachial vein) and advanced until the tip terminates in a large vein, typically the superior vena cava or cavoatrial junction
Surgical oversight in PICC line insertion refers to the involvement or supervision of a surgeon during the procedure, especially in complex cases or when the primary inserter is not a surgeon.
Epidemiology:
PICC lines are widely used in hospitals and outpatient settings for long-term IV access, antibiotics, chemotherapy, TPN, and hemodynamic monitoring
The incidence of PICC insertion has increased significantly with advances in technology and a growing need for reliable long-term venous access
Surgical involvement is less common for routine PICCs but becomes crucial for malpositions or complications.
Clinical Significance:
Properly placed PICCs provide reliable, long-term venous access, reducing the need for repeated venipuncture and associated patient discomfort
Surgical oversight ensures safe and effective placement, minimizes complications such as pneumothorax or arterial injury, and allows for timely management of any procedural difficulties or early complications, ultimately improving patient outcomes and reducing healthcare costs.
Indications
Indications For Placement:
Expected need for intravenous therapy for > 1 week
Administration of vesicant chemotherapy or irritant solutions
Long-term antibiotic therapy
Parenteral nutrition
Hemodynamic monitoring requiring central access
Patients with poor peripheral venous access
Hemodialysis (temporary).
Contraindications:
Absence of suitable peripheral veins
Local infection at the insertion site
Ipsilateral mastectomy or axillary lymphadenectomy (relative contraindication)
Significant coagulopathy or thrombocytopenia (relative contraindication, may require correction or closer monitoring)
Presence of indwelling transvenous pacemaker wires
Severe peripheral vascular disease.
Patient Selection:
Assessment of vein size, tortuosity, and condition of peripheral veins in the arm
Evaluation of patient's overall health status, including coagulation profile and any relevant comorbidities
Discussion of risks and benefits with the patient and obtaining informed consent.
Preoperative Preparation
Patient Assessment:
Review of medical history, allergies, and current medications
Confirmation of indications and contraindications
Assessment for infection risk
Assessment of coagulation status (INR, aPTT, platelet count).
Equipment Preparation:
Sterile PICC insertion tray (including guidewire, introducer needle, dilator, catheter, syringe)
Ultrasound machine with sterile probe cover
Appropriate personal protective equipment (PPE) for the inserter and assistant
Local anesthetic (e.g., lidocaine 1%)
Sterile dressing supplies (antiseptic solution, sterile gauze, transparent dressing)
Guidewire position monitor if available.
Site Preparation:
Identification of the appropriate insertion vein (cephalic, basilic, or brachial) using anatomical landmarks and ultrasound guidance
Preparation of the insertion site with antiseptic solution (e.g., chlorhexidine) in a sterile fashion
Draping the patient appropriately to maintain sterility.
Procedure Steps
Ultrasound Guidance:
Utilize ultrasound to identify the target vein, assess its diameter, and rule out thrombosis
Mark the insertion site proximal to the identified vein
Distend the vein if necessary by applying a tourniquet or asking the patient to bear down.
Vein Puncture And Guidewire Insertion:
Administer local anesthetic to the insertion site
Puncture the vein with an introducer needle under ultrasound guidance, aiming for a 45-60 degree angle
Once venous blood is aspirated, advance the guidewire through the needle into the vein and position it towards the superior vena cava
Remove the needle, leaving the guidewire in place.
Catheter Insertion:
Make a small incision at the guidewire insertion site
Advance the PICC catheter over the guidewire, peeling the peel-away sheath as the catheter advances
Ensure the tip of the catheter is advanced to the correct position in the SVC
If using a mid-arm insertion, the distal tip should be positioned at the cavoatrial junction.
Guidewire And Sheath Removal:
Once the catheter is in position, remove the guidewire and peel-away sheath
Secure the catheter using a sterile, occlusive dressing
Flush the catheter with saline and aspirate to confirm patency and the absence of blood reflux.
