PICC stands for "peripherally inserted central catheter." This intravenous catheter is inserted through the skin, into a vein in the arm, in the region above the elbow and below the shoulder. This is a peripheral insertion. The catheter is a long, thin tube that is advanced into the body in the veins until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart. This tube may have one or two openings, called lumens, that are used to deliver medication.

The purpose of the PICC insertion procedure is to provide medicinal therapy and fluids through an intravenous catheter.

A PICC must be ordered by your primary physician or surgeon or their consulting colleague.

The benefit of a PICC is that the catheter can remain for a long period, typically two to six weeks, over which a course of medication such as antibiotics can be delivered. The PICC can also be used for short intervals in a patient with difficult vein access. In some instances a PICC is used.

Typical intravenous (IV) therapies administered through a PICC include:

*Antibiotics

*Total parenteral nutrition (vitamins, minerals, electrolytes, proteins, carbohydrates, etc.)

*Blood products

*Chemotherapy

The patient is advised to lie on their back on a procedure table with the arm chosen for insertion resting on an arm board support. A tourniquet is placed around the arm just below the shoulder. The vein for the PICC access is selected using ultrasound. Under sterile conditions, lidocaine 1%, a common local anesthetic, is injected at the skin surface. Local anesthesia may sting or burn for a few seconds but after that becomes numb, so only a pressure sensation is felt when the PICC is being inserted.

Under ultrasound guidance, a thin needle is used to enter the vein. A thin safety guidewire with a floppy safety tip is inserted through the needle, into the vein, and the tourniquet is loosened. The needle is then removed and the catheter is advanced through the vein over the guide wire to the superior vena cava. The indwelling guide wire is removed and an injection cap is attached to the catheter hub.

The catheter is tested for blood return and then flushed with sterile, normal saline. The catheter is secured at the entry site with an attachment wing and a chlorhexidine impregnated, clear dressing is applied over that.

Prior to the procedure, information on medications like anticoagulant therapies such as Coumadin or Heparin is required. A blood test to check for potential bleeding complications may be requested.

A key contraindication is that patients on anticoagulant therapy who have an INR blood test result greater than 2.0 cannot undergo the procedure. In addition, certain conditions may affect which veins are safe for the insertion site.

An upper extremity vein cannot be used for a PICC insertion if there is a history of any of the following in the region of that upper extremity:

*major shoulder surgery

*vascular surgery

*radiation therapy

*venous thrombosis

*axillary lymph node dissection

Similarly, a vein should not be used for a PICC insertion in any place on the body where the skin has a local dermatitis, cellulitis, burn injury, abscess or infection.

Although rare, the risks associated with the PICC line procedure can include infection, bleeding, blood clot, increased venous thrombosis, pulmonary embolus, breakage of instrumentation during the procedure.

Introduction of infection: Risk is low (approximately 2%).

Bleeding: Risk is usually minimal and very easy to control.

Clotting of blood in the vein around the catheter or at the wall of the vein: Risk is approximately 20% to 40% of the time but is usually so minimal that it is not clinically evident or significant.

Increased venous thrombosis: Risk is extremely rare.

Pulmonary embolus: Risk is not common.

Allergic reactions to the local anesthetic, latex, sterile preparation solutions, flushing solutions or (rarely used) iodinated contrast agents: Risk is uncommon and patients are questioned about allergies prior to the procedure. Appropriate precautions are then taken.

Breakage of materials such as guide wire or catheters during the procedure: Risk is extremely rare.

Pain can be expected during the injection of the local anesthetic and discomfort, or pain, may occur related to table positioning during the procedure. Adherence of the catheter within the venous system at the time of removal can occur when the catheter has been in dwelling for a long periods of time, although this is a rare occurrence

Mild soreness can be expected at the entry site for one to two days after the procedure. There may be bleeding at the entry site, especially on the first or second day. If the gauze becomes soaked with blood, a nurse should be told to change the dressing. It is important to keep the dressing and the external tubing dry. If showering, cover the dressing and external tubing with a waterproof material, such as plastic wrap secured with tape or a commercially available waterproof cast cover. Do not submerge the entry site under water. If the dressing gets wet, have a nurse change it as soon as possible.