PICC MANUAL
2 BARD ACCESS SYSTEMS
Author / Project Manager:
Angela Grosklags, RN, MSN, VA-BC
Editors:
Chris London
Mona Shahrebani
Contributors:
Kim Alsbrooks, BSN, RN, RT(R), VA-BC
Sharon Armes, RN, CVAA (C)
Stacy Buckley, RN, CRNI
Kathy Kokotis, RN, BS, MBA
Richard B Lewis, RN, BS, VA-BC
Jamie Bowen Santolucito, RN, CRNI, VA-BC
Sandy Sucy, RN, MSN, VA-BC
Design / layout:
Steve Day
3
PICC MANUAL
4 BARD ACCESS SYSTEMS
It is estimated that over 90% of hospitalized patients will receive some form of vascular access. The
purpose of vascular access is to hydrate the patient, administer medication, take blood samples, and/
or perform blood transfusions. These things are done with a vascular access device (VAD), such as
a peripheral intravenous device (commonly called a peripheral IV or PIV), midline catheter, centrally
inserted central catheter (CICC), or a peripherally inserted central catheter (PICC). This manual focuses
on PICCs.
As a designer and manufacturer of PICCs, Bard Access Systems strives to educate clinicians on proper
PICC insertion and maintenance. Since PICC insertion is an advanced skill that is not covered in basic
nursing studies, clinicians should complete an eight-hour class, participate in hands-on training, and
engage other resources as appropriate. This manual can be used as a reference guide to supplement
such training. This manual is not intended to replace such training or clinical judgment.
The goal of clinicians inserting PICCs should be to administer the appropriate therapy to the patient
via safe and successful vascular access. In addition to providing guidance for PICC insertion, this
manual will discuss various complications and how they can be prevented, detected, documented, and
managed. Techniques for routine care and maintenance of a PICC and the patient are also discussed.
We at Bard Access Systems hope the information provided in this manual will help you, the clinician,
provide quality care for each patient.
INTRODUCTION
5
PICC MANUAL
6 BARD ACCESS SYSTEMS
BARD ACCESS SYSTEMS, INC.
605 North 5600 West, Salt Lake City, UT 84116 USA
customer service: 800-545-0890 • clinical information: 800-555-7422
bardaccess.com
Bard, Site-Scrub, Safety Excalibur Introducer, Sherlock 3CG Tip Confirmation System, Sherlock II Tip Location System, GuardIVa, Statlock, Groshong,
PowerPICC, Site~Rite Vision, Sherlock, and Sherlock 3CG are trademarks and/or registered trademarks of C.R. Bard, Inc.
All other trademarks are the property of their respective owners.
© 2015 C. R. Bard, Inc. All rights reserved. MC_1368_00
7
Overview ............................................................................................................................................... 3
Objectives ............................................................................................................................................. 3
Vessel Wall Structure ............................................................................................................................ 4
Vascular Characteristics ....................................................................................................................... 5
Large Veins of the Upper Arm .............................................................................................................. 6
Veins Used for PICC Insertion .............................................................................................................. 7
Vessels of the Thorax ........................................................................................................................... 8
Nerves of the Upper Arm ...................................................................................................................... 10
Physiology of the Venous System ....................................................................................................... 11
Virchow’s Triad ...................................................................................................................................... 12
Summary ............................................................................................................................................... 12
Overview ................................................................................................................................................ 15
Objectives .............................................................................................................................................. 15
Common Vascular Access Devices ...................................................................................................... 16
Considerations for Device Selection ................................................................................................... 18
PICCs ..................................................................................................................................................... 18
Infusate Characteristics ....................................................................................................................... 20
Catheter Features ................................................................................................................................. 23
Summary ............................................................................................................................................... 24
Overview ................................................................................................................................................ 27
Objectives .............................................................................................................................................. 27
Informed Consent .................................................................................................................................. 28
Pre-Insertion Assessment .................................................................................................................... 29
Patient and Clinician Education ........................................................................................................... 30
Positioning and Measuring Techniques ............................................................................................... 31
Maximal Sterile Barrier (MSB) Precautions .......................................................................................... 32
Verification and Time-Out ..................................................................................................................... 40
Summary ............................................................................................................................................... 40
Overview ................................................................................................................................................ 43
Objectives .............................................................................................................................................. 43
Techniques for PICC Insertion ............................................................................................................. 44
Using Ultrasound Guidance ................................................................................................................. 46
Catheter-Tip Navigation ........................................................................................................................ 48
Inserting a PICC .................................................................................................................................... 49
PICC MANUAL TABLE OF CONTENTS
8 BARD ACCESS SYSTEMS
Inserting a PICC Using the Sherlock™ II Tip-Location System (TLS) ................................................ 57
Inserting a PICC Using the Sherlock 3CG™ Tip-Confirmation System (TCS) ................................... 66
Summary ............................................................................................................................................... 75
Overview ................................................................................................................................................ 79
Objectives .............................................................................................................................................. 79
PICC-Tip Placement .............................................................................................................................. 80
Using Radiography to Confirm PICC Placement ................................................................................. 81
Using Electrocardiography (ECG) to Confirm PICC Placement .......................................................... 85
Summary ............................................................................................................................................... 86
Overview ................................................................................................................................................ 89
Objectives .............................................................................................................................................. 89
Complications ....................................................................................................................................... 90
Insertion-Related Complications .......................................................................................................... 91
Post-Insertion Complications .............................................................................................................. 92
Complications Occuring Anytime ........................................................................................................ 96
Summary ............................................................................................................................................... 100
Overview ................................................................................................................................................ 103
Objectives .............................................................................................................................................. 103
Skin Antisepsis ..................................................................................................................................... 104
PICC Stabilization ................................................................................................................................. 104
Chlorhexidine Sponges ........................................................................................................................ 106
PICC Dressings ..................................................................................................................................... 107
Flushing and Locking ........................................................................................................................... 108
Withdrawing Blood / Aspirating ........................................................................................................... 109
Power Injection ...................................................................................................................................... 110
Changing Needleless Connectors ....................................................................................................... 111
Clearing Occluded PICCs ..................................................................................................................... 113
Repairing Groshong® PICCs ................................................................................................................ 114
Removing PICCs .................................................................................................................................... 116
Troubleshooting .................................................................................................................................... 116
Summary ................................................................................................................................................ 118
......................................................................................... 121
..... 127
........................................ 133
........................................................................................................................................ 147
TABLE OF CONTENTS
9
PICC MANUAL
10 BARD ACCESS SYSTEMS
9,12,18,21,22]
The circulatory system is a complex circuit of the heart and blood vessels. Understanding the typical
vascular anatomy of veins and arteries is necessary prior to placing a peripherally inserted central
catheter (PICC). To insert a PICC, a needle is typically inserted through the skin and three layers of a vein
in the arm. After access is established, the PICC is threaded into the axillary vein (near the shoulder),
through the subclavian vein (above the clavicle), continuing through the brachiocephalic vein (leading
downward toward the heart) and into the superior vena cava (SVC). Ideally, the PICC tip will terminate
in the distal SVC or cavoatrial junction (CAJ). The increased blood flow in the SVC/CAJ (2,000 mL/
min compared to 20–40 mL/min in forearm vessels) facilitates hemodilution and mitigates vein irritation
caused by infusates. Inserting a PICC requires that clinicians understand the relevant anatomy and
physiology of the vascular system and that they know the best techniques to mitigate any complications.
This chapter will discuss this information.
• Identify vessel-wall structure.
• Identify and locate the vessels used for insertion of a PICC.
• C orrelate the anatomy and physiology of the venous structures of the arms, axillary, neck, and thorax
in relation to the placement of a PICC.
• Identify the anatomic location of arteries and nerves in close proximity to the veins of the upper extremeties.
UNDERSTANDING VASCULAR ANATOMY
11
This section is intended to provide a general overview of anatomy and physiology of the circulatory system and does not
replace clinical training or judgment. Users should refer to product Instructions for Use as well as applicable facility protocols.
There are three layers in veins: the tunica adventitia, tunica media, and tunica intima (also known as the endothelium).
Venous Valve
Tunica Adventitia
Tunica Media
Tunica Intima
PICC MANUAL
12 BARD ACCESS SYSTEMS
Characteristics Veins Arteries
[1,5,13,14,15,16] • C arry deoxygenated blood toward • Carry oxygenated blood away from
the heart. the heart.
Tunica Intima
• Thin walls. • Thick walls.
[2,3] • Contain valves to prevent back flow • Do not contain valves.
• Elastic tissue in walls.
of blood. • T he smooth muscle allows arteries to
• Three types: superficial, deep, and
constrict or dilate.
perforating (which connect superficial • More difficult to collapse than veins.
with deep). • U sually lie deep in the tissues and are
• M uscular, allowing veins to contract
and expand. protected by muscle.
• Collapse with pressure. • Pulsatile.
• Not pulsatile.
