Peripherally Inserted Central Catheters (PICC)

Picture this first scenario. You are a nurse with 15 years of experience in the medical-surgical arena, starting a new position as a home health nurse. As you arrive on your first day on the job, you go to the house of your first patient to find your patient has a PICC line, and while the line looks okay, the area above the line is reddened, swollen and tender to the touch. What do you do?

Picture this second scenario. You work in a busy ICU on the night shift. Your patient had a PICC line placed 48 hours prior so he could get his internal jugular central venous catheter removed. As you try to flush the one port of the line, you cannot flush it, and the second port is very sluggish to flush. What do you do?

These and other problems can be very common with PICC lines; some issues can be remedied easily while others can be quite serious. However, with the changes in the health care industry regarding reducing the use of central lines and patients being sent home with antibiotics, PICC lines are becoming more of the norm than the exception to the rule.

In this series, you will learn about PICC lines, from their insertion to their discontinuance, the clinical decision-making regarding a PICC, the contraindications for PICC lines, troubleshooting the problems, and the signs and symptoms of complications with having a PICC line. Nursing implications and a brief discussion on the midline catheter will also be discussed.

Simply put, PICC is short for a peripheral intravenous central catheter. The catheter is placed by either an interventional radiologist or a nurse specially trained in placing PICC lines. In recent years, the delegation for placing a PICC line has gone to nurses trained in their placement in routine, non-complicated cases, with the placement being performed at the bedside.

The reasons for needing a PICC are many and varied. The main reasons for needing a PICC line, according to Medcaretip (Singh, 2019). are when a patient needs frequent blood sampling, long-term antibiotics usually greater than four weeks, prolonged courses of chemotherapy, total parenteral nutritional therapy, and other substances that a normal intravenous route could not deliver due to their caustic nature. PICC lines can stay longer than regular central lines, usually up to one year and have a lower incidence of complications.

The reasons for not placing a PICC line are just as important as their placement. The absolute contraindications for a PICC line include an elevated INR, thrombocytopenia, septicemia, and an inadequate vessel for cannulation. A relative contraindication would be an A-V fistula, pacemaker, or a mastectomy site, in which case the opposite side would be used (Day, 2019).

The advantages to a patient having a PICC line are numerous, but the significant advantages to the patient are:

• Preservation of the peripheral veins and reduced discomfort from frequent venipunctures
• The reduced risk of phlebitis and infiltration
• The cost-effectiveness and the fact that the PICC can be used as a central venous pressure monitoring device for patients in the intensive care unit

The other reasons for having a PICC line versus a standard CVC per Brien et al. include:

• Lower costs in terms of placement
• Lower rate of complications and cost of complications
• and a reduced length of stay in the hospital (Brien, 2015)

The process for the insertion of the PICC line is similar to that of any other central line placed in the groin area, neck, or subclavian area. The procedure explained is the taught method from the Bard Access Clinical Didactic Training Site (Bard Access, 2018). Systems The process is considered a sterile procedure and is usually done at the bedside or in interventional radiology. Consent is obtained from the patient prior to the procedure being done. The patient is prepped by having the provider find the appropriate vessel using an ultrasound device and ensuring the vessel is a good vessel to use, as well as performing certain body measurements to confirm the catheter is cut at the appropriate length. The patient is prepped like any other central line procedure.

In my practice, I was taught the Modified Seldinger technique, which is done by cannulation of the vein first by a hypodermic needle, followed by the insertion of a guidewire through the needle. After the needle is removed and the guidewire left in place, a sheath is placed into the vein with the guidewire removed. After the guidewire is removed, the catheter is cut to the appropriate length and placed. It should be noted that when done in interventional radiology, the placement is confirmed by fluoroscopy; when it is done at the bedside, it is confirmed by chest radiography or by what is called a 3CG TPS placement.

The procedure usually takes about one to two hours, depending on the practitioner's skill and the patient's anatomy. Upon placement of the device, the practitioner should ensure that all lumens flush well and can aspirate blood. After the line is placed, the catheter is secured, usually with a catheter securement device to prevent migration of the catheter as well as a sterile dressing over the catheter. The practitioner will document the placement of the catheter to include the total length of the catheter to ensure that when the catheter is removed, the insertion measurement and the measurement upon discontinuance are the same in the case of catheter shear. The practitioner will also document if the catheter is out of the insertion site by so many centimeters to assess for catheter migration.

