Introduction:

• PICC line is a thin, soft, long catheter, that is inserted into peripheral vein and tip in positioned in superior vena cava where it drains into right atrium.
• PICC lines are useful for patients who require frequent
  • Withdrawal of blood
  • Administration of blood products
  • Parenteral nutrition
  • Infusional therapy- Chemotherapy, antibiotics etc.
• Chemoports are not used in hematology patients, as there is high risk of infection, thrombosis and bleeding. Port has selfsealing septum which can withstand up to 2000 needle punctures.
• Tunneled catheter (Hickman lines)- Inserted using seldinger technique under USG guidance. Dacron cuff near the exit site anchors the line in place. They allow administration of high volume infusions.

Uses:

• Total parenteral nutrition
• Fluid and electrolyte replacement
• Administration of medications/ chemotherapies (Especially for irritant medications)
• Blood sampling and administration of blood products`

Types of PICC lines available:

• Open ended: 
  • Require clamping to reduce likelyhood of blood backtracking down the line when not in use.
  • Line flushing is required once a week with heparinised saline
• Groshong PICC lines
  • Has pressure acticated three position valve at the end of the line which blows out during drug administration and sucks in when drawing blood and remains in neutral position preventing blood backtracking when not in use.
  • Line needs to be flushed once a week with NS

Brands of PICC lines available:

• Groshong NXT ClearVue
• Cook PICC with clamps
• BioFlo PICC
• Vascu-PICC
• Xcela PICC
• Vaxcel PICC

Advantages:

• Minimizes physical and psychological discomforts of repeated venipunctures
• Decreases risk of
  • Venous thrombosis
  • Phlebitis
  • Extravasation injury
• Maintains patient mobility
• Minimizes hospital stays
• Can be kept for 6 months to 12 months

Disadvantages:

• Visible outside and there is risk of pulling out
• Needs weekly dressing
• Difficulty in taking bath
• Sampling is difficult

Timing of insertion

• Prior to chemotherapy, before patient develops neutropenia/ thrombocytopenia

General requirements:

• Only competent staff must insert PICC line
• Choose catheter type and size.
• Take informed consent
• Documentation of procedure must include date of insertion, type of catheter used etc.
• After the procedure catheter tip position must be confirmed by doing chest X ray. Most appropriate position location is lower 1/3^rd of superior vena cava.

Contraindications for PICC line insertion

• Ipsilateral local cellulitis
• Thrombophlebitis
• Conditions affecting venous return such as lymphedema
• Hypercoagulable states
• Patients with renal failure, in whom AV fistula is being planned.
• Pralysed limb

Things needed for PICC line insertion:

• Consent
• Long drape-3
• Surgeon gown-1
• Hole towel- 1
• Torniquet-1
• Gauze piece- 6
• Betadine solution- 1
•  Surgical blade- 1
• Suture reverse cut (3-0)-1
• Needle- 26G- 3
• Inj. Lignocaine- 2%- 1
• Sterile gloves- 7.5- 3
• Normal saline- 100ml- 1
• Syringe- 5cc- 3
• Syringe- 10cc—3
• Needle 18G-3
• Needle- 23G- 3
• Tegaderm- 10X12cm- 1
• Inj. Heparin- 5000IU- 1 or Hepalock/ Cathflush- 3
• PICC Line- 5 French- 1
• Request for Chest X ray- AP

Procedure

• Both operator and assistant must wear cap, sterile gown, sterile gloves, surgical mask and protective eye wear.
• If excessive hairs are present at insertion site they must be removed using clippers. This improves adherence of dressing.
• Clean the insertion site and surrounding skin with chlorhexidine/ povidine-iodine and isopropyl alcohol.
• Drape entire upper body and arm of the patient, leaving small opening ininsertion site.
• Under ultrasound guidance, catheter is inserted 1-2 inches above the anterior cubital fossa into basilic or cephalic vein.
• Advance it into superior venacava
• Secure the catheter using sutures or sutureless fixation device

Care of PICC Line:

• Apply sterilium to hands and wear sterile gloves prior to touching line for any purpose. 
• Use 70% alcohol swab prior to accessing catheter 
• Keep caps and connectors in a small spirit bottle. 
• Line dressing should be done every week and date should be written on dressing. 
• Prior and after infusion or collecting blood for investigations, flush the line with 5ml Normal saline/ Cathflush/ Hepalock/Diluted Heparin (Mix 0.1ml- Heparin (5000IU in 10ml) with 10ml distilled water). Flush in a pulsatile motion. (5mlX2) 
• First clamp and then withdraw the syringe. 
• Dressing must never be immersed in water. Teach patient to use polythene cover while taking bath. 
• Inspect insertion site everyday for erythema, exudates, tenderness, redness, swelling and suture integrity 
• Do not use syringes larger than 10ml to avoid excess pressure and catheter rupture. 

Complications:

• Infections- Catheter related blood stream infections
• Complications of insertion
• Thrombosis/ phlebitis
• Hemorrhage
• Catheter fracture and embolization
• Air embolism

Catheter associated blood stream infection (CLABSI)

• It is bacteremia/ fungemia in a patient with intravascular catheter with more than 1 positive blood culture obtained from a peripheral vein with clinical manifestation of infection. (i.e. fever/ chills/ hypotension) and no apparent source of blood stream infection, other than catheter.
• Incidence- 5/1000 patient days
• Mortality rate- 3-25%
• Common organisms include- Coagulase negative staphylococci, staphylococcus aureus, enterococcus, candida
• Routes of infection
  • Migration of skin organisms at the insertion site into cutaneous catheter tract
  • Contamination of catheter hub leading to intraluminal colonization
  • Hematological seedling of catheter from infections at other sites
  • Infusate contamination
• Diagnosis
  • Send paired samples from PICC line and peripheral vein prior to starting antibiotics.
• Differential time to positivity- >120min of qualitative blood cultures suggests PICC line infection
• Clinical features
  • Fever, chills, hypotension, sepsis, shock
  • Exit site reaction
  • Resolution of fever after removal of line
• Measures for prevention
  • Education and training of healthcare workers for insertion and maintenance of CVCs
  • CVCs made from teflon , silicon or polyurethane are better than PVC as they are resistant to adhesion of microorganisms.
  • Cuffed and tunneled CVCsare better 
  • Subclavian site is better than lower limbs 
  • Full aseptic precautions while inserting CVCs (Hand hygiene, full barrier precautions, skin cleansing with chlorhexidine, avoid femoral site)
  • One port should be designated exclusively for hyper elimination, if multi lumen catheter is used
  • Regular dressing every 7 days
  • Catheter site must be monitored usually and by palpation
  • Catheter that are not in use must be removed promptly

Indications for removal of line:

• Infection with staph aureus (except coagulase negative), Pseudomonas aeruginosa, fungi, mycobacteria
• Tunnel/ port pocket infection
• Septic thrombosis
• Endocarditis
• Sepsis with hemodynamic instability
• Blood stream infection that persists despite >72hrs therapy with appropriate antibiotics

Send tip culture after removal of PICC line and continue antibiotics for total of 14 days.

For others: Systemic antibiotics should be given for at least 14 days

Blocked line:

• Prime each lumen with 1.5-3ml urokinase (diluted to 5000IU/ml)
• Leave in situ for 2-4hrs
• Try to aspirate
• If recanalized, flush with 10-20ml NS