Peripherally inserted central catheters (PICCs) are venous access devices used to administer all types of intravenous medications and solutions. PICCs are soft, flexible catheters about the size of a piece of spaghetti. They are inserted by specially trained nurses, physicians, physician assistants, nurse practitioners or radiological technologists. PICCs are used in all care centers and allow patients to have one access device for the full length of therapy.
The popularity of PICCs has increased due to the ease of insertion through the veins of the arm, the low risk associated with them and the low cost of insertion. As with all central lines, PICCs require x-ray confirmation immediately after placement and prior to administration of medication. Successful terminal tip location is the distal portion of the superior vena cava.
Why Would I Receive a PICC?
PICCs can be used for just about any therapy. This type of catheter comes in single, double or triple lumen (channel) designs. Like all catheters, no matter how many lumens, there is still only one entrance site (the place where the PICC is actually inserted into your vein) and exit site (the place where it comes out of your skin). The PICC exits the skin near the vein in which it is placed. On the outside of your skin is a small segment of the catheter covered with a cap. This is where your medications are infused into the catheter. Compared with other CVADs, PICCs are quick and easy to place as there is no tunnel or surgical pocket to create. No incision is required for a PICC, only a puncture into the vein. In addition, PICCs may have fewer complications than other CVADs.
Although most people need PICCs for only a few weeks or months, PICCs can last for years if taken care of properly. They are relatively small and flexible, so most people find them comfortable. However, because there is an external segment, all PICCs require regular flushing and dressing changes. Your doctor or healthcare provider will give you specific instructions about care, maintenance and any activity limitations. PICCs usually do not require any special procedure for removal. They slide out like a regular Intravenous (IV) catheter. A nurse can remove them in your doctor’s office or at home.
Common Problems with PICCs
“Blockages” in a PICC
There are common reasons for PICCs to become blocked. Contact your doctor or nurse who can help overcome most of these problems. Here are a few common reasons for blockages:
Blood clots in the blood vessel around your PICC can cause blockage. Clots can plug the catheter making infusions difficult. Sometimes you can infuse your medicines but are unable to get blood out. This may be caused by a fibrin sheath, which is tissue your body deposits on the catheter. Both of these problems can be treated with “clotbusting” drugs given through the PICC which help dissolve the clot or sheath. Sometimes, the catheter needs replacement or other methods are used to restore catheter function (including angioplasty, or “ballooning”).
Mechanical blockages or malpositions can occur when a catheter is in the wrong place in a blood vessel, is kinked or pinched, or is broken. This can happen if your CVAD has accidentally come out part of the way or been pushed in too far. Sometimes the catheter can be repositioned to restore function.
Residue or “precipitate” build-up inside the PICC can also cause blockage. This can occur if medications interact with one another, if they leave behind a residue, or if your PICC is not flushed properly. Sometimes solutions can be injected into your PICC to dissolve the residue. A blood clot can plug the catheter making infusion difficult.
Infection
Infections are caused by germs getting in or around a PICC and become a serious problem if not treated promptly.
Make sure to check daily for:
Redness, swelling, warmth, tenderness or drainage where the PICC enters or exits your body. You may have a “local” infection.
Fever, chills, vomiting, diarrhea, fatigue, weakness and loss of appetite may be signs that there is an infection in your bloodstream. If any of these occur, contact your doctor or nurse immediately.
Phlebitis
Inflammation of the vein, called phlebitis, occurs if the tissue or blood vessel near the PICC gets irritated or damaged. This happens in response to a foreign substance in the body (the catheter) or to the medicine or fluids being administered through the PICC. Notify your doctor or nurse if you have redness, swelling, pain, hardness or warmth near the CVAD.
PICC Tip Movement
Excessive vomiting, coughing, sneezing, hiccupping or vigorous arm movement may cause the tip (the deepest position) of your PICC to change positions within your body.
