Intravascular Therapy: Peripherally Inserted Central Catheters

CLINICAL GUIDELINES

A healthcare provider specially trained in peripherally inserted central catheter (PICC) placement performs insertion.
PICC access, site care, infusion, and removal may be performed by a competent healthcare provider, or appropriately trained child or family member. The RN is responsible for monitoring the site and the status of the child after PICC placement, particularly when anesthetic/sedation measures have been used.
A PICC is a catheter that is inserted percutaneously into a peripheral vein. When a PICC is placed in an upper extremity, the tip resides in the superior vena cava, and when placed in a lower extremity, the tip resides in the inferior vena cava. Location of the catheter tip must be confirmed radiographically before use.
Midline catheters are peripheral catheters with tip placement outside the central veins. These catheters are not indicated for use with power injection, parenteral nutrition (PN), irritants, or vesicants. These catheters may not be reliable for blood draws due to inconsistent blood return. Patency needs to be confirmed prior to each use. Midline catheters may remain in place up to 2 months.
There are two types of PICCs: nonpower injectable (open ended and valved) and power injectable.
- Open-ended or valved nonpower injectable PICCs are made of materials that can only withstand pressures of 25 pounds per square inch (psi). These catheters may be utilized for hand-injected contrast. In addition, valved PICCs have a valve, either at the tip or in the connection piece, to prevent backflow of blood. This valve opens with negative pressure for blood aspiration and positive pressure for infusions and is in the neutral position when not in use.
- Power injectable PICCs are made with a material to withstand pressures greater than 300 psi, strong enough to be used with the power injector in the MRI or CT suite.
A topical/local anesthetic agent, such as lidocaine cream, may be applied to the insertion site before catheter insertion. Sedation or anesthesia may be required in the young and/or fearful infant or child to help maintain a sterile field, promote venous dilation, and ensure successful placement.
Indications for PICC placement include the inability to gain and/or maintain vascular access for therapy greater than 5 days, intermediate to long-term intravenous (IV) access for antibiotics, pain medications, chemotherapy, irritants, vesicants, extreme pH medications, PN, hyperosmolar solutions, or blood products. The early use of PICCs may also spare peripheral veins and the pain of repeated needle sticks, which can be traumatic to children. PICCs may be used for central venous pressure monitoring. PICCs are not intended for hemophoresis or hemodialysis.
A discussion regarding line necessity and a vascular access assessment should be conducted to determine which type of vascular access catheter should be inserted.
Contraindications to PICCs include inadequate veins, bleeding disorders, trauma to involved extremity, severe burns or skin infections, severe immunosuppression, patient noncompliance, and lack of followup care.
Blood pressure cuffs and/or tourniquets should not be applied over the site of the PICC but may be placed distal to the catheter’s location.
All add-on devices shall have a Luer-lock connection.
All caps should be designed for neutral or positive pressure.
To minimize the associated risk for infection, aseptic technique must be used when caring for a PICC. Maximum barrier precautions must be followed during PICC placement and include the use of mask, protective eyewear, sterile gown, cap, powder-free sterile gloves, and full barrier precautions (sterile field covers patient from head to toe).

EQUIPMENT

For PICC dressing change:

Sterile antiseptic applicators/swabs: one 2% chlorhexidine-based preparation (preferred antiseptic; see Table 57-1) or three iodophor (e.g., 10% povidone-iodine) or 70% alcohol preparations can be used
Dressing materials: semipermeable, transparent dressing, chlorhexidine patch (optional). Gauze and tape should only be used if the site is oozing or the patient is allergic to the transparent dressing
Tape measure
Nonsterile gloves and sterile gloves
Catheter stabilization device
Material to secure IV tubing/line: catheter securement device, tape

caREminder

For flushing and locking PICC:

5- or 10-mL syringes
Sterile antiseptic applicators/swabs: one 2% chlorhexidine-based preparation (preferred antiseptic; see Table 57-1) or three iodophor (e.g., 10% povidoneiodine) or 70% alcohol preparations can be used
Heparinized saline per healthcare prescriber’s order (preservative-free in neonates)
Preservative-free 0.9% sodium chloride
Sterile needleless neutral or positive catheter cap
Soft jaw clamp (depending on the manufacturer)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Determine the child’s and the family’s understanding of the need for the PICC and the importance of site care and infection control.
Assess the need to provide developmentally appropriate material to the child to explain the mechanics of the PICC. Therapeutic play may also be beneficial.
Obtain a baseline circumference of the extremity if line is placed in an extremity.
In general, to maintain good blood flow around the catheter, children are encouraged to use the arm as usual where the PICC is placed, rather than guard it. Very active children are at greater risk for breaking or dislodging a PICC. Immobilization of the extremity may be necessary in these children, and this should be explained to the child/family with appropriate range of motion provided at regular intervals.