• Innermost layer.
• Innermost layer. • Endothelial lining is identical to that found
• Endothelial lining is identical to that found
in veins.
in arteries. • M ade up of a single layer of smooth, flat
• Made up of a single layer of smooth, flat
endothelial cells that span the length of
endothelial cells that span the length of each vessel.
each vessel. • A ny trauma that roughens the endothelial
• A ny trauma that roughens the endothelial lining encourages thrombin formation.
lining encourages thrombin formation. • D amage to these cells initiates the
• Damage to these cells initiates the inflammatory process of phlebitis.
inflammatory process of phlebitis.
Tunica Media • Middle layer. • Middle layer.
• Consists of muscular and elastic tissue. • Consists of muscular and elastic tissue.
[2,3] • Nerve fibers, both vasoconstrictors and • Nerve fibers, both vasoconstrictors and
Tunica vasodilators, are located in this middle layer. vasodilators, are located in this middle layer.
Adventitia • Stimulation by a change in temperature or • S timulation by a change in temperature or
[2,3] by mechanical or chemical irritation may by mechanical or chemical irritation may
produce spasms of the vein or artery. produce spasms of the vein or artery.
• Capable of controlling blood flow by
constriction and dilation.
• Outermost layer. • Outermost layer.
• C onnective tissue that surrounds and • A layer of connective tissue thicker than that in
supports a vessel. veins that surrounds and supports a vessel.
• Sympathetic nerves are located in the • S ympathetic nerves are located in larger
adventitia of larger veins. arteries.
UNDERSTANDING VASCULAR ANATOMY
13
A PICC is generally inserted into one of the large veins of the upper arm as they
are larger in diameter than the veins of the lower arm and aren't affected by the
bending of the arm. These veins may include the basilic, cephalic, brachial or
median anticubital and are identified in the image below:
Cephalic Vein
Brachial Vein
Basilic Vein
Median Cubital Vein
PICC MANUAL
14 BARD ACCESS SYSTEMS
Preferred veins for PICC insertion are the basilic, cephalic, brachial, and median cubital.
Vessel Name Anatomical Location Advantages Disadvantages
Basilic Vein [3,4,5] Courses upward in a direct • O ften the vein of choice for May be more difficult to
path along the inner side PICC placement. access or perform care and
of the bicep muscle and maintenance related to its
terminates in the axillary vein. • Typically large in size. location.
• Follows a straight path.
Cephalic Vein Courses down the arm, • Superficial. • Difficulty may be
lateral to the bicep muscle, • P ossible to enter at the encountered with catheter
[4,5,6] and then down the lateral threading due to the sharp
forearm. antecubital fossa. angle where it joins the
• V ein of choice for patients axillary vein.
on crutches. • T he cephalic vein is often
• Often used for obese the smallest of the arm
veins.
patients due to the vein's
superficial nature. • The location of the
cephalic vein over the
bicep muscle may result in
excessive movement of the
catheter during arm flexion
and extension, causing
discomfort and limiting arm
motion.
Brachial Vein The paired brachial veins T ypically large in size. • L ies deep in the upper arm
are located deep in the arm and cannot be visualized
[6,17,19] and paired within the same or palpated without
sheath as the brachial artery. ultrasound guidance.
• L ies in close proximity to
the brachial nerve and
artery.
Median Cubital This vein joins the cephalic • O ften visible without • May limit movement.
Vein [4,5,6,16] and basilic veins at about the ultrasound. • Cannulation in an area
level of the antecubital fossa.
• O ften readily accessible for of flexion may lead
venipuncture. to dislodgement or
mechanical phlebitis.
• Well supported by • The caudal turn at the
muscular and connective shoulder may result in
tissue. the catheter entering the
axillary vein in a peripheral
direction rather than a
central location.
UNDERSTANDING VASCULAR ANATOMY
15
The PICC tip should reside in the lower one-third of the SVC, or the CAJ.
Right (Innominate) External Jugular Vein
Brachiocephalic Vein
Subclavian Vein Internal Jugular Vein
Axillary Vein Left (Innominate)
Brachiocephalic Vein
Superior
Vena Cava Distal Superior Vena
Cava/cavoatrial junction
Right Atrium
PICC MANUAL
16 BARD ACCESS SYSTEMS
Vessel Name Anatomical Location
Axillary Vein [3] The axillary vein is classified as a deep vein, which extends from the lateral aspect of the
chest to the lateral border of the first rib. It receives the brachial vein at its midpoint and the
cephalic vein near the border of the rib. There are 3 suprascapular veins and several other
veins joining the axillary vein in this area and as many as 40 valves can be documented in
this region.
Subclavian Vein [3] The continuation of the axillary vein is the subclavian vein from the lateral edge of the first rib
to the sternal edge of the clavicle. This vein angles upwards as it arches over the first rib and
passes under the clavicle.
Internal and The jugular veins drain the head and face. The external jugular vein is superficial and lies
External Jugular on the outer border of the neck. The external jugular vein joins the subclavian vein at its
Veins [3] midpoint. The internal jugular vein is a deep vein covered by the muscles of the neck. It joins
the subclavian vein at its proximal end.
Brachiocephalic At the top of the thoracic inlet, the internal jugular and subclavian veins join to create the
(Innominate) brachiocephalic vein, also called the innominate vein. This junction contains the last venous
Veins [3] valve before the heart. The left brachiocephalic vein, which is approximately 6 cm in length,
is approximately twice as long as the right brachiocephalic vein.
Tributaries [3] Tributaries unite with the great thoracic veins and have been documented as aberrant locations
for central venous catheters (CVCs). The internal thoracic (mammary) vein joins the SVC at the
superior end. The left and right inferior thyroid veins join the respective brachiocephalic veins,
the esophageal, tracheal, and laryngeal areas. The left superior intercostal vein joins the left
brachiocephalic vein. The azygos vein drains the blood from the veins of the spinal column and
enters the posterior side of the SVC.
Superior Vena The SVC begins at the confluence of the left and right brachiocephalic veins. It is about 7
Cava [3] cm long, extending from the inferior border of the first costal cartilage behind the sternum to
the level of the third costal cartilage, where it joins the right atrium. The lower half of the SVC
is inside the fibrous pericardium at the level of the second intercostal cartilage. Variation of
the anatomy of the SVC can lead to the creation of a right and left location, leaving the SVC
exclusively on the left side of the mediastinum. This is known as persistent left superior vena
cava (PLSVC). This congenital anomaly occurs in 0.3% of healthy individuals and in 2%–4%
of those with other cardiac anomalies.
Right Atrium [3] The SVC and inferior vena cava (IVC) join the atrium of the right side of the heart on the
posterior aspect. The SVC returns blood from the upper part of the body and has no valve.
The IVC returns blood from the lower part of the body, is larger than the SVC, and has a
semilunar valve near the opening into the atrium.
UNDERSTANDING VASCULAR ANATOMY
17
Nerve Name Anatomical Location
Median Ulnar Branches off the brachial plexus. The median nerve passes laterally to the brachial artery,
and Radial crosses the artery, descends medially into the antecubial fossa, and descends into the
Nerves [3] forearm and palm of the hand.
Ulnar Nerve
Radial Nerve
Median Nerve
PICC MANUAL
18 BARD ACCESS SYSTEMS
Blood-Flow Dynamics [3]
The cardiac output of blood in the average resting adult is about 5 liters per minute. Blood circulates in
a closed system and is dependent upon multiple factors. Factors related to the venous system include:
viscosity, vein diameter, vessel flow rates, pressure, velocity, and flow.
Viscosity [3]
The viscosity of any fluid is defined as the degree of resistance to flow when pressure is applied.
Viscosity of blood is primarily determined by the percentage of cells in blood (hematocrit). Friction from
a high concentration of cells increases viscosity.
Viscosity is affected by vessel diameter. In larger vessels, the most rapid flow is in the center of the vessel;
the slowest flow is closest to the vessel wall. As velocity of flow decreases, the viscosity increases; therefore,
blood flowing through small vessels and capillaries has the highest viscosity. For that reason it’s important
to use the smallest catheter in the largest possible vessel.
Vessel Flow Rates and Vein Diameters [1,9,10,18,24] Approximate Diameter
Vein Flow Rate
Metacarpal 10 ml/min. 2–5 mm
Forearm 20–40 ml/min. 6 mm
Basilic Upper Arm Vein 90–150 ml/min. 8 mm
Axillary Vein 15–350 ml/min. 16 mm
Subclavian 350–500 ml/min. 6–19 mm
Superior Vena Cava 2000 ml/min. 20–30 mm
The presence of numerous venous valves in the peripheral veins creates turbulent flow, while the
absence of valves streamlines the flow in the SVC.
Volume in relation to flow rate is dependent on diameter, length, and resistance within the vessel. As the
data in the table demonstrates, the blood-flow rate in peripheral veins is significantly less than the rate in
the SVC.
