Percutaneous Central Catheter (Central Line Placement)

Overview of Percutaneous Central Catheter

Having access to a patient’s veins is crucial in both hospital and outpatient settings. This allows doctors to carry out a wide range of essential tests and treatments. For very ill patients, it can be needed for regular blood tests, the delivery of certain strong medications, quick fluid replacement, lengthy periods of antibiotic use, and more. Doctors gain this access to veins through several methods, including normal IV lines, midline catheters and central venous catheters (CVCs).

Peripherally inserted central catheters, also known as PICCs, are a type of central venous catheter. They are long, tube-like medical devices, inserted into an arm vein and positioned until its end reaches the chest area. PICCs can be single, double, or triple lumen catheters, basically tubes within tubes, ranging from 50 cm to 60 cm in length. They are commonly used when a patient needs venous access for a medium length of time, typically a few weeks up to six months.

Anatomy and Physiology of Percutaneous Central Catheter

A central catheter is a tool used by doctors to access the body’s veins. It ends up connecting to either the superior vena cava, which is a large vein near the heart, or the right atrium, a chamber of the heart. This catheter can be inserted through an entry point in the center of the body (known as a centrally inserted venous catheter, or CICC) or an entry point on the edge of the body (known as a peripherally inserted central catheter, or PICC). A PICC is usually inserted through one of the veins in your arm.

The right basilic vein, found in the upper arm, is the preferred choice for PICC because of its larger size and easy-to-reach location. It also has the easiest path to its final location as it flows through the axillary vein in the armpit, then the subclavian vein under the collarbone, and finally lands in the SVC. Additionally, this vein also has fewer valves, which can help with the flow of fluids, and it has a better angle for inserting the catheter compared to other veins.

The second-best choice for inserting a catheter is the median cubital vein because it is superficial in the front part of the elbow and flows directly into the basilic vein, continuing into the SVC. Yet, due to its location near the elbow, which bends often, there’s a greater risk of complications like irritation and inflammation in the vein (which doctors call “mechanical phlebitis”).

The cephalic vein is an alternative option, but it’s smaller than the basilic vein and may have a winding path, making it trickier. Plus, catheters placed through this vein are believed to have a higher chance of causing mechanical phlebitis, and its sharp insertion angle makes it hard to move the catheter.

The brachial vein can also be used for catheter placement. It’s large in size but is positioned deeper and closer to the brachial artery and median nerve, compared to the basilic vein. This means doctors usually use an ultrasound to place the catheter in the brachial vein accurately and safely.

Why do People Need Percutaneous Central Catheter

A PICC, or a Peripherally Inserted Central Catheter, is a safe method doctors use when they need to gain access to your central veins. Central veins are larger veins that can handle more potent or irritating medications. This method is a viable choice, especially if regular access to your veins is necessary for several weeks or months. This is due to the low risk of infection associated with a PICC. Both in-hospital and out-of-hospital patients can safely use PICCs.

A PICC might be advised in the following situations:

• If it’s challenging to find or use your smaller, peripheral veins.
• If you require certain medicine delivery over an extended period directly into your blood, such as antibiotics or antifungal medication.
• In the event you need to receive medications that can irritate smaller veins, such as certain vasoactive drugs or chemotherapy medicines.
• If you require the delivery of highly concentrated (hyperosmolar) solutions or substances with extreme acidity or alkalinity, such as when you’re receiving nutrients directly into your veins (also known as total parenteral nutrition).
• Should you need to receive blood products via infusion.
• If you require frequent blood sample collections.
• In situations where you have a blood clotting disorder (for instance, low platelet counts, also known as thrombocytopenia).
• If you have unnatural changes in your chest or neck structure that make it problematic to place a regular central venous catheter.
• When you require infusions rapidly.

When a Person Should Avoid Percutaneous Central Catheter

There’s really no situation where we absolutely can’t use a central venous catheter, which is a tube that doctors put into a large vein, especially in emergencies. However, there are some situations where it’s not the best option to put in a PICC, or peripherally inserted central catheter. Here are some things that might make a PICC not the best choice:

* The area where the PICC would go in is burned, injured, infected, has been exposed to radiation, or has had blood clots in the past.
* The patient has an ongoing bacterial infection in their blood.
* The patient has severe kidney disease and might need to have a tube put in for dialysis, a treatment that cleans the blood when the kidneys can’t. Doctors will want to save their veins for that.
* The veins in the patient’s arms are too small (less than 3 mm to 4 mm).
* The patient has had surgery to remove a breast and lymph nodes, which are small organs that help fight infection. This surgery can make it hard for fluid to drain from the area.
* The patient needs to use crutches, which can put pressure on the veins of the arm.
* The patient can’t stop coughing or vomiting. These actions increase pressure in the chest, which can lead to problems with the catheter.

