90% of participants will have increased confidence when taking care of a patient with a PICC line as well as comprehending when a PICC line is and isn’t appropriate.
By the end of this course, the learner will be able to:
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 are unable to 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. But 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 will also be discussed as well as a brief discussion on the midline catheter.
To put it simply, 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. It should be noted that in more 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 reason for needing a PICC are many and varied. The main reasons for needing a PICC line according to Medcaretips1 are that of 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 could not be delivered by a normal intravenous route due to the caustic nature of them. PICC lines are able to stay in longer than regular central lines of 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 the reasons for its 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 something such an A-V fistula, pacemaker or a mastectomy site, in which case the opposite side would be used.2
The advantages to a patient having a PICC line are numerous, but the significant advantages to the patient are:
The other reasons for having a PICC line versus a standard CVC per Brien et al3 include:
The process for the insertion of the PICC line is similar to that of any other central line that is placed in the groin area, neck, or subclavian area. The procedure explained is the taught method from the Bard Access Clinical Didactic Training Site.4 The process is considered a sterile procedure and is usually done either at the bedside or done 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 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 way of 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, placement is either confirmed by chest radiography or by what is called a 3CG TPS placement.
The whole procedure usually takes about one to two hours depending on the skill of the practitioner and the anatomy of the patient. Upon placement of the device, the practitioner should ensure that all lumens not only flush well but also are able to 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 that the insertion measurement and the measurement upon discontinuance is the same in 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 of the line. It is up to the provider placing the PICC line to consent the patient and go over the risks, benefits and alternatives to a PICC line. The PICC team will need to measure the arm circumference to compare in case of a 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 as well as 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 as well as adhering to process 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 the scenario #1, the nurse will need to watch for redness and tenderness at or near the site of insertion; the nurse will also need to measure the arm circumference the PICC is in. If there is a difference in arm circumference, the nurse will need to notify the patients’ 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 not only monitoring for complications but ensuring the PICC line functions well. The first point to make is that the PICC cannot be used without an order saying it is safe to use. In order for this to happen, there needs to be an x-ray for confirmation of placement. The only exception to this 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 issues with line clots or problems aspirating blood from the PICC, such as is the case 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, use per facility policy instructions. If the nurse if having 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 patients’ attending provider has to 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 caregivers of the patient as well. Patient education includes not only sterile dressing changes but also proper flushing techniques, signs and symptoms of complications as well as daily care of the PICC. It is now the norm for the patient to go home with a PICC line, so the long term education with documentation thereof 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, with the exception that there does not need to be a confirmation x-ray or another confirmation test such as 3cg technology used since the catheter is staying in the peripheral circulation.
In looking at the difference between a PICC and Midline catheter, the difference is in what the patient needs are and the length of time needed. If the patient will need intravenous fluids or medications, antibiotics, steroids or blood products for a short term duration, less than 30 days, then a midline would be appropriate. If, however, the patient is going to 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.5
In conclusion, PICC lines are now the norm in not only the hospital but in the home, nursing home, 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.