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Wednesday, November 24, 2010

VENOUS ACCESS -- PICC LINES: PURPOSE, USE AND CARE

By JC Leahy, RN, BSN, MA
When medical care requires direct access to the venous blood system, a device must be introduced through the skin into a vein.  This device is called an “IV access.”  There are many types of IV access.  They differ from each other in several ways: (1) the diameter and length of the tube inserted (2) the size and location of the vein to which the tube extends (3) the location on the body where the tube passes through the skin, and (4) special characteristics of some IV devices.  The smallest IV access device is called a “peripheral IV access.”  This is a small-gauge, very short plastic tube inserted through the skin into a small vein, usually in the arm or hand – rarely in the neck (external jugular vein) or lower extremity.  The disadvantages of peripheral IV access are twofold: (1) small veins are relatively delicate and (2) peripheral IV devices must be changed every 72 hours.  Because of the vein delicacy, certain medications may cause discomfort and medications that are caustic may cause irritation damage to the vein and/or surrounding tissue. Peripheral lines also impose limits on infusion rates.  Peripheral IV Lines smaller than 18 gauge may also hemolyze infused red blood cells.   Additionally, peripheral IV devices are not well suited to drawing blood samples because the vein may collapse or suffer damage.  

Because peripheral IV access has so many limitations, central IV access is often needed to treat hospitalized patients.  Central lines became popular in the hospital setting during the 1970’s.  A “central line” is a larger-gauge, longer plastic line inserted through the skin into a large vein.  The three veins to which a central line is normally inserted are the subclavian vein, the internal jugular vein, and the femoral vein.  With both internal jugular and subclavian central lines, the distal tip of the catheter resides in the superior vena cava, just upstream of the heart.  Central lines are better than peripheral lines in several respects:  (1) more suitable for higher-volume fluid administration, (2) more suitable for medications and certain special fluids, (3) more suitable for blood draws, and (4) may stay in place for longer than 72 hours.  Also, subclavian and internal jugular central lines may be used to measure central venous pressure to assess a patient’s fluid status.
Although traditional central lines are useful for hospitalized patients, they are unsuitable for use in non-hospitalized patients.  Primarily this is because they are too subject to infection and therefore may not remain in place for very long.  A femoral line, for example, should not remain in place for more than a week, and some institutions’ policies may specify even shorter times.  Internal jugular and subclavian lines that are older than a week require frequent monitoring for signs and symptoms of infection.  Consequently, patients are never discharged to home unless their central IV access has been removed.
For those patients who need IV access outside the hospital, a long-term IV access device is necessary.   Long-term IV’s include implanted ports (“mediports”), certain tunneled catheters, and “PICC lines”. 
PICC lines have so many advantages that it is a wonder that they are not used more.  Advantages include:
  1. Safety for long-term use:   Whereas peripheral lines should be changed every 3 days, and traditional central lines may last up to two weeks, a PICC may remain in place for up to a year. 
  2. Low risk of infection:  The PICC is typically inserted in the upper arm.  This is inherently cleaner than the insertion site for a femoral line or internal jugular line.  It is because of lower risk of infection that a PICC can remain in place for up to a year.
  3. Decreased Skin Puncture for Blood Sampling – A PICC can be used to draw venous blood samples for laboratory tests.  This not only enhances patient comfort but also reduces the risk of infection.   (Note: At least one PICC manufacturer, Groshong, recommends AGAINST drawing blood through its PICC lines.)
  4. Best use of medical resources – Most forms of non-PICC long-term IV access require the patient to undergo surgery in the operating room.  Surgery and anesthesia are risky for the patient as well as a tremendous commitment of hospital resources.  Traditional central lines require a physician to insert them.  A PICC, on the other hand, can be inserted by a specially trained Registered Nurse without any use of the operating room or general anesthesia.
  5. Low risk – When a physician places a subclavian line he always worries about the possibility puncturing the pleural cavity and consequently collapsing a lung.  This is a life-threatening event.  When a surgical team inserts an implanted port in the operating room, there are all the risks that go with anesthesia and surgery.   In contrast, insertion of a PICC is a relatively low-risk procedure.  The most serious risk of PICC insertion is that, as with ANY upper body central line, the catheter could be inserted too far, advancing into the heart and causing an irregular heartbeat.
  6. Early patient discharge – Since a PICC can be maintained in the home or outpatient clinic, a patient who requires 8 weeks of IV antibiotics can be discharged to home instead of spending the 8 weeks in the hospital.  This has many advantages, including patient comfort and sense of well-being, reduced risk of hospital acquired infections, and conservation of valuable hospital inpatient resources.
  7. Versatility – A PICC is versatile.  It is usually a dual-lumen device, so that multiple medications or fluids can be infused simultaneously.  It can be used to measure central venous pressure. It can be used to draw
