Editing Peripherally inserted central catheter

{{Short description|Catheter intended for long periods of use}}
{{Use American English|date = January 2019}}
{{Use mdy dates|date = January 2019}}
{{More citations needed|date=April 2011}}
{{infobox medical equipment
| name         = Peripherally inserted central catheter
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| image        = PICC line.jpg
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| caption      = Typical PICC line with a double lumen
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| specialty    = <!-- from Wikidata, can be overwritten -->
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A '''peripherally inserted central catheter'''  ('''PICC''' or '''PICC line'''), also called a '''percutaneous indwelling central catheter''' or '''longline''',<ref>{{cite journal |last1=Arnett |first1=A. M. |last2=Fleisher |first2=G. R. |title=Insertion of long lines in the pediatric emergency department |journal=Pediatric Emergency Care |date=October 1999 |volume=15 |issue=5 |pages=318–321 |doi=10.1097/00006565-199910000-00004 |url=https://pubmed.ncbi.nlm.nih.gov/10532658/ |access-date=15 May 2024 |issn=0749-5161}}</ref> is a form of [[intravenous]] access that can be used for a prolonged period of time (e.g., for long [[chemotherapy]] regimens, extended [[antibiotic therapy]], or [[total parenteral nutrition]]) or for administration of substances that should not be done peripherally (e.g., [[antihypotensive agent]]s a.k.a. pressors). It is a [[catheter]] that enters the body through the skin (percutaneously) at a [[peripheral vascular system|peripheral]] site, extends to the [[superior vena cava]] (a central venous trunk), and stays in place (dwells within the [[vein]]s) for days, weeks or even months.

First described in 1975,<ref>{{cite journal |vauthors=Hoshal VL |title=Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters |journal=Arch Surg |volume=110 |issue=5 |pages=644–6 |date=May 1975 |pmid=805577 |doi=10.1001/archsurg.1975.01360110190032}}</ref> it is an alternative to [[central venous catheter]]s in major [[veins]] such as the [[subclavian vein]], the [[internal jugular vein]] or the [[femoral vein]]. Subclavian and jugular line placements may result in [[pneumothorax]] (air in the pleural space of lung), while PICC lines have no such issue because of the method of placement.

==Medical uses==
[[File:PICC Line and IV Placement.jpg|thumb|A PICC (upper arm) and IV line (elbow area) inserted prior to chemotherapy.]]
Generally, PICC lines are considered when a person is expected to need more than two weeks of intravenous therapy.<ref name=Chop2015>{{cite journal | last1=Chopra | first1=V | last2=Flanders | first2=SA | last3=Saint | first3=S | last4=Woller | first4=SC | last5=O'Grady | first5=NP | last6=Safdar | first6=N | last7=Trerotola | first7=SO | last8=Saran | first8=R | last9=Moureau | first9=N | last10=Wiseman | first10=S | last11=Pittiruti | first11=M | last12=Akl | first12=EA | last13=Lee | first13=AY | last14=Courey | first14=A | last15=Swaminathan | first15=L | last16=LeDonne | first16=J | last17=Becker | first17=C | last18=Krein | first18=SL | last19=Bernstein | first19=SJ | display-authors=6 | name-list-style=vanc|title=The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method.|journal=Annals of Internal Medicine|date=15 September 2015|volume=163|issue=6 Suppl|pages=S1–S40|pmid=26369828|doi=10.7326/M15-0744|doi-access=}}</ref> A PICC line can remain inserted for an extended period of time compared to other forms of central IV access, ranging from seven days up to several months as long as the line remains viable.<ref>{{cite web |title=Guidelines for the Prevention of Intravascular Catheter-Related Infections |url=https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html |website=Centers for Disease Control and Prevention |publisher=Centers for Disease Control and Prevention |access-date=23 July 2019}}</ref> They are utilized in both the hospital and community settings. They are commonly used in people receiving total [[parenteral nutrition]] (TPN), chemotherapy, or long term medications such as antibiotics. They may also be used to obtain a blood sample if the lumen is of sufficient size (at least 4 [[French catheter scale|French gauge]]).

