PICC Line Insertion Technique: Step-by-Step Ultrasound-Guided Procedure

Ultrasound-guided PICC insertion using the modified Seldinger technique (MST) is the current standard of practice per INS 2021. When performed with maximal sterile barrier precautions and proper tip position verification, PICC insertion is safe, effective, and associated with low procedural complication rates.

This guide covers the complete insertion procedure from patient preparation through tip confirmation.

Parent guide: PICC Lines: Complete Clinical Reference

Pre-Insertion: Indication Confirmation and Patient Assessment

Before preparing equipment, confirm:

Clinical indication: Is the PICC still indicated? Apply MAGIC criteria — is the therapy duration ≥5–7 days, does the medication require central access, or is peripheral access inadequate? Document the indication in the insertion note.

Contraindication review:

ESRD or CKD Stage 3–5 → nephrology consultation required before proceeding
AV fistula or graft in either arm → absolute contraindication to ipsilateral PICC
Prior DVT in target vein → contraindicated; consider alternative
Active bacteremia/fungemia → defer until bacteremia controlled
Ipsilateral mastectomy with lymphedema → strong relative contraindication

Patient consent: Informed consent must be obtained and documented before proceeding. Review risks (DVT, CLABSI, mechanical complications, malposition) and alternatives.

Arm selection: Right arm → SVC approach is direct (right-sided drainage). Left arm → catheter must navigate the left subclavian to the SVC, slightly longer path, equivalent PICC outcomes. Basilic vein preferred (largest diameter, most medial, direct path to axillary vein).

Equipment Preparation

Catheter Selection

Device type: power-injectable PICC, valved or open-ended (per institutional formulary and clinical need)
Lumen count: determine based on concurrent infusion needs (single, double, or triple lumen); minimize lumens to clinical requirement
French size: 4 Fr (single), 5 Fr (double), 6 Fr (triple) — select smallest size that meets clinical need to minimize thrombosis risk
Length: most adult PICCs are 50–55 cm; use pre-insertion measurement to estimate required length

Supply Checklist (MST PICC Insertion Kit)

Ultrasound machine with sterile probe cover and sterile gel
PICC catheter with insertion kit (introducer needle, guidewire, peel-away sheath/dilator, extension set, stat lock securement)
Maximal sterile barrier (MSB): full-body drape, sterile gown, sterile gloves, surgical mask, cap
CHG-based skin antisepsis solution (2% CHG/70% isopropyl alcohol preferred)
Sterile saline flushes (10 mL syringes × 3–4 per lumen)
Dressing supplies: CHG-impregnated gel patch (preferred) or CHG-impregnated sponge, transparent semi-permeable membrane (TSM) dressing, securement device (StatLock or equivalent)
Tourniquet
Tape measure
ECG guidance system (if available) or post-procedure CXR order

Pre-Insertion Measurement

Accurate measurement prevents malposition. The goal is tip placement at the cavoatrial junction (CAJ) — lower SVC where it meets the right atrium.

Landmark measurement method (standard):

Place patient in supine position, arm abducted 90°
Identify planned insertion site (typically mid-upper arm, basilic vein)
Measure from insertion site → antecubital fossa → below clavicle to sternal notch → subtract 2 cm (right arm) or add 1 cm (left arm)

For right arm: Measure insertion site → shoulder → to sternal notch, then subtract 1–2 cm (varies by patient size; target is lower SVC, not RA)

For left arm: Same measurement pathway but the catheter must travel a longer path around the left subclavian/brachiocephalic junction; add 2–3 cm vs. right arm

Trim catheter to measured length. Record pre-trimmed and trimmed lengths in insertion note.

Site Preparation

Skin Antisepsis

Apply tourniquet to visualize and identify target vein with ultrasound
Release tourniquet
Apply CHG antiseptic solution to a large area of the planned insertion site (minimum 6–8 cm diameter)
Allow complete dry time: chlorhexidine-alcohol solutions require 30 seconds contact time and must be fully dry before needle insertion (typically 30–60 seconds drying)
Do not blot or fan to dry — let air dry completely

Maximal Sterile Barrier

MSB compliance is a required insertion bundle element:

Inserter: sterile gown, sterile gloves, surgical mask, cap
Patient: full-body sterile drape covering the entire patient except the insertion site window
Assistant/circulator: mask and cap
Sterile ultrasound probe cover applied by sterile technique

Insertion Procedure: Modified Seldinger Technique

Step 1: Ultrasound Vein Assessment

Before cannulation:

Apply sterile probe cover; use sterile gel on insertion field
Identify target vein (basilic preferred) in short axis
Confirm vein is compressible (differentiates from artery), non-thrombosed, adequate diameter (≥3 mm preferred for PICC placement)
Identify adjacent artery and nerve; map relative positions
Select insertion point (typically 2/3 of the way down the upper arm from shoulder to antecubital fossa)

