# A Novel Modified Ultrasound-Guided Venipuncture Technique for Non-Tunneled PICC Insertion in a Non-Operating Room Anesthesia (NORA) Setting: A Technical Report with Real-World Experience

## TL;DR

This paper introduces a modified ultrasound-guided technique for PICC insertion in non-operating room settings, aiming to reduce complications and improve patient safety.

## Contribution

A novel ultrasound-guided venipuncture technique for PICC insertion in NORA settings is proposed and validated with real-world clinical experience.

## Key findings

- The technique was associated with low early mechanical complications in over 5000 procedures.
- No cases of catheter-related deep vein thrombosis were observed during follow-up.
- The method enhances needle stability and procedural reliability in limited-resource environments.

## Abstract

Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided vascular access under conditions of limited resources and support, underscores the need for simple, reproducible, and inherently safe techniques. The objective of this technical note is to describe a modified ultrasound-guided venipuncture technique for non-tunneled PICC insertion, specifically developed for NORA settings, aimed at reducing procedure-related complications and preserving patient safety in routine clinical practice. Methods: The proposed technique consists of controlled intraluminal advancement of the needle tip (approximately 0.3–0.5 cm) under continuous ultrasound visualization, combined with progressive reduction in the insertion angle to achieve stable central intraluminal alignment before guidewire insertion. The technique has been applied in routine clinical practice across multiple Italian centers over the last two years, within a large multicenter real-world experience exceeding 5000 non-tunneled PICC procedures. Results: Based on real-world clinical observations, the systematic application of the technique was associated with a low incidence of early mechanical complications, including failed guidewire advancement, multiple venipuncture attempts, local pain, and hematoma formation. During standardized post-procedural ultrasound follow-up of the catheterized upper-extremity veins, no cases of catheter-related deep vein thrombosis were detected. Conclusions: This modified ultrasound-guided venipuncture technique represents a feasible and reproducible procedural refinement for non-tunneled PICC insertion in NORA environments. By enhancing intraluminal needle stability during guidewire advancement, it may contribute to improving procedural reliability and supporting patient safety in routine clinical practice. Further prospective and comparative studies are warranted to confirm these findings and define the generalizability of this approach.