Download PICC line Troubleshooting

Peripherally Inserted
Central Catheter (PICC)
Trouble Shooting
Chantal Miljours, RN BScN
Clinical Nurse Educator
Diagnostic Imaging Department
North Bay Regional Health Centre
Objectives
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How and why PICC lines are inserted
Identify catheter occlusion and trouble shooting
methods
Identify potential causes for redness in PICC
arm and at insertion site
Air Embolism
Case Studies
Purpose of Central Venous
Access Device
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To infuse fluids (allows for large volume boluses)
No peripheral access
To infuse TPN
To infuse medications
To sample venous blood (when no peripheral access is
available)
To provide a method for hemodynamic monitoring i.e.:
right atrial and PA pressures(acute care setting)
Blood Vessels involved in Central
Venous Therapy
basilic
 cephalic
 axillary
 jugular
 subclavian
 innominate
These veins all lead
to superior vena cava
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Central Venous Access Devices
Port-a-Cath
Hickmann Line
Central Venous Access Devices
Short term central catheter
Peripherally Inserted Central Catheter
PICC Line Placement
PICC Line Placement
PICC Lines
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PICC lines are inserted as a
sterile procedure in the
diagnostic imaging
department
Both Ultrasound and
Fluoroscopy are used insert
the PICC line and confirm
proper placement
Insertion is performed by
specially trained nurses and
placement is confirmed by
the radiologists
STATS 2014
PICC lines 2014
356 PICC lines inserted
in 2014
140
120
100
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12% for TPN
39% Antibiotics
39% Chemotherapy
10 % other
80
60
40
20
0
TPN
Abx
Chemo
Other
Troubleshooting
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In 2014 we saw 149
patients for PICC line
troubleshooting
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Only 57% of these
patients required
thrombolytics
3% 1%1%
5%
9%
Declot
Difficulty Removing PICC
No Problem
PICC pulled out
10%
Cap changed
57%
3 cc syringe
Extra saline flush
Line Kinked
14%
CVAD Occlusions
There are 3 types of occlusions
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Complete
Partial
Withdrawal
Signs of a CVAD Occlusion
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Resistance when flushing
Sluggish flow
Inability to infuse fluids
Frequent occlusion alarm on infusion pump
Infiltration or extravasion or swelling or leaking
at insertion site
Inability to withdraw blood
Sluggish blood return
Complete Occlusions
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Inability to infuse or
withdraw blood or fluid
into the CVAD
Can be mechanical,
chemical or thrombotic
Withdrawal Occlusions
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Inability to aspirate blood but ability to infuse
without resistance
Lack of free-flowing blood return
Partial Occlusions
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Decreased ability to infuse fluids
Resistance with flushing and aspiration
Sluggish flow through the catheter
Can me mechanical, chemical, or thrombotic
Types of Thrombotic Occlusions
Intraluminal
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Often cause
complete catheter
occlusions
Develops from
blood build up as a
result of insufficient
flushing, inadequate
infusion rate, or
frequent blood
withdrawals
Fibrin Tail
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Fibrin adheres to
the end of the
catheter and causes
more cells to be
deposited on the tail
Acts as a one-way
valve: fluids can be
pushed out but with
aspiration the tail is
sucked back over
the opening
Mural
Fibrin Sheath
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Fibrin adheres to
the external surface
of the catheter,
creating a “sock”
over the catheter
Occasionally the
sheath covers the
end of the catheter
and causes
occlusion
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Occurs when fibrin
from a vessel wall
injury binds to fibrin
covering the
catheter surface
Caused by the
catheter rubbing in
the vessel, traumatic
insertion, or poor
blood flow
Dual-Lumen PICC (Navalist)
Fibrin Sheath Occlusions
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Fluid can usually be
injected, but blood
cannot be aspirated
Infiltration/extravasation
can occur when
medications are infused
up the fibrin sheath and
back to the insertion site
May cause mixing of
incompatible solutions
CASE STUDIES
Case Study #1: The Repeat
Offender
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69 year old patient receiving antibiotics through
the PICC line is sent to DI by homecare for a
withdrawal occlusion. This patient has been
seen multiple times in the past 2 weeks.
