• Medications

  • Anesthesia

    • Local anesthetic: 1% lidocaine

    • Conscious sedation: Fentanyl, midazolam

    • General anesthesia (if needed)

  • Heparin

  • Heparinized saline

  • Prophylactic antibiotics

    • Based to local protocol

  • Management of co-morbidities  (allergy, blood glucose, blood pressure, nausea, etc)

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• Trolley/Equipment​

  • Balloons

  • Micropuncture access kit

  • PICC line kit:

    • Catheter

      • single or multi- lumen

      • Power injection capability

    • Peel-away sheath

    • Dilators

    • Microwire (0.018”)

    • Securing mechanism/sutures/dressing

  • Sheaths

  • Tourniquet

  • Wires 

    • 0.018”

    • 0.0035” (standard, hydrophilic, Amplatz superstiff)

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• Checklist

  • CIRSE (IR Patient Safety Checklist)

  • LocSSIPs (Local Safety Standards for Invasive Procedures)

  • NatSSIPs (National Safety Standards for Invasive Procedures)

  • WHO (World Health Organization Surgical Safety Checklist)

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• Access

  • Supine position with the arm abducted

    • Basilic, Cephalic or Brachial vein

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• Technique

  • Place the tourniquet high in the arm

  • Locate the target vein with the US

  • Cleanse the access site

  • Cover with sterile drape

  • Administer local anesthetic at the skin

  • Perform a skin nick 

  • Use the micropuncture kit to access the vein under ultrasound guidance and advance the microwire

    • Begin attempts from distal to proximal

  • Release the tourniquet

  • Remove the micropuncture needle, use the dilator and then introduce the peel-away sheath over the microwire 

  • Use the microwire to measure the length from the access to the SVC/RA level, under fluoroscopy

  • Adjust PICC’s length to the measured microwire length

  • Remove the sheaths dilator

  • Introduce the PICC line

    • The line should move freely, with no resistance

    • Guidewire can be used to reposition the line’s tip or to readjust the line’s length

  • Peel the sheath

  • Confirm fluoroscopically that the tip of the line is at the SVC/RA level

  • Flush/aspirate the lumens

  • Lock the lumens with heparin

    • Check manufacturer’s specifications

  • Secure the PICC line with fixation device, stitches and dressings

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• Tips​

  • Occasionally venogram or venoplasty are needed 

  • PICC line can be used immediately

  • Keep in mind that the tip of the line will rise as the patient stands

  • If the tip of the line is into the RA can cause arrhythmia

 

• Report

  • Describe the technique

  • Document PICC line’s position and function

  • Mention venous patency

  • Post-procedure instructions if needed