The State of the Art of

PICC Insertion

Ton van Boxtel

Disclosure
• Nothing to disclose
Many different Patients
 PICC insertion ‘old style’
• ‘Blind’ in the ante-cubital veins
• Clinician without proper training
• Unknown catheter-vein ratio
• In the cephalic vein as preferred vein
• Fixation with stitches
 Change of Practice
• From Drum catheter to polyurethane
powerinjectable PICC

• Almost all studies published in 2006 and before, use

data without using ultrasound for insertion
The Risk of Bloodstream Infection in Adults With Different
Intravascular Devices: A Systematic Review of 200 Published
Prospective Studies

Maki et all, Mayo Clinic proceedings, Sept

2006, 81, 9, 1159–1171
 VAD selection Non Acute Treatment in Adults

UMC Utrecht, 2009

Vascular Access Devices

MAGIC paper, Chopra et al, 2015

MAGIC paper, Chopra et al, 2015
 A classical approach

© UZ Leuven
Venous catheters
DRUGS/TREATMENT Non-irritant Irritant, vesicant

TIP POSITION Peripheral Central

TREAMENT DURATION < 2 weeks 2-4 weeks ≤ 4 weeks 4w–6m Months to years

Peripheral
CATHETER TYPE Midline Non-tunnelled CVC PICC Tunnelled catheter Implantable port
Cannula
© UZ Leuven © UZ Leuven © UZ Leuven © UZ Leuven © UZ Leuven

© UZ Leuven

AZ Leuven, Belgium
 SIP protocol
• Hand washing, aseptic technique and maximal barrier protection
• Bilateral US scan of all veins at arm and neck (RaCeVA)
• Choice of the appropriate vein at midarm (vein milimeter /cath. French)
• Clear identification of median nerve and brachial artery
• Ultrasound guided venipuncture
• US scan of IJV during introduction of the PICC
• EKG method for assessing tip position
• Securing the PICC with a sutureless device

SIP = Safe Implantation of PICC, GAVeCeLT, Assist Inferm Ric. 2014

 Some estimations for PICC’s
• USA ± 3 000 000
• China ± 1 500 000
• Italy ± 180 000
• Brazil ± 150 000
• UK ± 100 000
• France ± 50 000
• Scandinavia ± 15 000
• Switzerland ± 5000
• Netherlands ± 5000 -10 000
• Germany ± 5000
• ……………
 Trends in PICC
Some countries hardly do PICC,s
– Unknown
– Unwanted
• Do not want to see a PICC as a CVC
• Have not developed a structure for home infusion (yet)
– Still think a PICC is expensive when compared to other CVC‘s
• If you only calculate materials
US is the standard in VA
• Smaller
• Portable
• Easy to use
Consensus on use of Ultrasound for VA
 Ultrasound changed position PICC
• Less complications
– The ZIM, PICC insertion in the green zone
– First time access
– Vein catheter ratio
– More stable position on the arm
• Extended dwell time

Dawson, JAVA, 2011

 Skin disinfection
• Guidelines do recommend skin
preparation prior to insertion of
VAD’s but not how to apply
Tip positioning
Carina as a landmark

Br J Anaesth. 2006;96(3):335-340
Tip positioning
 ECG technique: CVC tip location

1998: NAVAN: lower one-third of the SVC, close to the

junction of the SVC and the right atrium
2007: EPIC: SVC
2009: ESPEN: cavo-atrial region or right atrium
2010: RCN: lower third SVC or right atrium
SIR: cavo-atrial region or right atrium
ASPEN: SVC adjacent to the right atrium
2016: INS: lower third of the SVC or the CAJ
With Courtesy, Pittiruti
ECG tip positioning
British Journal of Anesthesia
 PICC Insertion
• The interventional radiologist with fluoroscopy
• Technician using fluoroscopy
• VA nurse in a dedicated room
• VA nurse at the bedside
 Fluoroscopy
• Reliable and high success rate
• Anxiety, planning and patient transport
• Expensive compared to bedside
 Average time to insert a PICC
• 10.1 ± 0.9 min
Rotzinger, Gebauer, et all. Acta Radiol. 2017, 58(12):1468-1475

• 33.93 minutes with tip navigation / ECG

• 176.32 minutes Blind / CXR
Tomazewski, Ferko, et all. 2017
Nurse-Led PICC insertion: is it cost effective?

• Radiology 42% higher cost than PICC inserted by nurses

(p<0.01)

Graham Walker and Alistair Todd

British Journal of Nursing 2013 22:Sup19, S9-S15
 Nurse-Led PICC insertion: is it cost effective?

• Nurses insert PICC at bedside

• Less expensive
• Patients satisfaction
– Easier planning
– Less patient transport
– Immediate use of the PICC after ECG confirmed insertion
Cost US PICC’s

Catholic University, Rome, Italy 2012

 Of label PICC
• Jugular (peripheral)
• Axillary vein
• Femoral vein
• Tunneled to the thorax
• Brachiocephalic vein (neonates)

State of the Art of the future??

Glue
 Sutureless stabilization devices
• Winged adhesives
• Subcuteneous stabilization device
 Take Home Messages
• PICC is a cost-effective and reliable CVC
• Insertion of PICC can be done safely at bedside
• Small size US and ECG tip postioning brings PICC /CVC outside
the hospital
– Home infusion
– Alternative settings
 Conclusion
• Patients that need a CVAD for in hospital use and home
therapy for ± 4 week – 6 month are best indicated for a PICC
inserted at the bedside or a dedicated room