December 16, 2012
if you’re trying to decide between a picc line and a hickman/central venous catheter, i’m going to lay out a few of the pros and cons. obviously, this is just my opinion. because i had the cvc for 8 months and i’ve only had the picc for two months, my bias is probably going to really shine through.
a picc line is generally easier to insert and remove. i have a cuffed picc line, which means there is an interior cuff that prevents it from being pulled out. getting a tunneled picc line (a cuffed one) is rare and it requires interventional radiology to place the line. unlike a regular picc line, i’ll also have to return to interventional radiology to have it removed. if you have a regular picc, a nurse or doctor can pull the line while you’re in the office and doesn’t require a trip to the hospital. that said, a regular picc line can be dislodged fairly easily. alternately, the cvc is pretty hard to pull out, in part because they are always tunneled lines. i chose to get a tunneled picc because i have two 20-30lb dogs that unpredictably race across me when i’m laying on the couch. it would be really easy for them to pull my line out, especially when i’m infusing and there’s an iv tube dangling in a potential dog pathway. if you’re not going to have your line for very long, typically a picc is the preferred delivery system. if you know that you’re going to be a bionic iv med recipient for a long time, i would definitely go with the cvc, the longer term solution.
the chest catheter or cvc, is more sturdily placed. however, if it were to somehow be pulled out, you’re in for a big problem. the line enters the subclavian artery, which is a very large blood vessel with heavy blood flow, lots of pressure and direct access to the heart. if the line were pulled out unexpectedly, massive bleeding could occur. the picc line enters through a much smaller vein near the elbow (which is still large for a vein). veins receive blood after it has travelled a distance from the heart and do not have nearly the same amounts of pressure that arteries do. if a picc is dislodged, it’s most likely not going to be catastrophic. the potential for clotting or a clogged line is significantly higher with a picc than a cvc. though a clogged line feels panic inducing, the problem is general resolved by a trip to the hospital to have cathflo administered to clear the line. in some cases, they may need to remove the line.
you need to watch for signs of infection with both devices. there are two types of infections that can occur, one of the skin and one in the line. a skin infection can occur easily, especially if you’re chemically sensitive and are using harsh chemicals and adhesives to clean and dress the site. because your skin isn’t going to get a lot of air while you have either a picc or a cvc, if it’s irritated and you’re not working to resolve the redness and irritation, that can result in open wounds. any open wound makes you more susceptible to an infection. a skin infection, which does occur more frequently with picc lines, can lead to a line infection. speaking from experience, you do not want either of these, but you really don’t want an infection in your line. though i don’t know if bacteria entered my body through my cvc, i ended up with a blood infection that led to sepsis. this is the reason that i had my cvc removed and a picc line put in. signs of infection to look out for are: redness or swelling at the site, discharge from the site (after it has healed) and a fever. i had only one of these symptoms, a fever, which came and went, making it much harder for me to recognize that i had a rapidly progressing infection. i ended up in the hospital for a week with an experience that i wouldn’t wish on anyone.
so… if you suspect you may have any kind of infection, err on the side of caution and have a medical professional check you out. and really, preventative measures are the best defense. try to manage your insertion site before it becomes a problem. because they aren’t as caustic, i use betadine swabs instead of clorhexadine to clean my site. i wash that off with sterile water before putting on a biopatch and a foam statlock (the foam adhesive isn’t nearly as abrasive as a regular statlock’s). i change the types of window dressings that i use and sometimes i give my skin a very careful breather by covering it with 4×4 gauze and paper tape. i can’t recommend doing this though because it does leave you vulnerable to bacteria and infection. check with your doctor about safe protocols on how to give your skin a break if it does become irritated or painful.
i have to say, i hate this picc line. compared to a central venous catheter that enters through the chest, just below the clavicle, this line dangling from my left arm sucks. there was an adjustment period for the cvc (in my chest), but after a little while, i learned how to work around most of the difficulties i’d been having. showering was still a pain and often ended with a somewhat wet dressing, which meant that i had to change the dressing after the shower. during the summer, this wasn’t such a problem because every time i sweat, i had to swap out the old for the new. i live either in a humid forest or a sweltering concrete jungle. there was no shortage of sweat and i was often changing dressings every other day.
the picc line is easier to cover in the shower. i finally purchased a shower sleeve, a picc line arm protector from drycorp. it’s alright, but not totally airtight. if you bend your arm, which you’re probably going to do, it allows some water in. it’s also difficult to get on and cuts off the circulation to my hand. however, it’s a preferred alternative to using glad press’n seal and tape. there isn’t a cvc shower cover. if you have that, you either birdbath it or make a breast plate of saran wrap to try to seal it up so that water can’t get in.
i’m constantly irritated by my picc line. i can’t easily access it during the colder months because i’m wearing at least one layer with long sleeves. it doesn’t actually fit under shirts with tighter sleeves. the thumb clamp that keeps the line closed seems to pop open more frequently than my cvc did. this is just because the line sees more action, more movement and general jostling can open the clamp. the site on my arm is itchier than the site on my chest was. maybe that’s because of the dry weather and dry skin? that’s my best guess.
because of it’s location, the picc line in the arm requires more frequent dressing changes and unlike the chest catheter, it’s pretty much a two-person job. after a few months with the cvc, i was able to do my own dressing changes in front of a mirror. i prefer to use a tegaderm dressing to cover the insertion site because it’s gentler on the skin. unfortunately, the tegaderm isn’t as durable as other dressings and lately i’ve been using a sorbaview window dressing instead. the adhesive is stronger, which on one hand is great because the dressing stays in place for a longer duration. on the other hand, it’s more painful to take off, pulling out hairs and pulling off skin when it’s removed. the photo attached to this post is of my first attempt at changing my own picc dressing. i didn’t have anyone around to swap it out and thankfully, i was successful! it took me a long time to do it and i still couldn’t change the extension line (the extra tubing that allows me to access the line and do my own infusions). i was totally proud managing to change my own dressing. this was, of course, after 10 months of dealing with dressing changes in general, so i’ve had a lot of practice. no matter what device you’re changing the dressing on, be sure to use sterile procedure, taking care to wash your hands thoroughly and to clean the area surrounding where you place your sterile field.
i probably have a lot more to say about picc v. cvc, but i think this covers general bases. like i said, if you’re going to have the line for longer than a few months, i highly recommend going with a central venous catheter in your chest over a picc line in your arm. in the end, you should do your own research, figure out what you think you’ll feel more comfortable with and talk it over with your doctor. some practitioners don’t offer you a choice in which delivery method you’d prefer, but mine did. i’m glad that i had the cvc for those eight months and every time i flush my line or change my shirt, i long for that tube dangling from my clavicle. it felt so much less obtrusive to me. hopefully, my picc and i won’t be acquainted for nearly as long. and, because i have a macabre side, i have my old powerline cvc in a jar, a souvenir of my time with it. it’s not like i miss it that much.