The rate of blood flow at the SVC is 2000 ml/min. compared to 20–40 ml/min. in the vessels in the forearm.
The increased blood flow in the SVC offers greater hemodilution and less irritation to the vein by infusates.
UNDERSTANDING VASCULAR ANATOMY
19
Pressure [3,37]
The greatest pressure is found in the aorta because of the pumping action of the heart.
Velocity [3]
Velocity is the distance blood moves in a specific period of time.
Flow [3]
• All other factors being equal, flow through a single vessel is most affected by the diameter of the
vessel. When the diameter doubles, the flow rate increases 16 times; with a fourfold increase in lumen
diameter, the flow rate increases 256 times.
• Flow can be in two types of patterns: laminar or turbulent.
--In laminar flow, the blood moves in layers or concentric circles through the vessels. As blood moves
through the vessels, the layer touching the vessel wall is slowed because of adherence to the wall. The
next layer slides easily over the outer one, and the innermost layer moves easiest.
--T urbulent flow is in all directions, flowing crosswise and lengthwise along the vessel. This type of
Bloodflow is created when the vessel’s inner surface is rough, when there is an obstruction or a sharp turn
in the vessel, or when the amount of flow has increased greatly.
A deep vein thrombosis (DVT) is a potential complication associated with PICC insertion. When selecting Surface
a VAD, the clinician should select the smallest gauge with the least number of lumens to manage the
patient's prescribed therapy.
Virchow’s Triad traditionally describes the 3 key components of clot formation: endothelial injury,
circulatory stasis, and hypercoagulable states.
Flow
Blood Flow
Flow Surface • Disturbed bloodflow
• Status of flow
Surface
• Foreign body (catheter)
– Thrombus (including platelets and fibrin) can accumulate
on the external catheter surface.
• Vascular wall (Endothelium)
– PICC can cause persistent irritation resulting in a
thrombus developing on a vein wall (DVT)
Blood
• Hypercoagulability of patient – varies by individual
• Disease state
• Individual genetics
• Lifestyle (diet, smoking, etc.)
FlowDVT may be reduced by improved selection of patients and catheter size.
Larger catheters have been found to have an increased risk of DVT.
• Disturbed bloodflow
• Status of flow
Surface SV•ThFoisre–cigThnharbopomtdebyru(scha(atinhscelitudedre)inngtipfilaetdeletthseanvdefiinbrsina) ncadn aacrcteumrieulsatteypically involved in PICC insertion. Venous and arterial
3F SLcharacotnetrhiseteicxtserananldcapthheytesriosulorfagcye.have also been discussed. Understanding the body’s vasculature and how it
4F DL•wVoarskc–sulPiasIrCweCasclsla(enEnnctdaiuoastlehfeoplierurmcsil)sitneinctiairrnitsatwionhroesiunltsinegrtinPaICCs. The next chapter will discuss the different vascular access
devicetshr(oVmAbDussd)eavenlodpihnogwontaovdeiencwidalle(DwVhTe) n each one should be used.
Blood
• Hypercoagulability of patient – varies by individual
• Disease state HF HIGH 4F
• Individual genetics
• Lifestyle (diet, smoking, etc.)
PICC MANUAL
20 BARD ACCESS SYSTEMS
References:
1. Scanlon V. C., Sanders T. Essentials of Anatomy and Physiology. 4th ed; 2003:278,548
2. Weinstein S., ed. Plumer’s Principles & Practice of Intravenous Therapy. 8th ed. Philadephia, Pennsylvania: Lippin-
cott Williams & Wilkins; 2007.
3. A lexander M., Corrigan A., Gorski L., Hankins J., Perucca R. Infusion Nursing: An Evidence Based Approach.
Infusion Nurses Society. 3rd edition; 2010:145-187
4. Josephson, D.L. Intravenous Infusion Therapy for Nurses Principles & Practice. 2004;134-136.
5. Ridgway, D.P. Introduction to Vascular Scanning: A Guide for the Complete Beginner. Introduction to Vascular
Technology. 2nd edition. 2001;35-38,146
6. Pieters, P.C., Tisnado J., Mauro M.A. Venous Catheters: A Practical Manual. 2002;85-86.
7. Bard Access Systems, Bard Access Systems Media Library.
8. A nstett, M., Royer, T.I. The Impact of Ultrasound on PICC Placement. The Journal of the Association of Vascular
Access Devices. 2003;8(3):24-28.
9. Ryder, M.A. Peripheral access options. Surgical Oncology Clinics of North America. 1995;4(3):395-427.
10. Bard Access Systems, Early Vascular Assessment Advantage Program.
11. Yacopetti N. Central venous catheter-related thrombosis: a systematic review. J Infus Nurs. 2008;31(4):241-248.
12. D ariushnia, S.R., Wallace, M., Siddiqi, N., et. al. Quality Improvement Guidelines for Central Venous Access. J
Vasc Interv Radiol. 2010;21(7):976-81
13. Josephson D.L. Intravenous Infusion Therapy for Nurses: Principles & Practice. Albany: Delmar; 1999.
14. W einstein, S.M. Plumer’s Principles & Practice of Intravenous Therapy. 6th ed. Lippincott-Raven Publishers: Phila-
delphia, Pennsylvania; 1997.
15. H all J., Guyton A. Human Physiology and Mechanisms of Disease. 6th ed. W.B. Saunders Company: Philadel-
phia, Pennsylvania; 1997.
16. Dougherty L., Lamb J. Intravenous Therapy in Nursing Practice. 2nd ed. Churchill Livingstone: London; 2002.
17. Ryder, M.A., Peripherally inserted central venous catheters. Nurs Clin North Am. 1993;28(4):937-71.
e 18. INS PICC Education Module, I.P. Module.
19. Z.M.G. Inc., Zygote Body & 3D Data. 2012; Available from: http://www.zygotebodycom/#nav=1.77,108.83,84.68
20. T he Structure of the Vein Wall (Illustration). www.masterfile.com Royalty-Free Invoice/License No. PMI-560-808.
Accessed September 15, 2014.
21. M oureau, N., Lamperti, M., Kelly, L., & Dawson, R. et al. Evidence-based consensus on the insertion of central
venous access devices: definition of minimal requirements for training. British Journal of Anesthesia. 2013; 1-10.
22. Marieb, E., Hoehn, K. Human Anatomy & Physiology 9th ed. Glenview, IL: Pearson Education Inc.; 2013.
23. G uideline Peripherally Inserted Central Venous Catheter (PICC). 2013. http://www.health.qld.gov.au/qhpolicy/
docs/gdl/qh-gdl-321-6-1.pdf
24. Registered Nurses' Association of Ontario Assessment and Device Selection for Vascular Access;2008.
25. Infusion Nurses Society, A.M., Infusion Nursing Standards of Practice. 1st Norwood, MA;2011.
26. Evans, R. S., J. H. Sharp, and L. H. Linford. Risk of Symptomatic DVT Associated with Peripherally Inserted Cen-
tral Catheters. J Vascular Surgery. 2011.
UNDERSTANDING VASCULAR ANATOMY
F SL 21
PICC MANUAL
22 BARD ACCESS SYSTEMS
Prior to inserting a PICC, it is important that clinicians understand and perform certain preparation
steps. These steps include evaluating the patient, his/her medical history, and his/her vascular
condition; educating the patient about the medical care and treatment; obtaining a physician’s order
and informed consent; complying with requirements for a maximal sterile barrier (MSB) to mitigate the
risks for infection; and verifying through a “time-out” that the correct data is on file and the procedure
is still the appropriate thing to do. This chapter will discuss all of these preparation steps.
• Identify required elements of informed consent.
• Understand patient and vessel assessment required for PICC insertion.
• Understand how to educate patients and caregivers about PICC insertion.
• U nderstand measurement techniques related to PICC insertion.
• Identify universal precautions, sterile technique, and maximum barrier precautions pertaining to
PICC insertion.
• Discuss patient verification and universal time-out.
PREPARING FOR PICC INSERTION
23
This section is intended to provide a general overview of basic techniques and procedures, and does
not replace clinical training or judgement. Users should refer to product Instructions for Use, manufacturers’
indications and/or contraindications for any device as well as applicable facility protocols.
A patient’s right to informed consent includes knowing and understanding what health-care treatment is
being undertaken.
Clinical elements of informed consent [10]
• The patient’s diagnosis and name of the treatment, procedure, or medication.
• An explanation of the treatment, procedure, medication, and intended purpose.
• The hoped-for benefits of the proposed regiment (with no guarantee as to the outcome).
• The material risks, if any, of the treatment, procedure, or medication.
• Alternative treatments, if any.
• The prognosis if the recommended care, procedure, or medication is refused.
Documentation of informed consent [8,10]
The manner most often used to denote informed consent is the consent form. The consent form is used as a
supplement to the dialogue required between the patient and the health-care provider in obtaining consent.
