Nurse-Performed Point-Of-Care Ultrasound-guided Peripherally Inserted Central Catheter Insertion: A Standardized Nursing Protocol

Summary

This article presents a standardized nursing protocol for point-of-care ultrasound–guided peripherally inserted central catheter insertion in adults, detailing vein assessment, real-time ultrasound-guided puncture, catheter advancement, and nursing decision-making to support safe and reproducible clinical practice.

Abstract

This article presents a standardized, evidence-informed nursing protocol for point-of-care ultrasound–guided peripherally inserted central catheter (PICC) placement in adult patients. Rather than serving as a validation study, this work provides a structured procedural framework that translates current best evidence into a reproducible, step-by-step approach to support safe and consistent bedside practice by trained nurses. The protocol is organized using an operational adaptation of the Indication–Acquisition–Interpretation–Nursing Decision-Making framework to guide both clinical reasoning and technical execution. It details ultrasound system preparation, patient positioning, infection prevention, ultrasound-based vein assessment, real-time ultrasound-guided venipuncture using the modified Seldinger technique, catheter advancement, and post-insertion tip verification strategies. Key technical elements including probe selection, image optimization, catheter-to-vein ratio assessment, and troubleshooting in technically challenging cases are explicitly defined. Nursing decision-making related to catheter maintenance, post-insertion care, and patient education is also integrated. By incorporating ultrasound as an extension of bedside vascular assessment, this protocol aims to reduce mechanical complications, minimize multiple puncture attempts, and improve procedural accuracy. This standardized approach promotes patient safety, reduces variability in clinical practice, and supports the implementation of ultrasound-guided PICC placement as an advanced, evidence-based nursing intervention across diverse healthcare settings.

Introduction

Venous access is a fundamental component of patient care across a wide range of clinical settings. However, establishing and maintaining reliable vascular access remains challenging, particularly among individuals with difficult intravenous access (DIVA). The type of vascular access device (VAD), clinical context, and patient-related factors influence the risk of complications, including extravasation, thrombosis, local and bloodstream infections, occlusions, and catheter rupture¹. In this context, the peripherally inserted central catheter (PICC) is recognized as a safe and effective option for medium- to long-term intravenous therapies, including the administration of antibiotics, vesicant and irritant drugs, parenteral nutrition, and chemotherapy². PICCs are inserted through peripheral venous puncture and advanced until the catheter tip reaches the distal superior vena cava, providing a flexible, radiopaque device available in multiple gauges, lumen configurations, and biocompatible materials³.

Point-of-care ultrasonography (POCUS) refers to the use of portable ultrasound at the bedside to support real-time diagnostic and procedural decision-making². During PICC insertion, POCUS enables direct visualization of vascular structures, facilitates differentiation between arteries and veins, and allows dynamic guidance of needle insertion and catheter advancement. Studies have demonstrated that ultrasound-guided PICC placement using the Seldinger technique achieves high procedural success rates and accurate tip navigation⁴. Ultrasound guidance reduces the number of puncture attempts, improves first-pass success, and minimizes the need for post-procedural manipulation⁵. In addition, it enhances procedural safety by reducing inadvertent arterial puncture, local trauma, and other mechanical complications⁶˒⁷.

Ultrasound-guided PICC insertion has been shown to be feasible and safe when performed by trained nurses and other healthcare professionals in acute and critical care settings, with low rates of immediate complications⁸˒⁹. Compared with traditional landmark-based techniques, ultrasound guidance is associated with lower failure rates, reduced risk of hematoma and arterial injury, and decreased incidence of severe thoracic complications such as pneumothorax and hemothorax⁶. Real-time vessel assessment also enables selection of catheter size based on vein diameter, reducing the risk of mechanical phlebitis and improving catheter longevity¹⁰˒¹¹. Furthermore, ultrasound use has been associated with increased patient satisfaction and reduced procedural anxiety⁶.

POCUS has increasingly been integrated into clinical assessment frameworks and is now considered an extension of the physical examination, complementing inspection, palpation, percussion, and auscultation¹². For nurses, POCUS enhances clinical reasoning and supports decision-making in vascular access planning and monitoring¹³˒¹⁴. Despite its expanding use, variability persists in training pathways, competency assessment, procedural workflows, and institutional credentialing practices. Developing proficiency in image acquisition, interpretation, vessel selection, and catheter navigation remains a challenge, particularly in settings without standardized guidelines or structured educational programs¹⁵.

