PICC Line Placement and Management

Guideline-Recommended Position

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend that the lower third of the SVC, cavoatrial junction, or upper right atrium are all acceptable positions for PICC tip placement 1
The Association of Anaesthetists of Great Britain and Ireland specifically recommends positioning the tip "in the lower superior vena cava (SVC) or the upper right atrium" 2

The inferior third of the SVC provides several clinical advantages, including preventing catheter migration, with this position increasing stability and reducing the risk of secondary malposition where the catheter can flip back into the innominate or jugular veins 1
The American College of Cardiology is not mentioned, however, the Annals of Internal Medicine states that this position minimizes cardiac complications, preventing pericardial tamponade while avoiding the slightly increased arrhythmia risk associated with deeper right atrial placement 3

Radiographic confirmation must be documented before using the line, with post-insertion chest X-ray verification being mandatory after blind bedside placement, according to the Annals of Internal Medicine 3
The tip should be confirmed to be parallel to the vessel wall on imaging, as recommended by the Association of Anaesthetists of Great Britain and Ireland 2

The MAGIC panel explicitly rated adjustment of PICCs in the lower third of SVC as inappropriate, according to the Annals of Internal Medicine 3
Repositioning should only be considered if the tip is in the upper or middle third of SVC, right ventricle, or if there are functional problems, as stated by the Annals of Internal Medicine 3

The American College of Radiology recommends that the catheter tip should be placed in the lower third of the SVC or in the upper right atrium to avoid injury to the endothelium of the veins 4, 5, 6, 7
The European Society for Clinical Nutrition and Metabolism guidelines state that the tip of a central venous catheter should be positioned in the lower third of the superior vena cava, or at the atrio-caval junction, or in the upper portion of the right atrium 8, 9

Positioning the catheter tip in the lower third of the SVC prevents cardiac tamponade and minimizes thrombosis risk, as indicated by the Clinical Nutrition guidelines 10, 11
The lower third of the SVC is an acceptable position for pediatric patients, according to the Clinical Nutrition guidelines 10, 11

Radiological confirmation of tip position is essential before using the line, as stated by the Clinical Nutrition guidelines 10, 11
The carina can be used as a landmark in adults and older children to position the catheter tip above the carina and reduce the risk of pericardial perforation 10, 11

A PICC line with the tip positioned in the inferior third of the SVC can be used safely for infusions, including parenteral nutrition, chemotherapy, and other therapies, according to the American College of Radiology and Clinical Nutrition guidelines 4, 7, 11
No repositioning is necessary if the catheter is correctly positioned in the inferior third of the SVC, as indicated by the Clinical Nutrition guidelines 11