Infection, Prevention and Control - Peripherally inserted Central Catheter (PICC)

What is a PICC (Peripherally Inserted Central Catheter)?

A PICC is a long, thin, flexible tube known as a catheter. It is inserted into one of the large veins of the upper arm. The tip of the line sits in the lower third of the large vein above the heart.

The space in the middle of the tube is called the lumen. Sometimes the tube has two or three lumens (known as double or triple lumen). This allows different treatments to be given at the same time.

At the end of the tube outside the body, each lumen has a special cap, to which a drip line or syringe can be attached. There may also a clamp to keep the tube closed when it is not in use.
 
PICCs are also CT compatible, which means CT contrast can be administered through this line.

Why do I need a PICC?

Your doctor has decided that you require fluids or drug treatment into your bloodstream for a longer period of time or the drug you require must be given through a large vein near the heart.

In most situations a PICC can be used for taking blood samples. If the line is used for Parenteral Nutrition then this is not safe and you will require blood samples to be taken using the traditional method of a needle into your skin.

If necessary, a PICC can stay in for up to 2 years.

What are the alternatives?

The alternatives to having a PICC are as follows:

Cannulae

If you continue to have your treatment through a cannula you will require this changing every 7 days or sooner if there are signs of irritation to the vein.

Midline

This is a long thin tube inserted into one of the larger veins in the top of your arm. The tip of the line ends in the veins in your armpit. Not all medication can be given through a midline. A midline can only stay in place for between 4 weeks 6 months depending on the manufacturer.

A different central line

If a PICC is not appropriate for you there are other types of central lines that can be inserted through your neck or chest. A doctor or nurse will discuss this further with you if you require this type of line.

Who will put in my PICC?

A specially trained nurse, doctor or practitioner will discuss the PICC insertion procedure, any benefits, alternatives and potential risks and problems. You will be offered the opportunity to discuss any issues and will also need to consent to the procedure.

The procedure can be done on the ward and unless you are told otherwise, you can eat and drink normally before and after the procedure.

Who will care for my PICC?

While you are in hospital the nurses will look after your PICC.

This involves cleaning the exit site, applying new dressings, changing the bungs and flushing the line to prevent blockage.

When you leave the hospital, your local community nurses may be contacted to care for your PICC at your home.

How long will the PICC insertion procedure take?

The procedure usually takes between 60-90 minutes. From explaining and discussing the procedure, assessing your veins for suitability and placing the PICC.

Depending on which guidance is used (ultrasound, ECG or fluoroscopy) a chest x-ray may be required to confirm the correct position of the line before it can be used.

How is the PICC inserted?

The procedure will be done with you lay in a bed; you will be lying down with your arm extended to the side.

The doctor or nurse will clean the site, place sterile drapes around the area, and inject a local anaesthetic to numb the area where the line is to be inserted.
 
Next, a needle is used to locate a suitable vein in the top of your arm.

The PICC will be fed up into the vein. The procedure is usually pain free, though some patients do feel some minor discomfort. You won’t be able to feel the PICC being threaded up through the vein.

The PICC is secured with an orange device called ‘Securacath’ or with a ‘Statlock’.

Once the PICC is in place it will be covered with a clear dressing. The dressing will be changed the next day and then on a weekly basis unless it becomes soiled then it will be changed sooner.

How will the PICC affect me?

Your PICC line will be put in your upper arm so you will be able to use your arm normally, you can shower but will need to protect the line and dressing from getting wet, you can use a protective sleeve, Cling film or a plastic apron.

Problems with the PICC insertion

Most PICC insertions go smoothly, but occasionally there are problems. Sometimes, the shape of the vein can prevent the PICC from being threaded upwards.

If this happens, we will probably try again using a different vein. Sometimes the PICC goes in easily but the x-ray shows it is in the wrong position.

When this happens, we are usually able to adjust the position using a special flushing technique or by re-threading the same line.

During the procedure you may feel a shooting pain down your arm if the needle touches a nerve.

What can go wrong with PICCs?

Many patients don’t have any problems with their PICC, but there are certain risks involved. It is important for you to know what can go wrong so you can help prevent or deal with them if they happen.

