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PICC Zone Insertion Method™ (ZIM™): A systematic approach to determine the ideal insertion site for PICCs in the upper arm

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Abstract and Figures

The consequences of random PICC practice can be serious and manifest as deep vein thrombosis, pulmonary embolism, catheter related bloodstream infection, and post thrombotic syndrome. Risk factors related to site selection have been well established for other central venous access devices, but not for ultrasound guided PICC insertion in the upper arm. The author presents observations of upper arm PICC insertion designated by color zones to highlight the variability of PICC practice. The author also details site risk factors associated with each color zone and proposes an ideal insertion location for upper arm ultrasound guided PICC procedures.The PICC Zone Insertion Method (ZIM) is a proposed system design for patient safety related to PICC insertions; performed by optimizing and organizing the clinical approach. It aids in identifying the Ideal Zone for upper arm needle insertion with ultrasound guidance. The significance of a systematic approach is that it is reproducible, measurable, and as a result will reduce variation in PICC insertion practice. The ZIM combines known mechanisms for vascular access insertion site complications with a systematic measuring and ultrasound scanning process, to reduce the impact of site risk factors. The impact of thrombosis cannot be underestimated, as it will likely limit the future use of veins for life saving vascular access. This issue should not be ignored by hospitals or clinicians, in fact, systematic solutions like PICC Zone Insertion Method, should be explored and supported as part of a comprehensive approach to vascular access care.
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PICC Zone Insertion MethodTM (ZIMTM):
A Systematic Approach to Determine the Ideal Insertion
Site for PICCs in the Upper Arm
Robert B. Dawson
MSA, BSN, RN, CRNI, CPUI, VA-BC
Abstract
The consequences of random PICC practice can be serious and manifest as deep vein thrombosis, pulmonary embolism,
catheter related bloodstream infection, and post thrombotic syndrome. Risk factors related to site selection have been well es-
tablished for other central venous access devices, but not for ultrasound guided PICC insertion in the upper arm. The author
presents observations of upper arm PICC insertion designated by color zones to highlight the variability of PICC practice.
The author also details site risk factors associated with each color zone and proposes an ideal insertion location for upper
arm ultrasound guided PICC procedures.
The PICC Zone Insertion Method (ZIM) is a proposed system design for patient safety related to PICC insertions; per-
formed by optimizing and organizing the clinical approach. It aids in identifying the Ideal Zone for upper arm needle inser-
tion with ultrasound guidance. The signicance of a systematic approach is that it is reproducible, measurable, and as a
result will reduce variation in PICC insertion practice. The ZIM combines known mechanisms for vascular access insertion
site complications with a systematic measuring and ultrasound scanning process, to reduce the impact of site risk factors.
The impact of thrombosis cannot be underestimated, as it will likely limit the future use of veins for life saving vascular
access. This issue should not be ignored by hospitals or clinicians, in fact, systematic solutions like PICC Zone Insertion
Method, should be explored and supported as part of a comprehensive approach to vascular access care.
The PICC Zone Insertion Method (ZIM) is a systematic
approach to PICC insertion for the purpose of optimi-
zation of results and reduction in patient risk. It aids in
identifying the Ideal Zone (IZ) for upper arm needle insertion
with ultrasound guidance. The ZIM looks beyond common
PICC site selection practice; it reveals a specic pattern of
zones that offer various risks and benets for PICC insertion
and management. The ZIM utilizes musculoskeletal, skin, and
vessel characteristics that can be separated into red, green and
yellow zones. Like the trafc light system, the color of the zone
indicates whether or not a zone should be entered.
Observations of practice are presented to describe the benets
of the ZIM and the Ideal Zone for PICC insertion. This is a dis-
cussion of practice and a proposed methodology for selection of
PICC insertion sites in the upper arm. Clinical practice from the
author is reviewed as well as observations from other facilities
related to PICC insertion locations in the upper arm. Permission
was received to photograph and observe PICC insertion sites. The
prevalence of upper arm PICC insertion by zone color is present-
ed to highlight the variability of PICC practice. This is a proposed
system design for patient safety related to PICC insertions; ZIM
is a tool designed for the entire continuum of PICC practice to
include: assessment, planning, intervention and evaluation.
Signicance of ZIM
The PICC Zone Insertion Method provides an objective and
systematic method that should be reproducible. This is signi-
cant because it should allow for a more objective measurement
and association of PICC outcomes to insertion site. Patient safe-
ty is a reection of outcomes and events such as thrombosis,
infection, bleeding, and non-adherent dressings. The Joint Com-
mission explains that a patient safety solution is a system design
that can reduce harm from the care process.11 Therefore a safety
solution for PICC insertion practice should be consistent, mea-
surable, and reproducible in conjunction with known scientic
principles for risk reduction. The variance of PICC insertion sites
within a single vascular access team, or across the nation, leads
to unreliable correlation of outcomes related to upper arm PICC
site selection. The need to identify the relationship between com-
Correspondence concerning this article should be addressed to
rbdawson@me.com
DOI: 10.2309/java.16-3-5
SCHOLARLY
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MATERIAL
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plications such as thrombosis and infection with upper arm site
selection is vital to the future of vein preservation.
The incidence of upper extremity thrombosis related to PICC
insertion is an under-appreciated event; it is the next horizon of
clinical investigation in association with PICC use. Thrombosis
is serious regardless of lower or upper extremity vein origin, con-
sequences can include: catheter related blood stream infection
(CRBSI), pulmonary embolism (PE), post thrombotic syndrome
(PTS), and limiting the future use of vein pathways for life sav-
ing vascular access.2,3,4 Upper extremity deep vein thrombosis
(UEDVT) associated with PICCs is often sub-clinical, and as
such can occur without evaluation or intervention.2,3 The symp-
tomatic swelling or pain that often accompany DVTs is relative-
ly rare in comparison to the asymptomatic prevalence.3 Vesely5
described that an accurate symptomatic PICC associated UED-
VT rate is around 4-5%. Asymptomatic thrombosis associated
with indwelling catheters is more difcult to quantify with rates
ranging from 29%-72%.2 Lobo et al.6 reported a PICC associated
venous thromboembolic event rate of 5.10/1000 catheter days.
Shah et al.2 described reports of UEDVT complication rates for
pulmonary embolism at 36%, and post thrombotic syndrome as
high as 90%. Abdullah et al.7 also reported that PE rates could be
above 35% when associated with UEDVT in presence of a cen-
tral line. It seems the implications of PICC associated UEDVT
are not fully known or understood, but enough evidence exists to
suggest this issue should not be taken lightly when making deci-
sions regarding PICC site selection.
ZIM is a clinical procedure microsystem designed to utilize
ultrasound to account for the anatomy and physiology of the up-
per arm, in order to reduce risks associated with PICC insertion
and use. It provides a metric for documentation, evaluation and
comparison of site selection risk factors of the upper arm. The
value of objective site selection extends to consistency in practice
within a single vascular access team, and across the specialty eld
of vascular access. Consistent approach will lead to consistent
and reliable results. Furthering the methodological rigor of PICC
insertion practice will render greater condence in the use of
PICCs as a valuable, and sustainable vascular access resource.