Once informed consent is given and the form is signed, the consent is typically valid unless or until it is
retracted by the patient or a change in condition renders the informed consent invalid.
The health-care provider shall confirm that the patient’s informed consent was obtained for the defined
procedure as identified in facility protocols and/or practice guidelines and in accordance with local,
state, and federal regulations.
The health-care provider should ensure that informed consent includes, among other requirements, the
following elements:
--Documents written at or below the 5th-grade reading level and provided in the primary
language of the patient.
--Provision of a qualified medical interpreter or reader to assist patients with limited language
proficiency, limited health literacy, and visual or hearing impairments.
--Patient-centered information that is adequate and meaningful to the individual.
--A dialogue with the patient and, as appropriate, the family or other decision makers about the nature
and scope of the procedure.
Who obtains consent [10]
The physician is the one who has the primary duty to obtain the informed consent of the patient for medical
care and treatment. Other independent health-care providers, such as nurse anesthetists or surgeons,
are responsible for obtaining informed consent for their particular procedures. For procedures performed
by a nurse, the nurse would be the appropriate provider to obtain the consent. Refer to your own facility’s
policies with respect to obtaining informed consent.
PICC MANUAL
24 BARD ACCESS SYSTEMS
After a physician order and consent are obtained, assessment of the patient should be performed. This
may include reviewing the patient history, diagnosis, renal function, infusates, and duration of therapy.
These factors may determine if the patient is suitable for PICC placement.
Patient Assessment [1,2,3,5,7,8,12]
Thorough pre-insertion patient assessment should include, but is not limited to, the following:
• Obtain and review the physician order for the PICC.
• Verify the patient’s identity using two independent identifiers. (For more information on this refer to
section entitled “Verification and Time-Out.”)
• Medical diagnosis and prognosis.
• P atient condition, such as medication profile, coagulation status, and renal function.
N ote: In patients with CKD stage 4 or 5, forearm and upper-arm veins suitable for placement of VADs should not be used for
venipuncture or for placement of intravenous (IV) catheters, subclavian catheters, or PICCs.
• Past medical/surgical history.
• Co-morbidities, such as diabetes, steroid use, edema, lymphedema, vein harvesting, intravenous stent
placement, and the presence of other devices, such as defibrillators or pacemakers.
• Relevant radiographic studies, including a recent frontal-chest radiograph, provide valuable information
concerning existing intrathoracic devices (e.g., pacemaker, automatic internal cardiac defibrillator
(AICD), CVC, presence of intrathoracic mass, etc.), as well as in the determination of appropriate
catheter length for achieving optimal catheter-tip position. Venogram studies, computed tomography
(CT), and magnetic resonance imaging (MRI) may provide valuable information concerning aberrant
vascular anatomy and/or vascular thrombosis/stenosis.
N ote: The presence of a pacemaker requires careful evaluation and thorough assessment to select the appropriate catheter and
insertion site. The contralateral side is preferred for placement of a central vascular access device (CVAD), but if the ipsilateral
side is selected, a PICC may be the safest choice.
• Previous history of infusion therapy (peripheral or central), including devices,
therapies, and outcomes.
• History of intravenous drug use.
• P atient age—older patients may experience diminished renal function and cardiovascular changes.
• Allergies.
• Type and duration of infusion therapy.
• Patient preference.
• Mentation (e.g., level of cooperation or mental status).
• H ydration status—dehydration may result in poor venous filling.
• Activity and/or mobility level (e.g., the use of crutches, walkers, or transfer aids).
• Language and/or cultural barriers.
PREPARING FOR PICC INSERTION
25
Vessel Assessment
The site chosen for inserting a PICC will depend on the patient’s vasculature. The skin surrounding
the intended insertion site should be visually assessed. Vessel assessment via ultrasound should be
performed when possible.
Insertion-site selection should include consideration of the following: [2,8,9,21]
• Vessel size (recommended size is 3 times that of the catheter).
• Vessel location and path.
• Vessel health.
• Vessel compression—veins should compress easily with light to moderate pressure and be nonpulsatile.
• Condition of the skin at the intended insertion site.
• Condition of the vasculature at the insertion site and proximal to the insertion site.
• Avoid areas of pain on palpation and veins that are compromised (e.g., bruised, infiltrated, phlebitis,
sclerosed, or corded).
• Circulatory status (e.g., impaired circulation, lymphedema, post-operative swelling).
N ote: Veins in an upper extremity should be avoided on the side of breast surgery with axillary-node dissection, after radiation
therapy to that side, with lymphedema or the affected extremity from a cerebrovascular accident.
• An insertion site above the antecubital fossa to prevent mechanical irritation or kinking of the catheter
when the arm is in movement.
Patient and/or caregiver education should begin with an assessment of their baseline knowledge and include
expectations of placement, verification, potential complications, and care and maintenance of the PICC.
Education may include, but is not limited to the following:
• Expectations of the procedure for inserting a PICC and verifying its placement.
• Proper hand hygiene and aseptic technique to prevent infection.
• How to care for and maintain the PICC, including flushing and dressing changes.
• How to safely store, maintain, and dispose of PICC supplies.
• Prevention and identification of potential complications.
• Prevention and identification of infection.
• How and when to report issues with the PICC.
• Limitations to and management of activities pertaining to activities of daily living with a PICC.
PICC MANUAL
26 BARD ACCESS SYSTEMS
Prior to PICC insertion, the patient should be in bed and lying flat, if possible, to facilitate the procedure.
Measuring the approximate length of catheter required can ensure the appropriate length catheter is selected.
• Perform hand hygiene per facility protocol.
• T he patient should be positioned supine with arm at a 90-degree angle, when possible, to assist with
accurate measurement and prevention of possible complications.
• Identify the proposed PICC-insertion site as determined by pre-insertion assessment.
• M easure the distance from the intended insertion site to the desired terminal tip location. When possible,
measure directly on the patient’s skin. In centimeters (cm) measure the path from the planned insertion
site, using the following external landmarks:
Measuring
[14] [14]
1 . M easure from the insertion site to the 3. Measure from the right clavicular head
axillary crease. to the right sternal border of the third
intercostal space.
2. Measure from the axillary crease to the Note: The external measurement can never
right clavicular head. This applies to both
right-and left-sided insertions. exactly duplicate the internal venous anatomy.
PREPARING FOR PICC INSERTION
27
For the clinician placing the PICC and for those assisting in the procedure, maximal barrier precautions
means strict compliance with hand hygiene and wearing cap, mask, sterile gown, sterile gloves, and
utilizing a maximum-barrier patient drape.
Hand hygiene [12,23]
Hand hygiene is a standard precaution and should be performed prior to contact
with the patient, whenever contamination occurs, and after the procedure.
Procedure [12,23]
1. Remove all jewelry and ensure sleeves are above the wrists.
2. Adjust water to a warm temperature.
3. Wet the hands thoroughly with water.
4. Follow the manufacturer’s directions for application of soap.
5. L ather soap and rub the hands together, including between fingers, palms, and
backs of hands.
6. Keep the hands lower than the elbows.
7. Wash the hands for at least 15 seconds.
8. Rinse the hands to remove all soap.
9. D ry the hands thoroughly with a disposable towel.
10. Use a disposable towel to turn the water off.
PICC MANUAL
28 BARD ACCESS SYSTEMS
Cap [12,15]
All personnel in the procedure room should cover their head, even bald heads, and facial
hair, including sideburns and the nape of the neck.
The following should be considered:
• A clean, low-lint surgical head cover or hood that confines all hair and covers the
scalp should be worn. The head cover or hood should be designed to minimize
microbial dispersion.
• Reusable head coverings should be laundered in a health-care-accredited laundry
facility after each daily use.
• A cap or hood should be put on before the gown to protect the garment from
contamination by hair.
Procedure [23]
1. Secure hair.
2. Put the cap over head.
3. Ensure all hair is inside the cap.
Mask [12,15,23]
A single-use mask should be worn during PICC insertion to protect the inserter from
sprays of blood and body fluids and to protect the patient from infectious agents carried
in the inserter’s mouth or nose.
Consider the following:
• The mask should cover the mouth and nose and allow pinching to secure it at the nose.
• T he mask should be tied securely above the ears and at the neck to prevent
contamination of the sterile field.
• A new mask should be worn for each procedure.
• Masks should be worn before and during the PICC procedure.
Procedure
1. Locate the top of the mask (usually has a metal strip along edge).
2. E nsure the mask is over the bridge of the nose and tie the top two strings above the
ears and at the back of head.
3. E nsure the mask is under the chin and tie the bottom two strings at the nape of the neck.
PREPARING FOR PICC INSERTION
29
Sterile Gown [14,15,16,23]
A sterile gown is worn to maintain sterility between the wearer and the sterile field.
The following points should be remembered:
• S terile gowns should be donned away from the sterile field.