Notify your doctor or nurse if you have any pain or discomfort near your PICC or in the shoulder, jaw, ear or neck, or if you have a feeling of coldness or fullness in the area. If you hear flushing or have pain when your PICC is used, tell your nurse or doctor. Check your PICC to make sure the section outside your body does not seem longer than usual. If it does seem longer, it may have partially come out of the vein into which it was inserted. Secure the CVAD with a dressing and call your doctor or nurse immediately for help.
External Catheter Breakage
It is rare for your catheter to break or tear, but be aware that it can happen. Catheter breakage can be caused by using sharp objects around the catheter, twisting or bending the catheter when changing caps, using excessive force when flushing, or catching the external part of the catheter on something resulting in the catheter being pulled or stretched out of position.
Here are some simple steps to decrease the likelihood of catheter breakage:
Never use less than a 10 cc syringe, and do not use excessive force when flushing.
Avoid using sharp objects such as scissors near the catheter.
Avoid twisting or kinking the catheter.
Secure all external parts of the catheter so nothing is dangling free.
If your catheter does break, you may see that your dressing is wet, that fluid leaks out when you flush or that some blood is leaking out of the catheter. If the catheter is broken, immediately place a clamp above the break, close to your skin (after the catheter is placed, ask your nurse or doctor for an extra clamp to use in an emergency), and call your nurse or doctor. Some catheters can be repaired, while others may need to be removed and replaced.
Internal Catheter Breakage
Internal catheter breaks are very rare, and when they do occur, the catheter will need to be removed and replaced.
If your catheter breaks on the inside, you may notice that your catheter is not working correctly. You may also notice that your heart rate is a little faster or beating irregularly, and you may feel shortness of breath for no obvious reason. Call your nurse or doctor immediately for instruction.
Nurse info and FAQ's
Who Can Place a PICC?
According to INS position papers, a licensed physician or licensed register nurse (as determined by state regulations) who is educated and has demonstrated competency can insert a PICC. The RN must have demonstrated competency and proficiency in intravenous therapy including the insertion of short peripheral catheters and have a solid understanding of central venous catheters. Additionally, the RN should complete an educational program for PICC insertion. The educational program must include both theoretical content and clinical instruction on an anatomical model. Once the nurse has validated initial competency, there must be an ongoing continuum of competency assessment.
How Do I Learn to Place a PICC?
PICC Training is recommended with a minimum of 8 hours to reduce your liability and promote safe practice. The term PICC qualification applies to the process of completing Basic PICC insertion training then performing supervised insertions until competency is achieved. Upon completion of your supervised insertions, you are qualified to insert PICCs independently. PICC Excellence provides training for beginners through advanced inserters including all required curriculum and competencies. Training options include: Group training, DVD Self Study Training, Online Self Study Training, or contracted on-site training. Each of these training options must be accompanied by precepted/supervised insertions at your place of employment or at another arranged location. Email or call us and we will gladly answer any questions you have regarding setting up the best training program for you or your facility.
After initial qualification and experience, the next level for the PICC inserter is to achieve a CPUI™ (Certified PICC/Ultrasound Inserter) designation. PICC Excellence offers a program intended to provide the vascular access clinician validation of a higher level of knowledge and practice in the field of PICC placement. PICC Certification™ is intended to be recognized throughout the healthcare community. Certification is a process by which an association grants recognition to an individual who has met predetermined standards specified by that association or agency. PICC Certification™ does NOT verify competency. Rather, PICC Excellence™ is certifying that the applicant meets predetermined standards of knowledge and training specific to PICCs as a credentialing process.
When To Use PICCs
There are lots of indications that a PICC is the most appropriate CVAD to use. Here are a few of the most common indications:
Short term nutrition PPN or TPN
Chemotherapy lasting less than 1 year
IV Infusions for patient with bleeding disorders no matter the PTT or INR
Patients with less than three veins for more than three days of IVs
Medications known to damage the intima of veins, (i.e. irritants)
Patients receiving IV infusions for longer than 5 days, especially when irritating antibiotics or Phenergan are involved. (Give phenergan rectally or IM whenever possible)
More than 3 restarts of IV in 24 hours
Open chest wounds, tracheostomy or radial neck surgery contraindicating chest line placement
Heparin infusions where number of hematomas are more than available veins (Midline).