Anatomy and Physiology of PICC Site Selection
Insertion sites have anatomical and physiological features
that make them better or worse for vascular access device in-
sertion. Complication rates associated with central lines can be
directly attributed to the insertion site.4,8,9 The three body sys-
tems primarily involved in site selection of the upper arm are
vascular, musculoskeletal and integumentary. All three com-
bine to provide a pattern of risks and benets as the vein paths
course toward the axilla. Risk or benet is derived from known
mechanisms for the most common and severe complications
associated with PICC site selection: thrombosis, infection, ar-
terial puncture and even nerve damage. The mechanisms for
complications should be taken into account when assessing the
main body systems involved in PICC site selection.
A common mechanism of Catheter Related Bloodstream
Infections (CRBSIs) is the migration of microbes through the
catheter skin junction into the bloodstream.4 Given this patho-
genesis of CRBSIs an ideal insertion site should have decreased
risk of catheter pistoning, microbial colonization, and breaks in
both skin and dressing integrity. The presence of body hair and
sebaceous glands increases microbial colonization.10 Moisture
and hair also impact the ability for a dressing to stay clean, dry,
and intact potentially impacting site colonization.11 Catheter
motion at the skin junction could serve to push microbes into
the venous system along the catheter tract. Finally, it is known
that excessive joint motion impacts dressing adherence and in-
cidence of catheter-associated complications.8,12,13
Site selection can impact the development of catheter re-
lated thrombosis (CRT). Stokowski et al.8 demonstrates this
when switching from palpation method to ultrasound guided
PICC insertion, a 9.3% symptomatic thrombosis rate without
ultrasound compared to a 2.1% rate with ultrasound insertion.
This is signicant because technology affects the site of inser-
tion for PICCs. Ultrasound allows for upper arm insertion far
easier than the vein palpation method. Hertzog and Waybill14
describe a study where the use of the cephalic vein for PICCs
had a 57% thrombosis rate compared to a 14% basilic rate, and
10% brachial rate. Vein path impacts site risks, especially when
comparing the supercial, anterolateral cephalic route to the
deeper, medial routes of the basilic and brachial veins.
Thrombosis is commonly attributed to the three principles of
Virchow’s Triad:
• Endothelial Trauma
• Changes in Blood Flow
• Changes in Blood Coaguability or Hypercoaguability
The exact mix of Virchow elements may affect the develop-
ment of thrombosis with varying signicance, however, this
predictive recipe is not known. The concept of a predictive
thrombotic mix has been termed “thrombotic potential”.15 The
potential to clot when a threshold is exceeded is the key to un-
derstanding and reducing the risk for upper arm catheter asso-
ciated thrombosis. The threshold once exceeded leads to more
clotting than the intravascular antithrombotic mechanisms can
handle.16 It seems that venous stasis does not necessarily lead
to thrombosis but once endothelial trauma and or inammatory
mediators are present blood stasis will contribute to thrombo-
sis, creating a more “prothrombotic” environment.15,16,17 Fur-
ther research to dene the exact variables by site, vein path,
and catheter/vein ratio is needed; so that clinicians can make
more purposeful decisions on site and catheter selections in or-
der to prevent thrombosis.
Joint movement and muscle exion contribute to catheter
motion, site trauma and endothelial damage.8 Endothelial
trauma occurs from the insertion process with needle punc-
ture, guide wire advancement, and dilator introduction.14 The
insertion procedure is traumatic and the more traumatic the
insertion, the greater the risk for thrombosis and possibly in-
fection.8,18 Stokowski et al.8 described a study where complica-
tion rates increased from 4% to 24% when multiple attempts
were needed, compared to just one attempt. Vein trauma can
be reduced by site selection, attention to detail, technology, pa-
tience, and clinician skill. The combination of them all will
lead to minimally traumatic procedures.
Blood ow is the physiologic feature that represents the sta-
sis element of the triad. Blood ow in the native state is opti-
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mized with certain characteristics. Blood ow should be:
• Increased with greater vessel diameter (4th power effect)
• Laminar
• Fastest in the center
According to Poiseuille’s (‘Pwa-swee’) Law of uid ow in
a closed tube (vein) more ow is achieved with larger diam-
eters.19 Applying Virchow’s Triad for risk reduction a clinician
should seek the most ow and the least disruption of ow as
possible. Poiseuilles’s Law also accounts for velocity of vessel
ow. Blood ow is slowest at the vein wall and fastest mov-
ing toward the center of the vein. Friction is created when uid
comes in contact with a stationary object like the vein wall,
causing ow to become more sluggish at the vein wall.19 Pass-
ing a catheter into the vein creates more resistance to ow when
the blood contacts the catheter surface. Turbulent ow is erratic
and usually should not be present except in very large veins
related to high ow rates.19 Turbulence could also be created
when laminar owing blood contacts the catheter surface. Total
catheter surface area impacts stasis and turbulence inside the
vein. Damage of the vein wall starts a coagulation cascade that
can be worsened with stasis and turbulent ow.3 In a simulated
model, Nifong and McDevitt20 demonstrate that ow in a ves-
sel could be reduced by 40%-93%, depending on the size of
the catheter and vein used, or catheter-vein ratio. Nifong and
McDevitt20 also note that the catheter-vein ratio will result in less
ow reduction as the vein increases in diameter moving proxi-
mally. A preventative thrombotic strategy would be to insert the
smallest PICC necessary, in the largest vein possible, and in the
most reasonably proximal zone. This should minimize catheter
impact on vessel ow as it relates to Virchow’s Triad.
Decreasing the impact on vessel ow as it relates to Vir-
chow’s Triad. Decreasing the impact of anatomical and physio-
logical features that inuence Virchow’s Triad is the foundation
of PICC risk management. In fact, by virtue of having a PICC
inserted two of the three principles of Virchow’s Triad are au-
tomatically satised: vein damage and changes in blood ow.
It is also likely all three Virchow principles have been satis-
ed if the patient has any number of co-morbidities, or reasons
for a PICC, which could include: infection, malignancy, renal
disease, diabetes, or is just dehydrated. The importance of risk
factor reduction in every step of the vascular access process is
supported by the synergistic effect of thrombotic risk factors.
Two risk factors do not just give twice the risk for thrombosis,
they may give six times the risk, or increase the risk by thirty
times, depending on the exact mix of variables.15 The most pre-
dictive measure of thrombosis risk is a previous thrombosis
event.15 Thrombosis is a direct risk factor for CRBSI, PE and
the viability of future vein access.4,7,14 Prevention and manage-
ment of thrombosis is vital to PICC practice.
Description of PICC ZIM
The ZIMTM was created as a result of this author consistently
assessing the upper extremity basilic and brachial vein paths with
ultrasound for the best insertion location and image. The vein
paths were correlated with musculoskeletal and integumentary
characteristics known or theorized to increase patient risk related
to vascular access. The basilic vein is the primary focus for inser-
tion as it is typically the largest and most direct vein path of the
upper arm. The cephalic vein, while still considered a last option
for PICC insertion, does not factor into the risk management ap-
proach of ZIM, given its higher complication rates, narrower vein
diameter, and tortuous path. An ideal location does exist for PICC
insertion at or above the medial mid-upper arm.
