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C-86
Nursing Practice Reference
Title:
CENTRAL VENOUS CATHETERS: CARE AND MAINTENANCE OF
PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCs)
Effective Date:
Sites:

June, 2012
 All
 AC
CN
Approved:
 CSI

FVC

VC

VIC
Other
Reason for Directive:
To provide guidelines for the care and maintenance of peripherally inserted central
catheters (PICCs).
These guidelines are used in conjunction with:
BCCA NPR C-90 Central Venous Catheters, Generic Directives
BCCA ST Policy III-80 CVC Placement/Patency Algorithm
H:\EVERYONE\nursing\Provincial Nursing Orientation\Step 2\BCCA Infusion Therapy
Education Program for Registered Nurses
H:\EVERYONE\nursing\REFERENCES AND GUIDELINES\BCCA Nursing Practice
Reference Manual\PICC Pt Info.doc
PHSA Hand Hygiene Policy
Certification:
•
To perform any procedure on a PICC the RN must have completed the BCCA
Infusion Therapy Education Program for Registered Nurses.
•
Certified RNs may carry out routine care for any PICCs, but are not responsible for
accessing power PICCs for power-injection of contrast.
•
Any patient needing power-injection of contrast will be cared for in Diagnostic
Imaging with the required equipment and by trained personnel.
*cap = Neutral Displacement Needleless Connector
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Index
Page(s)
Insertion/Removal
3
Features of Picks
3
•
Open–ended PICCs
•
Closed-ended PICCs
Patient Teaching
3
Preventing Infection
3
Accessing a PICC
4
Flushing and Locking
4
Exit site assessment
5
•
Phlebitis Scale
•
External Catheter Marking
•
External Catheter Length
PROCEDURES
Routine Flush and Cap Change
6
Initiating an Infusion
7
Completing an Infusion
7
Drawing Blood Specimens
8
Dressing Change
9
Management of an Occluded PICC
11
Repairing a PICC Line
13
Removing a PICC Line
15
References
16
Appendix 1: Patient Information Handout
18-21
Appendix 2: Post-Insertion PICC Care - First 24 Hours
22-24
Appendix 3: Post-Insertion PICC Care – AFTER the First 24 Hours
25-26
*cap = Neutral Displacement Needleless Connector
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Insertion/Removal:
•
A physician order is required for a PICC insertion and removal.
•
Only health care professionals who have successfully completed a PICC insertion
course may insert PICCs.
•
The catheter tip is ideally located in the lower third of the superior vena cava.
Confirmation of tip placement by X-ray is done at time of catheter insertion.
•
A PICC catheter can be removed by a CVC certified nurse upon physician order.
For more details refer to:
o BCCA NPR C-90 Central Venous Catheters, Generic Directives
o Removing a PICC under PROCEDURES below.
•
A PICC line that has migrated out should never be re-advanced as the external
portion of the PICC cannot be rendered sterile. Re-advancing the PICC would put
the patient at risk for infection.
Features of PICCs:
•
Single or multi-lumen. Each lumen of a multi-lumen PICC is treated as a separate
catheter.
•
Open–ended PICCs:
o The PICC is open at the distal tip (e.g. Bard PowerPICC®)
o The PICC requires clamping before entry into, or exit out of the system
o Clamps will be present on external portion of the PICC
o Requires weekly flushing and heparin lock when not in use
•
Closed-ended or Valved PICCs:
o A valve is present near the distal tip of the catheter (e.g. Groshong® PICC) or in
the hub of the catheter (eg. PAS-V® valve, or Bard PowerPICC Solo2®)
o Clamping is not required as the valve is closed except during infusion or
aspiration
o Clamps will not be present on external portion of PICC
o Requires weekly flushing with Normal Saline only, when not in use
Patient Teaching:
The Patient Information Handout is located in Appendix 1 p. 18-21
*cap = Neutral Displacement Needleless Connector
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Preventing Infection:
•
Perform hand hygiene per PHSA Hand Hygiene Policy before and after an aseptic
procedure, such as PICC care.
•
Sterile technique will be used when the following procedures are performed on a
PICC line: dressing change, removal of PICC, repair of PICC, and PICC insertion.
Aseptic no-touch technique will be used for all other PICC procedures.
•
•
To cleanse the connection between any PICC, *cap or IV tubing, use the 3-swabno-touch technique (refer to NPR C-90).
•
The gauze pressure dressing applied at time of insertion will be removed within 24 48 hours and replaced with a transparent semi-permeable membrane dressing.
•
If a PICC catheter is removed for suspected infection, the tip of the catheter must be
placed in a sterile container and sent to the lab for C and S evaluation.
•
If a catheter extension tubing set is present, it remains in place for the life of the
catheter and is considered a permanent part of the line. The extension tubing is
only removed and replaced in extreme situations that compromise patient safety or
line functioning. The new extension tubing is primed and prepared under sterile
conditions.
