Ultrasound placement of peripherally inserted central catheters (PICCs) in adults with cystic fibrosis

Chronic Pseudomonas aeruginosa infection occurs in more than 85% of adults with cystic fibrosis. Recurrent courses of intravenous antibiotics are required to treat pulmonary exacerbations and the establishment of reliable intravenous access is necessary. Administration of multiple courses of antibiotics may require the insertion of long line or central venous catheters. Totally implanted venous devices are reserved for patients where alternative access is not feasible.1Peripherally inserted central catheters (PICCs) are increasingly used for the administration of antibiotics and chemotherapy. Ultrasound has been reported to assist the successful insertion of PICC lines.2 We report our experience with the use of ultrasound to assist the placement of PICC lines where access has been difficult, using a standard technique via the antecubital fossa.

During the past 23 months a total of 124 PICC lines have been inserted in patients with cystic fibrosis (clinic population 110). In a subgroup of patients 22 placements of the PICC have been guided by ultrasound. The criteria for the use of ultrasound include inability to access the vein via the antecubital fossa by an experienced anaesthetist or ICU consultant; inability to advance the catheter due to venous obstruction; and no other viable venous access. The procedure was performed by an interventional radiologist and ultrasonographer with the catheter inserted in the basilic or brachial vein in the upper arm. Ultrasound was used to select which vein to access and was determined by vein position (not lying superficial or adjacent to artery), calibre (>2 mm diameter), and tortuosity (straight). The position of the catheter was confirmed by fluoroscopy.

We retrospectively reviewed PICC insertion utilising ultrasound. In all patients the PICC line was inserted successfully. The mean catheter dwell time was 17 days (range 9–51, median 14). No catheter sepsis, obstruction, or breakage have been documented and one localised thrombus within the axillary vein was detected 12 days after insertion (symptoms resolved completely on PICC removal). Venous access may be difficult in patients with cystic fibrosis who require regular antibiotic therapy. Infection, occlusion, or erosion through the skin may complicate totally implanted venous devices. Ultrasound guided placement of a PICC may be used as a bridge to the insertion of a totally implanted venous access device, but does require the expertise of an interventional radiologist and ultrasonographer.