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.