Chemical Occlusions
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Many PICC line
occlusions are caused by
a build-up of precipitate
from antibiotic or other
medications
Precipitate
Troubleshooting tips
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First determine there is no mechanical cause for
the occlusion
Assess for kinks, closed clamps, or change in
external length
Assess for clogged cap or if the cap is on too
tight (finger tip tight)
Assess for positional catheter:
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Reposition arm, have patient cough, put patient in
Trendelenberg position
The Art of Flushing
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Knowing how PICC
feels with flushing can
tell you what is
happening with PICC
Flush with 20ml Normal
saline turbulent flush to
each port after each use
May require daily flushes
depending on medication
i.e. Vancomycin
Troubleshooting tips
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Remove any add on
devices such as cap or yconnector and attempt to
aspirate and flush the
catheter directly at the
hub with normal saline
Consider changing the
dressing to ensure there
is no twisting/kinking of
the catheter
Troubleshooting tips
Once mechanical obstructions have been ruled
out:
 If no blood return on aspiration, may alternate
gently drawing back and then gently flushing
 Try using a dry 3cc syringe to aspirate blood
returns as it exerts less negative pressure when
withdrawing
 If still unable to get returns will require Cathflo
instillation.
 Consider radiography to determine malposition
of the catheter tip
Case #2: What Do You See?
Case #2
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Patient sent to ED with a blocked PICC line, home
care nurse unable to flush or get venous returns
Upon assessment in ED blood noted backed up in
catheter hub. Cathflo instilled overnight in ED for
complete occlusion.
Patient to return in am for follow up assessment in am
with DI Nurse.
Case# 2
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What is missing?
What is wrong with
this PICC?
Solution
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When questioned about the missing clamp, the patient
states “ the nurse cut it off because it was digging into
his skin”
Do Not Remove any clamps that is attached a CVAD
RISK OF AIR EMBOLISIM
Patient required new PICC line insertion
If unsure about type of CVAD device look it up or
consult with DI nurse.
CVAD 911 Emergency!
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Damaged PICC line,
hickmann line or any
central line
RISK FOR AIR
EMBOLUS
DVT
Air Embolism
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Venous air embolism can occur during time
CVC insertion, while catheter in place or at time
of removal
Air can easily get into vascular system when
needle or catheter open to atmosphere
As little as 200ml of air can be fatal
Signs and Symptoms
Air Embolism
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Sudden complaints of dyspnea
Respiratory distress
Coughing
Chest pain
Tachyarrhythmia's
Cardiovascular collapse
Treatment for Air Embolus
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Lay patient on left side
Trendelenberg position
100% oxygen
Call 911
Supportive measures ( i.e. fluid resuscitation)
Case #3 :What Do You See?
CASE: 3
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65 year old woman with breast cancer is
receiving chemo through a PICC line in the
right basilic vein
CT tech unable to get blood returns from PICC
Pt had states had a recent fall on the ice injuring
her right shoulder
Upon further exam noted distended veins
Case #3: Deep Vein Thrombosis
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The patient had an obstrutive DVT in her right
arm from the basilic vein to the subclavian vein
Sent to ER for treatment of DVT
PICC line pulled and reinserted after DVT
resolved
“70-80% of thrombotic events occurring in
superficial and deep veins of upper extremity are
due to the presence of intravenous catheters”
DVT
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An extraluminal thrombus can
progress to a deep vein thrombosis
(DVT)
Fibrin build-up from the vein wall
to the catheter may cause blockage
of blood flow in the vein
This can lead to SVC syndrome when the SVC is completely
occluded and venous return cannot
empty into the right heart to be
oxygenated
This is an emergency!
DVT
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Pt may experience
redness to arm localized
or can extend up arm
Swelling to arm or
hand(compare to non
PICC line arm.
May experience pain to
arm chest neck
No fever noted
Vein Measurement
Thrombus to Vein
Case Study # 4: The Quick Draw
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60 year old female with hx of breast cancer,
presented to ED with a fever .
