Critical Appraisal Essay on the Use of Peripherally Inserted Central Catheter (PICC)

This essay critically appraises the use of Peripherally Inserted Central Catheter (PICC) in relation to its maintenance and removal. It discusses the relevance of the VAD product and provides recommendations for clinicians.

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Written Assignment: Critical Appraisal Essay
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1ESSAY
Introduction- There are three common methods that are used for gaining an access
into the blood namely, arteriovenous fistula, intravenous catheter, and synthetic grafts
(Deshmukh & Shinde, 2014). Vascular access devices (VADs) are generally inserted into the
veins via central or peripheral vessels for analytic or therapeutic aims, such as central venous
pressure readings, blood sampling, medication administration, fluid administration, blood
transfusion, and total parenteral nutrition (TPN) (Biffi, Toro, Pozzi & Di Carlo, 2014). A
peripherally inserted central catheter (PICC), also referred to as a percutaneous indwelling
central catheter refers to a type of intravenous vascular access that is used for a longer time
period such as, prolonged antibiotic therapy, chemotherapy and/or total parenteral nutrition
(Touré et al., 2015). The selection of VAD should always be grounded on the preferences and
demands of the patients, the primary reason for inserting the line, the duration it is required to
remain inserted, and the skills and expertise of the operator (Argueta-Morales et al., 2014).
VAD have also been found to provide a route for the onset of healthcare associated
infections, in particular blood stream infection, or local infection (Bratton, Johnstone &
McMullen, 2014). The current work context requires frequent administration of intravenous
therapy (IV) that helps in delivering liquid substances into the veins directly. This
intravenous route of substance administration most commonly involves injections and/or
infusions. PICC can be stated as a long intravenous line, which is commonly used in
contemporary practice. This essay will elaborate on a particular VAD and will critically
appraise the use of the product, in relation to its maintenance and removal.
VAD product- The PICC device is a catheter that is inserted in the body,
percutaneously through the skin at a peripheral location (Chopra et al., 2014). The device also
extends to the posterior vena cava and is found to remain in place, within the vein, for several
days and weeks. This type of VAD was first described in the year 1975 and is considered as a
major alternative to the use of central venous catheters in the major body veins namely,

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internal jugular vein, femoral vein, and the subclavian vein. There is mounting evidence for
the association between jugular line and subclavian line placements with pneumothorax
(Chopra et al., 2014). The procedure of insertion of a PICC is typically conducted in the X-
ray departments and usually takes around an hour. The healthcare staff administer local
anaesthetics, with the aim of making the area numb (Itkin et al., 2014). The PICC insertion
procedure is alike to insertion of a drip into the arm. The only exception lies in the fact that
ultrasound is used for locating the large vein and the preparation time is lengthier, owing to
the method being a sterile process. Specialised x-rays are often taken in order to check the
location of the PICC.
According to Liu et al. (2015) insertion of the PICC is usually conducted via the
peripheral vein located in the arm, such as, the brachial vein, basilica vein, and the cephalic
vein. This is followed by its proximal advancement towards the heart, through other veins
that have larger diameter, until the time the tip of the line is able to rest on cavoatrial junction
or the superior vena cava. The VAD is generally inserted by physician assistants, radiology
assistants, physicians, nurse practitioners, respiratory therapists, and radiologic technologists.
Furthermore, insertion of PICC is a sterile process, however does not need the presence of
any operating room. While being conducted at bedside, it is imperative to form and maintain
an appropriate sterile field, throughout the procedure. This is achieved by typically requesting
the visitors to leave the patient room until complete insertion of the PICC, concomitant
with skin preparation for cleaning the site of device insertion in the patient (Kieran et al.,
2018).
Relevance of the VAD product- PICC is generally considered a comfortable VAD
option, in comparison to other form of needle sticks that are administered for delivering
medications and drawing bloodstream from the patients. Showing similarity with standard
intravenous therapy, PICC lines also allow infusion of specific medication into the

