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PICC and Midline Catheters
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Infusion RN’s
• Deb Bucher RN BSN CRNI
• Dawn Finch RN CRNI
• Marianne Hansen RN BSN CRNI
• Karman Youngblood RN BS CRNI
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Infusion Pharmacist
• Kathy Cimakasky Pharm D
• Tamara Migut RPh
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Intravenous Decision Tree
No
Yes
No
Yes
Yes
No
Yes No
No Yes
Yes
Does patient need
IV access?
No need
for IV
access.
Is therapy
appropriate for
peripheral infusion?
Obtain MD order
for CIS consult
for central line
PICC vs. Chest
Does patient have
history of difficult IV
start and/or does
therapy consist of
multiple blood draws?
Obtain MD
order for CIS
consult for
midline/PICC
placement.
Is therapy planned
for greater than 3
days?
Place
peripheral IV.
Is therapy
greater than 3
days but less
than 4 weeks?
Is therapy
greater than 4
weeks?
Obtain MD order
for CIS consult
for midline.
Obtain MD
order for CIS
consult for
central line
PICC vs. Chest.
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What is a PICC
• Peripherally Inserted Central Catheter
• Indications for PICC
• TPN or other solutions requiring central
placement such as certain chemotherapies.
• Therapies that over time can cause chemical
phlebitis such as Vancomycin and Nafcillin
• Therapies lasting longer than 4 weeks
• Can be used for blood draws
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What is a Midline
• Peripherally inserted catheter that tip is not
centrally placed, such as a Groshong
• May remain in for 30 days
• Determine by measurement of line or CXR
• Indications for use: poor venous access
requiring multiple IV site changes and
therapies lasting less than 30 days
• May use for lab draws
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What is an Implantable Port
• A port (often referred to by brand names such as
MediPort) is a central venous line that does not
have an external connector; instead, it has a small
reservoir implanted under the skin.
• Medication is administered intermittently by
placing a small needle through the skin into the
reservoir.
• Ports are used for patients needing long-term
intermittent treatment.
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PICC and Midline Flushing
• Sodium Chloride- 5cc before and after
routine IV/medications
• 10cc NS before and after blood draws
(PICC only-10cc Sodium Chloride b/a
TPN)
• 20cc NS after blood product administration
• Heparin 100 units/cc 2.5cc final flush in
absence of continuous infusion and daily
when line not in use .
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Sterile Dressing Change
• Change dressing 24 hours post insertion
• Every 7 days
• Hibiclens followed by Chloraprep
• Biopatch – an antimicrobial dressing
• Steri-strips to secure site
• Clear bio-occlusive dressing
• Change cap every 7 days or whenever
removed
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Hibiclens scrub
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Chloraprep swab to remove soap
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Biopatch around line at insertion
site
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Biopatch over line at insertion
site
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Steristrips from insertion site to
hub
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Bio-occlusive dressing to cover
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Secured with K-lok over
extension tubing
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PICC Secured with Statlock
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Line Repair
• Clean site with Hibiclens and Chloraprep
• Clean segment of line to be trimmed
• Trim line above damaged portion
• Slide sleeve over line
• Grasp emerging line with sterile gloved
fingers
• Insert stylet tip fully into line and slide
sleeve up to connect firmly
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Line repair continued
• Single lumen Groshong lines will click
when securely fastened.
• Dual lumen Groshong lines will have white
stylet to remove after repair complete.
• After repair complete tug gently to ensure
secure connection
• Apply sterile dressing and flush line
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Hibiclens scrub (be sure to clean
area of line to be cut)
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Chloraprep swab (be sure to prep
area of line to be cut)
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Cut line above damaged portion
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Slide sleeve over cut line
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Grasp emerging end to prevent
internal migration
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Insert stylet into line up to hub
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Stylet fully inserted up to hub
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Slide sleeve up; align grooves
with the wings and click together
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Add extension and cap to
repaired PICC; flush and dress
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Lines that cannot be repaired
• Dual lumen lines that are broken above the
white y
• Lines that are clear and have clamps
attached to the line.
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De-clotting Line
• Mix solution according to pharmacy
directions
• Withdraw appropriate volume of solution
into syringe
• Remove injection cap, attach syringe with
de-clotting agent to hub of occluded lumen
• Inject de-clotting solution. (this may or may
not infuse easily
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De-clotting line continued
• If it is difficult to instill de-clotting use a
gentle push/pull action of the syringe to
allow gradual mixing. TO PREVENT
RUPTURE DO NOT FORCE.
• Remove or tape syringe down to arm and let
de-clotting solution work for 30-60 minutes
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De-clotting PICC continued
• Attempt to aspirated after 30-60 minutes
• If blood cannot be aspirated, try to aspirate
again in 15 minutes.
• If blood aspiration success
• Aspirate 5cc of blood and discard
• Irrigate catheter with 10cc Sodium Chloride
followed by 2.5cc Heparin 100units/cc
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Mix medication according to
directions and draw into syringe
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Attach syringe to hub and instill
medication
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De-clotting line waiting 30-60
min
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Attempt to aspirate and withdraw
4-5cc of blood to waste
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Flush line with NS 10cc followed
by Heparin 100u/cc 2.5cc
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Migration• Movement of catheter from its original
placement.
• To prevent further migration, line should be
adequately secured with securing device
and occlusive dressing.
• Repairable lines should be trimmed of
excessive exterior length and repaired.
• Assessment needs to be completed to
determine if placement remains adequate
for current IV therapy.
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PICC migrated outward several
inches
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Measure migrated line
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Phlebitis
• Phlebitis shall be defined as an
inflammation of the vein and is a potential
complication
• It will be rated according to a scale of 0
through +4
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Phlebitis Scale
0
• No clinical symptoms
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Phlebitis Scale
1+
• Erythema with or without pain
• Edema may or may not be present.
• No streak formation
• No palpable venous cord
• Moist heat may be applied if there is pain
• Patient may be asked to use the arm
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Phlebitis Scale
2+
• Erythema with or without pain
• Edema may or may not be present
• Streak formation
• No palpable venous cord
• Low heat for 2-3 days, elevate arm, mild exercise and follow up daily to see if decrease in symptoms
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Phlebitis Scale
3+
• Erythema with or without pain.
• Edema may or may not be present.
• Streak formation.
• Palpable cord.
• Daily visual monitoring for any decrease in
symptoms
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Phlebitis Scale
Grade 4
• Erythema with or without pain
• Edema may or may not be present
• Streak formation
• Palpable venous cord greater than 1 inch in length
• Purulent drainage
• Culture site, cleanse site, notify M.D., blood
cultures, may remove catheter and culture tip
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PICC line removal
• Gather supplies
• Remove dressing
• Gently retract line from arm
• Apply pressure to site
• Cover with gauze and apply occlusive
dressing
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Removing PICC line
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Gently pull line out
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Apply pressure with gauze when
line removed
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PICC line removed, dressing
applied
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Final measurement of removed
PICC line
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Questions
• RN is available on call 24 hours /day
• For questions call 383-3099
• Adapted with permission from the Carle Infusion
Department