There are a variety of short-, moderate-, and long-term vascular access devices available (i.e., midline catheters, nontunneled central venous catheters, peripheral inserted central catheters [PICCs], peripheral intravenous [IV] catheters, ports, tunneled central venous catheters, and ultrasound [US]-guided peripheral IV catheters). PICC lines are commonly used in adults and children.1-3 PICC lines provide options that routine peripheral IV access or other devices do not provide and without the risks associated with direct puncture of central vessels.4 PICC lines are a cost-effective option that can often be inserted at the bedside.5,6 A PICC line reduces health care costs by permitting the patient to receive care as an outpatient.7,8
The insertion of a PICC line is infrequently performed in the Emergency Department (ED) and rarely by an Emergency Physician (EP). A PICC line is inserted more commonly by an Interventional Radiologist and their team or a skilled nursing team dedicated to placing PICC lines. An EP may request PICC line placement for a patient given the appropriate clinical scenario. Patients with indwelling PICC lines may present to an ED with complications associated with the PICC line. Be prepared to recognize the device, determine its use and functionality, and troubleshoot any potential complications.
ANATOMY AND PATHOPHYSIOLOGY
The veins of the upper extremities are the typical sites for PICC lines to be placed (Figures 61-3 and 61-4). The vessels most frequently used are the basilic, brachial, and cephalic veins proximal to the antecubital fossa to avoid occlusion or damage caused by elbow flexion.9-12 Rarely, the axillary vein, scalp veins, superior vena cava (SVC), a transhepatic approach, or a translumbar approach may be used.13-15 The veins may be accessed by palpation or some form of diagnostic imaging to guide vein selection. US is often used prior to PICC line placement to determine the patency and size of the veins potentially being accessed (Figure 62-1). US use decreases the time needed for insertion, decreases PICC line manipulation, and decreases the need for ionizing radiation when compared to standard blind landmark or blind length techniques.16 A tourniquet may be used to impede venous return and make the target veins more dilated.9 Contrast venography of the upper extremity performed under fluoroscopy may be used to select the target vessels. This requires peripheral IV access in a distal superficial vein of the arm and injection of venous contrast to opacify the vessels during fluoroscopy. A tourniquet for venous dilatation will enhance opacification of the vessels.9
Transverse ultrasound image of the veins proximal to the antecubital fossa in the right upper extremity. BrA, brachial artery; BrV, brachial vein; BV, basilic vein. (Courtesy of Mark R. Werley, MD.)
PICC LINES VERSUS MIDLINE CATHETERS