Equipment used for Percutaneous Central Catheter

A Peripherally Inserted Central Catheter (PICC) line is a type of medical tubing that doctors place in a large vein in your arm and use to give you certain medicines or treatments. They come in different sizes, from 50 cm to 60 cm, can have different numbers of tubes or ‘lumens’ extending from them (from one to three), and can have special valves to stop blood going back up the tube. They also require different kinds of care and maintenance.

There are many different brands of PICC lines, and how they’re packaged and the kinds of equipment that come with them can vary a little. One common method for placing the PICC line is called the ‘modified Seldinger technique’. Here’s a typical list of equipment that doctors use in this technique:

– An ultrasound machine, to help guide the procedure, with a sterile cover and special gel

– Sterile gloves, a gown, a mask that also shields the face and a cover for the hair

– Sterile sheets and towels

– A special skin-cleaning solution that usually contains chlorhexidine and alcohol

– Saline, which is a type of sterile salt water, for cleaning

– A tape measure

If the doctor is actually inserting the PICC line, they will also need:

– The PICC line itself

– Needles in different sizes

– Syringes, typically 10 mL in size

– A guidewire, which is a flexible wire that leads the catheter into the vein

– A dilator, which is used to enlarge the vein so the catheter can be inserted

– An introducer, which is used to help get the catheter into the vein

– A small blade

– A local anesthetic (like lidocaine), to numb the area where the PICC line is being inserted

– Material for stitches

– A sterile dressing kit, which is used to cover the area once the PICC line is inserted. This is usually transparent and doesn’t let germs through.

Who is needed to perform Percutaneous Central Catheter?

A Peripherally Inserted Central Catheter (PICC) is a type of line used to give you certain types of medicines or fluids. Any doctor, nurse, or physician’s assistant who has been trained can put in a PICC. However, you’ll often see that many treatment centers have nurses who specialize in putting these catheters in place. They’re sometimes called PICC nurses. These skilled nurses know how to put the line in place effectively. Having them there can make it more likely that the line is put in correctly while reducing any risks. They do this by always following clean, safe procedures, and it’s actually quite cost-effective to do so.

Preparing for Percutaneous Central Catheter

Central venous catheters, which are a type of tube placed into a patient’s large vein, can be inserted either through surgery or by non-surgical methods. Peripherally inserted central catheters, also known as PICCs, are usually inserted without surgery, right at the patient’s bedside. Medical professionals typically use ultrasound to guide this process, and such guidance has shown to lead to better results. Preparation is an essential part of this procedure to make sure all needed supplies and equipment are available, this helps ensure successful outcomes.

Maintaining sterility, or keeping everything extremely clean, is incredibly important during this procedure to prevent catheter-related bloodstream infections, which are possible complications arising from germs entering the bloodstream via the catheter. Training on standardized methods of catheter placement, care and upkeep, as well as infection prevention, has significantly reduced the number of these infections.

The complete procedure, including the necessary preparation, is provided in the following section.

How is Percutaneous Central Catheter performed

Your doctor may use the Seldinger technique to place a PICC (peripherally inserted central catheter), a type of long, thin tube that goes into your body to give medicine or nutrition, or to take out blood for tests. Some doctors use other methods, but they may require larger veins, cause more bleeding, and possibly let air get into your veins.

Here’s how the Seldinger technique for PICC placement is done in a clean, sterile way:

1. First, your doctor would talk to you about the procedure and make sure you are okay with it.
2. Next, the doctor would prepare all the required tools and materials.
3. The doctor would measure your arm to check for any swelling that might happen due the procedure.
4. After that, the doctor would figure out which vein to put the PICC into, using an ultrasound device to get a good view of the veins.
5. Using a special band (like a blood pressure cuff) and making sure you have enough fluids in your body, the doctor can make the veins easier to see.
6. The doctor would then mark the spot where he will insert the PICC.
7. The doctor would figure out how far to push the PICC into your body, usually by measuring from the place where the PICC goes in, over to the middle of your right collarbone, and then down to the third space between your ribs.
8. After carefully washing their hands, the doctor would then clean your upper arm with a special germ-killing substance.
9. For safety, the doctor would put on a mask, face shield, hair cover, and a sterile gown and gloves.

The doctor would use ultrasound to find the vein again, and then put a needle into it until blood comes into the syringe. After taking off the syringe, the doctor pushes a guide wire through the needle, removes the needle, and checks that the wire is in the vein using ultrasound. The doctor would make a small cut alongside the wire using a scalpel. A dilator and introducer (a type of tool) would be put over the wire, and after removing the wire and dilator, only the introducer would remain. The catheter would be slid through the introducer up to the length previously determined and the introducer would be removed.

