Peripherally Inserted Central Catheters (PICC)

Patients need intravenous (IV) access for various reasons, whether for inpatient or outpatient treatment. Many patients need long-term IV access for administering medications, like antibiotics and immunotherapy, or routine bloodwork. So, instead of sticking a patient every time and potentially introducing bacteria and pain, many patients and healthcare providers opt for a more semi-permanent alternative, a peripherally inserted central catheter (PICC).

PICC lines are becoming more frequently ordered by healthcare providers. Thus, providers must understand their implications, management, and potential complications. In this course, you will learn about PICC lines, their contraindications, and their advantages and disadvantages. This course will also review the pre- and post-procedural nursing interventions, routine care, and management of potential complications.

A PICC is a type of central catheter inserted into a peripheral arm vein, such as the brachial, cephalic, basilic, or medial cubital veins. However, the most common insertion site is the right basilic vein since it's more superficial, has fewer valves, and is larger in diameter than the others. The PICC line continues up the arm vein and ends in the patient's superior vena cava (SVC) or heart's right atrium. They are either single, double or triple-lumen and can be used for several weeks up to six months. In addition, PICC lines can be inserted by an interventional radiologist, physician, mid-level provider, or nurse if they are specially trained in PICC line insertion. Using trained registered nurses to insert PICC lines has recently become a more popular and cost-effective option (Gonzalez & Cassaro, 2022).

PICC Line Access Sites

Patients need a PICC line inserted for various reasons. For example, if patients need bloodwork taken regularly or prolonged IV medication administration, like with antibiotics and chemotherapy. Also, they are often inserted in critically ill patients to monitor their central venous pressure, to administer vasoactive medications, and to administer medications that can destroy the vein or are caustic, like IV potassium. A PICC line is also useful for rapid fluid resuscitation and potential blood transfusions because the bore of the IV is larger, thus allowing for a faster infusion rate. They can also deliver short-term total paternal nutrition without a regular IV catheter (Gonzalez & Cassaro, 2022). Additionally, the central line-associated bloodstream infections (CLABSIs) rate has been proven to be lower in patients with PICC lines than in other central venous catheters (CVCs). Thus, making PICC lines a great alternative to placing CVCs or central lines (Pitiriga et al., 2022).

There are many advantages to inserting a PICC line, such as low risk of procedure-related trauma compared to other CVC insertions. Patients who require frequent needle sticks are more prone to skin bruising, infiltration, and phlebitis and would benefit from a PICC line (Mielke et al., 2020). In addition, PICC lines are more easily inserted and removed than central ports and catheters. PICC lines can also be placed in patients with thrombocytopenia and critically ill patients to monitor their central venous pressure (Gonzalez & Cassaro, 2022).

Contrary to its many advantages, there are some disadvantages to PICC lines. For instance, a central catheter is more beneficial if a patient needs frequent blood transfusions. Also, for patients who require IV medications administered for longer than six months, the PICC line will need to be removed or replaced at six months (Gonzalez & Cassaro, 2022). There are also some greater potential complications with PICC lines since they are inserted centrally, such as CLABSIs, obstructions, and thromboses forming (Bahoush et al., 2021).

Although PICC lines are a popular alternative to peripheral IVs or CVCs, some contraindications remain. Some contraindications to PICC line insertions are if the patient has a skin infection, trauma, or burns to the arm(s). Also, if the patient has an active blood infection (bacteremia), a PICC line should not be placed, or if the patient has chronic renal failure and needs a dialysis catheter placed instead (Montanarella et al., 2023). Prior mastectomy, arteriovenous (AV) fistula, and small arm veins are also contraindications. If the patient has a persistent cough or vomiting or needs to use crutches, a PICC line should not be inserted since these activities can potentially dislodge the catheter (Gonzalez & Cassaro, 2022).

Depending on the patient's acuity and potential complications, a PICC line can be inserted surgically under fluoroscopy or at the bedside. Generally, for stable patients, a PICC line can be inserted at the bedside using ultrasound guidance (Gonzalez & Cassaro, 2022). If the patients are at higher risk for complications or the radiologist is worried about catheter positioning, they may elect to insert the PICC line under fluoroscopy (Montanarella et al., 2023).

Once the healthcare provider determines a PICC line needs to be placed, they will need to discuss the reason for the procedure along with its potential complications. Afterward, the patient or healthcare proxy will sign an informed consent before the procedure.

After the procedure, the nurse should ensure the PICC line is in the correct position before administering anything through it. Correct placement is usually confirmed via chest x-ray or fluoroscopy and outlined in the radiology report. There should always be an order placed in the chart by the healthcare provider or radiologist for approved PICC line use. Additionally, the nurse continues with cardiac monitoring post-procedure for the designated time frame per their facility's protocol or healthcare provider's orders (Gonzalez & Cassaro, 2022). The nurse also monitors the insertion site and dressing for signs of uncontrolled bleeding and infection. The nurse should check each PICC line lumen for patency by aspirating blood and flushing it with normal saline (Montanarella et al., 2023).