• Sterile gowns should be sufficient in size to cover all of the clothing under the
gown. The front of the gown is considered sterile from the chest to the level of
the sterile field. Gown sleeves are considered sterile from 2 inches above the
elbow to the cuff.
• The neckline, shoulders, underarms, sleeve cuffs, and gown back are
considered nonsterile.
• S terile gloves must cover the cuffs of the gown completely to prevent
contamination of the sterile surface.
• The cuffs of the gown are considered contaminated.
• T he sleeves should be long enough so the cuffs cover the wrists.
• The sleeves should not be pulled up.
• S terile gowns should be fluid resistant to prevent blood and body fluids
from permeating.
Gowning Procedure [14,15,23]
The following is the procedure for donning a wrap-around, sterile surgical gown:
1. Pick up the gown from the sterile wrapper, touching only the inside
near the collar by the shoulders.
2. Locate the arm holes. With the gown away from you,
allow the gown to unfold.
3. With the arms at eye level, allow the arms to slip in
the sleeves but not through the cuff.
PICC MANUAL
30 BARD ACCESS SYSTEMS
4. A n assistant should be standing behind the wearer
to tie the gown at the waist.
5. The assistant shall tie the gown at the neckline.
6. After donning sterile gloves, the wearer should remove the
left short tie from the tag.
7. Holding the left tie, the tag should remain attached to the
right tie.
8. H and the tag with the right tie attached to it to the
assistant. The assistant will bring the tag with the tie
behind the wearer to their left. The wearer can then
pull the tie from the paper tag.
9. T he wearer then ties the long right tie to the short left tie
at the side of the gown.
PREPARING FOR PICC INSERTION
31
Gloving [14]
PICC insertion is an invasive procedure requiring sterile technique. After donning a sterile gown, the clinician
should apply sterile gloves. There are two techniques for sterile gloving, which include open and closed gloving.
Open-Gloving Technique [14,15]
Gowning for the open-gloving method is the same as it is for the closed-gloving method; the only difference is
that the scrubbed person extends the hands all the way through the cuffs and sleeves, leaving the hands totally
exposed outside the cuffs. This method is not recommended for the person establishing the sterile field, but is
helpful when changing a contaminated glove. Either hand can be gloved first.
The open-gloving method uses a skin-to-skin, glove-to-glove technique. The hand, although scrubbed, is not sterile
and must not contact the exterior of the sterile gloves. The folded cuff on the gloves exposes the inner surfaces. The
first glove is put on with the skin-to-skin technique, bare hand to inside cuff. The sterile fingers of that gloved hand
then may touch the sterile exterior of the second glove (i.e., glove-to-glove technique).
1. With the right or left hand, grasp the inner edge of the cuff of the
opposite glove and lift the glove from the wrapper. Take care not
to touch the inner aspect of the wrapper or the sterile exterior
portions of the glove.
2. Insert a hand into the glove, pulling the glove on and leaving the cuff
turned down well over the hand. Be sure to keep the thumb adducted
into the palm of the hand until it is well inside the confines of the glove.
Do not adjust the cuff; this will be done as a last step.
3. S lip the fingers of the sterile-gloved hand under the other everted
cuff on the sterile side of the glove. Pick up the glove and step back.
4. Align the fingers of the non-gloved hand and insert the hand into
the glove, keeping the thumb adducted until all fingers are well
inside the glove. Pull the glove on all the way, unfolding the cuff
and enclosing the knitted cuff at the wrist.
5. P ull the cuff of the other glove up and over the knitted cuff of the
sleeve. Avoid touching the bare wrist; sterile surfaces should touch
only sterile surfaces.
PICC MANUAL
32 BARD ACCESS SYSTEMS
Closed-Gloving Technique [14,15]
During the closed-gloving process the scrub person should keep his/her hands inside the
cuffs of the sterile gown. Either hand can be gloved first when establishing the sterile field.
1. If the gloves are still in the folded inner-paper wrapper, they
need to be opened. Using the cuff-covered hands, place
the wrapper in front of you like a book on a sterile surface.
Open the two sides. There is an inner fold to the glove
wrapper. With the two cuff-covered hands grasp the lower
inner corners of the bottom fold. Lift both corners open and
fold under at the same time. When this method is used, the
wrapper will remain open during the gloving process.
2. With the cuff-covered hand, pick up a glove from the inner
wrap of the glove package by grasping the glove fingers,
lifting the glove straight up, and placing the glove on the
palm thumb-side down. The glove fingers should be pointing
toward the body.
3. G rasp the edges of the glove cuff with the cuff-covered hand
and the opposite edge with the other hand. Peel the glove
over the cuff-covered hand and over the end of the sleeve and
wiggle the fingers to extend them into the glove-covered hand.
4. The cuff of the glove is now over the stockinette cuff of the
gown with the hand still inside the sleeve. Grasp the cuff of
the glove and underlying gown sleeve with the covered other
hand. Pull the glove on over the extended fingers until the
glove is completely on and the glove cuff completely covers
the stockinette cuff of the gown.
5. Reversing hands, glove the other hand in the same manner.
PREPARING FOR PICC INSERTION
33
Draping [14,15]
Draping is the procedure of covering the patient and surrounding areas to create a sterile barrier.
An effective barrier may eliminate the passage of microorganisms between nonsterile and sterile areas.
Drapes should be:
• Blood and fluid resistant to keep drapes dry and prevent migration of microorganisms between
nonsterile and sterile areas. Material should be impermeable to moist microbial penetration
(i.e., resistant to strike-through).
• R esistant to tearing, puncture, or abrasion that causes fiber breakdown and thus permits microbial penetration.
• Lint-free to reduce airborne contaminants and shedding onto the surgical site.
Fenestrated sheets [14,15,16]
The drape sheet has an opening (fenestration) that is placed to expose the anatomic area where the
insertion will be made. The size, direction, and shape of the fenestration vary to give adequate exposure
of the surgical site. Fenestrated sheets are usually marked to indicate the direction in which they should
be unfolded. This may be an arrow or label designating the top/head and bottom/foot.
Most fenestrated sheets are fan-folded toward the opening from the top and the bottom, and the folds are
rolled or fanned toward the center of the opening. The edges of the top and bottom folds of the sheet are
fanned to provide a cuff under which the scrubbed person may place his or her gloved hands. The top and
lower sections should be identified by markings to facilitate easy handling.
The following should be considered: [15,16]
• Place drapes on a dry area. The area around or under the patient may become damp from solutions
used in skin preparation. Remove damp items or cover the area to provide a dry field on which to lay
sterile drapes.
• Allow sufficient time to permit careful application.
• Allow sufficient space to observe sterile technique. Do not reach across a nonsterile surface.
• H andle sterile drapes as little as possible; movement of draping materials creates air currents through
which dust, lint, and other particles can migrate.
• Never reach across the bed to drape the opposite side.
• Hold sterile drapes above waist level until they are properly placed on the patient or device being
draped. If the end of a drape falls below waist level, it should not be retrieved because the area below
waist level is considered unsterile.
PICC MANUAL
34 BARD ACCESS SYSTEMS
• C arry folded drapes to the bed. Watch the front of the sterile gown; it may bulge and touch the
nonsterile bed. Stand well back from the nonsterile bed.
--Hold a drape high enough to avoid touching nonsterile areas.
--Hold a drape high until it is directly over the proper area and then lay it down where it is
to remain.
--O nce a sheet is placed, do not adjust it. Be careful not to slide the sheet out of place when
opening the folds.
--P rotect gloved hands by cuffing the end of the sheet over them. Do not let gloved hands touch
the skin of the patient.
--Control all parts of the drape at all times during placement, using precise and direct motions.
• When unfolding a sheet from the prepped area toward the foot or head of the bed, protect the
gloved hand by enclosing it in a turned-back cuff of a sheet provided for this purpose. Keep
hands at table level.
--Do not flip, fan, or shake drapes. Shaking a drape results in uncontrolled motion of the drape,
which may cause it to come into contact with an unsterile surface or object. A drape should be
carefully unfolded and allowed to fall gently into position by gravity.
• D rape the procedural area first and then the periphery. Always drape from a sterile area to an
unsterile area by draping the near side first.
• If a drape becomes contaminated, do not handle it further. Drop it and use another drape.
Discard it without contaminating gloves or other items.
--If the end of a sheet falls below waist level, do not handle it further. Drop it and use another sheet.
--If in doubt as to the sterility, consider a drape contaminated.
--If a drape is incorrectly placed, discard it.
• If a hole is found in the drape after it is laid down, the hole must be covered with another piece
of draping material. Use judgment in considering whether covering or discarding the drape is
appropriate. Discarding the drape is ideal if at all possible.
• A hair found on the drape must be removed and the area covered immediately.
Procedure for draping the patient: [17]
1. Remove full body fenestrated drape from the PICC-insertion kit.
2. D etermine whether the patient will need a left- or right-side placement. Remove the appropriate
liner to reveal the fenestration.