Accessing a PICC:
When accessing a PICC, (prior to blood sampling, initiating infusions or medications)
confirm PICC function by:
• Aspirating for brisk blood return, then
• Slowly injecting Normal Saline noting any resistance to flow.
o To prevent rupture NEVER use excessive force when flushing. The smallest
sized syringe that is safe to assess patency is a 10 mL syringe filled with
Normal Saline. Smaller syringes exert higher pressure and can rupture a
catheter.
• The PICC requires further investigation if unable to aspirate blood or flush freely.
See Managing Potential Catheter Occlusion in BCCA NPR C-90 Central Venous
Catheters, Generic Directives.
Flushing and Locking:
•
•
All PICCs shall be flushed with 20 mL Normal Saline:
o prior to each use to assess CVC function, and
o after each use (blood draw or infusion) to clear the catheter of blood, and to
prevent contact between incompatible medications.
For open-ended PICCs:
*cap = Neutral Displacement Needleless Connector
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•
•
o Each capped lumen will be flushed every 7 days with 20 mL Normal Saline,
followed by 5 mL Heparin (10 U/mL).
For closed-ended or valved (e.g. Groshong® ) PICCs
o Each capped lumen will be flushed every 7 days with 20 ml Normal Saline only.
Flushing and locking will be done in conjunction with weekly *cap and dressing
changes.
Exit Site Assessment:
•
Assess the PICC insertion site and vein pathway for redness, tenderness, swelling
or drainage at each access or dressing change, and if site infection or inflammation
is suspected. Use the following Phlebitis Scale:
Grade
0
1
2
3
4
Phlebitis Scale (INS 2011)
Clinical Criteria
No symptoms
Erythema at access site with or without pain
Pain at access site with erythema or edema
3 Pain at access site with erythema or edema
Streak formation
Palpable venous cord
Pain at access site with erythema and/or edema
Streak formation
Palpable venous cord > 1 inch in length
Purulent drainage
•
The RN removing an initial PICC dressing that has never been changed will note
and document the external catheter length and the external catheter marking at
the exit site on the patient record. If there is no documentation on the patient record
about the external catheter marking at the exit site at the time of insertion, then this
number will be used as baseline information at subsequent dressing changes.
•
The external catheter marking at the exit site will be noted and documented on the
patient record at each subsequent dressing change.
•
If on subsequent dressing changes, the external catheter marking at the exit site
has changed by more than 2 cm, migrating either in or out, from the marking
noted at the time of insertion or at the time of first dressing change, a repeat chest
x-ray is recommended to confirm tip placement.
Rationale:
The tip of the catheter should be in the lower 1/3 of the SVC which in
the average adult measured 7 cm. Migration of up to 2 cm should
still leave the catheter tip in the lower 1/3 of the SVC. Migration
outward of more than 2 cm might indicate that the tip lies outside of
the lower 1/3 of the SVC. Migration inward of more than 2 cm might
indicate the tip is now within the right atrium. Either of these would
*cap = Neutral Displacement Needleless Connector
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put the patient at risk for catheter-related complications (e.g.
thrombosis, thrombophlebitis, pericardial effusion, cardiac
tamponade, and cerebrovascular accident).
•
A PICC line that has migrated out should never be re-advanced as the external
portion of the PICC cannot be rendered sterile. Re-advancing the PICC would put
the patient at risk for infection.
Terminology:
External catheter marking: the number on the catheter at the exit site reflects the
internal measurement of the catheter in cm.
External catheter length: the length of the catheter visible from the exit site to an
identified terminus (usually the hub of the extension tubing or the base of the built-in
wings).
PROCEDURES
ROUTINE FLUSH AND CAP CHANGE:
Supplies:
Non-sterile gloves
For each lumen:
1-2 Alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
1 x 20 ml syringe of Normal Saline
1 x 10 ml syringe of 5 mL Heparin (10 units/mL) (for open-ended PICCs only)
*cap
Procedure:
1.
Perform hand hygiene.
2.
Prepare supplies.
3.
Don gloves.
4.
Cleanse PICC tubing connection and *cap.
5.
Disconnect *cap from PICC and connect new *cap.
6.
Connect syringe of Normal Saline to *cap and flush line. Discard syringe.
*cap = Neutral Displacement Needleless Connector
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7.
For open-ended PICCs only, inject Heparin flush solution through *cap. Discard
syringe.
8.
Repeat steps 4-7 for each lumen to be capped and flushed.
9.
Remove gloves and perform hand hygiene.
INITIATING AN INFUSION:
Supplies:
Non-sterile gloves
Alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
1 x 20 ml syringe of Normal Saline
Primed IV tubing
Procedure:
1.
Perform hand hygiene. Don gloves.
2.
Cleanse *cap surface with antiseptic swab, allow to dry.
3.
Confirm PICC patency with 20 mL Normal Saline syringe if not already done.
4.
Connect primed IV tubing to *cap.
5.
Initiate infusion. Ensure that the solution flows to gravity, and that there is no
swelling around PICC.
6.
Adjust IV rate as ordered.
6.
Secure tubing to patient’s arm with tape.
7.
Remove gloves and perform hand hygiene.
COMPLETING AN INFUSION :
Supplies:
Non-sterile gloves
3 alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
1 x 20 ml syringe Normal Saline
1 x 10 ml syringe of 5 mL Heparin (10 units/mL) (for open-ended PICCs only)
*cap = Neutral Displacement Needleless Connector
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Procedure:
1.
