PICC (Peripherally-Inserted Central Catheters) are central venous access points usually inserted by radiologists or anaesthetists. Indications for their insertion are varied, however it is important to note that these are CENTRAL LINES and require due care and diligence. PICC line sepsis is common and re-insertion rate is 54%.
Interns may be asked to:
- Withdraw blood from a PICC line
- Flush a PICC line
- Remove a PICC line
Withdrawing blood from a PICC
Explain the procedure and obtain verbal consent and Wash hands
The method for withdrawing PICC line blood has changed, the equipment listed below is for the old method which still can be used, however the new method is far more straight forward.
Collect the following:
- 10ml Normal Saline pre packed flush x 3 (make sure they are 10ml)
- blood bottles (including a Group and Hold bottle)
- Chlorhexidine caps (Green caps for tips of PICC lines)
- Bung with converter to attach to blood bottles.
Technique:
- Don gloves.
- Position patients arm, generally externally rotate, extend arm and ask patient to turn head to opposite side.
- Take off Green Chlorhexidine cap.
- With your first flush with one smooth action, deliver 3ml.
- Then pull back on the flush to start the blood flow.
- Next attach your converter so you can use your selected blood bottles.
- First bottle is a Group and Screen, place on un-vacuumed.
- Pull back on vacuum.
- Draw out 3-5ml of waste blood.
- Place on whatever bottles you require in the correct order (these can be prevacuumed).
- Remove the converter.
- With your second flush, deliver the full 10ml in one steady push.
- With your last flush, deliver it in a pulsatile manner, 1ml at a time.
- This is to facilitate the lumen locking again.
- Replace the Chlorhexidine cap with a fresh one.
NOTE: the older method can still be used but is far slower. There is also a clinical skills nurse that can unblock most PICCs or give you a refresher.
Equipment
- Dressing pack
- Sterile Gloves
- x2 10ml syringes
- x3 10ml Normal Saline
- Chlorhexidine/Alcohol disinfectant swabs
- Sterile gauze
- 20ml syringe
- Blood bottles
- x4 green or pink needles
Removing a PICC line
- Explain the procedure and obtain verbal consent.
- Ask if patient needs to urinate – bed rest for 30 minutes post-removal.
- Check coagulation profile: assess for risk of haemorrhage.
- Wash your hands.
- Remove the dressing carefully and ensure StatLock remains in situ.
- With chlorhexidine/alcohol wipes thoroughly disinfect the PICC Device.
- Disinfect the surrounding skin (Catheter-Skin Junction).
- With the suture cutter, carefully remove the two sutures at the StatLock.
- Once patient performing appropriate breathing maneuver (valsalva or exhale), gently and slowly pull the PICC Line 2-3cm at a time.
- DO NOT APPLY PRESSURE TO CATHETER-SKIN JUNCTION UNTIL THE PICC LINE HAS BEEN REMOVED COMPLETELY.
- Once removed apply immediate pressure to site with sterile gauze.
- Place the removed PICC Line on the Sterile field.
- Continue to apply pressure for 3-5 minutes and inspect.
- Apply an OCCLUSIVE DRESSING to puncture site (Tegaderm).
- This prevents air entry.
- Inspect the PICC Line and ensure that it is intact completely.
- With sterile scissors, cut the tip of the PICC Line and send to microbiology for culture
Equipment
- Dressing pack
- Sterile Gloves (x2)
- Suture Cutter
- Chlorhexidine/Alcohol swabs
- Sterile container for catheter tip
- Occlusive Dressing (Tegaderm)
- Blood Pressure / Pulse oximetry machine
- Sterile Scissors
Document the removal
- DATE and TIME of removal
- State whether aseptic technique was maintained throughout or not
- Document the state of the catheter-skin junction
- Document the condition and length of removed PICC Line
- Document the condition of the PICC Line Tip
- Document the dressing used to cover the insertion site
- Document the patient’s response to the procedure and any complications
- Ask nursing staff to re-check vitals 10 minutes post-removal
Important points to remember
- Flush with 10mls 0.9% Normal Saline, before and after drug administration.
- If only 1 port is used for drug administration, port NOT being used must also have 10 ml saline flush each time.
- PICC line sepsis is becoming more common. Re-insertion rate of PICC lines in UHL is approximately 54%.
- If properly maintained, PICC lines can last up to 6 weeks.
- Always suspect PICC line sepsis in any patient with SIRS/sepsis/pyrexia, regardless of how long the PICC is in situ.
- Take blood cultures from both the PICC and peripherally and label both samples carefully.
- PICC lines and other central venous access devices should not routinely be removed while on call (especially at night).
- This procedure has potential life-threatening complications and should only be performed during the day when there is full medical staff to attend to any adverse situations.
- One exception might be PICC line sepsis with persistent pyrexia/rigors.
- Confirm that the PICC line should be removed with your team.
- If continued IV access is required, it is best advised to obtain peripheral venous access PRIOR to removing the PICC Line.
- To reduce the risk of air embolism, all central lines should be removed in Trendelenberg position or flat and either in a Valsalva Maneuver (blow into a 20mLSyringe) or on expiration (Intrathoracic pressure needs to be greater than atmospheric pressure).
- If you cannot get blood from a PICC line, try repositioning the patient.
- Lean the patient to the opposite side or forwards, or get them to lift their arm above their head.
- Sometimes the tip of the catheter becomes apposed against the vessel wall and re-positioning is all that is required.
- Failing this, flush the lumen with HepSol in a pulsatile manner to dislodge any thrombus.