17/11/2021: The first PICC procedure
The first PICC procedure was implemented on 17 November 2021 by the PICC nurses in the Department of Cardiology in a specialized ward for procedures. Ketamine 10mg was intravenously administered to the patient prior to the procedure. Maximal sterile barriers and aseptic insertion techniques were strictly applied. The patient’s veins in the right upper extremity were selected. The desired length of the catheter was 21cm, which was measured from the veins in the patient’s right elbow to the distal to SVC. A peel-away cannula using a PICC size 24G from Vygon was utilized. After several attempts to access peripheral veins in the patient’s elbow, a successful venous access in the cephalic vein facilitated the threading of the catheter into the vein via the peel-away cannula and advancing to the SVC. When the catheter was threaded at above 17cm, an unknown pressure pushed the catheter back and prevented it from advancing into the SVC. No blood return was detected. Multiple cannula attempts with the position changes of the patient’s arms were made; however, the results were the same. A fifteenth cannula attempt was performed and the inserted catheter was 15cm in length, with blood return. The catheter tip was verified with X-ray. The tip location was confirmed in the right axillary vein near the beginning of the right subclavian vein. The cardiologist weighed the risks and allowed the catheter to remain indwelling. A heparin dose of 2U/ml was administered to flush the catheter. This procedure was performed without the support of high-resolution ultrasound or fluoroscopic venography with contrast. Figure 1 presents the catheter tip location of the first PICC procedure.
On 24 November 2021, the patient’s skin around the right clavicle bone was red and hotter than other areas. The cardiologist and the PICC team decided to remove the catheter. Physical assessment of the patient reported no signs of PICC-associated blood infection. Blood culture showed negative. A second PICC procedure was prescribed for ongoing intravenous nutritional therapy.