Perform hand hygiene. Don gloves.
2.
Cleanse the connection between the PICC *cap and IV tubing using the 3-swabno-touch technique (see BCCA NPR C-90 Central Venous Catheters,
Generic Directives).
3.
Disconnect the tubing from the cap*, attach syringe of Normal Saline. Flush
PICC with 20 mls Normal Saline.
4.
Remove saline syringe from *cap and discard.
5.
For open-ended PICCs only, inject Heparin flush solution through *cap. Discard
syringe.
6.
If procedures are complete, remove gloves and perform hand hygiene.
DRAWING BLOOD SPECIMENS:
Supplies:
Non-sterile gloves
Alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
2 x 20 ml syringes Normal Saline
Vacutainer
Appropriate lab tubes or 10 mL syringes if using Syringe Method
1 x 6 mL tube for discard
1 x 10 ml syringe of 5 mL Heparin (10 units/mL) (for open-ended PICCs only)
*cap (if need to change it)
Sterile dead-end cap (if capping an infusion)
Procedure:
1.
Perform hand hygiene. Don gloves.
2.
If no infusion is present, proceed to step 5. If an IV infusion is present,
proceed to steps 3 & 4.
3.
Discontinue infusion prior to obtaining blood samples. Cleanse the connection
between the PICC *cap and IV tubing using the 3-swab-no-touch technique
(see BCCA NPR C-90 Central Venous Catheters, Generic Directives).
*cap = Neutral Displacement Needleless Connector
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4.
Disconnect the tubing from the *cap; place a dead-end cap on the IV tubing if it
will be re-attached. Attach syringe of Normal Saline to PICC *cap. Flush PICC
with 20 mls Normal Saline to prevent contamination of sample with infusate.
EXCEPTION:
Prior to drawing blood cultures, do NOT flush the PICC or
discard the first draw as this sample is used for culture.
Therefore cultures should be drawn first before drawing other
blood specimens (draw aerobic sample 1st).
5.
Cleanse *cap surface with antiseptic swab, allow to dry.
6.
Luer lock the vacutainer onto *cap.
7.
Obtain discard sample (UNLESS drawing blood cultures, then NO discard).
Press tube (5-6 mL) onto vacutainer needle and allow tube to fill.
NB:
If tube does not fill, proceed with Standard Trouble Shooting Process
and draw blood by Syringe Method in BCCA NPR C-90 Central Venous
Catheters, Generic Directives.
8.
Clamp tubing if clamps present. Remove tube and discard, or discard syringe if
syringe method used.
9.
Repeat until all specimens are obtained.
10.
Remove vacutainer and discard.
11.
Flush PICC briskly through the *cap with 20 mls Normal Saline.
12.
Disconnect syringe from *cap, and discard.
13.
Go to next procedure, or remove gloves and perform hand hygiene.
DRESSING CHANGE:
•
Sterile technique will be used for PICC dressing changes.
Supplies:
Non-sterile gloves
Sterile gloves
Sterile dressing tray
Sterile cotton-tipped applicators
1-2 10 cm x 14 cm transparent semipermeable membrane dressing
2% chlorhexidine gluconate in 70% alcohol cleansing solution
Adhesive stabilization device (e.g. Steri-Strips®)
*cap = Neutral Displacement Needleless Connector
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Procedure:
1.
Perform hand hygiene.
2.
Prepare sterile tray and supplies. Pour in cleansing solution.
3.
Don non-sterile gloves.
4.
Assess insertion site for redness, tenderness, swelling or drainage.
5.
Remove dressing, beginning at PICC hub and gently peeling dressing toward the
insertion site. Remove and discard Steri-strips® (or Stat-Lock®).
6.
Remove and discard gloves.
7.
Perform hand hygiene.
8.
Don sterile gloves.
9.
Remove removable wings (if present). Place removable wings in cleansing
solution in sterile tray.
10.
Assess integrity of skin beneath dressing.
11.
Inspect the catheter site. If there is any sign of infection, swab the site for C&S
and notify the physician.
12.
Cleanse insertion site, around insertion site and catheter with applicators/gauze
soaked in cleansing solution:
• Cleanse the insertion site starting at the catheter and working outwards in a
circular motion to a radius of 10 cm. Avoid crossing over the catheter. Repeat
twice using a new swab each time.
• Gently remove any crusting. Soak crusting to allow for non-traumatic
removal.
• Cleanse the top and underside of the catheter, starting at the exit site, being
careful not to pull on the catheter.
• Allow to dry thoroughly.
13.
Cleanse wings with cleansing solution. Allow to dry.
14.
Re-apply removable wings by squeezing the wings together so that it splits open.
Place wings on catheter. Ensure that catheter is within the channel under the
wings.
Rationale:
Wings may pinch catheter if not fully in the channel.
*cap = Neutral Displacement Needleless Connector
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15.
Apply Steri-strips® to secure wings. Tuck Steri-strips® under wings and catheter
so that catheter is supported off skin, but secure.