Complications with peripheral IVs, more than one infiltration, more than one phlebitis indicating that the patient is sensitive to the medication infusion or push meds
Medications where pH or osmolarity indicate irritation will occur with peripheral IV (pH less than 5 greater than 9, osmolarity greater than 600)
Dopamine or Dobutamine (PICC ASAP)
Immediately place a PICC for burn patients, if area of skin is available
Immunocompromised patients requiring hospitalization and IVs (be sure to use Chlorhexidine/Chloraprep!)
Power Injection
Computerized Tomography (CT) is a scan that enables 3D visualization of tissue at various angles for a more complete picture. Blood vessels and other soft tissue cannot be seen on conventional x-rays. CT scans enable visualization with greater detail. Catheter patency must be verified by flushing the catheter with a 10cc syringe and sterile saline confirming normal flushing action without resistance. Free-flowing blood return may also be verified prior to procedure, followed by flushing. All contrast must be warmed to body temperature prior to power injection. A chest x-ray or other means of verification of tip placement prior to each CT injection is recommended.
The FDA has sent a reminder to radiologists, radiologic technologists, radiologic nurses, and IV team nurses about the potential for serious patient injury when vascular access devices not designed to tolerate high pressures are used for power injection CT or MR contrast media. That reminder specifies that prior to initiation of power injection the user should:
Check the labeling of each vascular access device for the maximum pressure and flow rate designation.
Know the pressure limit setting for your power injector and how to adjust it. Understand that if recommended pressure is exceeded, the device may weaken even if no rupture is obvious, and the weakened device could fail when used again.
Ensure that the pressure limit set for the power injector does not exceed the maximum labeled pressure for the vascular access device(s).
Be aware the pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow from kinks, curves or compression. Ruptures occur when the injection pressure exceeds the tolerance of any of the vascular access devices such as catheters, ports and extension tubing.
The pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow (e.g., kinks, curves, compression). To maintain the flow rate required for a CT or MRI study, a power injector may generate high pressures. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device(s). If you do know the maximum pressure that the vascular access device can withstand, be sure to adjust your power injector so that it doesn't exceed this limit. It is important to understand that if the recommended pressure for a vascular access device is exceeded, the device could be weakened even though no rupture is evident, and the weakened device could fail to operate properly when it is used again.
Physician info and FAQ's
Program Recommendation
While PICC training is certainly not a required part of your training, the popularity of PICCs is making PICC training almost a necessity. PICCs are different from other CVADs and require specific techniques for peripheral access and tips to increase your success. At PICC Excellence, we recommend you take the Basic PICC Qualification Training class as it is the technique that is most consistent with central line insertion practices. Whether you decide to take an actual class with an instructor or take a self-study class, you will benefit greatly by learning the specifics of this most popular vascular access device.
When to Use PICCs
There are lots of indications when a PICC is the most appropriate CVAD to use. Here are a few of the most common indications:
Short term nutrition PPN or TPN
Chemotherapy lasting less than 1 year
IV Infusions for patient with bleeding disorders no matter the PTT or INR
Patients with less than three veins for more than three days of IVs
Medications known to damage the intima of veins, i.e. irritants
Patients receiving IV infusions longer than 5 days, especially when irritating antibiotics or Phenergan are involved. (Give phenergan rectally or IM whenever possible)
More than 3 restarts of IV in 24 hours
Open chest wounds, tracheostomy or radial neck surgery contraindicating chest line placement
Heparin infusions where number of hematomas are more than available veins (Midline).
