VASCULAR ACCESS DEVICES

PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC) 101

PERIPHERALLY INSERTED CENTRAL CATHETER • A PICC is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. 102 CENTRAL VENOUS CATHETERIZATION

PERIPHERALLY INSERTED CENTRAL • The minimum necesCsaAryTnuHmbEeTr oEf luRmens, connectors and ports should be used • If total parenteral nutrition is being administered, clinicians should utilize one lumen exclusively for that use • Clinicians should use the smallest gauge of PICC that will accommodate the prescribed therapy to reduce the risk of phlebitis • PICCs are usually very long to accommodate different lengths of insertion. They are frequently trimmed prior to insertion to prevent dislodgement and for easy handling 103 CENTRAL VENOUS CATHETERIZATION

PICC CATHETER TYPES AND MATERIALS • PICC lines can differ in size (50 cm to 60 cm), the number of lumens (single to triple) and if they are valved (no clamp) or open ended (with clamp). Some may be able to be used for CT contrast injections • PICC lines are inserted using either ultrasound or fluoroscopic imaging guidance. The final position of the PICC is confirmed by the radiologist on a chest X-ray obtained at the time of the procedure • They can be indwelling for several weeks for up to 6 months 104 CENTRAL VENOUS CATHETERIZATION

PERIPHERALLY INSERTED CENTRAL CATHETER INSERTION 105

PICC INSERTION A. GATHER EQUIPMENT • Sterile gel • Absorbent drape • PICC line pack • Sterile gown, hat and sterile o Catheter gloves o Introducer needle o Peel-away sheath • Cleaning fluid (chlorhexidine) o Guidewire size 018 • 20 ml 0.9% NaCl flush o Tape measure • Suitable locking fluid o Scalpel • Means of securing line (e.g. • statlock) • Sterile dressing pack • Sterile drape Dressing • US machine and linear array • probe Sterile sheath for US probe 106 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION B. PERFORM INITIAL PATIENT ASSESSMENT • Check medical record o Completeness and accuracy o Patient history • Check armband • Explain procedure • Obtain signature on Informed Consent form https://www.sandwegandager.net /2020/12/informed-consent/ 107 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION C. SELECT SUITABLE VEIN • Patient is advised to lie on their back on a procedure table with the arm chosen for insertion resting on an arm board support. • Place absorbent drape • Apply tourniquet around the arm just below the shoulder • Identify brachial artery and suitable veins using ultrasound 108 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION 109 D. DETERMINE CATHETER LENGTH • Position patient’s arm at a 45- degree angle from the body • With a tape measure, begin measuring at the antecubital fossa, then proceed to the midclavicular line, then turn the tape measure to reach the third intercostal space at the right side of the sternum CENTRAL VENOUS CATHETERIZATION

PICC INSERTION E. SETUP STERILE FIELD • Full aseptic precautions are essential during PICC insertion to decrease the risk of catheter-related bloodstream infection • Cleanse the portion of the upper arm with chlorhexidine for a minimum of 30 seconds using a back and forth frictional scrub • Don mask with face shield and hair cover followed by sterile gown and gloves • Create sterile field by placing sterile towels and drape 110 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION F. FINAL PREPARATION BEFORE INSERTION • Prep line – cut to length as appropriate • Flash lumens of catheter using sterile saline • Place all necessary items within easy reach • Place sterile probe cover on the ultrasound probe 111 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION G. PERFORM MODIFIED SELDINGER TECHNIQUE • Re-identify vein using ultrasound • Anesthetize skin using lidocaine subcutaneously • Still using ultrasound as a guide, insert the access needle • into the vein and wait for blood return Remove the syringe and advance guide wire through the needle. • Remove the tourniquet • Remove the needle leaving the guide wire in place and confirm wire placement in vein using ultrasound 112 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION G. PERFORM MODIFIED SELDINGER TECHNIQUE • Using the scalpel, create small nick at insertion site alongside guide wire to accommodate dilator • Insert dilator and introducer over the guide wire • The introducer is now ready to facilitate the catheter entry into the vein • Remove guide wire and dilator, leaving only the introducer in place • Insert catheter through introducer 113 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION G. PERFORM MODIFIED SELDINGER TECHNIQUE • Instruct patient to take deep regular breaths, slowly advancing the catheter upon each inspiration • Once the catheter is fully inserted, remove the peel away introducer • Check aspiration and flush all PEEL-AWAY SHEATH lumens https://www.smiths- medical.com/products/vascular- access/peelaway-sheath- introducer 114 CENTRAL VENOUS CATHETERIZATION

