Anatomy and Placement

A PICC line may be inserted in the home or hospital setting by an RN who has been educated in PICC line insertion. Regardless of setting, sterile technique is essential and the sterile field must be maintained during placement. The nurse placing the PICC will use his/her professional judgment to select the best placement site, based upon patient history and anatomy. Most PICCs are inserted without incident, although some patients with anomalies in their vasculature may require fluoroscopic imaging to place the line.

A PICC may be inserted through the basilic, cephalic or median cubital veins. However, research indicates that the basilic vein is optimal (Mazzola, Schott-Baer & Addy, 1999). The basilic vein has the largest diameter and the greatest blood flow of the peripheral arm veins. The basilic vein also offers the straightest route to the superior vena cava (SVC).

While the median cubital vein is smaller than the cephalic vein and has a variable course, it usually offers the second best insertion choice. This is because it often takes a direct path to the the basilic vein and then on to the SVC.

The cephalic vein is often the third best insertion choice, because it often narrows along its path and may form an angle where it joins the axillary vein. Both of these issues increase the risk of insertion related mechanical phlebitis. Regardless of vein selection, the ideal point of insertion is just above the antecubital space in order to minimize the mechanical problems associated with arm bending.

Although placement of midline PICC catheters is in adherence to manufacturer's guidelines, results of some studies make this a controversial issue (Kapensky, 1998). If a midline catheter is placed, the INS standard for midline catheters is as follows:

"Therapies not acceptable for midline catheters include continuous vesicant chemotherapy, central formulation total parenteral nutrition, solutions and/or medications with pH less than 5 or greater than 9, and solutions/medications with a serum osmolality greater than 500 mOsm/L. Midline catheters are not used for routine blood drawing. Blood pressure cuffs or tourniquets should not be used on the arm where a midline catheter has been placed." (INS, 1998).

The tip of the midline catheter should rest in the upper extremity of the insertion arm, not in the midclavicular region as this may be associated with complications due to catheter whip and deep vein thrombosis.

The optimum vein for the insertion of a PICC catheter is the :

The Intravenous Nursing Standards of Practice, published by the INS (1998), are regarded by professionals across the healthcare spectrum as the authority on topics related to infusion therapy. Please visit their website for information about how to purchase them.