To help prevent the line from becoming clogged, the line should be regularly flushed with normal saline, and "locked" by filling it with [[heparin]] or [[normal saline]] when not in use.<ref>[https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0043-1764199 valved PIC]</ref>
<ref name="Aljediea 35–38">{{Cite journal |last=Aljediea |first=Ibraheem |last2=Alshehri |first2=Mohammed |last3=Alenazi |first3=Khaled |last4=Mimesh |first4=Amr |last5=Fleet |first5=Mustafa |date=January 2023 |title=Accuracy of Electrocardiography-guided PICC in Atrial Fibrillation Patients |url=http://www.thieme-connect.de/DOI/DOI?10.1055/s-0043-1764199 |journal=The Arab Journal of Interventional Radiology |volume=07 |issue=1 |pages=35–38 |doi=10.1055/s-0043-1764199 |issn=2542-7075|doi-access=free }}</ref>

==Contraindications==
A PICC line may not be inserted in a part of the body which is burned or has a local infection. Damage to the skin and surrounding tissue from radiation may also prevent the placement of a PICC line.<ref name="AAS 2013">{{cite journal |last1=Westergaard |first1=B. |last2=Classen |first2=V. |last3=Walther-Larsen |first3=S. |name-list-style=vanc |title=Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations: PICCs in children |journal=Acta Anaesthesiologica Scandinavica |date=March 2013 |volume=57 |issue=3 |pages=278–287 |doi=10.1111/aas.12024|pmid=23252685 |s2cid=10458652 }}</ref>

==Risks and complications==
As with any intravenous line, there is the risk for [[sepsis]] – a severe bloodstream infection that can be life-threatening. The majority of infections associated with PICC lines occur after a median duration of use of 10 days, and during an [[intensive care unit]] stay.<ref name="AJM2016">{{cite journal |last1=Chopra |first1=Vineet |last2=Ratz |first2=David |last3=Kuhn |first3=Latoya |last4=Lopus |first4=Tracy |last5=Chenoweth |first5=Carol |last6=Krein |first6=Sarah |name-list-style=vanc |title=PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors |journal=The American Journal of Medicine |date=April 2014 |volume=127 |issue=4 |pages=319–328 |doi=10.1016/j.amjmed.2014.01.001|pmid=24440542 |doi-access=free }}</ref> Adhering to strict infection control procedures, including [[aseptic technique]], when inserting or using a PICC line will reduce the risk of an infection.<ref>Guidelines for the Prenention of Intravascular Catheter-Related Infections, Centre for Disease Control 2011; Infusion Nurses Standards, 2010).[[Centre for Disease Control]]</ref> There is also a risk of [[Thrombosis|blood clots]].<ref name=Chop2015/> The use of heparin to maintain a PICC line is not universal, as heparin locks have been associated with complications, including heparin-induced [[thrombocytopaenia]].<ref>{{cite web |url=http://clinicaltrials.gov/ct2/show/related/NCT00994136 |title=Safety of Catheter Lock with or Without Heparin in Implanted Central Venous Catheters - Related Studies - ClinicalTrials.gov |access-date=2012-02-05 |url-status=dead |archive-url=https://web.archive.org/web/20130801043526/http://clinicaltrials.gov/ct2/show/related/NCT00994136 |archive-date=2013-08-01 }}</ref>

Other complications may include catheter occlusion, [[phlebitis]] and [[haemorrhage|bleeding]]. [[Urokinase]] or low-dose [[tissue plasminogen activator]] (tPA) may be required to [[lysis|break down]] obstructions, depending on the type and severity of the occlusion. A blood pressure reading can not be taken on an arm with a PICC line inserted.<ref>[http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1104449359467.html U Wisconsin, Preparing and Caring] {{Webarchive|url=https://web.archive.org/web/20130804002401/http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1104449359467.html |date=August 4, 2013 }}, accessed July 24, 2013</ref>

