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Introduction

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A peripherally inserted central catheter (PICC) is a relatively new form of central line inserted peripherally, threaded into a central location (Figure 37-1) intended for long-term, including outpatient, use. It is often used for administration of agents such as chemotherapeutic drugs, antibiotics, and parenteral nutrition, and may be associated with a lower rate of infection than centrally inserted catheters.

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Figure 37-1.
Graphic Jump Location

Diagrammatic representation of the course of a PICC.

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Definitions and Terms

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  • ▪  Cephalic vein: travels over the anterior surface of the bicep muscle
  • ▪  Basilic vein: travels along the medial aspect of the biceps muscle
  • ▪  Brachial vein: travels along the medial surface of the forearm
  • ▪  PICC: PICC line

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Techniques

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  • ▪  Indications for PICC.
    • —Intended long-term need for central access
    • —Unavailability of other central sites
  • ▪  Contraindications.
    • —Infected over or around intended site
    • —Coagulopathy
    • —History of axillary node dissection above intended site
    • —Radiation above intended site
    • —History deep venous thrombosis in veins proximal to intended site
    • —Vascular surgery (ie, dialysis access) proximal to intended site
  • ▪  Prior to procedure, obtain patient consent, prep and drape, and perform universal protocol as described in Section I.
  • ▪  Identify cannulation site based on patient anatomy and clinical situation.
  • ▪  Preparation.
    • —Skin: The CDC recommends preparation of the cannulation site with a 2% aqueous chlorhexidine-gluconate solution (Figure 37-2), which has been associated with lower blood stream infection rates than povidine-iodine or alcohol-based preparations. The skin and tissue around the vessel should be infiltrated with 1% lidocaine solution, except in patients with a known allergy to lidocaine, in whom alternative local anesthetics can be used.
    • —Hygiene: The operator should observe proper hand hygiene and use maximal barrier precautions including gown, mask and gloves, and a large sterile drape or multiple drapes covering a large area.
  • ▪  Ultrasound (Figures 37-3 and 37-4) is used to identify a patent peripheral vein.
  • ▪  A small bore needle is inserted into the vessel into which a wire is threaded, followed by a dilator/ tear-away sheath combination (Figures 37-5, 37-6, 37-7, and 37-8).
  • ▪  The dilator is removed from the sheath and the PICC catheter is threaded over the wire into the central circulation (Figures 37-9, 37-10, and 37-11).
  • ▪  The sheath is then peeled away and the wire removed, leaving the PICC in the vessel alone (Figure 37-12).
  • ▪  A chest x-ray is obtained to confirm the central location of the catheter tip (Figure 37-13).
  • ▪  Complications.
    • —Phlebitis
    • —Catheter occlusion
    • —Catheter fracture

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Figure 37-3.
Graphic Jump Location

Ultrasound probe over antecubital fossa.

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