Nursing management of a PICC line includes monitoring for complications and ensuring proper function. First, the insertion site is assessed daily to ensure no signs or symptoms of infection are present. Again, if signs of infection are present, the nurse must contact the healthcare provider, who will most likely order the PICC line removal. Once removed, the tip of the PICC line is sent for culture (CDC, 2015).

Catheter occlusions are one of the most common complications with PICC lines, which can be thrombotic or non-thrombotic. It is imperative for all lumens of the catheter to be flushed at least daily and for the nurse to check medication compatibility if administering two medications through the same lumen. If a catheter becomes occluded, the nurse can first attempt repositioning the patient, as sometimes it's positional. However, the nurse should contact the healthcare provider if the occlusion is still present. The healthcare provider often orders a one-time anticoagulant injection, such as alteplase, through the patient's PICC line to see if this resolves the occlusion (Gonzalez & Cassaro, 2022).

Deep vein thrombosis (DVT) is another potential complication that can develop in the extremity where the PICC line is placed. Signs of a DVT are redness, tenderness, and swelling of the affected extremity. If the nurse suspects a DVT, they should take a measuring tape and measure the circumference of the affected arm. Then, measure the circumference of the unaffected arm and compare it to the affected extremity. If the circumference of the affected extremity is larger, then there is high suspicion of a DVT. Again, the nurse notifies the healthcare provider immediately if this is suspected, and the provider will most likely order a Doppler ultrasound (Gonzalez & Cassaro, 2022).

Catheter misposition or migration is another common complication of PICC lines; this can occur when the patient strongly coughs during dressing changes or spontaneously. Sometimes, a catheter misposition is found when patients have new cardiac arrhythmias or pneumothorax. If the nurse suspects or knows the catheter has become displaced, they should stop using the PICC line immediately and call the healthcare provider. The provider usually orders an X-ray to confirm its placement (Gonzalez & Cassaro, 2022). Other complications to monitor for include phlebitis, air embolism, and infiltration.

Healthcare providers often have to remove PICC lines in their practice, which can be before discharge or as ordered by the provider. Nurses must follow their facility's protocol for removal techniques, as they can vary. Most removal techniques involve having the patient lie supine and keeping them relaxed. The dressing is removed, the insertion site cleansed, and the PICC line is gently pulled from the patient. After, the nurse applies pressure to the area for several minutes and then applies a dressing. The nurse then compares the length of the removed catheter to the length initially documented at insertion. If the length of the removed catheter is shorter, then it may have become dislodged inside the patient's vein. In this case, the healthcare provider is contacted to evaluate further potential thrombosis (Gonzalez & Cassaro, 2022).

Many patients are discharged home with PICC lines in place, so there are several instructions to review. First, the patient is instructed not to allow blood pressure to be taken or blood drawn on the PICC line arm. Patients are also instructed to routinely flush the line and use an aseptic technique when performing dressing changes. They should also be aware of signs and symptoms of infection to watch for and how to contact their provider.

A 56-year-old patient in the intensive care unit has a left-sided PICC line inserted for long-term IV antibiotic administration and regular blood draws. The patient has a continuous heparin infusion running through one of the lumens on their PICC line. The nurse assesses the patient's PICC line for the shift and notices that the insertion site looks erythematous and has a small amount of serous discharge. The nurse calls the healthcare provider and suspects the patient has an infection from the PICC line and recommends removal to the provider. However, several days later, it was confirmed that the patient had developed a deep vein thrombosis in their left arm. What steps could the nurse have taken to assess this patient further instead of assuming the erythema on the patient's arm was caused by an infection?

PICC lines are often a source of infection but can also become infiltrated or develop phlebitis, leading to DVT. In this case, the nurse could have taken the patient's temperature and reviewed the patient's recent white blood cell count. Patients with bloodstream infections caused by PICC lines often develop a fever and elevated WBC. Also, if the patient develops either, the source of the infection is not always the PICC line. In addition, the nurse could have used a measuring tape to measure the circumference of the patient's left arm and compare it to the circumference of the right arm. In the presence of DVTs, the extremity with the DVT is often swollen, and the circumference is larger. Also, the nurse should not assume that because the patient is on a continuous heparin infusion, they cannot develop a DVT. The heparin dosage might not have been within the therapeutic range. So again, the nurse would need to review the patient's medical record for their last partial thromboplastin time (PTT) and when the infusion was initially started. Before notifying the healthcare provider, the nurse must collect objective data about the patient before making recommendations or assumptions about the patient's condition.

PICC lines are becoming more widely used in healthcare settings, and thus, nurses must understand their implications and management. PICC lines are a safer, more cost-effective alternative to CVC and peripheral IVs for those who need ongoing IV medications for a few weeks up to six months.

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