Download Multidisciplinary Care in Regional Victoria

Management of
Central Venous Access Devices
4. PERIPHERALLY INSERTED
CENTRAL CATHETER - PICC
Nurse Education Workforce Strategy – Gippsland Region
Gippsland Oncology Nurses Group (GONG)
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Scope of Tutorial
•
•
•
•
•
•
What is a PICC?
What are indications for a PICC?
What types of PICCs are commonly used in Gippsland?
How do you measure the external length of a PICC?
What are the recommendations for flushing PICC lines?
What is the minimum size syringe when accessing a
PICC?
• List the key things to be documented immediately
following insertion of a PICC
• List the key things to be included in routine
documentation of care
• Describe three complications of PICC care and how to
troubleshoot them
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Peripherally Inserted Central Catheter (PICC)
• A PICC is a catheter
inserted into the basilic
or cephalic vein in the
cubital fossa or the
upper arm, with the tip
residing in the Superior
Vena Cava (SVC)
• PICCs are approximately
55cm in length
• They may be single or
multi lumen
• They can be indwelling
for up to 12 months or
longer
Catheter
insertion
site
Catheter
hub
Positive
Pressure
Bung
Arrow PICC
Anchoring
Device
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Indications
• Intermediate or long term therapies– ie.
drugs, infusions or chemotherapy
• Continuous infusions
• Poor venous access
• Administration of drugs or fluids that may be
irritable to peripheral veins
• Total Parenteral Nutrition
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Types of PICCS
Two main types of PICCs used in Gippsland are:
1. “Arrow” brand most
commonly used and is
identifiable by its white
coloured catheter
2. “Groshong” brand
identifiable by its blue
coloured catheter
Note: A PICC can be single or multi lumen
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Advantages
• A PICC is relatively easy to insert
• Insertion can be done at the bedside by a
nurse or radiologist trained in the procedure
• Pain free once inserted
• Suitable for continuous or intermittent
therapies
• Suitable for home therapy
• Avoids repeated peripheral cannulation
• Blood can be taken from PICC 4 French gauge
or larger
• Suitable for delivery of high risk drugs
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Disadvantages
• Abnormal venous anatomy may prevent
insertion of PICC
• High maintenance- eg. requires dressings
and flushing
• Not suitable for rapid infusions of large
volumes
• Altered body image
• May not suit active people
• May not be submerged in water
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Newly inserted PICCs
• After insertion there is a tendency to bleed
from the insertion site due to the introducer
being larger than the catheter.
• Restrict arm movement for the first 2 hours to
minimise bleeding
• Apply a pressure bandage directly on the
occlusive dressing to avoid redressing the
insertion site frequently in the first 24 hours
• A newly inserted PICC should be redressed
after 24 hours and then weekly unless there is
obvious ooze
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Confirmation of placement
• Every time the PICC is accessed, the nurse is
responsible for confirming correct placement by:
– Aspiration of blood from PICC line
– Ability to easily infuse solutions
– Normal appearance of PICC site and patient’s arm
– Measurement of PICC length from insertion site to
catheter hub
– Written x-ray report confirming correct placement
of PICC available in patient record
• If unable to confirm correct placement of PICC refer to
troubleshooting section of PICC management in the
GONG guidelines (see Resources)
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
Management of Central Venous Access Devices
External Measurement
• Measure from insertion site
of PICC to catheter hub
• Measure and record the
exposed catheter length at
each dressing change to
ensure migration has not
occurred
• If migration has occurred
refer to PICC Management
Guidelines (GONG Cancer
Care Guidelines)
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Figure 1: External Measurement
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Cap / Bung Description
•
•
•
The positive pressure bung
maintains a positive
pressure in the line to
prevent back flow of blood
into the end of the catheter
and possible subsequent
blockage of the PICC
A positive pressure bung
should be used with all
“Arrow” PICCs
A non-positive pressure
bung should be used with
a “Groshong” PICC, as it
has a non-reflux valve built
into the catheter
Non Positive
Pressure Bung
Positive
Pressure Bung
Note: Above is a sample of one
type of bung currently available
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
PICC Clamps
• Leave clamps open when a positive
pressure bung is in use
• Leave clamps closed if a non-positive
pressure bung is in use
• If there are no clamps and a non-positive
pressure bung is in situ, change to a positive
pressure bung
Note: A Groshong Catheter has its own inbuilt
positive pressure valve, so clamps are never used
on a Groshong catheter
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Changing a Cap / Bung
• Aseptic technique required, using a sterile tray
and sterile gloves
• Cap/bung must be changed at least every 7
days
• Where practical, dressing change should be
done at the same time
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Changing a Dressing
• Always use an aseptic technique
• Initial dressing should be changed 24 hours
post insertion of PICC
• Dressing should be changed every 7 days and
as required if dressing is not dry and intact
• Where practical, cap/bung change should be
done at the same time
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Dressing
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Changing an IV Line
• A clean technique* is required when the system is
closed (cap/bung is in situ)
• Continuous IV infusion line is changed every 72 hours
• For intermittent IV infusion, change line with each
infusion
• Change IV TPN/Lipid line every 24 hours
• Blood product infusion sets should be changed to
standard IV infusion set on completion of the blood
product infusion
* Recommended clean technique: clean gloves and
clean with 3 alcohol swabs and allow to air dry before
proceeding to access a closed system
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Accessing a PICC
• A clean technique* is required for accessing a
closed system through a cap/bung.