NB:
Wrapping Steri-strips® around catheter is NOT recommended. This may
increase the risk of dislodging catheter during the dressing change.
16.
Create a loose loop with the catheter so it is not twisted or kinked under the
dressing. Apply sterile dressing to site. Apply dressing ensuring that PICC hub
and extension-tubing connection are entirely covered by the dressing.
17.
Remove gloves and perform hand hygiene.
MANAGEMENT OF AN OCCLUDED PICC:
For general guidelines refer to:
BCCA NPR C-90 Central Venous Catheters, Generic Directives
BCCA ST Policy III-80 CVC Placement/Patency Algorithm
Supplies:
Non-sterile gloves
Alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
Transparent semipermeable membrane dressing
For each occluded lumen:
1 x 20 ml syringe Normal Saline
2 mg alteplase in 2 mL (in a10 mL syringe)
*cap
Procedure:
1.
Obtain physician’s order for alteplase (e.g. 2 mg alteplase in 2 mL for occluded
PICC; repeat x 1 if needed).
2.
Perform hand hygiene and don gloves.
3.
Scrub surface of *cap with cleansing swab. Or scrub connection and remove
*cap if suspected factor in occlusion.
4.
Attach 20 ml syringe Normal Saline. If possible clear line by flushing with Normal
Saline
5.
Pull back on syringe to assess for blood return.
*cap = Neutral Displacement Needleless Connector
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6.
If blood return is spontaneous, there is no need for alteplase – carry on with
procedures.
7.
If blood return is not spontaneous, remove syringe and initiate alteplase
procedure below.
8.
Attach 10 mL syringe with 2 mg/2 mL alteplase.
9.
For partial occlusion instill 2mg (in 2 mL) alteplase to PICC.
10.
For complete occlusion instill 2 mg (in 2 mL) alteplase using a gentle push-pull
action:
• Keeping the syringe upright (plunger at the top and PICC-syringe connection
below), pull plunger back by 2 mL and release slowly.
• Repeat several times to let alteplase reach thrombotic occlusion.
• Do not use excessive force to inject alteplase.
11.
Discard syringe and add *cap if not already present.
12.
Apply label to line with time of instillation (e.g. Alteplase @ 10:00).
13.
Allow alteplase to remain in catheter for 1 hour.
After 1 Hour:
Supplies:
For each occluded lumen:
1 x 20 ml syringe Normal Saline
1 x 20 ml syringe Normal Saline (dispose of 10 ml Saline to make room for discard)
Alcohol or CHG swabs (2% chlorhexidine gluconate in 70% alcohol)
Procedure:
14.
Perform hand hygiene and don gloves.
15.
Scrub *cap with cleansing swab.
16.
Attach 20 ml syringe of 10 mls Normal Saline.
17.
Pull back on syringe to assess for blood return.
18.
If blood return is spontaneous, withdraw 5 mL blood and discard. Use 2nd
Saline syringe to flush with 20 mL Normal Saline and carry on with other
procedures.
*cap = Neutral Displacement Needleless Connector
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19.
If blood return is NOT spontaneous, the line is still occluded.
20.
Obtain 2nd syringe of alteplase and REPEAT the alteplase procedure (Steps 713).
21.
Re-label line with new time of instillation.
After the 2nd hour:
22.
GO BACK TO STEPS 14 - 19 and assess for blood return.
23.
If blood return is NOT spontaneous, the line is still occluded.
NB:
•
Alteplase can only be instilled twice and then further investigations are
required. IF THE CATHETER IS STILL OCCLUDED AFTER 2
ATTEMPTS AT USING ALTEPLASE:
Contact the physician to write an order for x-ray contrast studies. Refer to BCCA ST
Policy III-80 CVC Placement/Patency Algorithm
REPAIRING A PICC LINE;
NB:
Only PICCs with a removable hub can be repaired; PowerPICCs®or any
PICCs with built-in wings cannot be repaired. Repair can only be
performed by a certified PICC inserter or designate.
Supplies:
Non-sterile gloves
1 x dressing tray
2% chlorhexidine gluconate in 70% alcohol (CHG) cleansing solution
Sterile Normal Saline 250 ml bottle
Replacement sterile grey hub
Sterile scissors
2 x sterile gloves
Transparent semipermeable membrane dressing
1 x 20 ml syringe Normal Saline
Extension tubing with * cap
*cap = Neutral Displacement Needleless Connector
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Procedure:
1.
Position patient.
2.
Perform hand hygiene.
3.
Prepare dressing tray with all supplies. Pour sterile Normal Saline into tray and
soak new hub pieces to facilitate connection. Add CHG cleansing solution to
another well in tray.
4.
Don gloves.
5.
Place drape under arm with PICC.
6.
Remove dressing and assess insertion site.
7.
Perform hand hygiene and don sterile gloves.
8.
Use sterile saline syringe to prime extension set through the *cap. Leave syringe
attached and clamp. Leave in dressing tray.
9.
Determine where the damaged PICC is to be cut off. Do not cut at this time. Be
sure to retain as much of the original external segment as possible. If the
external segment needs to be lengthened, the catheter may be released from
the suture wing and withdrawn 1-2 cm. A chest x-ray may be required to
determine appropriate tip placement if the catheter has been withdrawn.
