The practice of putting in a PICC using a subcutaneous tunnel seems to be growing. Separating the venipuncture site from the skin exit site may have benefits such as moving the exit site out of the area of neck motion and possible reduction in bloodstream infection from skin organisms, although the evidence supporting infection reduction is not strong.
A small size PICC inserted in the jugular vein offers the benefits of bypassing the subclavian vein, a site with higher risk of vein thrombosis. This may be beneficial in -renal failure patients where axillo-subclavian thrombosis can present significant concerns.
But don’t confuse a PICC inserted with a short subcutaneous tunnel with a tunneled cuffed catheter (e.g., Hickman®, Broviac®). The subcutaneous tunnel for a PICC is much shorter than the subcutaneous tunnel for a tunneled cuffed CVAD. A tunneled cuffed CVAD has a cuff made of a rough material encircling the outer lumen of the catheter. This cuff is positioned several centimeters away from the skin exit site usually in the middle of the chest. The subcutaneous tissue grows into this cuff causing a mechanical barrier to the migration of skin microorganisms into the bloodstream. It also adds a form of stabilization to prevent dislodgement of the CVAD. A tunneled PICC usually does NOT have this cuff encircling the catheter. Long-term hemodialysis catheters also have this subcutaneous cuff. I am not certain how many brands of PICCs are made with this subcutaneous cuff, however I don’t think there are many.
A question I recently received asked about no dressing on a tunneled PICC after it has “healed”, citing the statement in the INS Standard. The statement from the standard on dressing changes is, “When the subcutaneous tunnel is well-healed, consideration may be given to no dressing with a tunneled, cuffed CVAD.” (page S83) It specifically states a tunneled, cuffed CVAD, and this does not apply to PICCs. This statement applies to the time required for the subcutaneous tissue to grow into the cuff. That time varies with each person and depends upon many factors. Once again, most PICCs are not made with these cuffs and a stabilization device and a dressing is required for all PICCs. Skin irritation and inflammation should be prevented by using a skin barrier solution from the very first dressing. This solution (e.g., Skin-Prep®, Cavilon®) are solutions to prevent this irritation, but they are not designed to heal the skin after the irritation is present. Medical adhesive related skin injury (MARSI) is discussed in several standards and the use of this barrier solution is strongly recommended.