Peripherally Inserted Central Catheters | Copyright 2008 CEUFast.com

Course Contents

	Purpose/Goals    Objectives    Overview    Indications    Contraindications    Advantages    Disadvantages    Pre-insertion Teaching and Informed      Consent    Catheter Placement    PICC Line Site Care and Dressing Changes      Insertion Site Observation    Flushing    Blood Sampling from PICC Lines    Documentation    Complications        Insertion-Related Complications        Post-Insertion Complications    Patient and Caregiver Education    Discontinuation of PICC    References    Click any section in the index above to browse to the corresponding course section

Purpose/Goals

The purpose of this course is to educate healthcare professionals on the indications for and care and maintenance of peripherally inserted central catheters (PICC).

Objectives

After completing this course, the healthcare professional will be able to:

Overview

A peripherally inserted central catheter (PICC) is a central line that is inserted peripherally. The catheter is threaded through a large vein in the arm to the superior vena cava. The PICC is inserted by a specially trained RN or by interventional radiology. Site care and maintenance is performed by a professional nurse but the patient and/or family can be taught to do this to facilitate the patients care at home. The PICC should still be inspected by a professional nurse periodically (as established by your facilitys policy). Removal of the PICC should be done by a PICC line certified nurse.

PICC lines are available in single, double, and triple lumen catheters and are used when IV therapy is expected to last longer than two to four weeks (INS, 2000). Other indications for using a PICC include:

	the need for reliable access when limited venous access is available,
	delivery of hyperosmolar, vesicant, or irritating solutions (e.g. TPN, Vancomycin, dextrose 50%, 3% sodium chloride), and
	when there is a high risk involved in using a standard central venous catheter (CVC) (e.g. alterations in coagulopathy, presence of a tracheostomy, burns, radiation, surgical procedures or other injuries to the chest/neck).

Contraindications

Some contraindications for use of a PICC include:

	lack of a doctor's order,,
	lack of patient consent,
	inadequate vasculature,
	x-ray not available to verify placement,
	the presence of other intravascular devices within the vessel (e.g. pacemaker wires, a nonfunctioning port catheter, SVC filter), and
	extremities with AV grafts, lymphedema, contractures, or paralysis.

Advantages

Some advantages for using a PICC are:

	fewer insertion complications than other CVC approaches,
	less incidence of catheter related infection compared to other CVC approaches,
	requires fewer restarts than short term peripheral devices, reducing patient anxiety,
	less costly than other extended use devices or multiple peripheral devices,
	increased patient comfort and satisfaction,
	inserted by trained RN's (usually at the bedside) allowing for easier scheduling of the procedure, and
	decreased exposure of health care worker to needle stick injuries.

Disadvantages

Some disadvantages for using a PICC are:

	large bore catheter requires adequate vasculature in the anticubital region,
	vascular access device and dressing are visible,
	risk of malpositioning,
	requires availability of x-ray for placement verification, and
	requires specially trained personnel for placement.

Pre-insertion Teaching and Informed Consent

PICC insertion is an invasive procedure that is performed by a trained professional using sterile technique. It is essential to educate the patient and caregiver as well as obtain informed consent prior to insertion of the PICC. Patient education should include:

	explanation of why the PICC line is needed,
	alternative measures available,,
	description of the insertion procedure,
	potential complications involved, and
	patient and caregiver responsibility.

The patient's level of education and understanding should be evaluated and teaching should reflect these variables. Informed consent must be obtained prior to insertion of the PICC line. The form used should be facility specific according to organizational policy and be signed by the patient or a health care surrogate for the patient.

Catheter Placement

The most common sites for PICC insertion in an adult are the basilic vein, median cubital and cephalic vein. The insertion site is most often in what is referred to as the band of opportunity which extends from approximately two inches below the antecubital crease to approximately two inches above the antecubital crease. If the PICC has been placed by interventional radiology, it may be located higher in the arm, as the vessels located in this area can be found using fluoroscopy or ultrasound.