* Recommended clean technique: clean gloves and
clean with 3 alcohol swabs and allow to air dry before
proceeding to access a closed system
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Syringe Size
• Always use a 10ml
syringe or larger
• Smaller syringes
increase pressure
in the catheter
wall and increase
the risk of rupture
of the catheter
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Flushing
• Always flush in a pulsatile (stop/start) manner
to create turbulence in the lumen of the
catheter, remove debris and avoid blockage of
the catheter
• On accessing the PICC, flush with Normal
Saline 10ml when determining patency
• Flush before and after drug administration
with 10ml normal saline
• After blood sampling flush with 20ml of
Normal Saline
• Flush weekly when not in use
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Heparin Lock
• Heparin Lock (Heparinization) is not required
– For a “Groshong” PICC
– For an “Arrow” PICC when using a positive pressure
bung
• Weak Heparin Lock is required (50u/s in 5ml)
– ONLY when a non-positive pressure bung is in use
with an “Arrow” PICC
– After each use and weekly
* Remember, never use a syringe smaller than 10mls
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Blood Return
• Check for blood return
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Taking Blood
• Perform initial flush to determine patency (except for
blood cultures)
• Discard the first 5ml of blood withdrawn before
collecting sample (except for blood cultures)
• When taking blood cultures, do not perform initial flush
to determine patency, do not discard a sample. Retain
initial sample for blood culture
• Flush PICC with 20ml of Normal Saline after blood
sampling, continue with treatment as ordered and / or
heparinization if required due to lack of positive
pressure bung
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
PICC Removal
• Aseptic technique required
• Should be removed by an experienced practitioner
• Do not apply undue force as this may fracture the
catheter
• Remove the PICC slowly to minimise venospasm
• Application of heat may assist to minimise
venospasm
• Measure and examine the PICC to ensure it is
intact
• Collect catheter tip for pathology if ordered
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Documentation - After Insertion
•
•
•
•
•
•
•
•
•
•
•
•
•
Ensure PICC Worksheet is completed on insertion
Brand of PICC, product number, lot number
Size of PICC, number of lumen
Location of PICC
Internal and external catheter length
If the catheter has been shortened prior to insertion
Upper arm circumference
Type of cap or bung used
Name of person who verified placement X-ray
Name & signature of person inserting PICC
Medications and flushes administered
Strength of heparinization (if required)
Any troubleshooting required
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Documentation - Ongoing
Clear, consistent documentation is essential
after each treatment or shift. This should include:
• External length of PICC from insertion site to catheter
hub (see Figure 1)
• Ability to confirm placement
• Cap/bung change and type of bung/cap used
• Medications and flushes administered
• Dressing change
• Signs and symptoms of infection or thrombosis (if any)
• Any troubleshooting required
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Complications
1. Migration of PICC
2. Thrombosis
3. Blockage
4. Infection
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
1. Migration
• If PICC migrates more than 2cm in or out,
consult with physician
• X-ray confirmation of placement may be
required before re-access
• Documentation of placement is required
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
2. Thrombosis
• Redness, tenderness, swelling and heat may
be signs and symptoms of thrombosis around
the PICC
• Do not access PICC. Consult with physician
for further orders. Document physician’s
orders
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
3. Blockage
Difficulty flushing and/or aspirating blood
• Change cap or bung
• Ensure any clamps are open
• Change position of patient
• Refer to PICC MANAGEMENT GUIDELINES
(GONG Cancer Care Guidelines) for further
information
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
4. Infection
• Redness, discharge, tenderness, swelling, heat, patient
temperature and generally feeling unwell may be signs
and symptoms of infection associated with the PICC
• The infection may be at the insertion site, or in the vein
• Do not access PICC until discussed with physician and
remember to document instructions
• If proceeding with accessing the device be aware of a
possible septic shower* from the rapid circulation of
toxins when flushing the PICC
* Septic shower may occur immediately after flushing due to
infection in the line. There may be an absence of obvious
infection at entry. However, the patient will experience rigors
and generally feel unwell. Consult physician.
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Resources
• GONG Cancer Care Guidelines have been
accepted to guide the management of all
patients with a CVAD in Gippsland and are
available at each Gippsland Health Service.
• Also available on-line at
http://www.gha.net.au/grics are:
– PICC Worksheet
– PICC Patient Information brochure
TUTORIAL
PICC
This Tutorial
PICC Description
Indications
Types of PICCs
Advantages
Disadvantages
Newly Inserted PICCs
Confirm Placement
External Measurement
Principles of Care
> Cap/Bung Description
> PICC Clamps
> Changing a Cap/Bung
> Changing a Dressing
> Dressing
> Changing and IV Line
> Accessing a PICC
> Syringe Size
> Flushing
> Heparin Lock
> Blood Return
> Taking Blood
> PICC Removal
> Documentation - Initial
> Documentation - Ongoing
Complications
> 1. Migration
> 2. Thrombosis
> 3. Blockage
> 4. Infection
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
GONG Products
www.gha.net.au/grics