The ZIM is performed by dividing the medial upper arm
into three main color zones: red, green and yellow (Figure
1). The ideal target area for needle insertion is the upper half
of the Green Zone. The rst measurement is from the medial
epicondyle (MEC) to the axillary line (AL), this is the Total
Zone Measurement (TZM). The TZM is divided by three, to
form equal length color zones. The TZM will vary but is most
commonly between 20-22cm with an observed range from 18
24cm (Table 1). A TZM not easily divisible by three could
be rounded to the nearest number divisible by three. Because
nal determination of the needle insertion site is not based on
measurement alone, but in combination with ultrasound visu-
alization of the best vein image within the Green Zone (GZ),
the zone method provides some exibility so that decimals of a
centimeter will not impact ideal site selection.
The ideal area or zone is the most proximal half of the Green
Zone. It represents a width usually between 3-4 cm, and will be
one-half of the color zone measurement. Another way to quickly
nd the beginning of the Ideal Zone (IZ) is to divide the TZM in
half and this number will be the start of the Ideal Zone (Figure
2). The MEC is always the start of any measurement and is the
zero mark. The Red Zone (RZ) is the most distal zone, followed
by the Green and Yellow Zones. The RZ, as designated by color,
is not recommended for PICC insertion by this author, an expla-
nation is located in the Red Zone Characteristics discussion
section. The GZ starts when the RZ ends; this is an area where
the clinician should start the selection process for an ideal vein
image with ultrasound. The Yellow Zone (YZ) is the last zone,
Figure 1. This person has a 21cm Total Zone Measurement
(TZM), it divides into three 7cm zones to form the Red, Green
and Yellow Zones. The ideal basilic vein image was located at
12cm from the medical epicondyle (MEC), in the Ideal Zone.
Image by author.
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and the most proximal zone of the upper arm; it ends at the axil-
lary line. The YZ cautions that insertion in this area should be
carefully considered; do not venture too far into it. Each zone
will be described in detail corresponding to specic anatomical
and physiological features that are characteristic of it.
Red Zone Characteristics
The Red Zone or RZ starts at the medial epicondyle (MEC) and
extends one-third the distance to the Axillary Line. Most of the
RZ is comprised of a characteristic wedge of tissue. The wedge
angles inward as the wider aspect of elbow joint starts to narrow
to the circumference of the upper arm, ending approximately 5-
7cm above the MEC. This wedge of tissue, bone, muscle, nerves
and vessels is referred to as the Elbow Triangle (ET) by the au-
thor. It corresponds with rapid changes in arm circumference and
supercial vein paths coursing through the RZ. PICC insertion
can be more challenging and traumatic in this area, because of
the sloping and somewhat oblique path of the supercial veins.
The signicant veins for PICC insertion passing through the RZ
include the median cubital and basilic (Figure 3). They merge to
form a larger basilic vein near the end of the RZ (Figure 4). This
vessel communication does vary in distance from the MEC but
by the end of the RZ it is complete.
At times an area of ecchymosis is visualized just medial
and or inferior to the PICC insertion site in the ET. It is likely
that this, Elbow Triangle Ecchymosis (ETEC), is a result of
multiple attempts during the insertion procedure, and or with
post-insertion elbow exion (Figure 5). ETEC is a migrating
ecchymosis characteristic of vessel trauma, because as blood
seeps out of the vessel it pools inferior to the trauma, as a re-
sult of gravity. The Elbow Triangle is also an area of compres-
sion as a result of exion of the elbow joint. Tissue and muscle
compress in this area with elbow joint exion. The Brachialis
Anticus muscle located medial to the shaft of the humerus at-
taches above and below the elbow and assists in compression
of the vein path through the elbow triangle.21 Compression can
lead to catheter movement, bleeding, ecchymosis, and vein ir-
ritation (Figure 6).
Red Zone insertion can also alter blood ow related to catheter
insertion. A PICC inserted low in the RZ versus the Ideal Zone
will take up more space in the vein along the route to the superior
vena cava. As previously mentioned, Poisueille’s Law demon-
strates that changes in blood ow do occur in a tube related to the
Table 1.
Example Zone Measurements Observed in Practice
Total Zone Red Green Yellow Ideal Zone
Measurement Zone Zone Zone Needle
MEC-AL (cm) (cm) (cm) (cm) Insertion (cm)
21 0-7 7-14 14-21 10.5-14
24 0-8 8-16 16-24 12-16
18 0-6 6-12 12-18 9-12
20 0-6.7 6.7-13.3 13.3-20 10-13.3
Figure 2. Example of the color zones. Highlighted
in green is the Ideal Zone. Image by author.
Figure 3. Red Zone, merging of median cubital
and basilic veins. Image by author.
Figure 4. Red Zone, basilic vein after merging with
median cubital, and just before entering the GZ. Di-
ameter (A) = 6.2mm, Depth (B) = 4.3mm. Image by
author.
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size of the vessel and with resistance to ow created by a station-
ary wall or object.19 It is possible that with more catheter surface
area in the vein greater resistance, and obstruction to blood ow
will occur, creating a more prothrombotic environment.
Red Zone PICC insertion is the site that represents the most
risk for vein trauma both during and after the procedure. Fur-
thermore, the potential for blood ow changes related to catheter
surface area adds to the risk for thrombosis. Dressing adherence
can be impacted by joint motion. Bleeding can be exacerbat-
ed by ET compression and reduce the adherence of the sterile
dressing. The many risk factors associated with RZ characteris-
tics should prevent any clinician from considering this area for
PICC insertion when ultrasound technology is available.
Green Zone Characteristics
The Green Zone or GZ is the middle third of the upper arm.
A Total Zone of 21 cm would have a GZ located between 7cm -
14cm. The most important part of the GZ is the proximal half also
referred to as the Ideal Zone. A 7cm GZ will have an Ideal Zone
of 3.5cm in width, and located between 10.5–14cm. The basilic
vein path through the GZ is deeper than the RZ vein path. The
vein diameter will be larger as the basilic vein ascends toward the
axilla (Figure 8). Observations during procedures demonstrate the
basilic vein path in the ideal part of the GZ is unimpeded with
vein communications, easily visible, large, and stable compared
to the RZ.
The dening anatomical feature of the GZ is a large band of
fascia located in the mid-upper arm.21 The fascia of the mid-
upper arm corresponds with a transition to the Ideal Zone. The
signicance of the fascia is that it wraps the muscles and ves-
sels of the upper arm. It corresponds with deeper, larger cours-
ing basilic and brachial veins. Fascia applies tissue tension and
stabilizes the vein for needle insertion. The mid-arm fascia pro-
vides a more ideal needle insertion point. The advantage of the
mid-arm fascia may be less in emaciated or elderly persons be-
cause of muscle atrophy and loss of tissue integrity; however, it
still provides some vein stabilization not found in the RZ.
