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A PICC, a tunnelled line or a port is put in by a trained doctor, nurse or radiologist under local anaesthetic, using an ultrasound scan to find the vein, full sterile precautions and a check that the tip sits just above the heart before it is used. Afterwards your breathing and blood pressure are checked, and you should say if you feel short of breath or have chest pain.
The insertion bundle is the same for all three devices and comes from infection-prevention and oncology guidelines. A checklist (SHEA 2022, moderate), hand hygiene, alcoholic chlorhexidine skin preparation (ESMO [I, A]; SHEA high quality) and maximal sterile barrier precautions with cap, mask, sterile gown and gloves and a full body drape (CDC Category IB; SHEA moderate); ultrasound-guided venepuncture (SHEA high; CDC IB, by trained operators); the fewest lumens needed (CDC IB); no systemic antibiotic prophylaxis (ESMO [I, A]; CDC IB). Avoid the femoral vein (ESMO [I, A]); ITAC 2022 asks for right-sided jugular insertion with the tip at the junction of the superior vena cava and right atrium to reduce catheter-related thrombosis (grade 1B).
ESMO asks for implanted ports to be placed under strict sterile conditions in an operating room [II, B], and for the tip position to be confirmed by intraoperative fluoroscopy or post-operative chest X-ray [II, B], with intracavitary ECG as an alternative [V, D]. Newer practice moves tip location into the procedure: NICE HTG368 supports an ECG-based tip confirmation system for PICCs in adults, avoiding a chest X-ray unless there is no P wave, and the Italian GAVeCeLT SIC-Port bundle (2026) adds ultrasound vein assessment, a preference for the axillary vein, ultrasound exclusion of pneumothorax, ultrasound tip navigation, intracavitary ECG or echo tip location, and pocket closure with intradermal sutures and glue. After insertion ESMO asks for four-hourly observations and a chest X-ray for breathlessness or chest wall pain [II, C].
Why: Knowing the veins and the clotting risk beforehand lets the operator choose a safe vein of the right size and avoid complications.
“Careful preoperative assessment is advised. This should include the patient's medical history, a physical examination and the appropriate laboratory and radiological tests (discussed below).”
Why: Checklists make it much more likely every step is done every time.
“In ICU and non-ICU settings, a facility should have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the time of CVC insertion (Quality of Evidence: MODERATE)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: Each extra lumen is another route for infection and clots.
“Use a CVC with the minimum number of ports or lumens essential for the management of the patient [65–68]. Category IB”
CDC/HICPAC 2011 · Category IB
Why: Groin lines carry more infection and clot risk, and a right-sided line with its tip in the right place is less likely to cause a clot.
“Catheters should be inserted on the right side, in the jugular vein, and the distal extremity of the central catheter should be located at the junction of the superior vena cava and the right atrium (grade 1B).”
International Initiative on Thrombosis and Cancer (ITAC), The Lancet Oncology 2022 · 1B
Why: Most early line infections come from skin germs carried in at insertion, and full barriers cut that risk.
“Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange”
CDC/HICPAC 2011 · Category IB
Why: Ultrasound means fewer attempts and fewer punctures of arteries or lung.
“Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: Trials have not shown that preventive antibiotics stop line infections, and they encourage resistance.
“Antimicrobial prophylaxis to prevent catheter colonisation, before insertion or during maintenance of CVCs, is not recommended [I, A]”
ESMO (Annals of Oncology) 2015 · [I, A]
Why: A port sits in a surgical pocket under the skin, so it is inserted with surgical sterility.
“Insertion of an implantable venous access device should be carried out under strict sterile conditions, in the operating room [II, B]”
ESMO (Annals of Oncology) 2015 · [II, B]
Why: A tip in the wrong place can cause clots, irregular heartbeats or a line that does not work.
“Catheter tip position should be verified radiologically with an intraoperative fluoroscopy, or a post-operative chest X-ray [II, B]”
ESMO (Annals of Oncology) 2015 · [II, B]
Why: These are the early signs of a collapsed lung, bleeding or a misplaced line.
“After the procedure, patients require 4 hourly observations including: temperature, pulse, blood pressure and respiratory rate. A chest X-ray is required if the patient has dyspnoea or chest wall pain [II, C]”
ESMO (Annals of Oncology) 2015 · [II, C]
Why: This position helps keep air from blocking the outflow of the heart while help arrives.
