#PICC LINE SKIN#

#PICC LINE SKIN#

The skin at the chosen site of venous access is marked with marker pen. Extensive training and experience are required in ultrasound-guided venipuncture in infants and young children due to small caliber of veins. It is often small, demonstrates high incidence of anatomical variation in the course, presence of acute angulation in its course in axilla and association with higher incidences of thrombosis makes cephalic vein the least favorite.

Cephalic vein is less preferred due to multiple reasons. Although the incidence is rare, care should be taken to avoid inadvertent arterial puncture and injury to the median nerve during brachial vein access ( 10). It lies deeper and often in close proximity to the median nerve. It can be single or paired veins adjacent to brachial artery. The second preference is the brachial vein. Basilic vein can be easily identified in medial arm as it is very superficial. A patent, sizeable basilic vein is always preferred for initial access attempt. If the first attempt of venous access fails, further attempts can be made in mid and proximal arm, proximal to the vein injury. Antecubital fossa access should be avoided as it causes post procedure discomfort to the patient. The first attempt at venipuncture should be as distal as possible above the antecubital fossa. PICC size selection is based on the size of the vein, for example, if the vein is 5 mm in diameter then a 5 Fr PICC will be most suitable. The selected vein is accessed in a transverse short-axis section to avoid potential arterial puncture, especially if accessing brachial vein. Preliminary ultrasound (linear 7–12 MHz transducer for adult and 15–18 MHz hockey stick transducer for infants and young children) is used to map the available veins and assess their patency and compressibility. This includes explaining the procedure, complications, alternatives to the procedure as well as answering to their queries.Ī tourniquet is applied proximally in the upper extremity for adequate distention of veins without compromising the arterial blood flow ( 9). Ultrasound is also useful post procedure to evaluate for bleeding and hematoma formation ( 8).įinally, the most important pre-procedure step is to obtain informed consent from patient or legally responsible authority. Apart from medical measures, using ultrasound guidance and smallest gauge needle (optimally with a single pass) for peripheral venous access can significantly reduce bleeding risk, especially in high risk patients. Clopidogrel should be withheld for 5 days before the procedure and for Low molecular weight heparin (LMWH) withhold one therapeutic dose before the procedure, and there is no need to withhold aspirin for PICCs ( 8). Minimum platelet count requirement of 20,000/L, with blood transfusion recommended for counts below 20,000/L. International normalized ratio (INR) should be 2.0 requires treatment (i.e., FFP, vitamin K).

Optimizing the coagulation profile before performing the procedures is required. Medical history of coagulopathy or anticoagulant or antiplatelet therapy poses increased risk of bleeding complications. Use of alternate extremities should be done in those who need repeat procedure, to decrease the risk of injury and stenosis ( 7). Detailed inquiry should be made regarding which extremity and vein was utilized and if there was any difficulty in placement. It is important to review history of PICC placements as chronic venous injury and stenosis is a frequent complication especially in patients with history of multiple PICCs. If done in IR suite then fluoroscopic guidance is ideal. If the procedure is planned bedside, then the guidance may be obtained using electromagnetic method/EKG or Sherlock method for tip localization. Therefore, detailed review of surgical history and previous imaging is essential. Congenital anomalies include situs anomalies, duplicated superior vena cava (SVC) or left-sided SVC, and the presence of surgical shunts (e.g., Glenn cavo-pulmonary shunt). Presence of altered venous anatomy from congenital or acquired conditions can pose technical difficulties during PICC placement. Occasionally, in case of previous history of difficult access in adult patients and in all pediatric patients, alternate forms of venous access use, such as central venous catheter, typically through jugular or femoral approach, should also be discussed with the referring team, patient and/or family during the consent. In patients needing PICC placement, the clinical information is reviewed by a member of the interventional radiology (IR) team.

Picc line