Complications with peripheral IVs, more than one infiltration, more than one phlebitis indicating that the patient is sensitive to the medication infusion or push meds
Medications when pH or osmolarity indicate irritation will occur with peripheral IV (pH less than 5 greater than 9, osmolarity greater than 500)
Dopamine or Dobutamine (PICC ASAP)
Immediately place a PICC for burn patients, if area of skin is available.
Immunocompromised patients requiring hospitalization and IVs (be sure to use Chlorhexidine/Chloraprep!)
Power Injection
Computerized Tomography (CT) is a scan that enables 3D visualization of tissue at various angles for a more complete picture. Blood vessels and other soft tissue cannot be seen on conventional x-rays. CT scans enable visualization with greater detail. Catheter patency must be verified by flushing the catheter with a 10cc syringe and sterile saline confirming normal flushing action without resistance. Free-flowing blood return may also be verified prior to procedure, followed by flushing. All contrast must be warmed to body temperature prior to power injection. A chest x-ray or other means of verification of tip placement prior to each CT injection is recommended.
The FDA has sent a reminder to radiologists, radiologic technologists, radiologic nurses, and IV team nurses about the potential for serious patient injury when vascular access devices not designed to tolerate high pressures are used for power injection of CT or MR contrast media. That reminder specifies that prior to initiation of power injection the user should:
Check the labeling of each vascular access device for the maximum pressure and flow rate designation.
Know the pressure limit setting for your power injector and how to adjust it. Understand that if recommended pressure is exceeded, the device may weaken even if no rupture is obvious, and the weakened device could fail when used again.
Ensure that the pressure limit set for the power injector does not exceed the maximum labeled pressure for the vascular access device(s).
Be aware the pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow from kinks, curves and compression. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device such as catheters, ports and extension tubing.
The pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow (e.g., kinks, curves, compression). To maintain the flow rate required for a CT or MRI study, a power injector may generate high pressures. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device(s). If you do know the maximum pressure that the vascular access device can withstand, be sure to adjust your power injector so that it doesn't exceed this limit. It is important to understand that if the recommended pressure for a vascular access device is exceeded, the device could be weakened even though no rupture is evident, and the weakened device could fail to operate properly when it is used again.
Reimbursements for PICCs
Reimbursement information for PICCs and Midlines varies from outpatient to inpatient, one geographical area to another and one hospital to another. Reimbursement for PICCs and Midlines is not as easy as a simple dollar figure. With the institution of the Hospital Outpatient Prospective Payment System (HOPPS) implemented April 1, 2001, all previous CPT procedural codes have changed to Ambulatory Procedure Codes (APC). Implemented at this time was a transitional pass-through for devices in an effort to provide Universal coding for all brands and similar procedures. CPT and APC codes can be cross referenced here.
CPT or Q codes can be utilized to bill specific percutaneous insertions of central lines by a nurse, physician or radiologist. When no professional fee (MD or NP) coding is involved, the codes listed below are considered facility fees. These codes are as follows:
36468 - Placement of a catheter in subclavian or other vein, percutaneous, age 5 or under.
36469 - Placement of catheter in subclavian or other vein, percutaneous, over age 5.
36575 - Repair non tunneled CVC
36550 - Catheter Clearance Alteplase per 10mg or per 1mg. (Infusion 37201)
76937 - Ultrasound insertion of a vascular access device with the aid of ultrasound byPhysician or nurse. CPT/HCPCS 76937,( fluoroscopy 76998) agent. Q code overides CPT, not accepted by all carriers.
Radiologist info and FAQ's
Who can place a PICC?
According to INS position papers, a licensed physician or licensed register nurse (as determined by state regulations) who is educated and has demonstrated competency can insert a PICC. The RN must have demonstrated competency and proficiency in intravenous therapy including the insertion of short peripheral catheters and have a solid understanding of central venous catheters. Additionally, the RN should complete an educational program for PICC insertion. The educational program must include both theoretical content and clinical instruction on an anatomical model. Once the nurse has validated initial competency, there must be an ongoing continuum of competency assessment.