Tip Confirmation:
Post-procedural confirmation of tip position is mandatory, typically via chest X-ray to ensure the tip is in the superior vena cava and not in the heart or other mediastinal structures.
Surgical Oversight Role
Indications For Surgeonal Involvement:
Difficulty in venous access or guidewire manipulation
Suspected or actual arterial puncture during insertion attempt
Suspected malposition of the guidewire or catheter
Presence of significant anatomical variations or previous surgeries affecting venous anatomy
Management of immediate complications like bleeding or hematoma formation
Placement of PICC in patients with coagulopathy or difficult venous access requiring advanced techniques.
Techniques Employed By Surgeons:
Open cutdown for venous access if percutaneous attempts fail
Intraoperative ultrasound for precise guidance
Management of immediate bleeding with surgical hemostasis
Use of alternative guidewires or catheters if standard ones fail
Recognition and immediate management of arterial injuries or pseudoaneurysms.
Benefits Of Surgical Oversight:
Increased safety for complex cases
Reduced procedural time and patient discomfort
Minimized risk of serious complications
Improved success rates in difficult venous access scenarios
Enhanced ability to manage emergent complications.
Complications
Early Complications:
Arterial puncture or laceration
Pneumothorax or hemothorax (especially with subclavian or axillary vein approach)
Nerve injury
Hematoma or bleeding at the insertion site
Air embolism
Arrhythmias (if tip irritates myocardium).
Late Complications:
Catheter occlusion or blockage
Catheter-related bloodstream infection (CRBSI)
Deep vein thrombosis (DVT) of the arm
Phlebitis or venous spasm
Catheter fracture or migration
Skin erosion or breakdown at the exit site
Superior vena cava syndrome (rare).
Prevention Strategies:
Strict aseptic technique during insertion and dressing changes
Diligent post-insertion X-ray for tip confirmation
Regular flushing and locking of the catheter
Patient education on signs of infection or DVT
Use of ultrasound guidance to avoid arterial puncture
Proper patient selection and vein assessment
Prompt removal of catheter when no longer needed.
Postoperative Care And Follow Up
Immediate Post Procedure:
Chest X-ray to confirm tip placement
Secure dressing application
Monitor vital signs for hemodynamic stability
Observe for signs of bleeding or hematoma at the insertion site
Flush catheter to confirm patency and assess for any resistance or discomfort.
Routine Care:
Regular dressing changes (transparent dressing typically every 5-7 days or as per institutional policy, gauze dressing with securement every 48 hours or if soiled/loose)
Daily assessment of the insertion site for signs of infection (redness, swelling, pus)
Regular flushing and locking of the catheter with saline and/or heparin according to protocol to maintain patency.
Patient Education:
Instruct the patient on how to care for the PICC line site, signs and symptoms of infection, DVT, or catheter occlusion, and what to do in case of catheter damage or dislodgement
Emphasize the importance of not using the PICC arm for blood draws or blood pressure measurements unless specified by the physician.
Key Points
Exam Focus:
Understanding the indications and contraindications for PICC insertion
Recognizing the anatomical landmarks for common insertion sites
Knowing the steps of ultrasound-guided insertion and guidewire manipulation
Identifying potential early and late complications and their management
Differentiating between PICC-related infections and other causes of fever
Role of surgical oversight in complex cases.
Clinical Pearls:
Always use ultrasound for PICC insertion to improve success rates and reduce complications
Confirm tip position with a chest X-ray in all cases
Educate patients thoroughly about their line care to prevent infections and DVT
If resistance is met during flushing or withdrawal, do not force
assess for occlusion or malposition
Consult surgery or interventional radiology for difficult venous access or immediate complications.
Common Mistakes:
Attempting insertion without adequate training or supervision
Failing to use ultrasound guidance
Inadequate aseptic technique leading to infection
Incorrect tip placement (too proximal or too distal)
Forcing occluded lines
Failure to confirm line patency post-insertion
Delayed removal of the catheter when it is no longer indicated.