--For left-sided placements, remove the liner “LEFT.”
--For right-sided PICC placements, remove the liner “RIGHT.”
3. P lace the exposed fenestration securely on the patient’s arm over the
planned insertion site (press firmly to ensure adhesion to the arm).
4. Ensure the drape is properly aligned, that is, “Head” points to the
head of the bed and “Foot” points to the foot of bed.
5. U nfold the drape to each side of the patient.
6. U nfold the drape to the feet of the patient. Ensure that the drape
is fully extended, covering the patient’s feet.
7. Unfold the drape to cover the patient’s head.
8. If necessary, perforate the drape to reveal the patient’s head.
9. C ontinue preparation for the PICC insertion as determined by
hospital protocol.
PREPARING FOR PICC INSERTION
35
The purpose of pre-procedure verification is to correctly identify the patient and ensure the correct
procedure is being performed. The following points should be remembered:
• P rior to PICC insertion the patient should be identified using a minimum of two identifiers. Examples of
identifiers include the patients name, medical number, and date of birth.
• Relevant documents and information related to the PICC insertion should be:
--Available prior to starting the procedure.
--Labeled with the patient’s identifier.
--Reviewed prior to the procedure.
• A time-out should be performed immediately before starting the PICC insertion. The purpose of the time-
out is to conduct a final assessment on whether the correct patient, site, and procedure were identified.
• During the time-out, the team members should agree, at a minimum, on the following:
--Correct patient identity.
--Correct site.
--Procedure to be done.
• Document the completion of the time-out.
Note: The hospital determines the amount and type of documentation.
This chapter has discussed patients’ right to know what PICC insertion entails. Also discussed were
recommendations for both clinicians and patients on how to mitigate any complications, such as
insertion-related bloodstream infections. Finally, the chapter explained patient verification and time-out
so that clinicians can be sure the appropriate procedure is performed on the correct patient. The next
chapter will discuss PICC placement.
PICC MANUAL
36 BARD ACCESS SYSTEMS
References:
1. Infusion Nurses Society; Policies and Procedures for Infusion Nursing. J Infus Nurs. 4th ed.; 2011
2. Registered Nurses’ Association of Ontario. Assessment and Device Selection for Vascular Access. 2004.
3. N ational Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates:
Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis. 2006;244-245
4. E stimating GFR MDRD Study Equation. National Kidney Disease Education Program Web site. Updated January 10, 2015
5. Updates Clinical Practice Guidelines and Recommendations. National Kidney Foundation Web site. Updated 2015
6. Sansivero, G. Features and Selection of Vascular Access Devices. Seminars in Oncology Nursing. 2010; 26(2):88-101.
7. S antolucito, J.B. Optimizing PICC Tip Position: Technological Innovations and Advanced Practice Techniques. Association for
Vascular Access Scientific Meeting, San Jose, CA.; 2011.
8. Infusion Nursing Standards of Practice. J Infus Nurs. 2011;34(1):16-73
9. A lexander, M. A. Infusion Nursing: An Evidence Based Approach. Infusion Nurses Society. 3rd ed. Sauders Elsevier: St. Louis,
Missouri; 2010: 426,480-488
10. B rent, N.J. Nurses and the law: A Guide to Principles and Applications. 2nd ed. Philadelphia: W.B. Saunders; 2001:76-
77,206-213
11. Dougherty, L. J. Intravenous Therapy in Nursing Practice. 2nd ed., Churchill Livingstone: London; 2002.
12. P erioperative Standards and Recommended Practices: for inpatient and ambulatory settings. Denver, Colorado: AORN;
2012:62-88
13. 5 Million Lives Campaign, Getting Started Kit: Prevent Central Line Infections How-to-Guide. Cambridge, MA: Institute for
Healthcare Improvement; 2008. Available at www.ihi.org
14. Bard Access Systems, Media Library. Accessed September 1, 2014.
15. Phillips, N. Operating Room Technique. 12th ed. St. Louis, Mo.: Elsevier; 2013: 253-284, 510-521.
16. Rothrock, J. Alexander’s Care of the Patient in Surgery. 14th ed. St. Louis, Mo.: Mosby/Elsevier; 2011.
17. Bard Access Systems, Maximal Barrier Kit Drape Instructions for Use; 2008.
18. Bard Access Systems, PowerPICC SOLO® Instructions for Use; 2007.
19. Bard Access Systems, PICC Placement Instructions for Use with Sherlock 3CG™ Stylet Using Sherlock 3CG™.
20. T he Joint Commission. 2011-2012 National Patient Safety Goals. http://www.completehomecareservices.com/
uploads/2/7/0/8/2708795/2011-2012_nationalpatientsafetygoals.pdf
21. M oureau, N. Ultrasound Anatomy of Peripheral Veins and Ultrasound- Guided Venipunctrure. In: Sandrucci, S. Mussa, B., ed.
Peripherally Inserted Central Venous Catheters. Springer-Verlag Italia; 2014: 57.
22. Weinstein, S. Hagle, M. Plumer’s Principles & Practice of Infusion Therapy. 9th ed. Philadelphia: Wolters Kluwer; 2014.
23. P erry, A. Potter, P. Ostendorf, W. Clinical Nursing Skills & Techniques. 7th ed. St. Louis, Missouri: Mosby Elsevier; 2010.
24. O’Grady. Prevention, Guidelines for the prevention of intravascular catheter-related infections. U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention; 2011: 1-83.
PREPARING FOR PICC INSERTION
37
PICC MANUAL
38 BARD ACCESS SYSTEMS
There are different techniques and technologies for inserting a PICC. This chapter discusses the peel-
away sheath technique, modified Seldinger technique (MST), Seldinger technique, landmark approach,
ultrasound guidance, and magnetic tip tracking. Clinicians should be familiar with each of these, as
they have varying rates of success. This chapter provides the basic steps to insert a PICC using these
different techniques.
Understand techniques for PICC insertion including:
• Peel away and Break-Away Needle
• Modified Seldinger Technique
• Seldinger
• Landmark approach
• Ultrasound guidance
• Magnetic tip tracking
Understand PICC insertion procedures including:
• Basic
• Utilizing guidance
• Utilizing ECG
• Understanding different methods of inserting a PICC
INSERTING A PICC
39
This section is intended to provide a general overview of basic techniques and procedures, and does not
replace clinical training or judgement. Users should refer to product Instructions for Use as well as applicable
facility protocols. Manufacturers’ indications and/or contraindications for any device should be followed and
may vary per manufacturer.
Peel-Away Sheath Technique [7,21] Excalibur Needle
MST Kit
INDICATIONS: The Safety Excalibur™ Introducer is intended for access of peripheral
veins for the placement of PICC and Midline catheters.
The traditional peel-away cannula is similar to those of IV catheters with a
needle safety mechanism. The venipuncture is done in a visible or palpable
vein. The blood return is seen in the flashback chamber. The needle is
blunted as it is removed from the introducer catheter. The catheter is then
inserted and advanced and the introducer is removed.
Note: Not all peel-away cannula incorporate needle safety mechanisms.
Please consult product labels and inserts for any indications, contraindications,
hazards, warnings, precautions, and directions for use.
Modified Seldinger Technique (MST) [7,8,9,22]
This Microintroducer Kit is an introducer system designed for access of
peripheral veins using minimal insertion techniques for the placement of
PICC and Midline catheters.
Modified Seldinger Technique (MST), is a minimally invasive approach to
PICC placement. It has been shown to increase the likelihood of success,
particularly in target sites above the antecubital fossa. It also minimizes local
tissue and vessel trauma and the risk of artery or nerve injury. The essential
components of the micro-introducer technique include a needle, guidewire,
dilator-introducer sheath, and scalpel.
MST involves establishing initial venous access with a relatively small needle,
followed by guidewire insertion. The needle is removed and a small skin nick is
made to facilite insertion of the dilator/introducer sheath which is threaded over
the guidewire. The guidewire and dilator are then removed. Next, the catheter
is advanced through the introducer and the introducer is then removed.
Access can be established with a small bore peripheral IV cannula or the
micro-introducer needle.
PICC MANUAL
40 BARD ACCESS SYSTEMS
PEEL-AWAY SHEATH VS. MODIFIED
TECHNIQUE [8,10,21,26,33] SELDINGER
TECHNIQUE [8,11]
Conventional PICC introducer as large as 14 gauge.
Does not use a guidewire. A small needle is utilized to access a vein
May have a needle equipped with a self-activating regardless of the size of the catheter.
anti-stick mechanism. Utilizes a guidewire. It protects vessel patency.
Avoid sharp or acute angles during implantion The wire will not advance easily in a stenosed
that could compromise the patency of the catheter or thrombosed vessel.
lumen(s). Insertion of PICCs using the micro-introducer
A review of the literature shows insertion success technique may improve the practitioner’s
rates using the peel-away needle method to ability to access veins above the antecubital
range from 60-70% success rates (AVA Position fossa, particularly when paired with imaging
Statement 2011.) technology, such as ultrasound.