According to infusion nurse society (INS) standard #48, the distal tip of the PICC should dwell in the superior vena cava; catheter tip location shall be determined radiographically, and documented in the patients record prior to the initiation of the prescribed therapy (INS, 2000).

PICC Line Site Care and Dressing Changes

Many opinions exist based on numerous studies performed to identify proper site care and dressing change schedules for PICC lines. It is recommended that each organization institute a specific policy or procedure. The INS recommends that PICC line dressing changes should be performed using sterile technique at regular intervals. Dressings should be changed immediately if the integrity is compromised.

The Center for Disease Control and Prevention (CDC) recommends that transparent dressings can be safely left on peripherally inserted catheters for the duration of the catheter insertion without increasing the risk of thrombophlebitis. The CDC recommends the use of a transparent dressing that allows for easy evaluation of the catheter-skin junction. Gauze dressings are accepted in some facilities, but require more frequent changes due to decreased visibility of the insertion site. Many facilities are now using a chlorhexidine-impregnated sponge that can be placed underneath the occlusive dressing at the catheter-skin junction as an anti-microbial barrier. The use of such a patch allows for longer intervals between dressing changes and according to the INS (2000) reduces the risk for catheter colonization.

Insertion Site Observation

PICC line sites should be observed daily for visible signs of post-insertion clinical complications. Cellulitis, an infection of the subcutaneous tissue will generally present as erythema at the insertion site and should be addressed promptly to prevent bloodstream contamination. The area around the catheter-skin junction should also be observed for swelling, tenderness, drainage, or streaking which may indicate such problems as phlebitis and catheter sepsis.

Arm circumference at the insertion site should be measured prior to PICC line placement and recorded for future use to identify swelling that may not be accompanied by erythema. INS recommends that site measurement be obtained at regular intervals and suggests that it accompany dressing changes.

Flushing

Four major aspects of flushing are the type of solution, flushing frequency, volume of flushing solution used, and flushing method. While many studies have been done to determine a standard protocol for these issues, the results vary and should be determined by organizational policies. The most frequently used flush solutions are varying strengths of heparin and sodium chloride. Many studies have concluded that saline is as effective a flush solution as heparin. Some organizations use saline only, some use heparin, and some continue to use the S.A.S.H. method which incorporates both solutions.

Flushing frequency may range from every 8 to every 24 hours. Flush volumes vary between organizations. The most definitive guideline for flush volume indicated by the INS is at least twice the internal volume capacity of the catheter, which is normally 1-2ml per lumen and is frequently documented on the catheter itself.

The INS recommends a positive pressure flushing technique in which the flushing syringe is withdrawn while still injecting the flush solution. This technique is meant to prevent blood from entering the distal end of the catheter between uses. It creates turbulence in the line to prevent the formation of clots on the catheter wall. The syringe size most commonly used is 10ml or larger but should always be a minimum of 5ml. The above information includes recommended flushing volumes; however, you should always follow the policy of the organization where you work.

Blood Sampling from PICC Lines

Blood drawing from a PICC line is dependent upon the size of the catheter. It is most appropriate to draw from at least an 18Ga/4Fr lumen or greater. Blood should be collected via syringe following a flush-discard method per organizational policy. The discarded amount of blood should be of adequate amount to avoid laboratory error without compromising the patients safety per the INS. After collection of needed blood the line should be flushed to prevent occlusion. This again should be according to policy, but usually includes a saline flush of 10-20ml followed by a heparin flush.

Documentation

Documentation is critical as in all nursing practice. Remember the old saying if it is not documented, it was not done. PICC line insertion should be performed only after a signed informed consent is obtained and placed in the patients record. Documentation should be thorough and follow organizational policy. Appropriate lab values should be done prior to insertion (e.g. PT, PTT, INR).

There must be physician's orders for placement of the PICC line, to obtain x-ray for placement verification and an order stating the PICC line is cleared for use. It is important for the professional nurse to document:

	date and time of procedure,
	name of person who inserts the line,
	catheter information (e.g. manufacturer, lot number, # of lumens, size, internal and external length, length trimmed); many brands provide peel off labels for documentation,
	upper arm circumference,
	vein accessed,
	problems or complications encountered,
	x-ray confirmation of tip placement,
	catheter flushes,
	catheter is patent with good blood return, and
	dressing changes.