How Do I Learn to Place a PICC?
PICC Training is recommended with a minimum of 8 hours to reduce your liability and promote safe practice. The term PICC qualification applies to the process of completing the Basic training then performing supervised insertions until competency is achieved. Upon completion of your supervised insertions, you are qualified to insert PICCs independently. PICC Excellence provides training for beginners and advanced inserters including all the required curriculum and competencies. Training options include: Group training, DVD Self Study Training, Online Self Study, or contracted on-site training. Each of these training options must be accompanied by precepted/supervised insertions at your place of employment or at another arranged location. Email or call us and we gladly answer any questions you have regarding setting up the best training program for you or your facility.
After initial qualification and experience, the next level for the PICC inserter is to achieve a CPUI™ (Certified PICC/Ultrasound Inserter) designation. PICC Excellence offers a program intended to provide the vascular access clinician validation of a higher level of knowledge and practice in the field of PICC placement. PICC Certification™ is intended to be recognized throughout the healthcare community. Certification is a process by which an association grants recognition to an individual who has met predetermined standards specified by that association or agency. PICC Certification™ does NOT verify competency. Rather, PICC Excellence™ is certifying that the applicant meets predetermined standards of knowledge and training specific to PICCs as a credentialing process.
PICCs and IR: The Real Story
In the past, a large percentage of PICCs have been inserted is IRs. With the increasing popularity of PICCs, the high volume of PICC placements at hospitals in general, and the advent of PICC placement teams, it is time to take a closer look at the most cost effective and time efficient method of placing PICCs.
Based on a study conducted at the Department of Radiology, Dartmouth-Hitchcock Medical Center, the average cost for an RN to place a PICC bedside is $18 plus the cost of the PICC whereas the average cost for placement in IRs is $367 plus the price of the PICC. This difference may not be entirely accurate because the costs for IR placement are carefully calculated and inclusive whereas the costs for RN placement reflect only direct personnel costs and do not include institutional and administrative overhead, support personnel, or the cost of the follow-up chest radiography. According to Santolucito, the difference is even more pronounced with bedside insertions costing $200 versus radiology department insertions at a cost of $850. Nonetheless, it is apparent that the overall cost, particularly in light of the outcome of the PICC, is lower for placement by RNs at the bedside than it is for IRs.
With the 2004 Medicare professional reimbursement guidelines, interventionalists are no longer eager to place a PICC because reimbursement is set at $101 versus the cost of $850.
Despite the difference in cost, IR departments are essential for complicated placements, exchanges, advancements, and repositioning of PICCs. Therefore, it is reasonable and cost-effective to use a tiered approach where trained RNs place PICCS at the bedside whenever feasible relying on interventional radiology for complicated PICC placements, exchanges, advancements, and repositioning. Please refer to the references provided and consider the best options for the patient with placement of PICCs.
PICC is actually inserted into your vein) and exit site (the place where it comes out of your skin). The PICC exits the skin near the vein in which it is placed. On the outside of your skin is a small segment of the catheter covered with a cap. This is where your medications are infused into the catheter. Compared with other CVADs, PICCs are quick and easy to place as there is no tunnel or surgical pocket to create. No incision is required for a PICC, only a puncture into the vein. In addition, PICCs may have fewer complications than other CVADs.
your doctor or nurse who can help overcome most of these problems. Here are a few common reasons for blockages:
Computerized Tomography (CT) is a scan that enables 3D visualization of tissue at various angles for a more complete picture. Blood vessels and other soft tissue cannot be seen on conventional x-rays. CT scans enable visualization with greater detail. Catheter patency must be verified by flushing the catheter with a 10cc syringe and sterile saline confirming normal flushing action without resistance. Free-flowing blood return may also be verified prior to procedure, followed by flushing. All contrast must be warmed to body temperature prior to power injection. A chest x-ray or other means of verification of tip placement prior to each CT injection is recommended. 
