picc line final

7/18/2019 Picc Line Final

http://slidepdf.com/reader/full/picc-line-final 1/13

PICC LINE Technical Skills Program

Queen’s University

Department of Emergency Medicine

IntroductionA commonly used ! access option is the peripheral ! centralcatheter or P"" line# $hich shares features of %oth central andperipheral venous access& P"" lines are suita%le for long'termvascular access for %lood sampling# chemotherapyadministration# and infusion of hyperosmolar solutions such asthose used for total parenteral nutrition& A P"" line is composedof a thin tu%e of %iocompati%le material and an attachment hu%

that is inserted percutaneously into peripheral veins andadvanced into a large central vein&

Objectives(y the end of this teaching module# the student should %e a%leto)* +ist the indications for a P""* +ist the contraindications for a P""* Descri%e the techni,ue for -ushing* Descri%e the techni,ue for removal

* Descri%e strategies for dealing $ith di.cult line removals* +ist and descri%e the potential complications of P""s

Indications* Medium term intravenous therapy)

o Prolonged anti%iotic therapy o Prolonged ! -uids o "hemotherapy o TP/ 0total parenteral nutrition1

* Delivery of medications that are irritating to the peripheralvessels

Contraindications* 2ith the risk of e3travasation of irritating or tissue'in4uringsolutions 0colchicine# phenytoin# vasoconstrictors# and others1 or



su%optimal volume -o$# peripheral !s should not %e placed ine3tremities $ith) o Massive edema o (urns o Sclerosis

o Phle%itis o Throm%osis

* E3tremities ipsilateral to radical mastectomy or dialysis graftsshould %e avoided %ut may %e used in urgent conditions $hen noother peripheral ! access sites e3ist

* !eins that drain from area of neck trauma or into an a5ectedtraumatic e3tremity or the side of a chest or a%dominal trauma

* Sites of cellulitis 0%acteremia1

* E3tremities $ith shunts or 6stulas 0shunt infections orthrom%osis1

* ! access in feet or ankles is su%optimal for long'term use %utmay su.ce in emergencies

Material

P""s are made of t$o su%stances# either polyurethane orsilicone# and are radiopa,ue measuring 78 to 98 cm in length$ith an outside diameter of : to ; <rench 0<=1& The catheter mayhave a single' or dou%le'lumen and can %e open' or close'endedor valved& The particular device selected should %e therapyspeci6c# %ased on the num%er of lumens necessary for treatment#recogni>ing that the potential for infection increases $ith lumennum%er& The most common type of P"" line currently used is the7'<=# dou%le'lumen# closed'ended catheter&



AnatomyP"" lines are most fre,uently placed in the super6cial veinspro3imal to the antecu%ital fossa 0usually in the %asilic or thecephalic veins1& ?o$ever# they may also %e placed translum%aror transhepatically $hen the S!" is throm%osed or occluded&

An interventional radiologist $ill perform the insertion of a P""line& To con6rm correct placement in the S!" and rule out apneumothora3# a chest @'ray is taken& t is important that post



insertion# all patients %e monitored for signs and symptoms oflocal and systemic infection& Additionally# the site should %econtinually inspected for %leeding# drainage# hematoma# orseroma&

P"" line 0red1 inserted through the %asilic vein and advanced tothe S!"&

Flushing the PICC Linen order to ensure patency and avoid catheter occlusion# the P""line should %e -ushed %efore and after infusion $ith any

su%stance 0e&g& anti%iotics# medications# etc1 or $hen any %loodsample is taken& <lushing is done $ith normal saline# heparin# orhepaline and %oth the volume and method vary according topatient si>e and procedure&



Note: /ever connect a syringe $ith a volume less than 8m+ toan adult central line catheter& The pressure is too high $henin4ecting or $ithdra$ing and might damage the catheter&

PICC Line emovalP"" lines may re,uire routine or emergent removal 0e&g& in thecase of infection1& The follo$ing sections descri%e the e,uipmentand techni,ue for a safe P"" removal&

Equipment *Sterile gloves* Sterile dressing tray* Sterile scissors* "hlorhe3idine solution 0:B a,ueous1* Ccclusive dressing* Mask 0if patient immunocompromised1

Steps& =evie$ patient’s coagulation status and ensure $ithin

normal range



:& Ensure all lines are clampedlocked& Position patient supine& Turn the patient’s face a$ay from

the site as appropriateF& =emove dressing& Do not e3ert tension on the catheter7& Assess the site for drainage# s$elling# and in-ammation

9& Prepare the dressing tray and don gloves;& "leanse area $ith "hlorhe3idine :B a,ueous& Allo$ at least