Brachial veins will also become larger in diameter as they
course toward the axilla but may have a more tortuous path as
they wrap around the brachial artery. Additional concerns for
brachial vein insertion in the GZ would be the proximity to the
median nerve.21 Careful attention to indentifying the brachial
bundle features of artery and nerve is necessary to avoid inser-
tion complications with the brachial veins. Valves still need to
be contended with but this is also true of the other zones.
The GZ skin surface has minimal amounts of hair, less mois-
ture compared with the Yellow Zone, and no direct compression
of the insertion site as seen in the ET. Biceps muscle exion
does provide tissue movement but direct compression of the
vein and PICC is not seen. The integumentary and musculo-
skeletal features of the Green and Ideal Zones also provide for
better dressing adherence and maintenance. The higher up in the
GZ the PICC is inserted the easier it will be to have the catheter
securement device adhere to the skin. Also, stabilizing the PICC
so it is parallel to the vein and muscle path allows for the dress-
ing to be compact and less inuenced by arm motion (Figure
7). It is possible that parallel positioning and securement of the
PICC with the vein and muscle will also reduce vessel trauma.
Yellow Zone Characteristics
The YZ is the upper zone or the most proximal third of the
upper arm. It starts at the end of the GZ and ends at the axillary
line. The basilic vein in the upper most third is large and will
increase in depth and diameter as it enters the axilla (Figure 9).
Merging of the basilic and brachial veins may take place in the
Figure 5. Red Zone, example of Elbow Triangle
Ecchymosis. Image by author.
Figure 6. Elbow Triangle compression and post-in-
sertion bleeding. Notice the dressing not adhering at the
edge. Permission Concord Hospital. Image by author.
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YZ before becoming part of the axillary vein. The skin here
is moist and usually has some amount of hair. Moisture in the
axilla will likely support more bacterial colonization compared
to the Green or Red Zones. Moisture from the axilla may also
impact dressing adherence. Movement of the arm related to the
shoulder joint may compress the catheter, vein and dressing.
The lower portion of the YZ as it connects with the ideal por-
tion of the GZ is still very characteristic of the GZ. On occa-
sion, this author has used the junction of the Yellow and Green
Zones for PICC insertion. The lower half of the YZ may still be
the best location at times for PICC insertion. However, extend-
ing too far into the YZ may have consequences related to ex-
cessive moisture and dressing maintenance. Caution is advised
when considering PICC insertion here.
The Procedure of Ultrasound and ZIM
Patient positioning is important when using the ZIM. The pa-
tient should be as at as possible, the head-of-bed between 0-15
degrees, the arm should be abducted 90 degrees, and externally
rotated. Position the patient so that the elbow joint is resting on
the bed. Often a patient will need to be in the middle of the bed or
more toward the opposite side depending on arm length. A real
helpful trick is to take a hospital towel, roll it up a few turns and
tuck the roll under the soft tissue of the medial upper arm. The
towel roll assists with arm stabilization, external rotation, and
creates a at plane of tissue for more ideal angles of insonance
when scanning. Towel roll stabilization facilitates needle punc-
ture and wire advancement with ultrasound guided insertions.
This is more important for patients with loose skin, muscle atro-
phy and obesity. The towel roll can be made larger or smaller to
accommodate patient characteristics, with the goal of providing
a level surface from which to scan and work. The rolled towel
makes the patients arm position and comfort easier to maintain.
If the patient can not be at than build the arm up with pillows to
create a at plane and still use the towel roll.
Once positioned, scan with ultrasound, starting in the mid
upper arm. Locate the brachial artery and median nerve: these
structures must be identied to avoid accidental puncture, but
they are also great landmarks from which to start a systematic
vein assessment. Next, identify the brachial veins near the ar-
tery and then move medially to locate the basilic vein. Follow
each vein path the length of the upper arm from the antecubital
veins to the axillary vein. Apply the ZIM measurements and
start working the GZ to nd the ideal needle insertion point.
Figure 7. Ideal Zone insertion at 12cm from MEC
with a Total Zone Measurement of 18cm. Permission
Concord Hospital. Image by author.
Figure 8. Green Zone basilic vein at 12cm from MEC,
increased depth (B) 5.2mm, and diameter (A) 6.5mm,
compared to RZ basilic vein. Image by author.
Figure 9. Yellow Zone basilic vein at 16cm from MEC,
increased depth (B) 8.3mm, but not diameter (A) 6.4mm at
this point, compared to IZ basilic vein. Image by author.
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Specically look for the best basilic vein image at or above
the middle of the upper arm. Corresponding skin and muscu-
loskeletal features that will allow for a at, dry area to secure
the PICC are essential. If visualization of the veins is difcult,
insert the probe into the axilla. Visualize the large axillary vein.
While keeping that image centered on the screen, move back
down the arm to reach the Ideal Zone. This author consistently
nds himself placing PICCs in the Ideal Zone usually between
12-15cm from the MEC. Total Zone Measurements will vary
but most adults fall between 20-22cm. This is a very narrow
range but extremely consistent.
Observations of ZIM Practice
Though ZIM principles have been well-dened only in the
past two years, this author has been using the principles of ZIM
for 6 years. In my practice, 40 PICCS have been inserted with
ZIM between February 2009 and October 2010. Reasons for line
removal and documentation of complications were reviewed
and likely included: arm edema, leaking, pain, blood cultures
from the PICC, or inadvertent line removal. In the 18-month
review period in which 40 PICCs were inserted, zero infections
or other complications were documented. The basilic vein was
used for 38 insertions and a brachial vein used twice. Each line
was removed because it was no longer needed. Some patients
went home with PICCs and once discharged they were treated
as if the line had been removed. The mean inpatient PICC dwell
time was 9.2 days, with a maximum dwell of 37 days and a
minimum of 1 day. All PICCs were inserted with the use of
ultrasound and a tip locating system.
Discussion of ZIM Practice
Signicant outcomes related to practice that could be
measured include: insertion complications, dressing adher-
ence, bleeding, thrombosis, line colonization, and CRBSI or
CLABSI events. This author cannot reect upon the presence
of asymptomatic thrombosis, but no documentation was dis-
covered that showed symptomatic thrombosis. A zero per-
cent symptomatic thrombosis rate is something to consider as
relevant compared to the 7% reported by Yacopetti3 and the
4-5% described by Vesely5. A 100% inpatient completion of
therapy rate is signicant. In my experience as a consultant
and clinician, an 88-90% successful completion of therapy rate
would be more likely. Nichols and Humphrey18 demonstrated
an 89.3% completion of therapy with ultrasound guided PICC
insertions. Stokowski et al.8 showed an 82.9% completion
of therapy rate. None of the 40 PICCs were cultured for sus-
pected infection, which may indicate that a specic insertion
site of the upper arm could inuence colonization of the PICC
through the catheter skin junction.