Although international guidelines provide high-level recommendations regarding what should be achieved during ultrasound-guided vascular access, there remains a critical gap in how to operationalize these recommendations within a cohesive clinical workflow. Much of the existing literature focuses on isolated technical outcomes or device-specific metrics, without integrating real-time ultrasound interpretation with structured clinical decision-making²˒¹¹. Consequently, practice variability persists, as clinicians often lack a reproducible framework that extends beyond technical execution to incorporate systematic clinical reasoning.

Given the growing adoption of ultrasound-guided PICC insertion, there is a need to consolidate current evidence into a structured and reproducible approach that supports consistent clinical practice. However, the literature remains fragmented, with limited integration of procedural techniques, decision-making processes, and training considerations specific to nurse-performed POCUS. To address this gap, a standardized, nurse-performed protocol for ultrasound-guided PICC insertion that translates current best evidence into explicit, step-by-step clinical actions is presented. This protocol integrates ultrasound acquisition, interpretation, and nursing decision-making within a unified operational framework, supporting procedural consistency, patient safety, and reproducibility across diverse clinical settings.

Protocol

This study was approved by the Institutional Review Board of the Ribeirão Preto College of Nursing, University of São Paulo (CAAE No. 78296623.2.0000.5393). Written informed consent was obtained from all participants. All ultrasound images were collected and used with explicit authorization. This protocol follows an operational adaptation of the Indication–Acquisition–Interpretation–Nursing Decision-Making (I-AIN) framework¹⁶ to guide the step-by-step execution of ultrasound-guided PICC insertion and support reproducible nursing practice. The research tools, equipment and materials used in this protocol are listed in Table of Materials.

1. Pre-Insertion procedures and patient assessment

1. Ensure that two trained nurses are present.
2. Confirm the clinical indication for PICC placement.
3. Explain the procedure to the patient or caregiver.
4. Perform hand hygiene according to institutional protocol.
5. Position the patient supine.
6. Assess hemodynamic stability.
7. Apply a tourniquet for venous assessment.
8. Assess peripheral veins by inspection and palpation, identifying at least two potential access sites.
9. Prioritize vein selection: median basilic vein, basilic vein, cephalic vein, accessory cephalic vein.
10. Release the tourniquet.
11. Monitor patient comfort throughout the procedure.
12. Perform ultrasound assessment of the venous network.
13. Measure estimated catheter length (Section 5).
14. Measure arm circumference 2 cm above the insertion site.
15. Prepare and verify all required materials.

2. Ultrasound-based vein assessment (Acquisition)

1. Position the patient supine with head elevation between 0–15°.
2. Abduct the arm to approximately 90° with external rotation.
3. Support the arm using a rolled towel.
   NOTE: Arm stabilization improves image quality and needle visualization.
4. Place a linear transducer transversely over the mid-upper arm (Figure 1).
5. Identify the brachial artery and median nerve (Figure 2, Supplementary Videos 1, 2).
   CAUTION: Misidentification of vascular structures may result in arterial or nerve injury. Confirm vessel identity using compressibility testing and Doppler imaging before puncture.
   NOTE: Veins collapse with gentle pressure; arteries do not. Use Doppler to assess flow characteristics.
6. Select the basilic vein as the primary access site when suitable.
7. Apply the PICC zone insertion method (ZIM)¹⁷.
8. Target the proximal half of the Green Zone unless contraindicated by anatomical limitations.
9. Assess vein diameter, depth, patency, and presence of valves (Figure 3).
10. Select a vein that maintains a catheter-to-vein ratio <45%¹⁸.
    CAUTION: A catheter-to-vein ratio ≥45% increases thrombosis risk. Select an alternative vein or catheter size if necessary.

Figure 1: Ultrasound guidance planes for PICC venipuncture. Schematic and ultrasound images illustrating short-axis (out-of-plane, left) and long-axis (in-plane, right) approaches. The short-axis view displays the vessel in cross-section, whereas the long-axis view enables continuous visualization of the needle and guidewire along the vessel axis. Please click here to view a larger version of this figure.