8 seconds of contact time 0to dry1G& (eing careful not to cut the line# use sterile scissors to

remove any suturesH& Apply sterile gau>e $ith gentle pressure over the insertion

site&8&Irasp the catheter %y the hu% and slo$ly $ithdra$ the

catheter $hile having the patient perform a !alsalvaManoeuvre or e3hale slo$ly

&f resistance is noted $hile $ithdra$ing the line stop#reassess# reposition and seek assistance as re,uired

:&E3ert direct pressure on the site $ith gau>e until %leedinghas stopped completely& <or central lines# this $ill usually%e a minimum of 7 minutes&

&Cnce the %leeding has ceased# cover the e3it site $ithsterile gau>e and an occlusive dressing

F&nspect the line for a%normalities# evidence of infection# andlength& /ote) f the catheter is ragged or damaged# notify!= immediately& =etain the catheter and measure its

length&7&Discard in %ioha>ardous $aste if not %eing sent for culture&

f ordered# send the tip of the catheter to the Micro%iology+a%oratory for culture and sensitivity)

• Use sterile scissors to cut o5 at least cm of the tip

• Place the tip in a sterile container and seal

• Send the specimen immediately to the Micro%iology

+a%oratory

• : sets of %lood cultures are re,uired 0as ordered1 $hentips are sent for culture and sensitivity)

• Peripheral site) aero%ic J anaero%ic tu%e

• +ine) aero%ic tu%e for each lumen

!trategies "or #i$cult Line emovals



Persistent Resistance During Withdrawal

• =eposition the patient or a5ected lim%

2ith some P""s# resistance may %e related to vasospasm&"ontinuous heat promotes vasodilation# $hich $ill make the

removal easier• =eplace dressing and tape catheter

• Apply continuous heat to the venous path$ay from insertionsite up to a3illa for 8 minutes

• Cther tips include applying a $arm compress to thepatient’s hand or giving them a $arm %everage

• =eattempt removal

• f still met $ith resistance# apply a dressing to the site andreattempt in :':F hours

Catheter Breaks During Withdrawal

• f the catheter %reaks during removal %ut is still longenough to %e pulled# clamp the catheter and continueremoval

• f the catheter %reaks in the patient’s vein) immo%ili>e thearm and keep the patient still& Place the patient in

Trendelen%urg position and contact != immediately

Potential Com%lications

As P"" lines are %ecoming increasingly more common#healthcare professionals should %e a$are of the common signsand symptoms of potential complications as $ell as short andlong'term management options&

PhlebitisPhle%itis is a common complication after ! cannulation andadministration of medication# especially vancomycin# potassium#and any hyperosmolar solution or cytoto3ic agents& t is descri%edas the presence of a palpa%le cord accompanied %y $armth#

erythema# tenderness# and induration& Phle%itis $ill usuallymanifest as discomfort for the patient and necessitates removalof the catheter and replacement in another e3tremity

Infectionnfection may occur at the e3it site# inside the catheter or alongthe track through $hich it is tunneled& The main causes include



contamination of the hu% or in4ection site cap# contaminationfrom percutaneous entry# or systemic sepsis& Peripheral !catheters are most often associated $ith Staphylococciepidermidis# Stephylococcus aureus# and candida infections&nfectious complications can %e signi6cantly reduced %y hand

$ashing# $earing gloves# site preparation $ith iodine# andmonitoring site for signs of infection& f local signs of infection arepresent# the P"" must %e removed&

ir EmbolismAir may enter the catheter if it %ecomes disconnected $hileunclamped& During inspiration# intra'thoracic pressure decreasesrelative to atmospheric pressure# thus facilitating travel of an airem%olus from high pressure 0atmosphere1 to lo$ pressure 0intra'thoracic1& Prevention is keyK

& Ensure an in4ection cap is attached to each lumen of thecentral venous catheter

:& Ensure all connections are securely luer'locked& "lamp the catheter $hen opening the systemF& Ensure that any air $ithin the in4ection site capcatheter

has %een $ithdra$n prior to in4ecting any -uid7& /ever use scissors to remove the dressing9& f the line %ecomes disconnected# clamp pro3imal to the

damage& Attach a 8m+ syringe to remove air that may

have entered the catheter;& The catheter may %e repaired $ith a special kit speci6c for

type and si>e of the long'term central venous catheter#$hich can %e o%tained from the C=&

G& n case of an air em%olus)

• Turn the patient to left lateral Trendelen%urg position

• Administer o3ygen

Pneumothora!

