Ultrasound-Guided PICC Line Insertion

Pre-Procedural Preparation

The American College of Critical Care recommends following a systematic six-step approach for ultrasound-guided PICC line insertion that includes pre-procedural vein assessment, confirmation of patency, real-time needle guidance, and sequential verification of needle, wire, and catheter positioning 1
Maintain strict aseptic technique including maximal sterile barriers: hat, mask, sterile gloves, sterile body gown, large sterile drape covering the puncture site, sterile ultrasound probe cover with sterile gel 2, 3
Use a high-frequency linear ultrasound probe for optimal vessel visualization 4
Position yourself so the insertion site, needle, and ultrasound screen are all within your line of sight during the procedure 2, 5

Position the patient in Trendelenburg (head-down) position to increase venous filling and cross-sectional lumen of the target vein 6, 4
Minimize head rotation during internal jugular vein access to reduce arterial-venous overlap 4

Perform this assessment BEFORE prepping and draping to account for anatomic variability 1, 7
Use both short-axis (transverse) and long-axis (longitudinal) views to identify the vein and its relationship to the adjacent artery 8, 1, 7
Check for anatomic variations of vessels, which occur in a significant proportion of patients 4
Identify hypoplastic veins or underfilling due to hypovolemia 1, 9
Use color Doppler imaging and Doppler flow measurements to definitively differentiate venous from arterial vessels 8, 1, 7

Apply pressure with the ultrasound probe to test vein compressibility, confirming patency and excluding venous thrombosis 2, 3, 7
In patients with systolic arterial pressure <60 mmHg, the artery may also be compressible, potentially causing confusion 2, 3, 9

Hold the ultrasound probe with your nondominant hand while advancing the needle with your dominant hand 2, 3, 5
This allows optimal alignment of the ultrasound plane with the needle direction 2, 5
Constantly identify the needle tip during the entire approach to and puncture of the vein 2, 5
Use either short-axis/out-of-plane view OR long-axis/in-plane view for needle visualization 2, 5, 6

Use real-time ultrasound to confirm the needle tip is placed centrally in the vein before advancing the guidewire 2, 5, 6
Verify positioning in both short-axis and long-axis views 2, 6
Verify venous (not arterial) placement using ultrasound, manometry, or pressure waveform analysis to avoid arterial dilation or cannulation 4

After wire advancement, confirm correct guidewire position using both short-axis and long-axis ultrasound views 2, 5, 6
If the complete guidewire cannot be located in the procedural field, order chest radiography to check for wire retention in the vascular system 4

After placing the PICC over the guidewire, visualize correct catheter position using ultrasound in both short-axis and long-axis views 3, 5, 6

If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and immediately consult vascular surgery or interventional radiology 4