What is a PICC?
Peripherally inserted central catheters (PICC) are catheters that consist of a small catheter that is inserted into a vein in the upper arm. They come in single, double, and triple lumens and various lengths. PICC’s can be used for short-term venous access and for patients who require venous access for several weeks to months due to their low infection rates. The catheter allows medications, nutritional fluids, and blood products to be delivered directly into the bloodstream.
PICC’s are inserted through a peripheral vein with tip residing in superior vena cava (SVC). These catheters are inserted using a sterile technique. This means that they will take precautions to prevent germs from entering the body.
The basilic, medium antecubital, or cephalic vein may be assessed. The basilic vein above the antecubital fossa is the preferred site due to its larger size and superficial location. It has the straightest route to its destination, as it courses through the axillary vein then through the subclavian, and finally settles in the SVC.
Modified Seldinger Technique
The Modified Seldinger Technique (MST) is a minimally invasive technique in which the practitioner accesses the target vessel with a small-gauge needle. The introduction of the modified seldinger technique improves catheter insertion success rates; when coupled with real-time ultrasound guided for vessel identification, MST increases success rates even further. It is the best practice and the standard method of insertion of PICC lines.
Directions for Modified Seldinger Technique Insertion
Prior to Placement
Identify insertion site and vein, considering the following variables:
- Patient Diagnosis
- Age & Size of Patient
- Unusual Anatomical Variables
Pre-flush the catheter, side port adapter, and needleless access ports.
1) Attach saline filled syringe to luer of side port adapter and flush adapter and catheter. Clamp side port extension and remove syringe. If using a double lumen catheter, attach needleless access port to remaining extension. Attach saline filled syringe to the needleless access port and completely flush catheter lumen. Remove syringe from needleless access port prior to clamping extension.
2) Strict aseptic technique must be used during insertion, maintenance, and catheter removal procedures. Provide a sterile operative field. Use sterile drapes, instruments, and accessories. Preform skin antisepsis following the manufactures instructions for use. Wear gown, cap, gloves, and mask.
3) Apply tourniquet to arm above anticipated insertion site to distend the vein.
4) Insert the introducer needle with attached syringe into the target vein. Aspirate to insure proper placement. Release tourniquet.
5) Remove the syringe and place thumb over the end of the needle to prevent blood loss or air embolism. Draw the flexible end of marked .018” guidewire back into the advancer’s distal end into the needle hub. Advance guidewire with forward motion into and past the needle hub into the vein target vein.
6) Remove needle, leaving guidewire in the target vein. Thread sheath/dilator over the proximal end of the guidewire into target vein.
7) Loosen locking collar of side port and withdraw stylet back beyond the point where the catheter is to be trimmed by at least ¼ inch (1 cm).
8) Once proper catheter length and stylet position has been achieved, tighten locking collar to keep stylet in place.
9) Remove dilator from sheath.
10) Insert distal tip of catheter into and through the sheath until catheter tip is correctly positioned in the target vein.
11) Remove the tear-away sheath by slowly pulling it out of the vessel while simultaneously splitting the sheath by grasping the tabs and pulling them apart (a slight twisting motion may be helpful).
12) The distal tip should be positioned at the level of the caval atrial junction.
13) Remove side port adapter and replace with needleless access port. Attach saline filled syringe to needleless access port, aspirate lumen and then irrigate with saline. Remove syringe prior to clamping extension.
14) Attach syringe(s) to extension(s) and open clamp(s). Blood should aspirate easily. If excessive resistance to blood aspiration is experienced, the catheter may need to be repositioned to obtain adequate flow.
15) Once adequate aspiration has been achieved, lumen(s) should be irrigated with saline filled syringe(s), clamp(s) should be open for this procedure.
16) Remove the syringe(s) and close extension clamp(s). Avoid air embolism by keeping catheter tubing always clamped when not in use and by aspirating then irrigating the catheter with saline prior to each use. With each change in tubing connections, purge air from the catheter and all connecting tubes and caps.
17) Confirm and document proper tip placement. The distal tip should be positioned at the level of the caval atrial junction.
18) Cover the exit site according to the facility policy.
19) Record catheter length, catheter lot number, and tip position on patient’s chart.
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Goodwin ML. The Seldinger Method for PICC Insertion. J Intraven Nurs. 1989: 12:238-43.
Gonzalez R, Cassaro S. Percutaneous Central Catheter. [Updated 2021 Sep 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459338/
Gorski LA, Hadaway L, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(suppl 1):S1S2-S224. Doi:10.1097/NAN.0000000000000396