DOI: 10.1097/ANC.0b013e318209b91c

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PMID: 21285657

Issn Print: 1536-0903

Publication Date: 2011/02/01


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The Use of Bedside Ultrasonography for PICC Placement and Insertion

Heidi L. Fidler

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Excerpt

In the neonatal intensive care unit (NICU), central venous access devices (CVAD), such as peripherally inserted central catheters (PICC), umbilical venous catheters, and central venous catheters, are frequently used for infants requiring mid-term to long-term duration of venous access or instillation of irritating fluids.1 Traditionally, landmarks, palpation, and visualization have been the methods used to determine the desired vein and insertion site, but in the past few years, multiple reviews encouraging the use of bedside ultrasonography (US) to assist in vein detection and evaluation have been published.2–7 This evidence-based practice brief will examine the current research and most recently published integrated reviews related to the use of bedside US during insertion and placement of PICCs and the learning curves associated with adoption of this technology.
In the 1990s, the shrinking size of US machines and their increased portability enabled nurses and physicians to use this technology at the bedside, while decreasing the need for transfers for acute patients requiring this technology.8 This increase in US portability encouraged research investigating bedside US use for PICC insertions in the adult and pediatric population. In the late 1990s, researchers began to publish data indicating positive outcomes associated with US use for CVAD placement (Table 1).9–12 More recently, these positive results, and successive studies substantiating them, have led to the endorsement of this practice by government agencies such as the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality.2,7
The use of portable US for CVAD placement in NICUs has been slower to be endorsed and adopted. This is likely because of multiple factors, including a historical lack of adequately sized US probes and the feeling that visual aids are not needed in patients whose veins are so easily accessible. With the advent of smaller and more appropriately sized probes and the growing understanding of all the benefits the US can provide, its use in the NICU setting for PICC insertion has began to increase.13
Potential for the benefits of US-guided PICC placement to translate from the adult and pediatric population to the neonatal and infant population is likely but has yet to be revealed through a randomized clinical trial.4,9,13 Critically important additional benefits could be realized if the increased PICC placement success rates seen in these other populations were repeated in the NICU patients. An increase in success rates would naturally lead to a decrease in the number of venous sticks required. This would also decrease the total duration of painful stimuli the infant would experience, a critically important event for a developing premature brain.14–16 The ability to visualize vessel size and valves would provide the clinician additional information to determine the most appropriate PICC insertion site. It would also provide better visualization of vessels that might not be less accessible, providing an increased number of vessels available for use. This increase in accessible vessels would provide more opportunities to avoid areas known to experience frequent movement, such as the antecubital region and other joints. The ability to choose optimal sites know to have less catheter movement is desirable, since catheter movement is known to be associated with mechanical phlebitis. Placement of more PICCs in areas other than joints would also lead to a decrease in the need for joint immobilization.5 These are just a few of the known and potential benefits.
It is important to realize that with all the benefits of US-guided PICC placement, there are some initial drawbacks, the first of course being the initial monetary outlay (Table 1). As with any new practice, there is a learning curve to overcome.

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