PICC INSERTION 115 H. ANCHORING AND DRESSING • Secure the PICC line to the patient’s arm with adhesive securement device • Remove sterile drape and discard • Cover insertion site with transparent film dressing • Confirm proper placement of catheter by obtaining chest x-ray CENTRAL VENOUS CATHETERIZATION

PICC INSERTION I. COMPLETION 116 • Document the confirmation of tip location in the medical record including the date, time, person reading the x-ray and confirmation that the PICC is ready for use • Measure patient's arm circumference; this serves as a reference to determine any arm swelling should it occur due to complications from PICC placement • Measure and record length of catheter outside vein for possible PICC migration https://piccsox.com.au/size-measuring- guide/ CENTRAL VENOUS CATHETERIZATION

PICC DRESSING, FLUSHING AND LOCKING 117

PICC DRESSING • All dressings should be replaced routinely as well as when the dressing becomes damp, loosened, no longer occlusive or adherent, soiled, if there is evidence of inflammation, or excessive accumulation of fluid • The dressing (including polyurethane types) should not be immersed or submerged in water in order to prevent colonization with Gram negative organisms • Clinicians should utilize an aseptic technique including sterile dressing (or dressing change) pack with drape and sterile gloves when changing the dressing on a PICC 118 CENTRAL VENOUS CATHETERIZATION

PICC DRESSING • PICC dressings should be changed 24 hours after insertion and as below: DRESSING TYPE REPLACEMENT REMARKS Transparent, INTERVAL Benefits include protecting the semi-permeable, site from extrinsic self-adhesive Weekly contamination, allowing polyurethane continuous observation of the insertion site, and helping stabilize and secure the catheter The clinician should inspect the dressing on the exit site each shift 119 CENTRAL VENOUS CATHETERIZATION

PICC DRESSING DRESSING TYPE REPLACEMENT REMARKS Gauze INTERVAL Gauze dressings should only be used by clinicians if there is a true Second daily contraindication to polyurethane dressings including diaphoresis or excessive ooze from the insertion site and should be replaced by a transparent dressing as soon as possible If gauze is used in combination with a semi-permeable dressing, it is considered a gauze dressing and should be changed every 48 hours 120 CENTRAL VENOUS CATHETERIZATION

PICC DRESSING DRESSING REPLACEMENT REMARKS TYPE INTERVAL Chlorhexidine-impregnated dressings and sponges have Chlorhexidine Weekly been shown to reduce the risk -impregnated of exit site infection and catheter-related bacteremia 121 CENTRAL VENOUS CATHETERIZATION

PICC FLUSHING 122 • Flushing is recommended to promote and maintain patency and prevent the mixing of incompatible medications and solutions • Sterile 0.9% sodium chloride for injection should be used by clinicians to flush a catheter unless the manufacturer recommends flushing with heparin sodium solution • 2 ml of solution should be sufficient for PICC line flushing. • Use a syringe with the internal diameter of a 10mL syringe (or larger), to avoid excessive pressure and catheter rupture • Clinicians should flush in a pulsatile (push-pause or start- stop-start) motion CENTRAL VENOUS CATHETERIZATION

PICC FLUSHING 123 • Clinicians should flush catheters immediately: o After placement o Prior to and after fluid infusion or injection (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) o Prior to and after blood drawing CENTRAL VENOUS CATHETERIZATION

PICC LOCKING • PICCs should not be left in situ when no longer required as the risk of infection is greater than risks associated with reinsertion of a new device • Locking involves instilling a solution to prevent occlusion when the device is not in use • Sterile sodium chloride 0.9% should be used by clinicians to 124 lock a catheter that is no longer required for continuous infusions in preparation for future use; unless the manufacturer recommends catheter lumens be locked with an alternate solution CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATION 125