Observation of PICC Insertion Sites
The author observed the insertion location of PICCs in an
acute rehabilitation hospital located in the Northeast U.S. The pa-
tients at this facility are admitted from surrounding area hospitals,
many of which are large academic facilities. This hospital also
contracts with a PICC insertion service. A notation was made of
where the PICC was inserted on patients admitted to this facility
as opportunity presented itself. After six weeks, 33 PICC sites
were observed according to the ZIM color scheme (Table 3). The
Figure 10. Arm abducted, rolled towel supporting
arm. Measuring the Total Zone and dividing by three.
Image by author.
Figure 11. A 21cm TZM is divided into three 7cm
zones. Image by author.
Table 2.
Review of Individual Practice
PICCs Average Documented Max Minimum Completion
Inserted Dwell Complications Dwell Dwell of Therapy
40 9.2 days 0 37 days 1 day 100%
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goal was to obtain some measure as to the prevalence of insertion
by color zone. The results show that the majority of PICCs were
inserted in the Red Zone at 73%, and the fewest number were
inserted in the upper Green Zone or Ideal Zone at 3%.
A colleague from western Canada was intrigued by the ZIM and
after learning how to measure, and dene the zones, she observed
PICC insertion sites by the zone color scheme at her facility (Table
4). This was an observation done on a single day. The sample was
31, 23% Red Zone, 45% Green Zone (lower half) and 32% Yellow
Zone. Averaging the two sites together gives a Red Zone preva-
lence of 45% and a Green Zone prevalence of 32%. One out of
every 3 PICCs were inserted in some part of the Green Zone and
only 1.6%, or 1 out of 64 PICCs were inserted in the Ideal Zone.
Discussion of PICC Practice
The author’s observations of PICC insertion sites suggest that in-
sertion practice is highly variable, and that PICCs are often inserted
too low in the upper arm. More consideration should be given to
all insertion location risk factors. This may mean that more formal
education and training is needed in the use of ultrasound for vas-
cular access assessment. It may also mean that the minimum stan-
dard of quality for ultrasound machines in vascular access needs to
be increased. Ultrasounds for vascular access should provide for
reasonably effortless differentiation between an artery, vein, nerve,
and lymph vessel. All ultrasound machines used for vascular ac-
cess should be able to clearly dene vessel characteristics like:
path, size, ow, and the presence of echogenic material.
Ultrasound has revolutionized patient safety related to suc-
cessful and less traumatic PICC insertion, evidenced by reduced
complication rates and increased successful insertion rates,
with the latter ranging from 96-100%.8,18 However, evolution of
practice has uncovered that successful insertion is only one-half
of the PICC equation. Successful completion of therapy and the
measurement of asymptomatic UEDVT may be more compel-
ling measures to have a safe and quality PICC practice.
This presents two relevant questions:
1. Why is ultrasound use for vascular access not universal,
when it is a known signicant safety measure for access de-
vice insertions?
2. Why is PICC insertion practice so variable, given what we
know about site risk factors?
Figure 12. Ideal Zone, basilic vein identied at 12cm
from the MEC. Image by author.
Figure 13. Ideal Zone, image of basilic vein identi-
ed at 12cm from the MEC. Image by author.
Table 3. Observation of PICC Insertion Sites from
a Hospital in Northeast U.S.
ZONE PICCs PERCENT BY
INSERTED LOCATION
RED (RZ) 24 73%
GREEN (Lower GZ) 6 18%
IDEAL (Upper GZ) 1 3%
YELLOW (YZ) 2 6%
33 100%
Table 4. Observation of PICC Insertion Sites from a
Hospital in Western Canada
ZONE PICCs PERCENT BY
INSERTED LOCATION
RED (RZ) 7 23%
GREEN (Lower GZ) 14 45%
IDEAL (Upper GZ) 0 0%
YELLOW (YZ) 10 32%
31 100%
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These questions are important because patients at any given
hospital are typically members of that community, and there-
fore repeatedly seek care at the same facility. Repeated care in
combination with poor site selection with or without ultrasound
is a misguided application of practice. Veins are a limited and
precious resource for infusion therapy. Every reasonable effort
should be made to preserve veins through purposeful planning
and the use of appropriate technology. Lack of the systematic
use of ultrasound for PICC insertion is short sighted and a cost-
ly approach to vascular access care. It is not usually a single
measurable event that will impact the value of systematic vas-
cular access care, but the totality of all events over a longer
period of time. This reactive and episodic care common to vas-
cular access forgoes planning and system wide implementation
of safety solutions. In other words, the big picture is lost and
we simply solve one crisis at a time. Too often the catalyst for
real change in any care process is the result of a single senti-
nel event and not the result of proactive planning, assessment,
and intervention. Variations in vascular access practice must be
reduced with the use of ultrasound and systematic processes
that apply relevant evidence and theory to practice. Vascular
access clinicians can no longer wait for training to nd them or
for guidelines to be issued to address these concerns. Facilities
and clinicians must accept the challenge to fully support and
implement systematic vascular access programs and the use of
ultrasound technology.
Conclusion
The reduction of practice variation based on evidence and
clinical theory is necessary for patient safety. The PICC Zone
Insertion Method is a proposed clinical microsystem, and pa-
tient safety solution. It achieves safety by applying risk man-
agement strategies related to PICC site selection in a standard-
ized, reproducible, and measurable manner. Site selection is a
known contributor to CRBSIs, thrombosis, and phlebitis. The
future use of veins for life saving vascular access may very well
depend on decisions we make today when planning, assessing
and performing vascular access. This author has undergone
a purposeful exploration to rene and validate the principles
of the PICC ZIM. The observations are limited, but should be
meaningful enough to peak the curiosity of colleagues. Stan-
dardization based upon sound principles of practice is neces-
sary for meaningful outcomes measurement, which will take
PICC insertion to the next level of scientic inquiry. At the
very least we owe a great deal of professional obligation to use
technology and systematic care to the very best of our ability.
References
1. The Joint Commission. Patient safety solutions. Joint Commis-
sion Resources website. http://www.ccforpatientsafety.org/Pa-
tient-Safety-Solutions/. Updated 2008. Accessed June 2010.
2. Shah MK, Burke DT, Shah SH. Upper extremity deep vein
thrombosis. South Med J. 2003;96(7):669-672.
3. Yacopetti N. Central venous catheter-related thrombosis. J
Infus Nurs. 2008;31(4):241-248.
4. O’Grady NP, Alexander M, Burns LA, Dellinger P, Garland J,
Heard SO, et al. Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control and
Prevention (CDC). www.cdc.gov/hicpac/pdf/guidelines/bsi-
guidelines-2011.pdf. Updated 2011. Accessed May 15, 2011.
5. Vesely T. Management of catheter associated venous throm-
bosis. Topic presented at: 39th LITE Conference; March
2011;Washington, PA.
6. Lobo BL, Vaidean G, Broyles J, Reaves AB, Shorr RL.
Risk of venous thromboembolism in hospitalized patients
with peripherally inserted central catheters. J Hosp Med.
2009;4(7):417-422.
7. Abdullah BJJ, Mohammad N, Sangkar JV, Abd Aziz YF, Gan
GG, Goh KY, et al. Incidence of upper limb venous throm-
bosis associated with peripherally inserted central catheters
(PICC). Br J Radiol.2005;78:596-600.