Figure 2: Transverse ultrasound anatomy of the upper arm relevant to PICC insertion. Short-axis ultrasound image identifying key anatomical structures, including the basilic vein (BV), brachial veins (V), brachial artery (A), and median nerve (N). Please click here to view a larger version of this figure.

Figure 3: Ultrasound measurement of the basilic vein prior to PICC insertion. Short-axis ultrasound image demonstrating real-time measurement of the basilic vein diameter, with calipers positioned to assess the anteroposterior internal diameter. Please click here to view a larger version of this figure.

3. Ultrasound system preparation

1. Turn on the ultrasound device and select the vascular preset.
2. Use a high-frequency linear transducer (5–15 MHz).
3. Ensure adequate battery or power supply.
4. Prepare a sterile probe cover and sterile gel.
5. Position the ultrasound system on the ipsilateral side.
   NOTE: Optimize depth, gain, and focus before sterile preparation.

4. PICC selection and preparation

1. Select catheter type, size, and number of lumens based on therapy and vein diameter (Figure 4).
2. Prefer polyurethane catheters for high-flow requirements.
3. Identify high-pressure catheters by labeling or lumen color.
4. Select the minimum number of lumens required.
5. Confirm catheter-to-vein ratio <45%.
6. Prime all components with sterile 0.9% saline and check for leakage.
7. If trimming is required, retract the guidewire and cut using sterile scissors. Do not trim catheters with distal valves.

Figure 4: Peripherally inserted central catheter (PICC) with different lumen configurations. Representative image of PICCs with single-, double-, and triple-lumen configurations, including color-coded valved needleless connectors. Please click here to view a larger version of this figure.

5. Catheter length measurement

1. Maintain the patient supine with the arm abducted to 90°.
2. Measure catheter length: Right arm: insertion site → right sternoclavicular joint → third intercostal space ; Left arm: insertion site → left sternoclavicular joint → right sternoclavicular joint → third intercostal space
   NOTE: External measurements are estimates.
   CAUTION: Inaccurate measurement may result in catheter malposition. Confirm tip location using imaging.

6. Sterile preparation and barrier precautions

1. Verify all equipment and supplies.
2. Test ultrasound functionality.
3. Don cap, mask, and eye protection.
4. Perform surgical hand antisepsis.
5. Dry hands with a sterile towel.
6. Don sterile gown and gloves.
7. Prepare a sterile field (Figure 5).
8. Inspect sterile packages.
9. Open packages using aseptic technique.
10. Flush catheter and components.
11. Prepare catheter if trimming is required.
12. Maintain sterile handling of all materials.
13. Discard compromised items.
14. Apply maximal sterile barrier to the patient.
    NOTE: A second nurse assists with sterile setup.

Figure 5: Preparation of the sterile field for ultrasound-guided PICC insertion. Arrangement of sterile materials, including barrier precautions, antiseptic solutions, gauze, syringes, needleless connectors, guidewire and catheter components, securement devices, flushing supplies, and sterile instruments. Please click here to view a larger version of this figure.

7. Skin preparation and ultrasound-guided venipuncture

1. Apply sterile probe cover and gel.
2. Perform skin antisepsis using chlorhexidine solutions and allow drying.
3. Apply sterile drapes.
4. Administer local anesthesia (1–2 mL lidocaine).
5. Apply a sterile tourniquet.
6. Visualize the target vein in short-axis view.
7. Insert the needle under real-time ultrasound guidance (Supplementary Video 3).
   CAUTION: Maintain continuous needle-tip visualization to prevent posterior wall perforation and arterial injury.
8. Confirm intraluminal placement via blood return and ultrasound visualization.
   CAUTION: Failure to confirm placement may result in extravascular catheter insertion.
9. Release the tourniquet.
10. Advance the guidewire under ultrasound visualization (Supplementary Video 4).
    CAUTION: Do not advance the guidewire if resistance is encountered. Reassess position before proceeding.
11. Remove the needle while maintaining guidewire position.

8. Catheter advancement and securement

1. Advance the dilator and introducer over the guidewire.
2. Remove the guidewire as appropriate.
3. Advance the PICC to the predetermined length (Supplementary Video 5).
   CAUTION: Do not force catheter advancement. Resistance may indicate malposition or vessel injury.
4. Remove the peel-away sheath (Supplementary Videos 6, 7).
5. Confirm patency by aspiration and saline flush.
6. Secure the catheter using a stabilization device.
7. Apply sterile dressing (Figure 6).