As the su%clavian vein lies in close pro3imity to the lung# duringinsertion the catheter may inadvertently %e threaded through%oth the visceral and parietal pleura and into the lung# resultingin a pneumothora3& n this case# the patient may display signs orcomplain of) shortness of %reath# decreased %reath sounds ona5ected side# tracheal deviation a$ay from a5ected side#tachycardia# and hypotension& Alternatively# the patient may



appear una5ected# $hich is $hy a chest 3'ray is al$ays re,uiredpost'insertion of a P"" line& n the case of a pneumothora3#administer o3ygen and insert a chest tu%e as indicated&

"cclusion

Ccclusion of the line may occur for a variety of reasons) catheterthrom%osis# medication precipitate# 6%rin sheath formation#catheter tip resting against the $all of the vein# and failure to usepositive pressure& To prevent occlusion# al$ays assess catheterpatency prior to administering any medication or -uid# -ush thecatheter a minimum of once $eekly and follo$ing each use# anduse the positive pressure techni,ue $hen heparini>ing thecatheter to prevent re-u3 of %lood into the catheter tip&

f occlusion does occur)

& Ask the patient to change positions# raise their arms# andorcough repeatedly in order to shift the position of the catheterfrom the $all of the vein

:& Attach a 8m+ syringe $ith m+ /a"l 8&HB to the catheter&Attempt to $ithdra$ a possi%le clot %y pulling and thenreleasing on the plunger& /ever in4ect any solution into thecatheter $hen patency is not clearly esta%lished& "ontinue$ith the previous interventions

& <luoroscopy may %e performed to determine the presence of

a 6%rin sheath or a throm%us

<i%rin or clots may %e dissolved using Urokinase 07888 Um+1instillation into the catheter& This procedure is typicallyperformed %y !=&

!ELF&A!!E!!MEN' ()E!'ION!(uestion *P"" lines are suita%le for $hich of the follo$ingL

a& +ong term vascular access for %lood sampling

%& "hemotherapy

c& +ong term anti%iotic administration



d& TP/

e& All of the a%ove

(uestion +All of the follo$ing are contraindications to P"" line insertion in alim% E@"EPT)

a& Phle%itis

%& Trauma

c& Tattoo

d& psilateral radical mastectomy

e& Throm%osis

(uestion , The risk of infection increases $ith increasing catheter lumennum%er

True <alse

(uestion -2hen -ushing an adult P"" line# the minimum volume of thesyringe must %e)

a& m+

%& m+

c& 8m+

d& 8m+

(uestion .



2hen %lood sampling from an adult $ith a central line# a $astevolume of must %e dra$n pre'sample# $ith a post'sample -ush&

a& 7m+# 8m+

%& 8m+# :8m+

c& 8m+# 8m+

d& :8m+# 8m+

(uestion /2hen removing the catheter

a& Quickly remove $ith a strong# 6rm pull

%& Slo$ly $ithdra$ $hile the patient slo$ly inhales

c& Apply very strong manual pressure over the removal site

d& Slo$ly $ithdra$ $hile the patient performs the !alsalvamanoeuvre

(uestion 0<ollo$ing removal of a central venous catheter or sheath# applymanual pressure directly over the site for a minimum of)

a& minute

%& minutes or less

c& 7 minutes

d& 7 minutes

(uestion 1C%serve the removed catheter for all E@"EPT)



a& Patency

%& =ough edges

c& "ontamination

d& +ength

(uestion 2f the catheter appears infected# do all of the follo$ing E@"EPT)

a& S$a% discharge and send for culture and sensitivity

%& Send catheter tip for culture and sensitivity

c& /otify !=

d& +eave the site open to air to assist drainage

(uestion *3 To prevent air em%oli $hen removing the catheter)

a& Place the patient in a prone position prior to removal

%& ?ave the patient inhale through the mouth during removal

c& "over the site $ith an occlusive dressing follo$ing removal

d& Administer o3ygen prior to removal

Credits

"ongratulationsK

Nou have no$ completed the P"" module&

Credits



• This module $as $ritten and developed %y /icole =occa forthe QueenOs University <aculty of ?ealth Sciences PatientSimulation +a%&

• "ontri%utors) Dr& (o% McIra$# ane Tyerman# and +ucy=e%elo

• The module $as created using e3e ) e+earning @?TM+ editor$ith support from Amy Allcock and the QueenOs UniversitySchool of Medicine MedTech Unit&

#icense

This module is licensed under the "reative "ommons Attri%ution/on'"ommercial /o Derivatives license& The module may %eredistri%uted and used provided that credit is given to the authorand it is used for non'commercial purposes only& The contents ofthis presentation cannot %e changed or used individually& <ormore information on the "reative "ommons license model andthe speci6c terms of this license# please visitcreativecommons&ca&

References

& This module $as developed %ased on a learning guide$ritten %y the /ursing Education Service at ingstonIeneral ?ospital

:& Mar3 A) Peritoneal Procedures& n =o%erts =# ?edges =# etal 0eds1) "linical Procedures in Emergency Medicine# Fth ed&Pennsylvania# Elsevier# :88F# p G7'G79&

picc line final

Documents