10.
Thoroughly cleanse the skin around the insertion site. Then lift the catheter with
non-dominant hand and cleanse the whole PICC catheter. Do not lie catheter
down.
11.
Let dry for 30 seconds keeping catheter aloft.
12.
Using sterile scissors, cut the PICC at a 90 degree angle, removing the damaged
portion of the catheter.
13.
Slide the PICC catheter through the blue over-sleeve of the replacement hub
until the cut end of the PICC is visible again.
14.
Insert the grey blunt of the second connector piece into the PICC.
15.
Slide the over-sleeve and the winged blunt connector together, aligning the
grooves on the over-sleeve with the barbs on the winged blunt connector. Do not
twist. Firmly push the two connector pieces together until they are locked (listen
for the click).
16.
Attach a pre-filled extension set and flush briskly with Normal Saline.
*cap = Neutral Displacement Needleless Connector
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17.
Apply sterile dressing.
18.
Determine if a chest x-ray is required to assess tip placement. Repeat chest xray if more than 2 cm of catheter was pulled back.
REMOVING A PICC LINE:
Supplies:
Clean gloves
Sterile gloves
Sterile dressing tray
2% chlorhexidine gluconate in 70% alcohol (CHG) cleansing solution
C & S container (obtain tip culture for C & S only if catheter is being removed due to
suspected infection)
Sterile scissors to cut catheter tip if culturing
Transparent semipermeable membrane dressing
Procedure:
1.
Position patient.
2.
Perform hand hygiene.
3.
Prepare dressing tray with all supplies.
4.
Don gloves.
5.
Place drape under arm with PICC.
6.
Remove dressing and assess insertion site.
7.
Perform hand hygiene and don sterile gloves.
8.
Cleanse site as if performing dressing change.
Rationale:
This prevents contamination if there is difficulty removing PICC and
it needs to remain in place
*cap = Neutral Displacement Needleless Connector
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9.
Grasp the catheter (not the hub) and gently pull the catheter straight out parallel
to the vein. Pull out short segments of catheter (3-5 cm), pause, and continue in
this manner until PICC is fully removed.
NB:
If resistance is encountered DO NOT attempt to remove the catheter. Try
to:
• Re-position patient with arm perpendicular to body to minimize bends
in catheter.
• Inject saline into the catheter while slowly removing the catheter.
• Protect site with dressing. Apply warm moist heat over the catheter
tract for 30 minutes to decrease resistance related to venospasm.
• If still unable to remove catheter, contact physician.
10.
If infection is suspected, use sterile scissors to cut 1” of catheter tip into sterile
container and send for culture and sensitivity. Take care to prevent
contamination.
11.
Cover site with sterile 2x2 gauze and apply pressure for 5 minutes. Apply TSM
dressing.
12.
Instruct patient to:
• monitor site for bleeding for 24 hours
• apply pressure again for bleeding
• dressing may be removed after 24 hours if oozing has stopped
• monitor and report any signs of infection
13.
If catheter appears defective, save in plastic bag for further investigation.
References:
Dawn Camp, L. (1988). Care of the GROSHONG® Catheter. Oncology Nursing Forum.
15(6):745-749.
Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of
Intravenous Nursing, Supplement. 34(1S).
th
Infusion Nurses Society. (2011). Policies and Procedures for Infusing Nursing. 4 ed.
Oncology Nursing Society. (2011). Access Device Guidelines - Recommendations for
Nursing Practice and Education. 3rd ed.
PHSA Hand Hygiene Policy No. AS 160, Hand Hygiene.pdf.
RNAO (2005). Nursing Best Practice Guideline – Care and Maintenance to Reduce
Vascular Access Complications.
*cap = Neutral Displacement Needleless Connector
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RNAO (2008). Nursing Best Practice Guideline – Care and Maintenance to Reduce
Vascular Access Complications (Supplement).
Developed By:
Nancy Runzer, Clinical Educator - VC
Revised By:
Michelle Moore, Clinical Resource Nurse, ACCU - VC
Reviewed By:
Allison Filewich, Clinical Nurse Coordinator – CSI
Sue Gill, Clinical Nurse Coordinator – AC
Arlyn Heywood, Education Resource Nurse, 5 West – VC
Seana Hutchison, Clinical Nurse Coordinator – FVC
Karen Janes, Regional Professional Practice Leader, Nursing – VC/CSI
Brenda LaPrairie, Clinical Nurse Coordinator – VIC
Nancy Runzer, Clinical Nurse Coordinator – VC
Education Resource Nurses Group
Nursing Practice Committee Members
Unit of Origin:
Education Resource Nurses - BCCA.
*cap = Neutral Displacement Needleless Connector
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Appendix 1
Patient Information Handout
Peripherally Inserted
Central Venous Catheter
(PICC)
Introduction
You and your doctor have chosen to have a Peripherally Inserted Central Venous
Catheter (PICC) based on your treatment. Since the PICC can be left in place for long
periods of time (weeks, months, years), it is important that you are aware of what it is
and how to take care of it. The PICC can be used to receive IV therapy (i.e.
chemotherapy) and take blood work. The PICC is meant to provide safe access for your
treatment and prevent repeated needle sticks to your hand and arm veins.