8. Stokowski G, Steele D, Wilson D. The use of ultrasound
to improve practice and reduce complication rates in pe-
ripherally inserted central catheter insertions. J Infus
Nurs.2009;32(3): 145-154.
9. Miller DL, O’Grady NP. Guidelines for the prevention of
intravascular catheter-related infections: recommendations
relevant to interventional radiology. J Vasc Interv Radiol.
2003;14: S355-S358.
10. Stonecypher K. Going around in circles is this the best practice
for preparing the skin? Crit Care Nurs Q. 2009;32(2):94-98.
11. Dawson RB. Nursing beyond the “Process”: collegiality
and consultation improves outcomes by protecting the tissue
integrity of PICC insertion sites. JAVA. 2008;13(1):8-11.
12. Tripathi S, Kaushik V, Singh V. Peripheral IVs: factors af-
fecting complications and patency-a randomized controlled
trial. J Infus Nurs. 2008;31(3):182-188.
13. Bierman S. Mitigating the risks with zone defense. Manag-
ing Infection Control. 2003;37-41.
14. Hertzog DR, Waybill PN. Complications and controversies
associated with peripherally inserted central catheters. J In-
fus Nurs.2008;31(3):159-163.
15. Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep
vein thrombosis. Tech Vasc Interv Radiol. 2004;7(2):50-54.
16. Patel K, Feied CF. Deep vein thrombosis [Vascular Sur-
gery – Medical Topics]. The eMedicine Clinical Knowledge
Base website. http://phstw1p1.partners.org:2217/printtopic.
asp?bookid=6&topic=2785 Updated January 16, 2009. Ac-
cessed March 18, 2011.
17. Dickson BC. Venous thrombosis: on the history of Vir-
chow’s triad. Univ Tor Med J .2004;81(3):166-171.
18. Nichols I, Humphrey JP. The efcacy of upper arm place-
ment of peripherally inserted central catheters using bedside
ultrasound and microintroducer technique. J Infus Nurs.
2008;31(3):165-176.
19. Nave CR. Poiseuille’s law [Hyperphysics, Newtonian Fluids].
Department of Physics and Astronomy, Georgia State Univer-
sity website. http://hyperphysics.phy-astr.gsu.edu/hbase/pturb.
html#aor. Updated 2010. Accessed March 18, 2011.
20. Nifong TP, McDevitt TJ. The effect of catheter to vein ratio
on blood ow rates in a simulated model of peripherally in-
serted central venous catheters. Chest. 2011;140(1):48-53.
21. Gray H. The Classic Collectors Gray’s Anatomy. Pick TP,
Howden R, eds. New York, NY: Bounty Books;1977.
... 24 25 Nurse-led vascular access teams composed of specialised inserters have gained recognition in recent decades as an important mediator of improved PICC outcomes. 24 25 These teams adhere to evidence-based practices including ultrasound guidance during insertion, selection of catheter gauge and lumens according to the vessel size, insertion of the catheter in ideal sites using evidence-based techniques (eg, ZIM) 15 and ensuring optimal tip position, 26 thus leading to fewer complications, such as infection and thrombosis. 15 26-28 ...
Article
Full-text available
Background Little is known about peripherally inserted central catheter (PICC) use, appropriateness and device outcomes in Brazil. Methods We conducted an observational, prospective, cohort study spanning 16 Brazilian hospitals from October 2018 to August 2020. Patients ≥18 years receiving a PICC were included. PICC placement variables were abstracted from medical records. PICC-related major (deep vein thrombosis (DVT), central line-associated bloodstream infection (CLABSI) and catheter occlusion) and minor complications were collected. Appropriateness was evaluated using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Devices were considered inappropriate if they were in place for < 5 days, were multi-lumen, and/or were placed in patients with a creatinine >2.0 mg/dL. PICCs considered appropriate met none of these criteria. Mixed-effects logistic regression models adjusting for patient-level and hospital-level characteristics assessed the association between appropriateness and major complications. Results Data from 12 725 PICCs were included. Mean patient age was 66.4±19 years and 51.0% were female. The most common indications for PICCs were intravenous antibiotics (81.1%) and difficult access (62.7%). Most PICCs (72.2%) were placed under ultrasound guidance. The prevalence of complications was low: CLABSI (0.9%); catheter-related DVT (1.0%) and reversible occlusion (2.5%). Of the 12 725 devices included, a total of 7935 (62.3%) PICCs were inappropriate according to MAGIC. With respect to individual metrics for appropriateness, 17.0% were placed for < 5 days, 60.8% were multi-lumen and 11.3% were in patients with creatinine >2.0 mg/dL. After adjusting for patient and hospital-level characteristics, multi-lumen PICCs considered inappropriate were associated with greater odds of major complications (OR 2.54, 95% CI 1.61 to 4.02). Conclusions Use of PICCs in Brazilian hospitals appears to be safe and comparable with North America. However, opportunities to improve appropriateness remain. Future studies examining barriers and facilitators to improving device use in Brazil would be welcomed.
... A single-lumen 4-5 Fr midline catheter (from Amecath Medical Technologies US, Wilmington County, DE or from Medical Components, Harleysville, PA, both in the USA, or from Vygon, Ecouen, France) is then inserted under modified Seldinger technique alternatively in the basilic/brachial/cephalic vein (in the sequence of preference) at mid-arm (Dawson's green zone), stabilizing the catheter with a sutureless device at the end of the procedure. 21 The length of the MCs ranged between 20 and 25 cm, and after the procedure the malposition of the catheter in the ipsilateral IJV was ruled out by US. Instead, the catheter tip position (in axillary or subclavian vein) is not usually recorded in our clinical practice. ...
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Background: In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development. Methods: Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications. Results: A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications. Conclusions: MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.
... O procedimento é realizado à beira-leito e o enfermeiro tem autonomia de optar pela utilização do aparelho de US para auxiliar ou guiar a punção por meio de técnica de Seldinger modificada e micropunção (13) , pois ambos estão discriminados no protocolo. Para a escolha adequada do sítio de inserção, utilizou-se o Zone Insertion Method (ZIM), que divide o braço em 3 zonas: a primeira, tendo como ponto inicial o epicôndilo, é a zona vermelha, contraindicada para inserção devido ao maior risco de trombose e sangramentos; o terço médio corresponde à zona verde, sendo o local indicado para a punção com menores riscos de complicação; e a terceira, a zona amarela, abrange o final da zona verde até a linha axilar, onde a concentração de pelos e maior umidade gera potencial risco para a ocorrência de infecção e deve ser evitada (20) . ...