Complications

There are several complications that may occur related to PICC line insertion. Most complications listed are potential hazards with all vascular access devices.

Insertion-Related Complications

Catheter embolism occurs when a portion of the catheter becomes dislodged and travels within the vascular system. Catheter shearing may occur if the catheter is pulled back against the insertion needle or break-away introducer during insertion of the PICC line. The nurse should notify a physician immediately. An x-ray will need to be obtained to determine the location of the foreign body.

Arrhythmias may occur if the tip of the PICC line catheter or guide wire is advanced into the atrium or ventricle of the heart. Clinical manifestations may include the sudden onset of an irregular heart beat. The patient may complain of having chest pain or feeling a fluttering sensation in their chest. The nurse should notify a physician immediately. If the patient is stable, a chest x-ray should be obtained and the catheter tip should be retracted according to findings.

Difficulty advancing the catheter can occur due to a number of factors during the insertion process. A visual assessment should be done to determine possible causes. Venous spasm can be resolved by applying warm compresses prior to insertion or having the patient hold something warm during insertion along with other distraction or relaxation methods. Obstruction may be caused by narrowing of a vessel, a valve, or if a tourniquet was not removed. The tourniquet should be removed if it is the cause of obstruction. A valve may be opened by flushing with saline. If the vessel becomes too narrow a smaller catheter may be required. Incorrect positioning of the introducer or catheter may also restrict catheter advancement and should be resolved by repositioning the introducer.

Arterial puncture and nerve damage are also possible insertion related complications. Both are rare and can be minimized by correct assessment at the venous access site.

Post-Insertion Complications

Air embolism may occur when air enters the catheter during medication administration or tubing changes. The risk is greater with central lines due to negative intrathoracic pressure. Clinical manifestations may include mental status changes, cyanosis, tachypnea, drop in blood pressure, rise in heart rate, and central venous pressure. If this occurs, turn the patient on his left side and place him in a trendelenberg position, inform physician immediately, and administer oxygen as needed. Prevention may include:

	proper priming of all tubing prior to infusions,
	securing all connections, and
	changing solution containers before they run dry.

Post-insertion catheter embolism occurs when a damaged piece of the catheter becomes dislodged and travels within the vascular system. Clinical manifestations may include shortness of breath, signs of shock, mental status changes, or anxiety. The catheter can be severed when dressing changes are being preformed or may break during removal of the PICC line. If catheter embolism is suspected and there is a possibility that the fragment may still be in the arm the nurse should apply a tourniquet loosely to prevent venous flow and notify a physician. Prevention includes:

	proper priming of all tubing prior to infusions,
	scissors should not be used during dressing changes,
	catheters should not be pulled or stretched, and
	pressure should not be applied to the arm during removal of the catheter.

Thrombosis or blood clot formation is most commonly related to inadequate catheter maintenance; other causes may include vessel wall damage, dehydration, hypercoagulable states, or from irritating solutions. Clinical manifestations may include pain and/or edema in the neck or extremity, restricted patency of catheter including slowed infusion, or an inability to aspirate blood. The nurse should inform the physician. Thrombolytic agents may be required to dissolve the clot. Low dose coumadin is sometimes used throughout the catheter dwell time. Catheter removal is occasionally necessary. Local care may include the use of heat, elevation of effected extremity, and antibiotics. Prevention includes:

	maintaining adequate hydration,
	using approved flushing schedule and solutions,
	insuring adequate catheter tip placement, and
	encouraging normal but not excessive use of the extremity.