With all these advantages, why are PICC lines not used more frequently?  That’s a good question! 
WHAT TO EXPECT WHEN YOUR PICC LINE IS INSERTED
A PICC is usually inserted by a specially trained nurse right in your hospital room or in a hospital clinic.  However, if the nurse has difficulty with insertion or if special problems are anticipated, you may be sent to the interventional radiology department for insertion.
The nurse will clean your arm and employ sterile-procedure precautions, including a small sterile drape around the insertion site.
The nurse may use a portable ultrasound machine to find a vein in your upper arm.
The nurse will administer a local numbing medication.  This will probably be an injection of lidocaine or lidocaine with epinephrine.
The nurse will measure your anatomy and may trim the PICC catheter to the correct length.
The nurse will insert an introducer needle into the vein and then guide the PICC line into the vein near your heart.
The nurse will secure the PICC in place with sutures or some other anchoring device.
You will then have a chest x-ray to be sure the PICC is in the correct location.
The nurse will cover the PICC site with a sterile dressing and a pressure bandage.  The dressing will be changed after 24 hours and then according to institutional policy – probably once or twice per week.
COMMON INDICATIONS FOR A PICC
  • Long term treatments such as chemotherapy or IV antibiotics
  • Hyper alimentation
  • Repeated administration of blood products
  • Venous blood sampling
  • Measurement of CVP (central venous pressure)
WHAT TO EXPECT AFTER YOUR PICC HAS BEEN INSERTED
There may be a little soreness at the insertion site for a couple of days.
There may be a little blood under the dressing around the insertion site for a day or two.  This is normal unless it is of large amount. 
RECOGNIZING PROBLEMS: CALL YOUR HEALTH CARE PROVIDER RIGHT AWAY IF YOU EXPERIENCE:
  • Pain
  • Fever
  • Blood around the insertion site larger than a half-dollar in diameter.
  • Redness or swelling around the insertion site
  • Any breakage or tear in the PICC
  • Inability to flush the PICC
  • IV pump alarms even after you have flushed the PICC
  • IV fluid seems to leak out from around the insertion site
HOME CARE OF A PICC
Rest your arm for a couple of days after the PICC has been inserted.  Then, while the PICC is in place, do not lift items heavier than 10 pounds or perform repetitive exercises with the PICC arm.
Do no immerse any part of the PICC in a bath or hot tub.  Do not go swimming.
Cover the PICC and insertion site with plastic before you shower and keep them dry.
Follow all PICC care instructions that you receive from your home-health nurse or clinic.
In the home and outpatient setting, the PICC should be flushed after each use and at least once per day. There are, however, outpatient organizations whose standard is to flush unused PICC's only once a week with dressing changes.  (In the inpatient setting, institutional policy may require more frequent flushing, such as twice a day or every nursing shift.)  Refer to your organizational policy and the PICC manufacturer's guidelines.
Your PICC dressing needs to be changed at least once a week.  Your medical providers will provide a plan.  For example, when I had a PICC for 8 weeks of home antibiotic therapy, a home-health nurse visited me once a week to change the dressing, inspect the site, and perform other line care as needed.  Once she had to de-clot the PICC with streptokinase.  On a daily basis, my wife and I were responsible for inspecting the site and flushing the line after each use.
To help prevent infection, clean the PICC's injection caps with alcohol swabs before and after each use or each flushing.
Avoid blood pressure measurement on the PICC’s arm.
Always protect the PICC from accidentally catching on something and getting pulled.  This precludes your participation in rough contact sports.
Avoid having dental work performed while the PICC is in place.  There is a risk that dental work could release bacteria into the blood stream which could lodge in the tip of the PICC and cause an infection.  If you must have dental work performed, be sure to tell the dentist about the PICC IN ADVANCE of your dental appointment.
SPECIFIC INSTRUCTIONS FOR CHANGING THE PICC DRESSING
Every effort should be made to maintain sterility around the PICC insertion site.  Until around 10 years ago, the procedure for changing the dressing used to go something like this: Wash your hands. Gather your supplies.  Don a face mask. Remove the old dressing.  Don sterile gloves.   Clean an area around the site, going from the center outward, first with at least 3 alcohol swabs, then with at least 3 betadine swabs, and finally with 3 tincture of benzoin swabs.  Then cover the site with a clear dressing such as Tegraderm.  Then change the injection caps with new caps and, if necessary, secure the tubing so that it does not get accidentally pulled.  If the PICC has clamps, you MUST clamp the line before changing the  injection caps to avoid the risk of air embolus.   (If the PICC does NOT have clamps, the PICC probably has a one-way valve designed into each lumen to prevent air embolus.  These valves are called PASV's - pressure activated safety valves. Some manufacturers of PASV PICC's actually recommend AGAINST clamping the line when changing the caps. ) This old procedure is still fundamentally sound, except for one thing:  A new chemical was introduced which is more effective than the alcohol/betadine treatment.  It is called ChloraPrep (chlorhexidine ).  Chlorhexidine has a longer lasting effect than alcohol and betadine treatment.  Consequently, central line dressings with chlorhexidine can be changed once a week instead of once every 3 days, as before.

