4. PERIPHERALLY INSERTED CENTRAL CATHETER - PICC

1
4. PERIPHERALLY INSERTED CENTRAL CATHETER - PICC
2
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

3
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 hub
Catheter insertion site
Positive Pressure Bung
Arrow PICC
Anchoring Device
4
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

5
Types of PICCS
Two main types of PICCs used in Gippsland are

• Arrow brand most commonly used and is
  identifiable by its white coloured catheter

• Groshong brand identifiable by its blue
  coloured catheter

Note A PICC can be single or multi lumen
6
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

7
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

8
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

9
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 patients 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)

10
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)

Figure 1 External Measurement
11
Cap / Bung Description
Non Positive Pressure Bung

• 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

Positive Pressure Bung
Note Above is a sample of one type of bung
currently available
12
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
13
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

14
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

15
Dressing
16
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

17
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

18
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

19
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

20
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

21
Blood Return

• Check for blood return

22
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

23
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

24
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

25
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

26
Complications

• Migration of PICC
• Thrombosis
• Blockage
• Infection

27
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

28
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 physicians orders

29
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

30
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.

31
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/gr
  ics are
• PICC Worksheet
• PICC Patient Information brochure

32
GONG Products

• www.gha.net.au/grics