What is a PICC?
A PICC is a central venous catheter made from a soft, flexible material. The catheter
has a plastic adapter or hub, a plastic clamp (optional) and a winged portion to help it
attach to the skin. A needleless injection cap is attached to the hub end of the catheter.
The needleless injection cap allows the infusion of fluids into the PICC and prevents
blood from backing up into the catheter. The PICC is inserted into a large vein located
below or above the bend of your elbow with a portion remaining on the outside so that it
can be accessed for your treatment. The tip of the PICC is placed in a vein connected
to your heart.
What Will It Look Like?
A short part of the PICC is outside your body on your arm. It is always covered with a
clear dressing.
How is the PICC Inserted?
A PICC insertion can be an inpatient or outpatient procedure. It is performed by trained
and qualified health care professionals such as certified registered nurses and
physicians. The entire procedure will be explained to you prior to the procedure starting.
It is very important that a sterile area be made for the procedure. The nurse/doctor will
wear a sterile gown, gloves and mask. The area around the vein selected will be
cleaned with a special cleaning solution and then a sterile drape applied.
A small amount of local freezing is injected into the insertion site, usually just above or
below the bend in your arm. An ultrasound probe is used to locate the vein.
Once inserted the tip is positioned in an area of high blood flow near the heart to allow
for better mixing of your IV medications.
What will happen once the PICC is in place?
A chest x-ray is taken after the PICC is inserted to check the exact position of the
catheter tip. After the x-ray is reviewed and the position is confirmed you can go home.
You will be asked to return to the clinic the next day to have the dressing changed. It is
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C-86
not unusual to have some blood oozing from the insertion site, but this usually stops
after 24 hours.
What Care does my PICC require?
A weekly dressing change, line flush and cap change are necessary. You will be
informed of the specific arrangements for this care.
Can I bathe or swim?
The dressing and PICC insertion site should be kept dry. You can bathe or be in a pool
as long as you keep your PICC arm out of the water. If your dressing accidentally gets
wet and loose, it needs to be changed immediately. When showering you can cover
the area with plastic wrap.
Important Reminders:
•
Do not allow anyone to take your blood pressure on the arm that has the PICC in it.
This is to avoid damaging the PICC.
•
Do not allow anyone to take blood samples from the arm that has the PICC in it.
This is to prevent damaging the catheter.
•
Apply low heat (such as a heating pad on low setting) to your upper arm, above the
PICC as much as you can during the first 2-3 days after it has been inserted. This
increases the blood flow around the catheter and allows the body to adjust to the
PICC.
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C-86
POTENTIAL PROBLEMS
The following is a list of potential problems which may occur with your PICC and some
recommended solutions.
Problem
What you will see or feel
What to do
How to avoid it
BLEEDING
• Excessive oozing or
• Apply pressure, call • Avoid carrying
bleeding from insertion
the telephone
anything heavy and
site (minimal bleeding
nurse line or 811
avoid strenuous
for first 24 hours is
(Health Link BC)
physical exercise for
expected)
after clinic hours
the first 24 hours
Mechanical
• Tenderness/pain,
• Call the telephone
• Frequent observation
Phlebitis
hardening of vein,
nurse line or 811
• Use heat per
swelling,
(Health Link BC)
instructions
redness/warmth, along
after clinic hours
• Regularly and
the vein path. This
• If tenderness does
frequently squeeze
usually occurs during
not resolve, apply
your hand into a fist
the first 5-10 days
moist heat (warm
(you can use a soft
wet towel in a
ball for this)
plastic bag) 20
minutes on and 20
minutes off
• Keep continuous
low heat to upper
arm with PICC for
at least the first 2-3
days as much as
possible
• Elevate and rest
your arm
PLUGGED
• Unable to flush or
• Change position of • Flush PICC once a
PICC
aspirate using normal
arm
week
pressure
• DO NOT USE
• Make sure PICC is
flushed following any
EXTRA
blood work or use
PRESSURE
• Call contact phone • Flush line if any
backflow of blood in
number
• The PICC will need
to be unplugged by
medical personal
ACCIDENTAL • catheter partly or
• cover with
• always secure
REMOVAL
completely dislodged
occlusive tape
catheter well
OF PICC
• catheter out further
• Call the telephone
• avoid tugging or
than it previously had
nurse line or 811
pulling at catheter
been
(Health Link BC)
after clinic hours
• discomfort when
flushing catheter
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C-86
Problem
BREAK IN
PICC
What you will see or feel
• Leaking
• Pain during infusion
•
•
INFECTION
AIR IN PICC
THROMBO
EMBOLISM
(breaking off
of a blood clot
from inside
the catheter)
You may have:
• Fever or chills
• Temperature above
o
o
38 C (101 F)
• Flu-like feeling, lack of
energy
• Redness, swelling
and/or drainage (pus)
at catheter site
•
•
You may have
shortness of breath,
chest pain, light
headedness, fast heart
beat
•
Swelling of arm,
shoulder, neck or face
Distended arm or neck
veins
Pain
Arm turns bluish when
not elevated
•
•
•
•
•
•
•
•
•
•
What to do
Bend the end of the
catheter over and
apply a sterile
dressing
Call the telephone
nurse line or 811
(Health Link BC)
after clinic hours
Call the telephone
nurse line. Outside
of clinic hours call
the Medical
Oncologist on call
or your local
emergency
department
Antibiotics or other
treatments may be
ordered
This is an
EMERGENCY
Lie down on your
left side
Call an ambulance
(911) and go to the
nearest Emergency
Department
This is an
EMERGENCY
Lie down on your
left side
Call an ambulance
(911) and go to the
nearest Emergency
Department
•
•
•
•
•
•
•
How to avoid it
Never use excessive
force when flushing
Never use a syringe
smaller than 10 cc
Never have scissors
near the PICC
Always make sure
PICC is securely
taped
Ensure occlusive
dressing remains
intact
Keep supplies clean
and dry
Change dressing if
wet
•
Use careful and
proper flushing
technique
•
Flush catheter once a
week
Do not use force to
flush
Maintain adequate
hydration
Encourage normal
movement of
extremity
•
•
•
*cap = Neutral Displacement Needleless Connector
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C-86
APPENDIX 2
Post-Insertion PICC Care
First 24 Hours
Immediately following insertion, the patient should be monitored for the following
complications and the appropriate prevention techniques and nursing interventions
should be utilized.