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8 de RESUMO Objetivos: analisar o custo direto médio do procedimento de inserção do PICC por enfermeiros. Métodos: trata-se de um estudo de caso único de abordagem quantitativa. A observação ocorreu em hospital público, coletando-se informações sobre insumos utilizados e tempo do procedimento. Para o cálculo dos custos, multiplicou-se o tempo pelo custo do enfermeiro somado aos insumos. Utilizou-se o dólar americano para apresentação dos cálculos. Na análise, utilizou-se a estatística descritiva de medidas de tendência central e de variabilidade. Resultados: a amostra correspondeu a 139 observações. O custo médio do procedimento de inserção do PICC totalizou US$286,04, sendo 90,8% dos materiais, principalmente cateter, e 9,2% da mão de obra. O procedimento durou em média 50 minutos, a US$0,26 o minuto do enfermeiro. Conclusões: o custo direto médio do procedimento de inserção do PICC foi US$286,04, com destaque para o cateter. Os resultados podem fundamentar decisões gerenciais para adequado dimensionamento material e profissional. ABSTRACT Objectives: to analyze the average direct cost of PICC insertion by nurses. Methods: this is a unique case study with a quantitative approach. The observation took place in a public hospital, collecting information on inputs used and procedure length. For the calculation of costs, time was multiplied by nurses' costs plus supplies. The US dollar was used to present the calculations. In the analysis, descriptive statistics of measures of central tendency and variability were used. Results: the sample corresponded to 139 observations. The average cost of PICC insertion totaled US$286.04, with 90.8% of materials, mainly catheter, and 9.2% of the labor. The procedure took an average of 50 minutes, at US$0.26 per minute for nurses. Conclusions: the average direct cost of PICC insertion was US$286.04, with emphasis on the catheter. The results can support management decisions for adequate material and professional sizing. RESUMEN Objetivos: analizar el costo directo promedio del procedimiento de inserción de PICC por enfermeras. Métodos: se trata de un estudio de caso único con enfoque cuantitativo. La observación se realizó en un hospital público, recolectando información sobre insumos utilizados y tiempo del procedimiento. Para el cálculo de los costos, el tiempo se multiplicó por el costo de la enfermera más los insumos. Se utilizó el dólar estadounidense para presentar los cálculos. En el análisis se utilizó estadística descriptiva de medidas de tendencia central y variabilidad. Resultados: la muestra correspondió a 139 observaciones. El costo promedio del procedimiento de inserción de PICC fue de US$286,04, con el 90,8% de los materiales, principalmente catéter, y el 9,2% de la mano de obra. El procedimiento tomó un promedio de 50 minutos, a US$0,26 por minuto para la enfermera. Conclusiones: el costo directo promedio del procedimiento de inserción de PICC fue de US$286,04, con énfasis en el catéter. Los resultados pueden apoyar las decisiones de gestión para un adecuado dimensionamiento material y profesional.
Chapter
In this chapter, we deal with vascular accesses in cancer patients, complications associated with those devices, and nursery care. Long-term venous catheters, especially tunneled catheters, are essential for cancer treatment, with wide applicability in various stages of treatment. In addition to enabling the infusion of drugs and blood products, they also allow the collection of blood samples for laboratory analysis, the monitoring of hemodynamic parameters, parenteral nutrition, and the performance of essential procedures for maintaining life, such as hemodialysis sessions. The indications and types of catheters are discussed, taking into account the time of use, the compatibility of the drug with the peripheral venous system, and the risk of infection. Most frequent complications and how to avoid them are also a subject in this chapter.
Chapter
Infections represent the most severe and most dangerous complication potentially related to venous access devices (VADs), in the pediatric patient (neonate, infant, child) as much as in adults. Any VAD implies a breakthrough of the defense barriers of the body, with the possibility of invasion of bacteria inside the tissues and into the bloodstream. Such invasion may happen through different routes, the most important being the so-called ‘extraluminal route’ (i.e., bacteria entering in the breech between the catheter and the surrounding skin, colonizing the external wall of the catheter and/or entering the bloodstream) and the so-called ‘intraluminal route’ (i.e., bacteria colonizing the internal walls of the catheter after entering through the infusion line, sometimes originating from contaminated solutions but more frequently through hubs and stopcocks). There is no such thing as a ‘sterile’ catheter: few hours after insertion any venous access device is already colonized. Bacteria and yeasts stick to the internal walls of the catheter producing a special glycol-protein medium (also containing lipids and nucleic acids), called ‘biofilm’, which acts as a matrix that includes and protects the micro-organisms. The degree of colonization may be low enough to be detected only by electronic microscopy; heavier colonization (or more massive mobilization of the bacteria from the biofilm) may be detected by microbiological methods, either direct (culture of the catheter after removal) or indirect (culture of blood drawn from the catheter). A massive colonization will be potentially associated with inoculation of a relevant number of micro-organisms from the device into the blood, eventually causing clinically detectable bacteremia and catheter-related bloodstream infection (CRBSI). Though central VADs are traditionally considered more prone to CRBSI, this life-threatening complication may occur also with peripheral VADs.
Chapter
After completing the maneuver of insertion, the securement of the catheter and protection of the exit site are of paramount importance for the optimal performance of the venous access device (VAD) and for the minimization of complications such as infection, catheter dislodgment and venous thrombosis.
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Insertion of Peripherally Inserted Central Catheters (PICCs) is potentially associated with the risk of immediate/early adverse events, some of them minimal (repeated punctures) and some relevant (accidental arterial puncture or nerve-related injury). Several strategies adopted during the insertion process may minimize the risk of such events, including late complication risks such as infection, venous thrombosis, or catheter dislodgment and/or malposition. This paper describes an update version of the SIP protocol (Safe Insertion of PICCs), an insertion bundle which includes eight effective strategies that aims to minimize immediate, early, or late insertion-associated complications. These strategies include: preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; appropriate skin antiseptic technique; choice of appropriate vein, adoption of the Zone Insertion Method™; clear identification of the median nerve and brachial artery; ultrasound-guided puncture; ultrasound-guided tip navigation; intra-procedural assessment of tip location; correct securement of the catheter, and appropriate protection of the exit site. This updated version of the SIP protocol includes several novelties based on the most recent evidence-based scientific literature on PICC insertion, such as the clinical relevance of the tunneling technique, the use of ultrasound for intra-procedural tip navigation and tip location, and the new technologies for the protection of the exit site (cyanoacrylate glue) and for the securement of the catheter (subcutaneous anchorage).
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Article
Background Multimodal research and guidelines recognize veins in the forearm used for peripheral intravenous catheter (PIVC) insertion can optimize dwell time. Yet, many PIVCs are still placed in areas of flexion or suboptimal locations such as the back of the hand causing premature failure of >50%. This study identified characteristics of the forearm cephalic vein that make the anatomical location highly successful for PIVC insertion. The goal was to increase the understanding of the human vasculature in association with fluid mechanics in veins above the wrist and below the antecubital fossa. Methodology A prospective in-vivo study with 10 consented healthy human volunteers (HHVs) was performed with Color Pulse Wave Doppler Ultrasound that captured high-resolution video and images of vein diameter, velocity of blood flow, and location of venous valves in the forearm. Results Forearm vein diameter was not directly correlated with higher or lower Velocity of Blood Flow (0.58 cm = 3.0 cm/s). However, Volumetric Blood Flow rates tended to be lower (2.51–8.28 mL/min) with Vein Diameters smaller than 0.29 cm. Ultrasound assessments and Volumetric Blood Flow calculations confirmed natural turbulence in blood and retrograde blood reflux correlated with venous valves opening and closing. Areas of turbulence, with pulse flushing, created backflow with retrograde blood flow around and into the catheter. Conclusions Placement of long PIVCs in the cephalic veins of the upper forearm yield adequate flow and hemodilution capacity for veins with at least a 3 to 1 hemodilution ratio. The data from this study, along with previous research, suggest that PIVC placement in the cephalic vein, based on selection criteria, may help to reduce or eliminate intravenous complications such as chemical or mechanical thrombophlebitis causing premature catheter failure. Application of these investigational principles may result in better outcomes and catheter longevity for patients who require intravenous infusions.