To complicate matters just a bit further, there are certain safety caps that apparently have a PASV-like valve in them.  Use of these valves may obviate the need for a heparin flush, but when you change the caps, clamp the PICC if the PICC is designed with clamps.
If you are using chlorhexidine, substitute cleaning with chlorhexidine instead of cleaning with alcohol and betadine.  The purpose of the tincture of benzoin was always to help the dressing adhere well to the skin.  I believe it is still useful for that purpose.  There is also a relatively new item called a "Biopatch" that should always be used after you have cleaned the insertion area with chlorhexidine.  A Biopatch is a little fabric disk impregnated with chlorhexidine that fits around the base of the catheter at the insertion site. Always remove the old Biopatch when you remove the old dressing and place a new one before you install the new dressing.  To repeat, be sure to change the Biopatch and the injection caps with every dressing change.  Some anchoring devices may also be suitable for changing.
There are a couple of special precautions to observe when changing your PICC dressing.  Do not use scissors to remove the old dressing, for you may accidentally cut the catheter.  Also do not use tape remover (containing acetone) to remove the old dressing, as this may cause damage to the catheter.  If you choose to use a hemostat to clamp the PICC during an inection cap change, make sure it is a toothless hemostat.
FLUSHING YOUR PICC
The Society of Infusion Nurses recommends flushing all PICC's every 12 hours.  Some outpatient organizations flush unused outpatient PICC's only weekly with the dressing changes.   For inpatients, the PICC should be flushed every 12 hours and after each use, or per institutional policy, possibly q-shift. Before flushing, the injection cap should be cleaned with an alcohol swab, and clamps, if any, must be opened.  For each of the two lumens, flushing is performed with 10 ml of 0.9% normal saline followed by 5 ml of 0.9% normal saline containing heparin at a concentration of 10 units per ml.  If the PICC has a clamp, clamp the catheter at the end of the flush process while you are still flushing to avoid air getting in the line. Both the 10 ml of normal saline and the 5 ml of heparin solution are available in pre-filled syringes.  The heparin syringe is called a “heparin lock flush.”
Some PICC lines do not require the heparin flush, only normal saline.  These are called “saline only” PICC’s.  Some manufacturers call them “heparin optional” PICC’s.  You can recognize a “heparin optional” PICC by the absence of clamps.  Only heparin PICC’s have clamps. (If you know WHY this is true, be sure and let me know.  Use e-mail or the “comment” function at the end of this article.  My guess is that PICC's requiring heparin flushes lack integerated PASV's)  The disadvantage to using heparin is that some patients may experience heparin induced thorombocytopenia.

Cautionary note for nurses:  As to frequency and procedure for flushing a PICC, check your institutional policy AND the manufacturers recommendations.  If you deviate from these and something goes wrong, it will counted as a nurse error.
PICC PROBLEM SOLVING
  • If you think your PICC is occluded by a clot: (1) check to see if it is clamped, (2) check to see if it is kinked.  If it is not kinked or clamped, do not force-flush it; instead, call the home care nurse. She may be able to de-clot it with an agent such as streptokinase.
  • If you have signs of infection (fever, chills, irritation or tenderness or swelling at the insertion site or pus at the insertion site) call your physician immediately.   One caveat:  Some patients experience some redness around the insertion site around 2 weeks after insertion.  This may be a normal part of the healing process, and therefore not a problem.  In that event, it should go away in a day or two.  However, if the redness is accompanied by pain or increased skin temperature, phlebitis is to be suspected and you should call your physician.
  • If the PICC comes out, don’t panic. Hold pressure on the site for at least 5 minutes until the bleeding stops.  Then apply an antibacterial agent if available and cover it with a dressing.  Meanwhile, call your physician or home care nurse.
  • If the PICC appears longer than it used to be, don’t push it back in.  Call your physician or nurse.
  • If the PICC breaks: Clamp it or kink it and secure the kink with rubber band or tape to prevent blood outflow and call your physician or nurse.
  • If you see blood in the PICC catheter, flush it.
  • If you see swelling of your hand, arm, shoulder or neck and arm on the PICC side, this could be a sign of central venous thrombosis.  Call your physician immediately.
  • If you see air in your catheter, this could be caused by breakage of the catheter or a loose injection cap.  If enough air enters, you may experience shortness of breath, chest pain, or lightheadedness.  In this event, dial 911.  Kink the catheter and secure the kink with a rubber band or tape – or use the clamp, if available.  If there is not enough catheter to kink, pull some out and kink it.  If you have dialed 911, lie down on your left side and wait for emergency help. 
All in all, PICC lines have significant advantages over other forms of IV access. They are relatively safe to insert, have low risk of infection, are versatile, do not require operating room resources or even a physician to perform the insertion, and can remain in place for up to a year even outside the hospital.  It is a wonder that they are not used more frequently.!!!

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