Peripherally inserted central catheter
Encyclopedia
Chemotherapy
Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....
regimens, extended antibiotic therapy, or total parenteral nutrition
Total parenteral nutrition
Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids and added vitamins and dietary minerals...
). First described in 1975, it is an alternative to subclavian lines, internal jugular lines or femoral lines which have higher rates of infection. Subclavian and internal jugular line placements may result in pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
(air in the pleural space of lung).
Insertion
A PICC is inserted in a peripheral veinVein
In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...
, such as the cephalic vein
Cephalic vein
In human anatomy, the cephalic vein is a superficial vein of the upper limb.It communicates with the basilic vein via the median cubital vein at the elbow and is located in the superficial fascia along the anterolateral surface of the biceps brachii muscle.Superiorly the cephalic vein passes...
, basilic vein
Basilic vein
In human anatomy, the basilic vein is a large superficial vein of the upper limb that helps drain parts of hand and forearm. It originates on the medial side of the dorsal venous network of the hand, and it travels up the base of the forearm and arm...
, or brachial vein and then advanced through increasingly larger veins, toward the heart until the tip rests in the distal superior vena cava
Superior vena cava
The superior vena cava is truly superior, a large diameter, yet short, vein that carries deoxygenated blood from the upper half of the body to the heart's right atrium...
or cavoatrial junction
Cavoatrial junction
The cavoatrial junction is the point at which the superior vena cava meets and melds into the superior wall of the cardiac right atrium. Both the superior and inferior vena cavae enter the right atrium, but only the superior entry is called the cavoatrial junction...
.
PICCs are usually inserted by physicians, physician assistant
Physician assistant
A physician assistant/associate ' is a healthcare professional trained and licensed to practice medicine with limited supervision by a physician.-General description:...
s (in the USA), radiologist assistants (in the USA), nurse practitioners, or specially trained certified registered nurse
Registered nurse
A registered nurse is a nurse who has graduated from a nursing program at a university or college and has passed a national licensing exam. A registered nurse helps individuals, families, and groups to achieve health and prevent disease...
s and radiologic technologists using ultrasound
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
, chest radiographs, and fluoroscopy
Fluoroscopy
Fluoroscopy is an imaging technique commonly used by physicians to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed...
to aid in their insertion and to confirm placement. PICC insertion is a sterile
Asepsis
Asepsis is the state of being free from disease-causing contaminants or, preventing contact with microorganisms. The term asepsis often refers to those practices used to promote or induce asepsis in an operative field in surgery or medicine to prevent infection...
procedure, but does not require the use of an operating room. When done at bedside (that is, in the patient's room), a suitable sterile field must be established and maintained throughout the procedure. For this reason, visitors are normally requested to leave the room until the insertion is complete and some form of skin preparation should be used to clean patient skin.
The insertable portion of a PICC varies from 25 to 60 centimeters in length, that being adequate to reach the desired tip position in most patients. Some lines are designed to be trimmed to the desired length before insertion, others are simply inserted to the needed depth with the excess left outside. As supplied, the line has a guide wire inside. This wire is provided to stiffen the (otherwise very flexible) line so it can be threaded through the veins. The wire is removed and discarded after insertion.
The PICC is also provided with a "wing" having holes for either sutures or an adhesive securement device such as Statlock. Other new technologies which may provide advantages are being introduced to the market such as the SecurAcath subcutaneous securement technology. Securing the catheter prevents post-insertion movement of the line, as that could place the tip in an unsafe position.
Usage
PICCs generally will remain in place no longer than 30 days, although duration of use varies from just a few days in patients requiring short courses of chemotherapy or biotherapyBiotherapy
Zootherapy is the use of living animals for medical treatment or as an adjunct to medical diagnosis.-Overview:Zootherapy is the use of living organisms to diagnose, treat or cure disease or disease symptoms...
to a year for patients requiring longer treatment. Commonly, other forms of intravenous access are considered if the treatment course is protracted. While replacement is generally considered a year post-insertion, patients have survived with the same PICC in situ for several years without complication. Complications may include catheter occlusion, phlebitis
Phlebitis
Phlebitis is an inflammation of a vein, usually in the legs.When phlebitis is associated with the formation of blood clots , usually in the deep veins of the legs, the condition is called thrombophlebitis...
, haemorrhage, thrombosis
Thrombosis
Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets and fibrin to form a blood clot to prevent blood loss...
and infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
. Urokinase
Urokinase
Urokinase , also called urokinase-type plasminogen activator , is a serine protease . Urokinase was originally isolated from human urine, but is present in several physiological locations, such as blood stream and the extracellular matrix...
or low dose tPA (AKA: Alteplase or Cathflo (Genentech, Inc) may be used to lyse obstructions.
Certain types of PICCs have recently been approved by the FDA
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
for use in power injection. These PICCs, often referred to as power injectable PICCs, are designed to withstand the high pressures associated with radiocontrast
Radiocontrast
Radiocontrast agents are a type of medical contrast medium used to improve the visibility of internal bodily structures in an X-ray based imaging techniques such as computed tomography or radiography...
studies.
PICCs can also be used to measure the CVP (Central Venous Pressure
Central venous pressure
Central venous pressure describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart...
). CVP is a rough estimate of the right atrial pressures of the heart and can give valuable information about fluid status of the patient.
Removal
Removal of a PICC line is a considerably more simple procedure in most cases. Generally, the catheter line can be safely and quickly removed by a trained nurse, even in the patient's own home, in a matter of minutes. After removal, the insertion site is normally bandaged with sterile gauze and kept dry for a few days, during which the wound can close and begin healing. Usually, a smaller adhesive bandage can be placed over the wound site after the gauze is removed if the wound is slow to heal.Further reading
- Bender, C.M., Rosenzweig, M. & Green, E. (2006) Cancer. In S. Goldsworthy & M.A. Barry. Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems. (1st Canadian ed). Mosby: Toronto. ISBN 0779699696.