OBSERVATION/
ASSESSMENT
POSSIBLE CAUSES
BLEEDING
•
• Moderate Bleeding or •
Oozing
•
•
Large size of introducer
Vigorous physical
activity
Traumatic insertion
Patient may have
coagulopathies,
thrombocytopenia or be
on anticoagulants
NURSING INTERVENTIONS
Prevention:
• Instruct patient to minimize
activity (in 1st 24 hours).
• Apply pressure to the site
after placement, especially
with decreased platelet
count or coagulopathies.
Intervention/Guidelines:
• Utilize pressure dressing
for the first 24 hours, then
change to a transparent
dressing per Nursing policy
C-86.
• Change the dressing if it
becomes saturated.
ECCHYMOSIS OR
BRUISING
•
•
Vein trauma.
Patient may have
coagulopathies,
thrombocytopenia or be
on anticoagulants
•
Monitor for changes. If
bruising increases, arrange
assessment by PICC
nurse.
PAIN
• Mild to Moderate
Pain at Insertion Site
•
Traumatic vein access
•
•
Apply low continuous heat.
Arrange assessment by
PICC nurse if no relief after
24 hours.
If not contraindicated by
medical condition, Tylenol
may be taken for pain
relief.
•
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C-86
APPENDIX 3
Post-Insertion PICC Care
AFTER the First 24 Hours
OBSERVATION/
ASSESSMENT
MECHANICAL
PHLEBITIS
POSSIBLE CAUSES
•
NURSING INTERVENTIONS
Inflammation of vein
caused by body’s
response to a foreign
material. Not an
infectious process
Primarily occurs during
first week (i.e., 3-7
days.
Prevention:
• Do not baby the arm.
Recommend that patient
regularly squeeze hand into a
fist (may use a soft ball for this).
Damaged or torn
catheter from too small
a syringe used
• Vasospasm
See Mechanical Phlebitis
above
• Determine location of pain
• Notify physician
X-ray with contrast median may be
required
CATHETER/VEIN PATH
• Tenderness/pain
• Redness/Warmth
• Venous cord
• Swelling
•
PAIN DURING INFUSION
•
Intervention/Guidelines:
• Teach patient frequent
observation, for tenderness.
• At the first sign of tenderness,
apply moist heat (warm wet
towel in a plastic bag), 20
minutes on and 20 minutes off.
• If tenderness does not resolve,
apply continuous low heat.
• Rate phlebitis according to scale
provided in NPRM C-86, pg. 6.
• Grade 2 or less: Apply
continuous low heat for 2-3
days. Elevate extremity,
encourage mild exercise.
Arrange for phone follow-up at
24-48 hrs to assess decreasing
symptoms.
• Grade 3 or more requires q24h
visual monitoring.
Post-Insertion PICC Care
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C-86
AFTER the First 24 Hours (continued)
OBSERVATION/
ASSESSMENT
POSSIBLE CAUSES
INFECTION/SEPSIS
• Fever/chills
• Redness, drainage and
swelling at site
• Pain/tenderness at site
Tachypnea or hypotension
•
•
CELLULITIS
• Warmth
• Swelling
• Redness
• Pain/tenderness
• Doesn’t follow course of
vein
• Spreads in diffuse
circular manner
• Extends beyond limits
of dressing
•
THROMBOPHLEBITIS
• Edema of arm,
shoulder, neck/face
• Distended arm or neck
veins
• Pain of arm, shoulder,
neck
• Arm turns dusky colour
when in dependent
position.
•
•
•
•
NURSING INTERVENTIONS
Immunosuppression.
Failure to maintain
aseptic, sterile
technique in catheter
case.