The care for the patient in preparation for receiving a PICC line includes explaining what a PICC line is, the reason for the line, and what to expect during the insertion. It is up to the provider placing the PICC line to consent the patient and review the risks, benefits, and alternatives to a PICC line. The PICC team will need to measure the arm circumference to compare in case of deep vein thrombosis. The post-procedure care of the PICC patient includes frequent assessment for site infection, deep vein thrombosis and catheter migration.

In assessing for infection, the nurse needs to look for site tenderness, purulent drainage, fevers, and an increase in white blood cell count. If the PICC line needs to be discontinued for concern over an infection, the catheter tip will need to be sent for culture and sensitivity. The injection hub needs to be scrubbed with alcohol per facility policy and adhere to a strict sterile procedure when changing the PICC dressing. Always follow facility policy when doing so.

In looking at a deep vein thrombosis, which is what the problem was in scenario #1, the nurse will need to watch for redness and tenderness at or near the insertion site; the nurse will also need to measure the arm circumference of the PICC is in. If there is a difference in arm circumference, the nurse will need to notify the patient's attending provider for further orders.

The problem of catheter migration occurs when the PICC line is not secured to a securing device such as a Statlock device. When not adequately secured, the catheter can migrate out; while this may not be a problem if there is a secure, transparent dressing, it can be if that dressing is not intact or becomes loose. The catheter can not only migrate out but also be the cause of infection and phlebitis. A device such as a Statlock device should be used to prevent migration.

The nursing implications include monitoring for complications and ensuring the PICC line functions well. The first point is that the PICC cannot be used without an order saying it is safe to use. For this to happen, there needs to be an x-ray to confirm placement. The only exception is if the PICC was placed using 3cg technology; when this is done, there will still be proof of the catheter being okay to use, and the accompanying order will follow.

There may be problems in using the line due to line clots or problems aspirating blood from the PICC, as in our second scenario. The answer to this, of course, is getting rid of the clot. If a line clot is suspected, the nurse can obtain an order for a clot-busting medication such as streptokinase, used per facility policy instructions. If the nurse has trouble aspirating blood and a clot is not suspected, the catheter may be against the vessel wall; a change in patient position may help. To prevent blood clotting, ensure the patient has adequate hydration and that the line is flushed regularly according to facility policy.

Removal of the PICC line should be done by someone trained in performing this practice. The most important thing to know about this is that upon removal of the line, the line itself needs to be measured and compared with the documented insertion length. If there is a shortage of length in the catheter, the patient's attending provider must be contacted at once, and a STAT chest x-ray is ordered and performed.

In performing patient education, it is important to include not only the patient but also the patient's caregivers. Patient education includes not only sterile dressing changes but also proper flushing techniques, signs and symptoms of complications, and daily care of the PICC. It is now the norm for the patient to go home with a PICC line, so long-term education with documentation is very important.

The midline catheter is a catheter that is smaller in length, meaning that it does not go into the central circulation of the patient. The insertion process is the same for the midline catheter, except that there does not need to be a confirmation x-ray or another confirmation test such as 3cg technology used since the catheter stays in the peripheral circulation.

In looking at the difference between a PICC and Midline catheter, the difference is in what the patient needs, and the length of time needed. If the patient needs intravenous fluids or medications, antibiotics, steroids, or blood products for a short-term duration of fewer than 30 days, then a midline would be appropriate. If, however, the patient will need longer-term treatment such as chemotherapy, total parental nutrition, or antibiotics greater than thirty days, then a PICC would be most appropriate. Please see this pdf for a complete list of clinical indications for a PICC and Midline catheter (IV-Therapy.net, 2019).

In conclusion, PICC lines are now the norm in hospitals, homes, nursing homes, and rehab facilities and are here to stay. The PICC is better for the patient, is safer for the patient and is more cost-effective. Only with the proper nursing care will they remain so.

• Bard Access Systems. Bard Access Systems.com Clinical Training Site. Accessed in 2018. Visit Source.
• Brien, C., Govender, P., Torregiani, Doody, O. PICC Line Trends and Cost-Effectiveness. European Society of Radiology. Electronic Presentation Online System. 2015. DOI: 10.1594/ecr2015/C-0656. Accessed 2018.
• Day, K. Generally, we look at things. Accessed 09/22/2019. Visit Source.
• IV-Therapy.net. Accessed 09/14/2019. Visit Source.
• Singh, A. Peripherally Inserted Central Catheter-Indication and Procedures. Med Care Tips, Health and Medical Care 2019. Accessed 09/22/2019. Visit Source.