Article
Peripherally inserted central catheters (PICCs) are central vascular access devices inserted via deep veins of the arm, also useful in critical care settings. The purpose of this article is to offer to a critical care clinician with good skills in central venous catheterization, but who has limited experience on PICC catheters, the basic information on how the procedure is performed and how to minimize the risks of complications or failure of the maneuver. The main technical steps and the main precautions to be taken during PICC placement will be analyzed, with reference to the differences compared to central catheterization. Specifically, the pre-procedural phase and the intraprocedural main steps of the maneuver will be analyzed. A dedicated Vascular Access Team is considered useful and desirable by the current literature, but when the use of the PICC proves useful or even mandatory, the intensive care physician skilled in central venous catheters can transfer skills from central to peripheral catheterization.
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Hospital-acquired infections, which include bloodstream infections and surgical site infections, result in high rates of morbidity and mortality in the United States annually. Proper aseptic care of the skin prior to any skin breach is of paramount importance to reduce these outcomes. The application of the most appropriate skin preparation solution is significant but possibly not as important as the technique employed to apply the solution itself. Historically, concentric circles were the method of choice taught to nurses prior to any venipuncture. More recently, the back-and-forth friction method is being promoted. There is no evidence to support either method, yet effective reduction of infections is occurring. It is the intent of this article to address concerns for hospital-acquired infections and offer evidence-based suggestions to improve outcomes, as one method of skin preparation demonstrates greater efficacy.
Article
Background: Although many catheter-related bloodstream infections (CR-BSIs) are preventable, measures to reduce these infections are not uniformly implemented. Objective: To update an existing evidenced-based guideline that promotes strategies to prevent CR-BSIs. Data Sources: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. Studies Included: Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiological investigations. Outcome Measures: Reduction in CR-BSI, catheter colonization, or catheter-related infection. Synthesis: The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e. education and training, maximal sterile barrier precautions and 2% chlorhexidine for skin antisepsis). Conclusion: Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection. (Am J Infect Control 2002;30:476-89.)
Article
Peripheral intravenous access is a common but stressful pediatric procedure. Though in use for some decades now, there is no consensus on factors affecting the duration of patency and complications. The present study is a randomized controlled trial covering all aspects associated with vascular access. This prospective interventional study was conducted over a period of 6 months in a general pediatric ward of Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital. This sample was composed of 88 patients, from neonates to 12-year-olds who were admitted to the pediatric ward, on whom a total of 377 catheters were started. Intravenous cannulations were randomized for heparin flushes (1:100 dilution) and splints. Prospective data were collected regarding duration of patency and complications. Both univariate and multivariate analysis were done. There was a statistically significant increase in the duration of patency with the use of heparin flushes and splints. The incidence of phlebitis increased with heparin flushes. Shorter patency duration and increased complications were associated with younger age, wrist and scalp insertions, and 24-gauge catheters.
Article
Peripherally inserted central catheters (PICC) are increasingly used in hospitalized patients. The benefit can be offset by complications such as upper extremity deep vein thrombosis (UEDVT). Retrospective study of patients who received a PICC while hospitalized at the Methodist University Hospital (MUH) in Memphis, TN. All adult consecutive patients who had PICCs inserted during the study period and who did not have a UEDVT at the time of PICC insertion were included in the study. A UEDVT was defined as a symptomatic event in the ipsilateral extremity, leading to the performance of duplex ultrasonography, which confirmed the diagnosis of UEDVT. Pulmonary embolism (PE) was defined as a symptomatic event prompting the performance of ventilation-perfusion lung scan or spiral computed tomography (CT). Among 777 patients, 38 patients experienced 1 or more venous thromboembolisms (VTEs), yielding an incidence of 4.89%. A total of 7444 PICC-days were recorded for 777 patients. This yields a rate of 5.10 VTEs/1000 PICC-days. Compared to patients whose PICC was inserted in the SVC, patients whose PICC was in another location had an increased risk (odds ratio = 2.61 [95% CI = 1.28-5.35]) of VTE. PICC related VTE was significantly more common among patients with a past history of VTE (odds ratio = 10.83 [95% CI = 4.89-23.95]). About 5% of patients undergoing PICC placement in acute care hospitals will develop thromboembolic complications. Thromboembolic complications were especially common among persons with a past history of VTE. Catheter tip location at the time of insertion may be an important modifiable risk factor. Journal of Hospital Medicine 2009;4:417–422.
Article
Thrombosis related to central venous catheters is often underappreciated and misdiagnosed, despite its incidence and impact on patient morbidity and mortality. The purpose of this article is to offer a review of the literature, investigate the pathophysiology of the condition, and summarize the key points. Recommendations for the treatment and prevention of this complication are explored to help guide clinical practice.
Article
Catheter-related thrombosis is a common complication in all anatomic sites, especially when smaller veins of the upper extremity are considered. It is presumed that the presence of a catheter within the lumen of a vein will decrease flow and potentially create stasis, and clinical data suggest that the size of the catheter impacts thrombosis rates. We sought to determine, both mathematically and experimentally, the impact of catheters on fluid flow rates. We used fluid mechanics to calculate relative flow rates as a function of the ratio of the catheter to vein diameters. We also measured the flow rate of a blood analyte solution in an annular flow model using diameters that simulate the size of upper extremity veins and commonly used peripherally inserted central catheters (PICCs). We compared each of the derived relative flow rates to the experimentally determined ones for three cylinder sizes and found a correlation of r(2) = 0.90. We also confirmed that the decrease in fluid flow rate with each successive catheter size is statistically significant (P < .0001). Our results demonstrate that fluid flow is dramatically decreased by the insertion of a centrally located obstruction. Assuming that blood flow in veins behaves in a similar manner to our models, PICCs, in particular, may substantially decrease venous flow rates by as much as 93%.
Article
The risk of thrombosis related to peripherally inserted central catheters (PICCs) is a well-known complication. A study was conducted to compare thrombosis rates associated with the old technique of inserting PICCs by visualizing veins in the antecubital fossa, using anatomical landmarks and palpation versus using ultrasound guidance to locate veins in the upper arm. The findings from data collected on 538 patients included a significant decline in the thrombosis rates, as thrombosis decreased from 9.3% with the palpation method to 1.9% with the ultrasound method, and successful PICC placements by registered nurses increased from 76.9% when using the old method to 98.9% when using ultrasound guidance.