PICC COMPLICATIONS • INFECTION o Central line associated bloodstream infection (CLABSI) ⮚ Blood stream infection in patient with central venous catheter (CVC) in situ for > 48 hours not attributable to other sources o Catheter-related bloodstream infection (CRBSI) ⮚ A clinical definition typically requiring microbiological data identifying catheter as source of blood stream infection such as cultures of catheter tip and/or blood, and differential time to positivity 126 CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS 127 • CATHETER MALPOSITION/MIGRATION o CATHETER MIGRATION ⮚ A change in the length of catheter extruding from the insertion site ⮚ This can occur with high-frequency ventilation, extreme physical activity and rapid infusion, forceful flushing of fluid. ⮚ It can cause cardiac tamponade via erosion of the catheter through the ra or ventricle CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • CATHETER MALPOSITION/MIGRATION o CATHETER MALPOSITION ⮚ PICC can be misplaced in the jugular vein, brachiocephalic vein, or azygos vein. Causes include vascular abnormalities, a patient’s position during insertion or changes in venous pressure inside the chest if a patient coughs or vomits • Catheter malposition and migration can be assessed using chest radiographs as well as by administering contrast dye to determine the path of veins 128 CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • MECHANICAL MALFUNCTION o Another major complication is device malfunction, with anywhere between 10% and 27% of PICCs developing mechanical failure o Catheter “pistoning” in the vein can increase the possibility of phlebitis. They can embolize during placement if sheared by needles or surgical instruments o Fractures of the internal portion of the catheter are also possible, which would possibly require removal through surgery or interventional radiology 129 CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • PHLEBITIS/INFILTRATION o Phlebitis is a result of mechanical damage from the catheter itself or chemical irritation (medications) o Phlebitis may occur within the first week after insertion and can be treated using non-steroidal anti- inflammatory agents or with the warm compress. Removal of the catheter is not necessary o If chemical irritation causes it, diluting medications or 130 administering them at a lower rate can decrease inflammation CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • AIR EMBOLISM o They are caused by an inability to maintain a closed system between the catheter and vasculature o Catheter damage, line disconnection, or lack of occlusive dressings are all capable of disrupting this closed system o Other causes of air emboli are lack of line flushing or improper flushing technique 131 CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • CARDIAC ARRHYTHMIAS o Arrhythmias are caused by the catheter tip being positioned “too low” into the RA or ventricle due to primary or secondary malpositioning, resulting in conduction abnormalities o It can be easily corrected by withdrawing catheter to its correct position and securing it to prevent migration 132 CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • CATHETER OCCLUSION Catheter occlusion can occur as a result thrombotic and non-thrombotic causes. o THROMBOTIC 133 ⮚ A blood clot is the most common cause of catheter occlusions. The positioning of the catheter tip high in the SVC, septicemia, more than one insertion attempt, vessel wall damage from previous catheter placement, ovarian cancer, left-sided insertion, and triple lumen catheters. CENTRAL VENOUS CATHETERIZATION

PICC COMPLICATIONS • CATHETER OCCLUSION o NON THROMBOTIC 134 ⮚ Malpositioning, such as catheter abutment against the wall of a vessel or kinking, can cause occlusion. Additionally, drug precipitation among incompatible medications/ solutions can block the catheter. Common drugs known to precipitate are etoposide, calcium, diazepam, phenytoin, heparin and total parenteral nutrition. CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CENTRAL CATHETER 135

NON TUNNELED CENTRAL CATHETER • Non tunneled central catheter is https://oley.org/page/SecuringCVAD often referred to as a short-term percutaneous central venous catheter • It is inserted directly into a central vein which is most commonly the internal jugular vein and threaded to superior vena cava 136 CENTRAL VENOUS CATHETERIZATION

NON TUNNELED CENTRAL CATHETER • Non-tunneled catheters can also be inserted into the subclavian vein o Done in emergency situations o Without ultrasound guidance • Non tunneled percutaneous CVCs are most commonly used for emergent or trauma situations, critical care, and surgery • The lifespan of the catheter is 5 to 10 days, and can provide up to 5 lumens for separate access 137 CENTRAL VENOUS CATHETERIZATION

NON TUNNELED CENTRAL CATHETER • Insertion of these central catheters requires the patient to be placed in the Trendelenburg position, usually with a rolled towel between the shoulder blades https://basicmedicalkey.com/central-venous- 138 catheter-insertion/ CENTRAL VENOUS CATHETERIZATION