==Technique==
[[File:PICC line-correct position-with annotation.jpg|thumb|300px|Chest X-ray showing tip of PICC line in the superior vena cava. Arrows provided to highlight the PICC line.]]
[[File:Blausen 0193 Catheter PICC.png|thumb|Illustration of fully inserted PICC]]
A PICC is inserted in a [[peripheral vascular system|peripheral vein]] such as the [[cephalic vein]], [[basilic vein]] or [[brachial vein]] in the arm, and then threaded through the veins toward the heart, until the end of the catheter rests in the proximal [[superior vena cava]] or [[cavoatrial junction]]. They must be inserted by a trained medical professional, including a [[physician]], but also any trained medical professional such as a specially trained [[registered nurse]].<ref name=AJM2016 /> and [https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0041-1739303 Interventional Radiology Technogists].<ref name="Aljediea 35–38"/><ref>{{Cite journal |last=Aljediea |first=I. |last2=Alshehri |first2=M. |last3=Alenazi |first3=K. |last4=Memesh |first4=A. |last5=Fleet |first5=M. |date=July 2021 |title=Experience of Radiology Technologists Performing Peripherally Inserted Central Catheters (PICC) |url=http://www.thieme-connect.de/DOI/DOI?10.1055/s-0041-1739303 |journal=The Arab Journal of Interventional Radiology |volume=05 |issue=2 |pages=88–92 |doi=10.1055/s-0041-1739303 |issn=2542-7075|doi-access=free }}</ref>  An [[medical ultrasonography|ultrasound]] or chest X-ray,  the use of [[fluoroscopy]], or [https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0043-1764199 electrocardiography navigation] can be used during insertion and to confirm placement. The insertion is a [[Asepsis|sterile]] procedure, but does not need to be performed in a completely sterile environment like an operating room.

===Selection of vein and catheter===
A PICC line is an invasive medical procedure, and may require local or general anesthesia during the placement. The [[basilic vein]] is an appropriate size, but is not preferred in children due to its depth and surrounding tissue. On the other hand, the [[cephalic vein]] may be used, though in some people it will not be possible to advance the line to the desired location through the cephalic vein. The [[brachial vein]] is large enough for a PICC line, but is also located close to other features such as the brachial artery and plexus. Imaging is commonly used to evaluate the length and path of the potential veins before the practitioner selects the most appropriate vein.<ref name=AJM2016 /> The catheter size for PICC lines is generally measured in [[French catheter scale|French gauge]], and may range from 2 to 6. The number of lumens may vary from one to three, allowing for concurrent administration of different medications which cannot be mixed. Catheters are also manufactured from multiple materials, including silicone and polyurethane. The insertable portion of a PICC varies from 25 to 60&nbsp;cm in length, which is sufficient to reach the desired end position in most cases. Some catheters are designed to be trimmed to the required length before insertion whereas others are simply inserted to the needed depth with the excess remaining outside the body. Catheters are supplied with a guidewire. This wire is provided to stiffen the (otherwise very flexible) line so it can be more easily threaded through the veins, and is removed after insertion. Some PICC lines are manufactured with an antimicrobial coating intended to reduce the chance of an infection from the line, but these are not yet in widespread use.<ref name=AJM2016 />

===Insertion===
While an operating room is not required for the insertion of a PICC line, it is important to maintain a [[Asepsis|sterile]] environment surrounding the insertion site. This involves cleaning the skin around the site, as well as the use of a sterile gown, gloves, and drape to reduce the risk of environmental contamination. After the skin is prepared, an incision is made and a device called an "introducer/peelaway sheath" is inserted into the vein. The catheter is trimmed to the desired length if required, and filled with saline for the duration of the insertion. The PICC line is inserted via the introducer device, and threaded through the veins to the desired end location.<ref name=AJM2016 /> [[Fluoroscopy]] or [[Echocardiography|echocardiographic]] guidance may be used to monitor the tip position during insertion.

===Removal===
In most cases the removal of a PICC is a simple procedure. 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. The tip of the catheter is sent for microscopy culture and sensitivity (MCS) if the patient is systemically unwell at the time of removal of the PICC. In certain units, it is sent as routine investigation.

==See also==
* [[Central venous catheter]]
* [[Hickman line]]

==References==
{{reflist}}

==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|0-7796-9969-6}}.

==External links==
* [https://web.archive.org/web/20070415220522/http://www.cancerbackup.org.uk/Treatments/Chemotherapy/Linesports/PICCline Description and images of PICC line insertion]
* [https://lavascular.com/picc-line-midline-catheter/ PICC line indications, insertion, care and complications]

{{Intravenous therapy}}

[[Category:Catheters]]