This includes explaining the procedure, complications, alternatives to the procedure as well as answering to their queries. 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 can be used as a temporary measure in patients who need chronic or lifelong access (sickle cell, cystic fibrosis, short gut) or frequently hospitalized, as tunneled central venous catheter is preferred method in that patient population. Patients can be discharged form hospital with PICC lines for completion of intravenous therapy at home or nursing homes ( 5, 6). Placement of PICC in burns patients early in the course of treatment decreases risk of bacteremia ( 5, 6). It is useful in premature neonates ( 4) and in patients who receive frequent phlebotomy ( 5). PICC is favored when the course of infusion is 14 days or greater but less than 3 months ( 2, 3). The medications include but not limited to antibiotics and chemotherapeutic agents. PICC is used for infusion of medications over prolonged period of time and total parenteral nutrition (TPN). Ultrasound guidance has shown a better rate of success ( 1). As the name suggests the catheter is inserted in a peripheral vein and advanced so that its tip lies in central venous system. Peripheral inserted central venous catheter (PICC) placement is the most common vascular interventional procedure performed in both adults and pediatric patients.
Keywords: Peripherally inserted central catheters (PICC) pediatric adult ultrasound
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