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bloodstream. Nonetheless, they are considered more durable and reliable than other
intravenous options (Sharp et al., 2014). They are also used for delivering greater volumes of
medications and fluids that are usually not tolerated by the tissues, when inserted through
standard IV. PICC lines are administer for a range of causes, characteristically amid patients
who are anticipated to require IV medication for a number of weeks. A PICC line is also
found to remain in the location for several months, or as long as there is no onset of infection
at the site of insertion of the line (Fallouh, McGuirk, Flanders & Chopra, 2015). Owing to the
fact that the bloodstream circulates in a rapid rate inside the large veins that are leading
towards the heart, the solutions and medicines hold a chance of getting mixed with the blood.
Insertion of PICC line prevents the potential damage that might occur in such cases.
A PICC line is often used under situations when the healthcare team fails to insert an
IV, notwithstanding repeated efforts. It might also be used to guard the blood vessels from
medicines that are scathing and could possibly damage the skin round an IV place, or result
in impending damage to the blood vessels, like in chemotherapy. Sharp et al. (2015)
conducted a research where they stated that PICC lines are also inserted with the aim of
preventing the patients from being stuck recurrently. One common example is the onset of
certain types of infections that daily require IV antibiotics for more than six weeks. While
most PICC are not removed hastily, if there are no signs and symptoms of infection, most
healthcare facilities allow standard IV to continue at the site, 3-4 days prior to its removal and
insertion of a new IV.
Despite the potential advantages that PICC offers over standard IV, some of the major
risk factors allied with the VAD procedure are bleeding, development of blood clot in veins
(thrombosis), abnormal rhythm of the heart, puncture of adjacent arteries and veins, infection,
and contrast allergic reaction (Sharp et al., 2015).

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Critical appraisal- A randomised controlled trial was conducted by Li et al. (2014)
among 100 chemotherapy patients to determine the long term impact of PICC placement with
the use of B-mode ultrasound. Results from the trial suggested that upon comparison with the
control group (blind puncture), the experimental group (PICC placement by BUMST)
demonstrated reduced rates of unplanned removal of catheter (4.0% vs. 18.7%; p = 0.02),
reduced incidence rate of venous thrombosis (0% vs. 8.3%; p = 0.037), decreased incidence
rate related to mechanical phlebitis (0% vs. 22.9%; p < 0.001), and an increase in the
incidence of catheter migration (32% vs. 2.1%; p < 0.001). Owing to the significant
reduction in the severity of contact dermatitis in the experimental group (p = 0.038), and
decreased maintenance costs (p < 0.05), it can be stated that the authors were accurate in
demonstrating the effectiveness of PICC line over blind puncture method (Li et al., 2014).
However, more effectiveness of PICC line insertion over blind puncture was not in
accordance with the results of another study by Patel et al. (2014) that compared PICC with
port-chamber catheters that were subcutaneously inserted in patients who were subjected to
chemotherapy for the treatment of non-haematological malignancies. Upon randomly
assigning the patients to port and PICC, it was found that the port devices were associated
with lower complication rates, in comparison to inserted PICC lines (HR- 0.25, CI, 0.09–
0.86, P = 0.038).
This was concomitant with a decrease in the major rates of complication in the port
arm, in contrast to PICC arm, where 6% and 20% patients manifested complications due to
insertion (0.047 versus 0.193 major complications/100 catheter days, P = 0.034). Insertion
and maintenance of PICC was also found responsible for a noteworthy increase in onset of
thrombosis amid the patients (25% vs. 0%, P = 0.013). Hence, the study failed to demonstrate
the effectiveness of PICC as an intravenous device, which can be largely accredited to the

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low sample size and the preferences of the patients and physicians for the type of VAD that
was to be inserted amid the former (Patel et al., 2014).
However, Delarbre et al. (2014) stated that it is imperative to maintain PICC line for
avoiding mechanical complications, and also cited the need for providing adequate training to
the healthcare staff. Accidental removal of catheter was found among two patients, which
could have been avoided with the appropriate administration of occlusive dressing.
Furthermore, the authors also indicated that careful maintenance of the catheter and
introduction of a bidirectional valve are some of the key procedures that might prove
beneficial in averting PICC line obstructions. With the aim of evaluating the nature and rates
of complications that are associated with the insertion and withdrawal of Central Peripheral
Access Catheter (PICC or CVCAP), Lacostena-Pérez, Buesa-Escar and Gil-Alós (2018)
conducted a prospective observational study. Suspicion of infection (17.36%; 15.2 per 1000
PICC days) was the most commonly reported complication, followed by 6.25% confirmed
infections (5.5 per 1000 PICC days), 1.39% infections in ICU group (1.2 per 1000 PICC
days), and 4.86% infections in non-ICU groups (4.2 per 1000 PICC days). This helped in
establishing the fact that insertion of PICC line, in place of standard IV is more effective in
lowering the risks of implantation complications and does not require immediate removal.
This was in contrast with another study that was conducted with the aim of improving the
quality to reduce PICC associated complications. Upon the application of a Plan-Do-Study-
Act cycle, significant reductions were observed in the complication rate, followed by an
improvement in the rate of patient satisfaction. This proved operative in decreasing the
complication rate of thrombosis (67%), occlusion (75%), and use of alteplase (87%), besides
the absence of any infection occurrence during the study (Walters & Price, 2019). Thus, the
research was able to establish the fact that it is utmost essential to take care of the inserted
PICC line for preventing onset of major health complications.