Finally, the doctor would check the position of the catheter by getting a chest x-ray to make sure the catheter is properly placed

Once it’s confirmed that the PICC has been properly placed and it works as it should, the doctors will take steps to reduce the risk of complications. They will secure the PICC with a special device, flush it regularly with salt water or a solution that contains a type of blood thinner called heparin, and change sterile dressings at certain intervals.

Possible Complications of Percutaneous Central Catheter

Whenever a tube (catheter) is implanted into the body, there’s always a risk of infection. This could lead to skin inflammation, abscesses (pockets of pus), or bacteria spreading through your blood causing a system-wide infection. Some of the common infectious bugs are staph bacteria and a type of yeast called Candida.

When it comes to Peripherally Inserted Central Catheters (PICCs, a type of catheter placed in your arm and threaded to your heart), there’s roughly a chance of 1.1 infections for every 1000 days the PICC is placed. The risk seems higher for hospital in-patients as compared to out-patients because hospitalized patients are usually sicker and the catheter is used more often. The infection rates also seem higher if the PICC is put in the bend of your elbow than in the upper arm, or when multiple tubes are attached to the catheter.

To prevent infections, antibiotics have not really been helpful and are not recommended. Antimicrobial or antiseptic devices might help to reduce the chances of infection. It might seem reasonable to change the catheter regularly to prevent infection, but this is not recommended by the Centers for Disease Control and Prevention (CDC).

If you develop serious infections like sepsis, heart, bone, or blood vessel-related infections among others, the catheter would need to be removed.

Wrong placement or movement (migration) of the catheter is also common. This could be due to abnormal blood vessel structure, your position during insertion, or changes in blood pressure in the chest if you cough or vomit. If the catheter tip moves after it was originally placed properly, it can affect the ability to draw blood and even cause a life-threatening condition called cardiac tamponade, which requires immediate medical attention.

Placement of the catheter can be checked using a chest X-ray, and can usually be repositioned using a simple bedside technique.

Catheter malfunction is another major issue, with mechanical failure commonly happening. This can cause irritation and inflammation in the vein or the catheter can break and get stuck in the blood vessels.

Phlebitis and infiltration, which are irritations caused by the catheter or medication, happen to about 2.2% to 23% of patients with PICCs. This can be treated with anti-inflammatory agents or warm compress and does not usually require removal of the catheter.

Air emboli or air bubbles in your blood vessels are extremely rare, but they can happen and are a medical emergency. They are caused by not being able to maintain a closed system between the catheter and your blood vessels.

Heart rhythm problems can happen if the catheter is placed too low, creating abnormal electrical activity. This can be easily fixed by moving the catheter to its correct position.

Blockage of the catheter can happen due to a blood clot or non-clotting causes. Blood clot is the most common cause. Blockage can also happen if the catheter is placed too high up in the large vein carrying deoxygenated blood into your heart (Superior vena cava or SVC). Having a blood infection (septicemia) greatly increases the chance of clotting. Other risks include having more than one attempt at insertion, damage from previous catheter placement, ovarian cancer, left-sided insertion, and multiple tube catheters. Non-clotting causes of blockage include wrong positioning of the catheter or blockage from precipitation of incompatible medications.

To prevent blockages by drug precipitation, make sure to properly flush catheters before and after taking blood or giving medications. Making sure the drug and solution compatibility can also prevent precipitation. In some cases, simply moving the patient or the catheter can unblock the catheter.

What Else Should I Know About Percutaneous Central Catheter?

Since the 1970s, central venous access devices have been a reliable and safest method for giving patients long-term medication and fluids, especially those in Intensive Care Units (ICUs) in the hospital. Nowadays, these devices are also used for patients who need regular treatment and are not staying in the hospital.

One type of these devices is called a Peripherally Inserted Central Catheter, or PICC. PICCs have several advantages. They can be used for a few weeks up to 6 months, while other similar devices might only be used for a few days. They’re also easy to insert and take out by the hospital staff because of where they are placed on the body. And they can deliver the same kind of strong medications and fluids at the same speed as other devices. PICCs can even be used in patients with low platelet count (a condition known as thrombocytopenia), while other devices might pose a risk of causing a bruise or a collection of blood (hematoma).

PICCs aren’t perfect, though. They’re typically smaller, which means they may not be as convenient for taking blood samples. If a patient needs daily access for things like stem cell or blood product treatments, devices inserted through surgery are typically preferred. Finally, other catheters and ports can be used for longer than six months, which is not the case with PICCs, although some have been used for more than 300 days.

In conclusion, PICCs offer a good choice for different medical tests and treatments. Because they’re more cost-effective and have fewer complications than some other devices, it’s no wonder that they’re becoming more popular in intensive care settings.