Phlebitis or inflammation of the vessel wall can result from mechanical or chemical injury as well as the introduction of bacteria through non-asceptic PICC care. Early-stage mechanical phlebitis (ESMP) is the proper term for phlebitis when onset is during the first 7-10 days after PICC insertion. Clinical manifestations may include erythema, pain/tenderness, mild to moderate edema, warmth, and streaking. If this occurs, inform the physician, apply cold compress initially to relieve discomfort and follow with warm, moist compresses to stimulate blood circulation, initiate frequent assessments of the entire extremity, document interventions and assessments, and provide thorough teaching to the patient and caregiver. Prevention includes:

	appropriate sterile technique during insertion,
	avoiding contact of the cannula with abrasive substances during insertion,
	slow, gentle advancement of the catheter,
	proper post-insertion site care, and
	frequent assessment of the entire extremity.

Signs and symptoms of chemical phlebitis will be similar to those of mechanical phlebitis but interventions will require removal of the catheter followed by the application of heat compresses. Prevention includes:

	monitoring solution dilution and
	monitoring infusion rate.

Infection or contamination of the PICC line by microorganisms may result due to several factors including improper use of sterile technique during catheter insertion or dressing changes. Other causes can be introduction of microbes via the catheter hub from contaminated equipment or infusate, cross-contamination from other infection sites, prolonged catheter dwell time, or migration of microbes from the skin. If undetected or untreated the infection may progress to septic shock. Clinical manifestations may include fever, chills, nausea, emesis, elevated white blood cell count, malaise, and confusion. Local symptoms at the site include erythema, edema, tenderness/pain, and possible purulent drainage. If this occurs, notify the physician. The PICC line should be removed. Orders for blood cultures, CBC, and catheter tip culture should be collected. IV antibiotics should be ordered and adjusted according to culture sensitivities. Symptoms should be treated accordingly including local site care. Prevention may include:

	sterile technique during PICC line insertion and dressing changes,
	following organizational policies regarding dressing and IV tubing changes, and
	proper handwashing techniques.

Catheter tip migration or malposition may occur due to improper anchoring of the catheter at the insertion site or the occurrence of frequent or extensive changes in intrathoracic pressure. Intrathoracic pressure may be affected by persistent coughing, vomiting, mechanical ventilation, or lifting heavy objects. Clinical manifestations may include difficulty infusing or aspirating from the catheter. The patient may complain of hearing a swishing or gurgling sound, or a sensation of pain may occur with irrigation or medication administration. If this occurs, inform the physician. An x-ray should be obtained to confirm tip placement. Repositioning the patient, power flushing, and other radiographic techniques are a few successful methods for repositioning the catheter tip. The catheter however may have to be removed if attempts to reposition are unsuccessful. Prevention includes:

	proper insertion technique,
	confirmation of tip placement following insertion,
	proper anchoring of the external device, and
	patient and caregiver education on activity limitations.

Patient and Caregiver Education

It is important to educate both the patient and the caregiver regarding possible complications with both the insertion and the post insertion of the PICC. Also teaching needs to be given regarding signs and symptoms that may occur and need to be reported to his/her healthcare provider. The patient and caregiver also need to be instructed on both the dressing of the PICC and proper flushing of the PICC. All teaching needs to be documented.
 

Discontinuation of PICC

The removal of a PICC line should be performed when ordered by a physician or when deemed necessary by a professional registered nurse. Only the physician or a specially trained nurse should remove the catheter. Prior to removal, the procedure should be explained to the patient. After removal of the PICC, a pressure dressing should be applied. The catheter length should be measured and compared to the recorded length in the insertion record. If the catheter is shorter than expected, it should immediately be reported to the physician so that a follow-up chest x-ray and physical examination can be done (see Catheter Embolism). Document the catheter removal.

References

http://www.bccancer.bc.ca/HPI/Nursing/References/NursingBCCA/PICC-TSGuide.htm

Alexander, M. & Corrigan, A. (2004). Core curriculum for infusion nursing (3rd ed.) Philadelphia, PA: Lippincott Williams & Wilkins.

Alexander, M. (2000). Catheter placement. Journal of Intravenous Nursing, 23, 42-43.

Nettina, S. (2001). The Lippincott Manual of Nursing Practice (7th ed.). Philadelphia: Lippincott.

PICC and Midline Catheters: Viable Vascular Access Options. (1999). Milner, GA: Lynn Hadaway Associations.