Figure 6: Initial dressing after PICC placement. Sterile dressing applied immediately after catheter insertion, showing catheter securement and coverage with gauze and a transparent adhesive film. Please click here to view a larger version of this figure.

9. Catheter tip confirmation (Interpretation)

1. Track catheter progression using ultrasound (Figure 7).
2. Obtain chest radiography if needed.
3. Confirm tip location: Lower third of the superior vena cava (upper extremity) or upper third of the inferior vena cava (lower extremity)
   CAUTION: Incorrect tip positioning may result in thrombosis, arrhythmias, or ineffective therapy. Always confirm placement before use.

Figure 7: Radiographic confirmation of PICC tip position. Post-insertion radiograph demonstrating catheter tip location in an
anteroposterior chest radiograph after upper extremity insertion. Please click here to view a larger version of this figure.

10. Post-insertion care and nursing decision-making

1. Document all procedural steps.
2. Flush the catheter with sterile saline.
3. Inspect the insertion site daily.
4. Change dressings at recommended intervals.
5. Educate the patient on catheter care and complications.

Results

A successful application of this standardized protocol is characterized by clear ultrasound visualization of the target vein, real-time tracking of needle and guidewire entry, and smooth catheter advancement without resistance. Final catheter tip positioning is confirmed using radiography, ultrasound, or intracavitary electrocardiography (IC-ECG), depending on availability and clinical context.

The representative images provided in this manuscript (Figures 1–7) illustrat...

Discussion

Compared with traditional landmark-based methods, ultrasound-guided PICC insertion has clear clinical relevance because it enables direct vascular visualization, improves first-attempt success rates, and reduces mechanical complications⁷˒²³˒²⁴. This protocol structures nursing practice using an adapted Indication–Acquisition–Interpretation–Nursing Decision-Making (I-AIN) model¹⁶, providing a cohesiv...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
1 mL syringe and 13 × 45 mm needle	BD Luer Lock	9421	Syringe and needle for injection
10 mL syringe	BD Luer Lock	990172	Syringe for fluid administration
10ml syringe	BD Luer Lock	990172	1un for flushing
1ml syringe and 13 x 45 mm needle	BD Luer Lock	9421	1 un For anesthetic
Chlorhexidine solution	Riohex 0.5%	FDS039	Antiseptic solution for skin preparation
Device for sutureless fixation	Health Line	A14-04160	Catheter securement device
Device for sutureless fixation	Health Line	A14-04160	1un
Disposable surgical cap	Descarpack	93201	Disposable head covering
Disposable surgical mask	Descarpack	110601	Disposable face mask
Kit PICC catheter (Introducer needle, Guidewire, Dilator, Blade)	Health Line	A14-04160	01 un
Leaded glasses	Valeplast	CA. 40186	Protective eyewear
Leaded glasses	Valeplast	CA. 40186	1un
Local anesthetic (1 ou 2% lidocaine)	Xylestesin 2%	7.89668E+12	1un
Local anesthetic (1% or 2% lidocaine)	Xylestesin 2%	7.90E+12	Local anesthetic agent
Measuring tape	Premium	B0FX34MZ1C	Device for length measurement
PICC catheter kit (introducer needle, guidewire, dilator, blade)	Health Line	A14-04160	Complete catheter insertion kit
Sterile gloves	Sensitex	10092410023	Sterile hand protection
Sterile saline solution for flushing	Equiplex	47760	Sterile solution for catheter flushing
Sterile saline solution for flushing	Equiplex	47760	5un
Sterile surgical drape	Sorb Drape POLARFIX	F08273	Sterile barrier drape for procedural field
Sterile surgical gown	Shanghai Medplus Medical Supply Co., Ltd	CA 42.581	Sterile protective garment
Sterile ultrasound probe covers, latex-free (kit)	Mediss	B085ZL2MT2	Sterile cover for ultrasound transducer
Tablet	Samsung Galaxy	RX2X700EB6D	Device for image display and documentation
Ultrasound machine with high-frequency transducer	RC Medical - 3 in one	WXPCEDK002	Ultrasound system for vascular imaging