Same size access needle or IV cannula can
be utilized to insert catheter sizes 3 French
and larger.
Patients may find placement higher in the
arm more comfortable, allowing for full range
of motion.
Increased success rates of PICC insertion and
less venous trauma.
Avoid sharp or acute angles during implantion
that could compromise the patency of the
catheter lumen(s).
INSERTING A PICC
41
Seldinger Technique [9,8,22]
The Seldinger technique is a method of inserting a vascular-access catheter percutaneously into a
blood vessel. The vessel is accessed with a needle, and a guidewire is placed through the needle.
The needle is then removed, and a catheter is placed over the guidewire and advanced to the desired
location. The guidewire is then removed, leaving the catheter in place.
When utilizing the Seldinger technique for PICC insertion, observe the following precautions:
• Never advance a PICC over a wire that is shorter than the PICC. The wire should be at least 30 cm
longer than the PICC.
• Do not advance wire past the axilla without fluoroscopic guidance.
Landmark Approach[1]
• P uncture of a palpable vessel based upon anatomical structures.
• Does not require extensive additional equipment
• Limitations of this technique
-- P lacing VADs using anatomical landmarks can be problematic due to significant anatomic variation.
-- Puncture-related complications are higher overall using the landmark technique.
-- C omplications increase as the number of attempts increase.
Ultrasound technology utilizes a probe that transmits sound waves through the tissues. Depending on the
density of the tissue, fluid, or bone, sound waves are bounced back to the probe. These sound waves are
converted to an image displayed on the ultrasound screen. The denser the structure, the darker the image
viewed on the ultrasound screen. Veins and arteries can be identified.
Real-time ultrasound-guidance technique involves using ultrasound to guide a small gauged needle into
the selected vein. Veins can be accessed that cannot be felt or seen by the naked eye.
Ultrasound Guidance Technique Disadvantages [1,5]
• Initial capital investment
Advantages [1,4,5] • Disposable equipment is required
• Portable (assuming use of portable ultrasound machine) • Requires new hand-eye coordination
• P rovides real-time imaging of veins, arteries, needles, • Requires experience for proficiency
and wires
• Assess patency of the vessel
• D oppler mode on some machines may be used to assess
blood flow
• Decreases potential for arterial puncture
• Increases success on insertion
• Decreased trauma
• M ore patients are potential PICC candidates.
• Allows access to larger, deeper veins of the upper arms
• Fewer referrals to Interventional Radiology
• Decrease in mechanical phlebitis
• Increased patient satisfaction and comfort
• P rovides non-invasive, non-ionizing imaging, reducing
radiation exposure
3
PICC MANUAL
42 BARD ACCESS SYSTEMS
Terminology Applicable to Ultrasound [2,3,7]
The ultrasound wave emitted from a transducer.
Depth and Gain
Two basic functions to optimize image on the ultrasound screen. The gain should be adjusted until there is
a slight fill-in with echos or white flecks in the vein. The depth should be adjusted so that the view of the
target structures is maximized while allowing structures posterior to the target to also be seen.
Brightness/Contrast
Adjust brightness/contrast to assist with visualization in different environments.
Features
The standard ultrasound screen may display hash marks or dots that are placed at 0.5 cm intervals.
Using these markings, one can determine the depth of the image vessel from the skin surface.
Differentiating Veins from Arteries using Ultrasound [1,3,7]
Veins
Vein
Artery
Veins Arteries
• Applying pressure to the tissue under the Arteries may compress with pressure, but they
will generally pulsate with minimal compression.
transducer normally causes veins to compress.
• F luid-filled structures, such as veins, should
appear black or anechoic.
• A vein should compress easily. If it doesn’t
compress, compresses unevenly, or appears
opaque, it may be a sign of thrombosis.
INSERTING A PICC
43
Longitudinal View [7] Transverse View [7]
The transducer is parallel along the long axis of the vein to The transducer is perpendicular to the vein to facilitate
facilitate imaging of the device and guidewire advancement. imaging of the needle and guidewire as they enter the vein.
Advantages Advantages
• E ntire needle can be visualized as it advances and Better lateral resolution, which results in higher success rate.
enters the vein. Disadvantage
• Depth orientation is better with this approach. • Challenge of not losing sight of needle tip.
Disadvantages
• Poor lateral resolution.
• N eedle located just to the side of the vessel can
appear to be in the same plane.
INDICATIONS: Catheter stylets provide internal reinforcement to aid in catheter placement. The SherlockTM II TLS Stylet contains
passive magnets that generate a magnetic field. This field can be detected by the SherlockTM II TLS Detector to provide the placer rapid
feedback on catheter tip location.
The Sherlock™ II Tip Location System (TLS) detector quickly locates the position of specially designed, magnet-tipped Peripherally
inserted Central Catheters (PICCS) and Central Venous Catheters (CVCs) during and after initial placement. This device may be used
by appropriate caregivers in hospitals, long-term care facilities or home-care settings. The Sherlock™ II TLS detector provides rapid
feedback to the caregiver but was not designed to replace conventional methods of placement verification. Users are urged to confirm
correct placement according to their established facility protocol and clinical judgment.
Please consult product labels and inserts for any indications, contraindications, hazards, warnings, precautions, and directions for use.
Some catheter navigation systems use a stylet in the catheter that is magnetic, allowing it to be tracked externally by
a sensor. The navigation systems can be portable, hand held, battery operated, and provide audible and visual
indicators. Some devices may be compatible with or integrated into ultrasound systems. The navigation systems
provide real-time directional guidance of the catheter-tip as it is advanced, allowing the inserter to detect obvious
catheter malpositions. Navigation systems are generally unable to determine the exact location of the catheter-tip within
the anatomy and are not designed to replace conventional methods of verification.
To reduce potential interference with the magnetic tip-location equipment, cell phones, watches, pagers, name tags,
jewelry, and motor-driven equipment must be removed or placed at least 5 feet away from the patient.
PICC MANUAL
44 BARD ACCESS SYSTEMS
4a,b Preparing for insertion [7]
1. Perform hand hygiene per facility protocol.
2. Verify the patient’s identity using two independent identifiers. (refer to
section entitled “Verification and Time-Out.”)
3. Perform pre-procedural patient assessment, education, and consent per
facility protocol.
4. Gather supplies, which may include, but are not limited to, the following:
• PICC kit (verify package integrity and expiration date)
• Ultrasound machine and coupling gel
• N eedleguide kit (optional) and sterile ultrasound probe sheath and
coupling gel
• If not included in catheter kit:
--Extra antiseptic applicators
-- Catheter stabilization device
-- Catheter dressing
-- Sterile 4x4’s, 2x2’s and sterile surgical adhesive strips
-- Chlorhexidine-impregnated sponge as per facility protocol
-- Needleless connector and/or add-on device
--Sterile 10 mL syringes and preservative-free 0.9% sodium
chloride (USP)
--Intradermal anesthetic agent with sterile small-bore needle and syringe
-- D isposable tourniquet and tape measure
-- M aximal sterile barrier precautions: mask, sterile gown, cap, sterile
gloves, protective eyewear, and large full body drape
Note: Sterile non-latex, powder-free gloves
Patient positioning and measurement [7,12,16,20,27]
1. P lace the patient in recumbent position (as tolerated) and adjust the
appropriate arm to the proper position from the body at a 90-degree angle.
2. Use ultrasound to identify proposed PICC-insertion site.
3. Assess skin integrity at the potential insertion site and all vessels in the upper
arm for size, pathway, compressability, and proximity to artery and nerves.
4. M easure the distance from the intended insertion site to the desired
terminal tip location.
a. Insertion site to axillary crease.
b. A xillary crease to right clavicular head. Measure to the right clavicular
head for left or right-sided placements.
c. R ight clavicular head to the right sternal border of the third intercostal space.
Note: The external measurement can never exactly duplicate the internal venous anatomy.
5. C lose the door to the room and post “Sterile Procedure in Progress—
Do Not Enter.”
6. Apply ultrasound coupling gel to the acoustic window of the probe head
and place the probe in the designated area on the ultrasound machine.
Consult product labels and inserts for any indications, contraindications, hazards,
warnings, precautions, and instructions for use.
4c
INSERTING A PICC
45
Equipment setup and patient preparation
[7,9,12,13,14,15,16,19,20,22]
1. Perform hand hygiene per facility protocol.
2. Apply non-sterile prep gloves.
3. Disinfect the work area with antimicrobial solution and allow it
to dry completely.
4. Open the PICC kit outer package and place it on the bedside
table or work area.
5. P lace the absorbent drape under the patient’s arm and
shoulder area.
6. Loosely place a tourniquet under the area high on the upper
arm close to the axilla. The tourniquet can be tightened before
the patient is draped.