Contaminated catheter
Fibrin sheath
TPN, steroid therapy
Prevention:
• Do not leave any crusting at
insertions site during routine
dressing changes
A localized exit site
infection.
Due to contamination of
site.
•
•
Intervention/Guidelines:
• Notify physician.
• Blood cultures to be drawn.
• Swab exit site.
• Catheter removal followed by
culture of tip.
• Antibiotics.
• Investigate other causes/sites
of infection
•
Deep vein thrombosis
of the subclavian vein
due to:
- Obstruction of blood
flow,
- Injury to intima wall
vein,
- Increased blood
- Viscosity due to
dehydration.
•
•
•
•
Notify physician.
Cellulitis responds well to oral
antibiotics or increased site
care and may not require
removal of catheter (up to
discretion of physician).
If catheter removed, it must
be cultured
Notify physician.
Verify with venogram.
Use of anticoagulant therapy.
Remove catheter.
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C-86
Post-Insertion PICC Care
AFTER the First 24 Hours (continued)
OBSERVATION/
ASSESSMENT
POSSIBLE CAUSES
NURSING INTERVENTIONS
SKIN REACTION
• Related to sensitivity Prevention:
to dressing or
• Redness
• Do not use tinted chlorhexidine
cleansing
solution
as the dye is associated with skin
• Pruritis
reactions.
• Encompassed by
dressing
Intervention/Guidelines:
• To prevent skin irritation or burn, allow cleansing solution to dry completely before
applying dressing; 30-60 seconds for 2% chlorhexidine gluconate in 70% alcohol, 2
minutes for aqueous or iodine solutions.
•
Managing skin reactions requires some creative thinking; the principles you are trying to
maintain are:
1. Reduce the bacterial count on the skin. Chlorhexidine is the most effective agent
and 2% chlorhexidine gluconate in 70% alcohol is the most effective product.
2. Cover the insertion site with a barrier. IV 3000® is the most effective dressing.
3. Maintain the integrity of the skin around the insertion site. Do NOT stretch the
dressing to apply; peel back gently to remove. Avoid the use of adhesives on
damaged skin. If patient seems sensitive to orange border on IV 3000®, remove.
•
When the skin around the insertion site becomes itchy and/or reddened under the
dressing do a patch test on the patient's chest using:
o 70% alcohol on one patch
o aqueous chlorhexidine 2% on a 2nd patch, and
rd
o IV 3000® on a 3 patch.
o This will distinguish between sensitivity to alcohol, chlorhexidine, and IV 3000.
o Check site in 24 hours.
•
If the patient is sensitive to alcohol, then switch cleansing solution to aqueous
chlorhexidine 2%.
•
If the patient is sensitive to chlorhexidine (will show sensitivity to aqueous chlorhexidine
2%), change the cleansing solution to povidone iodine.
•
If the patient is sensitive to IV 3000®, change the dressing to Tegaderm®. The 3rd
option is Mepore®.
•
If the skin becomes irritated, cleanse with appropriate agent, make the dressing over the
insertion site as small as possible and use a small, sterile adhesive bandage.
•
If the skin becomes excoriated or weeping, cleanse with appropriate agent, dress with
gauze and cling. Assess q24-48 hours.
*cap = Neutral Displacement Needleless Connector
Page 25 of 26
C-86
Post-Insertion PICC Care
AFTER the First 24 Hours (continued)
OBSERVATION/
ASSESSMENT
BLOCKED
CATHETER
• Unable to flush
catheter or aspirate
blood from catheter
•
•
•
•
CATHETER
•
MIGRATION
• Increased length of •
external catheter
•
• Lack of blood return
• Swelling in chest or
neck during infusion
• Pain or discomfort
during infusion
• Leaking at catheter
exit site
AIR EMBOLISM
• Chest pain
• Dyspnea
• Pallor
• Light headedness
• Tachycardia/
hypotension
• Confusion
•
•
•
POSSIBLE CAUSES
NURSING INTERVENTIONS
Drug precipitate.
Fibrin Sheath.
Blood clot in catheter due
to blood reflux in catheter
due to improper flushing,
vomiting, coughing,
heavy lifting or strenuous
exercise.
Catheter tip or valve
against vessel wall.
•
Severe coughing or
vomiting.
Physically active patient.
Catheter not securely
anchored.
Prevention:
• Secure anchoring of
catheter with Steri-strips.
• Teach patient to observe
external length of catheter
and report changes
•
Assess cause, reposition
patient.
For fibrin sheath, make
arrangements with PICC
nurse to declot according
to C-86.
Intervention/Guidelines:
• Assess cause
• Notify physician
• X-ray for placement
• Remove catheter if
necessary
Air enters circulatory
system and travels to
right ventricle through the
vena cava
Open tubing while patient
vomiting or coughing.
Air accidentally injected
due to improper priming
of lines.
Prevention:
• Do procedures through
*cap to decrease opening
the system
Intervention/Guidelines:
• Turn patient on left side in
trendelenburg position
• Notify physician.
• Do vital signs.
• 02 as per Doctor’s Orders.
*cap = Neutral Displacement Needleless Connector
Page 26 of 26