PROCEDURE
PICC Site Care and Dressing Change

Steps	Rationale/Points of Emphasis
1 Gather the necessary supplies and obtain the assistance of an additional person as needed; check institutional policy, a second person may be required. Check the record for the initially documented external visible length (EVL) of the catheter. Involve family in comforting/distracting the child during procedure. Have the child assume a comfortable position with arm well supported.	Promotes efficient time management and provides an organized approach to the procedure. Assistance may be required to hold the child securely to prevent dislodging catheter or breaking the sterile field, this is recommended whenever possible to also ensure no steps are missed and the sterile field maintained.
2 Perform hand hygiene and don mask and gloves. Remove old dressing carefully to avoid dislodging catheter. Discard old dressing in trash receptacle and remove gloves.	Standard precautions to reduce transmission of microorganisms.
	caREminder
	To facilitate removing transparent dressing, pull edges first in outward direction, parallel to the skin surface. This releases the adhesive bonds of the dressing and lifts it off the skin, decreasing skin trauma. Consider adhesive removing swabs for tender skin.
3 Apply new sterile gloves; inspect site for redness, inflammation, drainage, tenderness, or streaking (Figure 55-1).	Aseptic technique helps decrease risk of infection in central venous catheters with extended dwell times.

Figure 55-1 The PICC catheter is inserted percutaneously into a peripheral vein, with the tip of the catheter residing in the superior or inferior vena cava, a central vein.
4 If external segment of catheter is visible, measure from the exit site to the hub of catheter and document being careful to maintain sterility. Compare with the baseline external length documented at the time of PICC insertion. The PICC may have external centimeter markings on it, which can be used to determine the length.	Comparison will allow for monitoring of catheter migration. A discrepancy of more than 2 cm in length should be reported to the healthcare prescriber. If the EVL is less than the original, the RN may withdraw the catheter to the original EVL. But if the EVL is more than the original EVL, do not insert the catheter further.
5 Cleanse around exit site with antiseptic applicator or swab.	Cleanses microorganisms from exit site.
5a If using 2% chlorhexidine applicator, scrub in back-and-forth motion using friction for 30 seconds. Only one applicator is required with this product. Allow site to air-dry for at least 30 seconds; do not fan or blow on skin. Remove antiseptic from skin of neonates with sterile water or sterile saline using sterile gauze.	Antiseptics must be applied with sufficient friction to ensure that the solution reaches into the cracks and fissures of the skin. Chlorhexidine requires 30 seconds with friction scrub for antiseptic effectiveness. Drying for 30 seconds decreases the chance of contact dermatitis. Fanning or blowing may introduce contaminants and hasten drying, reducing antimicrobial action.
5b If using 10% povidone-iodine solution, use one swab to cleanse, beginning at the PICC exit site and working outward in a circular pattern, cleansing an area the size of the dressing that will be applied; do not return to an already cleaned area with the same swab. Repeat twice more with a new swab for a total time of 2 minutes. Allow site to air-dry; do not fan or blow on skin. Remove povidone-iodine solution from skin after air-drying with sterile water or sterile saline using sterile gauze.	Povidone-iodine must remain on the skin for 2 minutes and dry to be most effective; thus, three swabs are used. It has been thought that working from the center outward moves microorganisms away from the exit site, although there is no research to support this. Working outward does allow area to dry, facilitating antiseptic effectiveness. One swab can be used, using a slower cleansing technique to cleanse for 2 minutes.
5c Do not use antimicrobial ointment in routine site care.	Use of polyantibiotic ointments may increase the risk for Candida colonization.
KidKare Some infants and children have sensitivity to iodine products, which may also affect the neonatal thyroid. These products should not remain on the skin. Also, use of chlorhexidine if not allowed to thoroughly dry, may be associated with contact dermatitis in low-birth-weight neonates.
6 Ensure that any external catheter present is looped away from the antecubital fossa and secured before applying dressing.	Avoiding the antecubital fossa prevents kinking of the catheter during infusions.
7 Apply chlorhexidine patch (optional) and semipermeable transparent dressing to site so that it is covered occlusively. Change transparent dressings at least every 7 days; do not change if the risk of catheter dislodgement outweighs the benefit of changing the dressing (O’Grady, Alexander, Burns, et al., 2011) or more frequently if wet, soiled, or loose, as needed.	Added antiseptic action from chlorhexidine patch may provide protection from microorganisms. The use of chlorhexidine gluconate in infants weighing <1,000 g has been associated with contact dermatitis, use with caution in this population. Studies demonstrate no clinically substantial differences between gauze and transparent dressings in either the incidences of catheter-site colonization or phlebitis. Transparent dressings provide visualization of site.
8 Secure hub and extension tubing of PICC to skin with a catheter securement device (preferable), sterile closure tape strips, or tape. All connections should be a Luer Lock design. Secure the IV tubing with additional tape as needed to prevent pulling and inadvertent removal.	Most PICCs are not sutured in place in children. Inadvertent dislodgement is one of the most frequently reported complications in children. Use of securement devices has been shown to reduce phlebitis and infection by reducing the pistoning motion of tape-secured catheters. Securement devices are the recommended method to secure PICCs. KidKare In the young child, cover the PICC line to keep out of sight. Use armboard as needed to prevent excessive movement.
9 Change primary and secondary intravenous (IV) tubing at least every 7 days but no more frequently than at 96-hour intervals (O’Grady et al., 2011) or per institutional policy, except for tubing used to administer fat emulsions or blood or blood products, which should be changed within 24 hours of infusion initiation. PICC IV tubing is changed up to the extension set.	Prevents microorganisms from growing in IV tubing. Exposure to fat emulsions and blood products has been identified as an independent risk factor for bloodstream infections. Dislodging the line is possible when tubing is changed at hub. There is no increased risk for infection provided that extension tubing is attached under sterile conditions.