Anatomy and Placement
PICC line insertion can be performed as an inpatient or outpatient procedure by a registered nurse who has had specialized training. Regardless of setting, maximum barrier precautions and aseptic technique are essential throughout the procedure. The nurse placing the PICC will use his/her professional judgment to select the best placement site based upon patient history and anatomy. Nurses identify insertion sites using visualization, palpation and ultrasound assisted insertion is becoming common. Ultrasound-guided insertion can minimize the physical and emotional trauma of multiple attempts through visual confirmation of vein adequacy and catheter placement.
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 is relatively superficial and 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).
The median cubital vein has a small diameter and a variable course but it may offer the second best insertion choice for smaller catheters. This is because it often takes a direct path to the the basilic vein and then on to the SVC.
The cephalic vein may be 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.
Brachial insertion has a higher risk of injury. The brachial veins are located deep in soft tissue, adjacent to the brachial artery and close to the median nerve. Insertion may require ultrasound or fluoroscopic guidance to protect adjacent structures. The steep angle necessary to access the vein can predispose to catheter kinking .
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.
The optimum vein for the insertion of a PICC catheter is the :