Step 2: Venipuncture

Apply tourniquet
Using ultrasound guidance (short-axis or long-axis), advance introducer needle toward vein at approximately 30–45° angle
Visualize needle tip entering vein; confirm venous blood return
Flatten needle angle; advance slightly to ensure bevel is fully in vein lumen
Release tourniquet

Step 3: Guidewire Insertion

Advance flexible guidewire through introducer needle into vein
The guidewire should advance smoothly without resistance; resistance indicates extravascular placement, needle kinking, or valvular obstruction
Advance to appropriate length (typically 15–20 cm from insertion site)
Remove needle while maintaining guidewire position (never release guidewire)

Step 4: Dilator/Sheath Insertion

With a #11 scalpel or introducer tip, make a small nick in the skin at the guidewire entry site (to facilitate sheath insertion)
Advance the peel-away sheath/dilator unit over the guidewire with a twisting motion
Remove dilator and guidewire simultaneously while holding sheath in place
Immediately cover sheath hub with thumb to prevent air entry and blood loss

Step 5: Catheter Insertion

Advance PICC catheter through peel-away sheath
Advance to pre-measured length
Peel away the sheath by pulling tabs apart and away while advancing catheter (do not pull sheath back over catheter — peel it away laterally)
Confirm external catheter length matches expected measurement

Step 6: Lumen Aspiration and Flush

Aspirate each lumen to confirm blood return (brisk, dark venous blood)
Flush each lumen with 10 mL normal saline using pulsatile technique
Note: if blood return is absent, do not abandon the line yet — blood return absence may reflect malposition or fibrin sheath; proceed to tip confirmation

Tip Position Confirmation

The catheter must not be used for infusion until tip position is confirmed in the lower SVC at the cavoatrial junction.

ECG-Guided Tip Confirmation (Preferred)

Intraprocedural ECG guidance (e.g., Sherlock 3CG, PALMS system) uses the P-wave deflection pattern to identify the CAJ in real time:

A maximum upright P-wave indicates the catheter tip is at the CAJ
A P-wave that begins to invert indicates the tip has entered the right atrium — withdraw 1–2 cm
ECG guidance reduces CXR confirmation requirements at many institutions; confirm institutional policy

Post-Procedure CXR Confirmation

If ECG guidance is not available or inconclusive:

Order portable CXR immediately after PICC placement
Document tip position in insertion note once radiologist reads the CXR
Acceptable tip position: lower SVC, at or just above the cavoatrial junction
Not acceptable: RA, RV, SVC–RA junction (within RA), subclavian vein (too proximal), or any malposition (contralateral arm, IJ, azygos)

Post-Insertion: Dressing and Securement

Apply CHG-impregnated patch or sponge directly to insertion site
Stabilize catheter with securement device (StatLock or equivalent) — do not use sutures routinely
Apply transparent semi-permeable membrane (TSM) dressing over insertion site and securement device
Confirm dressing is dry, occlusive, and intact
Apply extension set to catheter hub; cap unused lumens with needleless connectors
Label dressing with insertion date, external length, catheter gauge/Fr, and inserter initials

Insertion Note Documentation

Required elements per INS 2021 and institutional policy:

Date and time
Indication for central access
Device type, brand, catalog number, Fr size, lumen count
Arm, vein, insertion site (cm from antecubital fossa)
Catheter length: external at insertion, trimmed length
Number of insertion attempts
MSB compliance: confirmed
CHG antisepsis: confirmed, dry time met
Informed consent reference
Blood return: confirmed all lumens
Flush: all lumens flushed without resistance or swelling
Securement and dressing type
Tip confirmation method and result (ECG with P-wave description, or CXR ordered/pending/read)
Patient tolerance
Inserter name and credentials

Troubleshooting Common Insertion Problems

Guidewire resistance: Do not force. The wire may be at a valve, entering a side branch (cephalic), or in an area of stenosis. Repositioning the arm (internal rotation, abduction, or asking patient to turn head toward the insertion arm) often resolves guidewire advancement issues.

Catheter stops at shoulder/subclavian junction: Withdraw 3–5 cm and ask patient to turn head toward the insertion arm while readvancing. Abducting the arm further may help. If the catheter consistently enters the IJ, withdraw to shoulder, turn head, and try again.

No blood return after insertion: Flush gently. If flush meets resistance, suspect extravascular malposition or collapsed vein — confirm with CXR before use. If flush meets no resistance but no blood return, may be positional; obtain CXR for tip confirmation and reassess.

Catheter longer than pre-measured length: Withdraw to correct external length and re-secure before tip confirmation.

Related guides:

Related policies:

References

Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standards 26–36). J Infus Nurs, 44(Suppl 1).
Moureau NL, et al. (2013). Evidence-based consensus on the insertion of CVADs. Br J Nurs, 22(Sup8):S4–S10.
Chopra V, et al. (2015). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Ann Intern Med, 163(6 Suppl):S1–S40.
Egan G, et al. (2012). Catheter tip position for PICC. J Vasc Access, 13(2):163–167.
O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).