7. P repare the insertion site and surrounding skin with the skin
antiseptic applicator or according to institutional policy. If the
intended insertion site is visibly soiled, cleanse it with antiseptic
soap and water prior to application of antiseptic solution(s).
N ote: Chlorhexidine solution is preferred for skin antisepsis. One percent to two
percent tincture of iodine, iodophor (povidone-iodine), and 70% alcohol may also
be used. Chlorhexidine is not recommended for infants under 2 months of age.
a. If using a winged chlorhexidine gluconate applicator, pinch
the wings of the applicator to break the ampule and release
the antiseptic solution.
Note: Do not touch the sponge.
b. W et the sponge by repeatedly pressing and releasing the
sponge against the treatment area until fluid is visible on the
skin. Use repeated back-and-forth and up-and-down strokes
6 of the sponge for approximately 30 seconds. Completely wet
the treatment area with antiseptic.
c. A llow the area to dry completely. Do not blot or wipe away
the antiseptic.
d. If alcohol and/or betadine are used as skin prep, it must be
allowed to completely air dry before the insertion procedure
is started.
e. Antiseptic solutions in a single unit configuration shall be used.
8. A pply the tourniquet above the intended insertion site to
7 distend the vessel.
9. Remove and discard gloves.
10. Open wrapped sterile supplies by opening the wrapper flap
furthest away first to prevent contamination from passing an
unsterile arm over a sterile item. Next, open each of the side
flaps. The nearest wrapper flap should be opened last.
N ote: The sterile field should be prepared in the location in which it will be
used. Moving tables stirs air currents that can contaminate the sterile field.
Note: A sterile field should be maintained and monitored constantly.
Note: Sterile fields should not be covered.
8
PICC MANUAL
46 BARD ACCESS SYSTEMS
11. Don a sterile gown and gloves.
N ote: Prepare supplies on the sterile field in order of use. This allows the
inserter to have an organized approach with each step of the placement
procedure.
12. Drape the patient.
a. E nsure that the drape is properly aligned, that is,
“Head” pointing to the patient’s head and “Foot”
pointing to the patient’s feet.
11 b. D etermine whether the patient will need a left-or right-
sided placement. Remove the appropriate liner to reveal
the fenestration (for left-sided PICC placements, remove
the liner “LEFT,” and for right-sided PICC placements,
remove the liner “RIGHT”).
c. P lace the exposed fenestration securely on the patient’s
arm over the planned insertion site and just below the
level of the tourniquet. Press firmly to ensure adhesion
to the arm.
12b d. U nfold the drape to each side of the patient. The drape
should unfold over the patient’s chest, away from the
insertion site.
e. U nfold the drape to the feet of the patient. Ensure that
the drape is fully extended covering the patient’s feet.
f. Unfold the drape to cover the head of the patient. If
necessary, aseptically perforate the drape to reveal the
patient’s head.
12f 13. Prepare the ultrasound system probe.
a. P lace the probe cover over the probe head, being
careful not to wipe off the coupling gel.
b. Cover the probe and probe cable with the probe cover,
maintaining sterile technique.
c. Smooth the probe cover over the acoustic window of
the probe head to remove any air bubbles or folds in
the sheath.
13 d. Be sure no air is trapped between the ultrasound probe
and the skin, which can obstruct vessel visualization.
e. Secure the probe cover with provided fasteners.
13b
13d
INSERTING A PICC
47
14. D raw up anesthetic agent and 0.9% sodium chloride
(USP) in 10 mL syringes, maintaining sterile technique.
Label the syringes and place them on the field in ready to
use fashion with small-bore needle on anesthetic agent.
15. P re-flush all the lumens of the catheter with normal sterile
saline to wet the hydrophilic stylet. Follow the manufacturer’s
instructions for use and facility protocol.
Note: Follow manufacturer’s instructions for use to determine the catheter
14 length modification.
16. Trim the catheter.
a. M easure the distance from the zero mark on the catheter
to the pre-determined catheter measurement.
Note: Catheter markings are in centimeters.
b. Loosen the T-lock connector/stylet assembly.
Note: Ensure that all lumens of the catheter have been pre-flushed
with sterile normal saline to wet the hydrophilic stylet.
c. R etract the entire T-lock connector/stylet assembly as
one unit until the stylet is well behind the location where
15 the catheter is to be cut.
d. U sing a sterile scalpel or scissors, carefully cut the catheter.
Caution: The stylet or stiffening wire needs to be well behind the point
the catheter is to be cut. NEVER cut the stylet or stiffening wire.
Inspect the cut surface to ensure there is no loose material.
e. R e-advance the T-lock connector/stylet assembly
locking the connector to the catheter hub. Ensure the
stylet tip is intact.
16 f. G ently retract the stylet through the locked T-lock connector
16b until the stylet tip is contained inside the catheter.
g. A ssure proper alignment of the stylet to the distal end of
the trimmed catheter.
Caution: Follow manufacturer’s instructions for use and facility policy
when modifying catheter length.
N ote: Prior to catheter insertion, ensure that the stylet tip is contained
inside and within the catheter but not more than 1 cm from the
trimmed end of the catheter. Failure to do so could result in degraded
magnetic navigation.
W arning: Ensure that the stylet tip does not extend beyond the trimmed
end of the catheter. Extension of the stylet tip beyond the catheter end,
combined with kinking and excessive forces, may result in vessel
damage, stylet damage, difficult removal, stylet tip separation, potential
embolism and risk of patient injury.
16g
PICC MANUAL
48 BARD ACCESS SYSTEMS
Catheter Insertion [7,9,12,13,16,21,24,25]
1. C onduct a time-out immediately before starting the invasive
procedure. During the time-out, the team members should
agree, at a minimum, on the following:
a. Correct patient identity,
b. Correct site,
c. Correct procedure to be done (Refer to section entitled
1 “Patient Verification and Time-Out”).
2. A pply a layer of sterile coupling gel to the covered acoustic
window of the ultrasound probe.
3. Using ultrasound, locate the target vessel, as well as an
adjacent artery and nerve. Center the dot markers on
the target vessel. The dot markers are displayed on the
ultrasound screen.
4. Optional: choose the appropriate needle guide based on
the needle gauge and the depth of the target structure.
4 a. E nsure that a sterile probe cover has been placed over
the probe.
b. Clip the short end of the needle guide to the end of the
needle guide hook closest to the top of the probe.
c. Push the larger end of the needle guide toward the probe
until the needle guide snaps onto the needle guide hook.
Do not slide.
C aution: Always snap the needle guide on to the needle guide hook.
Do not slide the needle guide on to the needle guide hook, as the
sterile sheath may tear.
4e d. S lide the appropriately sized needle, beveled edge facing
the probe, into the channel on the guide.
e. P lace the probe against the skin, perpendicular to the
target structure.
f. H old the probe so that the needle guide points away from
the heart.
g. Center the dot markers on the target vessel.
5. Administer local anesthetic at the intended venipuncture site
while keeping the dot markers centered on the target vessel.
5 6. W hile keeping the dot markers centered on the target vessel,
slowly advance the needle while looking at the ultrasound
screen. When the needle approaches the target vessel, you
should see the anterior wall indenting.
6
INSERTING A PICC
49
7. Once venipuncture occurs, the vessel returns to it’s normal shape.
8. Observe venous blood return.
9. H old the needle and gently rock the probe away from the
needle for a smooth separation. The needle guide channel
should open, and the needle should smoothly disengage from
the guide.
10. R emove the guidewire tip protector from the guidewire hoop
7 and insert the flexible end of the guidewire into the introducer
needle or catheter and into the vein. Advance the guidewire to
the desired depth.
Caution: Do not advance the guidewire past the axilla without fluoroscopic
guidance or other tip location methods. Do not advance the guidewire
against resistance.
11. Gently withdraw and remove the introducer needle or catheter
while holding the guidewire in position.
C aution: If the guidewire must be withdrawn while the needle is inserted,
remove both the needle and wire as a unit to prevent the needle from
damaging or shearing the guidewire.
10 12. Remove the tourniquet.
13. A dvance the dilator and introducer sheath together as a unit
over the guidewire, using a slight rotational motion. If necessary,
a small incision may be made adjacent to the guidewire to
facilitate insertion of the dilator and introducer sheath.
Note: Verify facility guidelines concerning the use of a scalpel prior to making
incision. To avoid potential damage to the vessel and guidewire, the scalpel
blade should be bevel side-up.
W arning: To avoid guidewire embolism, maintain control and position of the
guidewire at all times.
11 14. Remove the guidewire and dilator from the introducer sheath
and per the manufacturer’s instructions for use and facility
policy. Withdraw the dilator and guidewire, leaving the
introducer sheath in place.
Warning: Place a finger over the orifice of the sheath to minimize blood loss and
risk of air aspiration. The risk of air embolism is reduced by performing this part
of the procedure with the patient performing the Valsalva maneuver.
13
14
PICC MANUAL
50 BARD ACCESS SYSTEMS
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