“Air embolism: immediately place the patient in the lateral decubitus head down position and deliver 100% oxygen [ 29 ].”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Insertion checklist (SHEA moderate), hand hygiene, alcoholic chlorhexidine (ESMO [I, A]; SHEA high), maximal sterile barrier precautions (CDC IB), real-time ultrasound guidance (SHEA high; CDC IB), fewest lumens (CDC IB), no antibiotic prophylaxis (ESMO [I, A]), no femoral site (ESMO [I, A]), right jugular with the tip at the cavoatrial junction (ITAC 1B), ports in a sterile operating environment (ESMO [II, B]) and confirmed tip position before use. On tip confirmation the sources differ by date: ESMO 2015 prefers fluoroscopy or chest X-ray [II, B] and rates intracavitary ECG [V, D], while NICE (2015, updated 2019) supports ECG-based tip confirmation for PICCs in adults and the 2026 GAVeCeLT bundle uses intracavitary ECG or echocardiography during the procedure instead of X-ray. ESMO also notes the open cephalic cut-down avoids immediate complications [IV, D], where newer bundles use ultrasound-guided puncture.
ESMO (Annals of Oncology) 2015 · CDC/HICPAC 2011 · SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · International Initiative on Thrombosis and Cancer (ITAC), The Lancet Oncology 2022 · NICE 2019 · Journal of Vascular Access (Brescia et al., GAVeCeLT) 2026
Where it differs: Eight steps: a systematic ultrasound survey of the neck and chest veins (RaCeVA), chlorhexidine 2% in 70% alcohol with maximal barriers, ultrasound-guided puncture preferring the axillary vein to avoid tunnelling over the collarbone, ultrasound to exclude pneumothorax, ultrasound tip navigation, tip location by intracavitary ECG or echocardiography with a bubble test, a pocket made by hydro-dissection over the pectoral muscle, and closure with absorbable intradermal sutures and cyanoacrylate glue. It also advises micro-introducer kits and a vein at least three times the catheter's diameter.
Evidence: A society consensus bundle drawn from the recent literature, adopted in GAVeCeLT training courses; not tested as a bundle in a trial.
Where it differs: Uses an ECG-based tip confirmation system during PICC insertion so the line can be used without a confirmatory chest X-ray; an X-ray is still needed if there is no P wave, as in atrial fibrillation.
Evidence: NICE found the case for adoption supported by the evidence, with cost similar to blind insertion plus X-ray outside intensive care and an estimated saving of 109 pounds per patient against fluoroscopy. ESMO 2015 graded the intracavitary ECG method [V, D].
Where it differs: Exposes the cephalic vein in the shoulder groove surgically instead of puncturing a vein with a needle.
Evidence: ESMO calls it the best approach to avoid immediate complications, graded [IV, D]. Newer guidance makes ultrasound-guided puncture the standard (SHEA high quality; SIC-Port).
ESMO (Annals of Oncology) 2015 · SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Journal of Vascular Access (Brescia et al., GAVeCeLT) 2026
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Avoid the femoral vein unless other sites are contraindicated “There is insufficient evidence to recommend a specific insertion site, but the femoral vein should be avoided unless there is a contraindication to the other sites (e.g. SVC syndrome), due to the increased risk of infection and concerns about thrombosis [I, A]” | [I, A] | ESMO (Annals of Oncology) 2015 |
| Chlorhexidine solutions with alcohol at insertion “Chlorhexidine solutions with alcohol should be used [I, A]” | [I, A] | ESMO (Annals of Oncology) 2015 |
| Alcoholic chlorhexidine for skin preparation “Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence: HIGH)” | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Maximum sterile barrier precautions during CVC insertion “Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence: MODERATE)” | Quality of Evidence: MODERATE | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Ultrasound guidance, if available, by fully trained operators “Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications.” | Category IB | CDC/HICPAC 2011 |
| No routine systemic antimicrobial prophylaxis before insertion “Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI [114].” | Category IB | CDC/HICPAC 2011 |
| Intracavitary ECG as an alternative to radiological tip confirmation “An alternative to radiologic confirmation is the intracavitary electrocardiogram (ECG) method, where arrhythmia is documented during insertion of the wire [V, D]” | [V, D] | ESMO (Annals of Oncology) 2015 |
| Open cephalic cut-down to avoid immediate complications “The open technique (cephalic vein cut-down) is the best approach to avoid the risk of immediate complications [IV, D]” | [IV, D] | ESMO (Annals of Oncology) 2015 |
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