6ESSAY
This was in accordance with another systematic review and meta-analysis by Ma,
Cheng, Ding, Li and Wang (2018) that illustrated the efficacy of the WeChat smartphone
application in self-management of PICC, following discharge of patients from hospitals.
Patient group receiving WeChat follow-up demonstrated reduced risks of complications
related to PICC (OR- 0.23, 95% CI- 0.19-0.27, P < 0.00001), enhanced ability of self-care
(mean difference: 36.41, 95% CI- 34.68-38.14, P < 0.00001), greater maintenance
dependency of PICC (OR: 4.27, 95% CI: 3.35-5.44, P < 0.00001), and a substantial
improvement in patient satisfaction (OR: 6.20, 95% CI: 4.32-8.90, P < 0.00001). Thus, an
analysis of the evidences discussed helps in establishing the fact that PICC can lead to
infections in the patients, if not maintained in an appropriate manner and should be
immediately withdrawn for averting further complications. Hence, proper PICC insertion and
maintenance is beneficial for patients, and any failure in doing so results in health
complications.
Recommendations- It is imperative for the clinicians to select a suitable intravascular
device (IVD), and take into consideration the type of the catheter, number of lumen, catheter
length, site of insertion, type of therapy, risk of difficulties together with infection, and other
patient factors. The insertion of this VAD must always be performed by competent staff
and/or training staff, under the supervision of experienced workforce, for minimising
infection and other healthcare complications (Sheth et al., 2014). Efforts must be taken by the
clinician for explaining to the patient, and their parent/guardian, the process and necessity for
catheterisation. Adequate control measures such as, closed door and pulled curtains must also
be taken, with the aim of eliminating several environmental risk factors that might worsen the
health condition of the patients (Bouaziz et al., 2015). Sterile occlusive dressings must be put,
during removal of PICC line, as a method of air embolism aversion protocol. Further
recommendations also involve setting up of sterile fields, proximately before any insertion

7ESSAY
procedure is carried out by the suitably trained juniors or clinicians. Performing ultrasound
will reduce the frequency of cannulation attempts. During PICC insertion, there trolleys
and/or carts having necessary medical supplies must be at close proximity. There is also a
need for the precise certification and record keeping by the clinician, in order to guarantee
patient safety, permit for audits, and trail occurrences of infection. The physicians must also
administer thrombolytic agents like Alteplase for declotting the PICC lines (Dougherty,
2014). The credentials should take account of the time and date of insertion, together with
category of VAD, name of operator, length of the line on addition and elimination, skin
preparation solution used, gauge, anatomical location, observation at site and device
replacement or elimination details (Yagnik, Graves & Thong, 2017). All clinicians who are
responsible for the addition and maintenance of VADs must guarantee that this is contained
by their scope of medical practice, governed by the individual’s authorisations, tutoring,
training, capability and maintenance of enactment at a predictable level of care and quality
(Department of Health, 2018). The scope of practice of the healthcare professionals is largely
reliant on the ability and aptitude of the health facility in which they are employed.
Conclusion- To conclude, defining fitting suggestions for the insertion, care, and
maintenance of PICCs is significant for patient protection. Vascular access refers to the direct
and rapid procedure of insertion or removal of chemicals and devices from the bloodstream
of patients. Vascular access is typically used in haemodialysis for removing blood of the
patient, for its filtration through a dialyser. PICC is a type of VAD that is inserted through the
veins located in the upper arm and helps in conducting essential medicines and nutrients
inside the body. Flushing the catheter at regular intervals, and changing the dressings form an
essential aspect of PICC insertion and its maintenance. Hence, adherence to the
recommendations and consideration of the scholarly evidences will deliver clarity for
supervision of composite situations before, during and after PICC insertion.

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