The person putting in your PICC will spend time explaining this in detail.

Potential problems

Thrombosis (blood clot)

Having a PICC sitting in a vein does mean there is a risk of causing a blood clot. This sounds very alarming, but in fact when it does happen, it’s very unlikely to cause a serious problem.

Therefore, on the same side the PICC is placed, if you have any pain, redness or swelling in your arm or neck - this could be a sign that a blood clot has formed in one of the veins.
 
Patients who develop a clot due to their PICC are usually given medication. There is often no need to remove the line and it can continue to be used.

Dislodgement

If your PICC becomes dislodged, or pulled out from its original position, please inform the team caring for you.

Infection

This can be a problem, particularly for patients who have a low resistance to infection or having intravenous feeding.

Great care is always taken when putting the PICC in and when cleaning and flushing the line. Even so, infections can happen at any stage.

Often infections can be treated with antibiotics, but sometimes we will need to remove the PICC to prevent the infection from getting worse.

Palpitations

Occasionally patients experience palpitations after the PICC has been put in.

Some patients describe this as a “fluttering” feeling in their chest. Other people say they are aware of their heart beating more strongly than normal or with a different rhythm. When this happens the PICC will be pulled out by a few centimetres and the palpitations will usually stop straight away.

Not bleeding back

A PICC is designed to allow blood samples to be taken, but sometimes blood cannot be withdrawn. This is not a serious complication, but it can be disappointing - nobody likes having blood tests taken with a needle. If this happens your nurses will use special techniques or medication in the line which usually solves the problem.

Damaged or split line

It is very important to prevent the PICC from getting damaged - for example, you should never use scissors near it! If the PICC splits or breaks, it will need to be removed.

Blocked line

Sometimes a PICC can become blocked.

It is important that the line is always flushed before and after any medication is put through the line.

If this happens your nurses will use special techniques or medication to unblock the line.

If a PICC cannot be unblocked the PICC will need to be removed.

PICC falling out/migrating/dislodged

A PICC falling out or dislodging from its original position is rare but if this happens please inform the team caring for you straight away.

If you are out of the hospital and this happens:

• If your PICC has partially fallen out of place you should fix the line to your arm with tape or a plaster
• If the PICC has completely falling out you should apply pressure to the insertion site if it is bleeding and cover with a plaster

Things to look out for

If you experience cold and shivery attacks during and after flushing your line or if you have a temperature above 38 degrees centigrade, it is very important that you tell a member of nursing/medical staff.

Remember to check daily for:

• Redness
• Tenderness or pain in the arm or armpit of the arm containing the PICC
• Oozing from where the line comes out of your arm
• Hot to touch
• Swelling of your arm
• Leaking
• Damage to your PICC

If you are worried about your PICC please speak to your doctors or nurses.

How should I care for my PICC?

Your PICC should not stop you from doing anything that you would usually do, and you should carry out your daily routine as normal.

However, once the PICC is in place it needs to be looked after carefully to prevent problems from occurring.

The nurse will perform weekly dressings, bung changes and flush the line. The PICC will always be covered with a clear dressing.
This keeps the PICC in place and reduces the risk of infection.

Please do not submerge the PICC in water or go swimming while your PICC is in place. Sports such as tennis and golf and vigorous gym exercises are discouraged.

There is a risk that your PICC could become dislodged because of excessive upper body movement.

Should the dressing get loose, dirty, wet and or start to peel off contact the nurse straight away so the dressing can be changed.
 
You should have no reason to touch your PICC unless you are undergoing self-administration therapies. If you do touch your PICC always wash your hands prior to touching any part of the line and ensure anyone else who is dealing with your PICC also washes their hands.

Before using your PICC Nursing and medical staff MUST:

• Wash their hands
• Put on gloves and an apron
• Clean the end of the line with a wipe for 15 seconds
• Allow this to dry completely before accessing the PICC
• Flush PICC with normal saline before and after using line or weekly if not in use
• Remove gloves and apron
• Wash hands

This is to protect you and other patientsfrom any infection.

Further information

If you have any questions about PICCs please don’t hesitate to ask your nurse or doctor.