NON TUNNELED CENTRAL CATHETER Length 15 to 30 cm Materials • Polyurethane • Silicone polymers Lumens may be single up to 5 lumens Configuration • Heparin-coated, • Chlorhexidine, • Antibiotic-coated lines, or • Silver impregnated to help avoid thrombosis or infection 139 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CENTRAL CATHETER INSERTION 140

NON-TUNNELED CATHETER INSERTION A. GATHER EQUIPMENT • Sterile drape • Syringe and needle for • Sterile gown, cap, local anesthetic • Small vial of 1% lidocaine gloves and facemask • Syringe and introducer • Chlorhexidine needle • Ultrasound • Scalpel • Sterile ultrasound • Guidewire • Tissue dilator probe cover • Sterile dressing • Suture and needle • Central line catheter 141 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION B. PERFORM INITIAL PATIENT ASSESSMENT • Check medical record o Completeness and accuracy o Patient history • Check armband • Explain procedure • Obtain signature on Informed Consent form https://www.sandwegandager.net /2020/12/informed-consent/ 142 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION C. PATIENT PREPARATION • Place the patient in the appropriate position for the site selected, then prepare the site in a sterile fashion using the sterile solution, sterile gauze, and sterile drapes. o Internal jugular and subclavian approach ⮚ Trendelenburg with the head turned to the opposite side of the site 143 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION C. PATIENT PREPARATION o Femoral vein ⮚ Supine position with the inguinal area exposed; target leg should be bent at the knee with the lateral aspect resting on the stretcher or bed https://journals.plos.org/plosone/arti cle?id=10.1371/journal.pone.0182623 144 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION D. FINAL PREPARATION BEFORE INSERTION • Prime lumens of catheter generously with saline • Thumb the guidewire back and forth to make sure it glides smoothly • Place all necessary items within easy reach • Place sterile probe cover on the ultrasound probe • Use your finger to snug the probe cover against the probe, removing any folds and air bubbles 145 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION E. INSERTION 146 • Re-identify vein using ultrasound • Infiltrate the skin with 1% lidocaine for local anesthesia around the site of the needle insertion • Remember that you will sewing the line in, so you also need to inject where you anticipate the suture needle will be passing https://www.emra.org/emresident/arti cle/us-guided-subclavian-access/ CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION E. INSERTION • If using landmarks for the subclavian vein CVL, the needle should be inserted approximately 1 cm inferior to the junction of the middle and medial third of the clavicle • If using landmarks for the femoral line CVL, the needle insertion site should be located approximately 1 cm to 3 cm below the inguinal ligament and 0.5 cm to 1 cm medial to where the femoral artery is pulsated https://uscemprocedures.files.word press.com/2015/09/femoral-central- line_chavez.pdf https://aneskey.com/subclavian- vein-central-venous-access/ 147 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CATHETER INSERTION E. INSERTION (MODIFIED SELDINGER TECHNIQUE) • Insert the introducer needle with negative pressure until venous blood is aspirated • Direct the tip of the needle towards the suprasternal notch until venous blood is aspirated • Whenever possible, the introducer needle should be advanced under ultrasound guidance to ensure the tip does not enter the incorrect vessel or puncture through the distal edge of the vein • Carefully remove the syringe and thread the guidewire 148 through the introducer needle hub CENTRAL VENOUS CATHETERIZATION

NON TUNNELED CATHETER INSERTION E. INSERTION (MODIFIED SELDINGER TECHNIQUE) • While still holding the guidewire in place, remove the introducer needle hub • Use the ultrasound to confirm the guidewire is in the target vessel in two different views • Using the scalpel, create small nick at insertion site alongside guide wire to accommodate dilator Dilator insertion • Insert dilator with a twisting motion https://www.uptodate.com/contents/image/print?im ageKey=EM%2F77656&topicKey=SURG%2F15672&sou 149 rce=outline_link CENTRAL VENOUS CATHETERIZATION

NON TUNNELED CATHETER INSERTION E. INSERTION (MODIFIED SELDINGER TECHNIQUE) • Advance the CVL over the guidewire • Once the CVL is in place, remove the guidewire • Flush and aspirate all ports with sterile saline • Secure the CVL in place with the suture and place a sterile dressing over the site Normal right Vascath • Call x-ray to confirm placement https://radiopaedia.org/articles/central- venous-catheter 150 CENTRAL VENOUS CATHETERIZATION