Urine culture came back positive and admitted
to hospital for urosepsis and was started on
antibiotics
No blood culture drawn from PICC
PICC line pulled and tip sent for culture, came
back negative
Case # 4
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Patient starting to improve on antibiotics
A febrile now
Limited peripheral veins due to lymph node
involvement
Important to establish if patient has a true
Catheter Related Blood Stream Infection
(CRBSI) in order to decide whether to salvage,
exchange, or remove the catheter.
Systemic Antibiotic Therapy is
NOT required for the following:
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Positive catheter tip in absence of clinical signs
of infection
Positive blood cultures obtained through a
catheter with negative cultures through a
peripheral vein
Phlebitis in the absence of infection, the risk of
CRBSI usually low
CRBSI –catheter removal
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Severe sepsis
Hemodynamic instability
Endocarditis or evidence of metastatic infection
Erythema or exudate due to suppurative
thrombophlebitis
Persistant bacteremia after 72hrs of
antimicrobial therapy to which the organism is
suseptible
Difficult PICC line Removal
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This usually due to venous spasm
Sometimes PICC lines can be difficult to
remove especially if catheter too big for size of
vein
Ask patient to relax arm
Apply warm compress
After these measures the PICC line usually
comes out easily
Case #5:What do you see?
Contact Dermatitis
Dermatitis
 Dermatitis presents as reddened irritated skin at
the site
 Always allow antiseptic (ie. Chlorhexidine) to
dry completely before applying dressing
 Consider changing dressing to IV3000
 Consider changing antiseptic solution to
povidone-iodine solution
Case #6 :
What Do You See?
PICC Line Site problems
Infection vs Dermatitis
 Dermatitis presents as reddened irritated skin at
the site
 Infection presents as redness, swelling, warmth,
and possible purulent drainage at site?
 Does patient have a fever?
 Does patient have any swelling to arm?
What do you See?
PICC Line Infection
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Send to ER with signs of sepsis (ie. Fever, chills,
tachycardia, hypotension)
Rule out other sources of infection
Obtain cultures – draw blood culture from
PICC line (do not discard a waste sample) and
consider swab for C&S if site infection noted
Administer antimicrobials
Do not necessarily pull the PICC!
Prevention
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Good hand hygiene
Ensure to “Scrub the hub”
with Chlorehexidine for
minimum 30sec prior to
accessing devices
Wear sterile gloves and mask
(pt should wear mask as well)
anytime opening dressing.
Removal of unnecessary
CVC should be regularly
assessed.
Leaking at PICC site
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If leaking at site is
present when flushing or
infusing through CVAD
Send to DI for cathetero-gram (to rule out a
hole in the catheter)
Doppler studies (to rule
out thrombosis
Case 4: Pain in the neck
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A 59 year old man with a PICC line in the right
basilic vein presents with a withdrawal
occlusion.
Has also been complaining lately of a constant
“wooshing” sound in his right ear
The patient has been vomiting lately due to
chemo treatment
Chest xray done to confirm proper placement…
PICC line malposition
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PICC line must be removed and reinserted
If PICC pulled out more than 2cm from original
position, tape it in current position do not pull it
out completely
Do Not attempt to push catheter back into
position
Do not use PICC until tip placement confirmed
by chest X-ray
Cracked PICC
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If there is a crack or a hole present, determine
location
Fold catheter over on itself and cover with
tegaderm or other film dressing
Close catheter clamp if there is one
Send to hospital right away
Cap on TOO Tight
Crack more
visible with
cap on
Crack faintly
visible with cap
off
Prevent Damage to PICC
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Never put steri-strips over picc line, always
make sure they are underneath the line or on top
of white wing
Do not force fluid into PICC if resistance is met
Ensure clamps are open before attempting to
flush
Do not over tighten cap
Broken PICC
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If the end of the catheter
breaks off grab CVAD (to
prevent it from migrating
internally)
Fold catheter over, cleanse
catheter, tape securely to
arm, and send patient to
hospital right away with the
external portion of the
catheter
Monitor for air embolism
Broken PICC
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If catheter disappears inside vein:
Apply tourniquet to upper arm close to axilla
 Place patient in Trendelenburg position
 Call 911
 Monitor for air or obstructive embolism
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QUESTIONS ???