IN PART 1 of this article (August 2007), we discussed when peripherally inserted central catheters (PICCs) are used. Now let's look at PICC care and maintenance.
Assess the PICC insertion site according to your facility's policy. Watch for signs and symptoms of phlebitis and thrombosis (such as pain, erythema, edema, and drainage), infection (drainage, odor), and compromised catheter integrity (wet dressing; kinked, cracked, or leaking external catheter).
The dressing should be dry, intact, clean, and adherent. Change a transparent semipermeable membrane dressing and catheter securement device at least every 7 days; sooner if the dressing is wet, soiled, or nonadherent. If gauze was placed under the transparent semipermeable membrane dressing, change both dressings every 48 hours.1
If you see excessive bleeding at the insertion site, consider obtaining an order for a topical hemostatic agent to use with a pressure dressing. To maintain catheter patency, flush the catheter every 12 to 24 hours when it's not in use and before and after any infusions.1 Infusion Nurses Society standards recommend that the minimum flush volume be at least twice the volume capacity of the catheter and add-on devices. To prevent catheter damage, use the syringe size recommended by the catheter manufacturer. Generally, a 10-mL syringe is recommended for flushing.
The flush solution you use depends on facility policy, the type of catheter, infusate, and patient's allergy history. Many facilities have steered away from the routine use of heparin flushes because of the risk of heparin-induced thrombocytopenia.
Many valved catheters and positive displacement and neutral end caps can be flushed with 0.9% sodium chloride solution. If you use 0.9% sodium solution for flushing, it should be preservative-free.1
Follow your facility's policies and procedures for flushing. If you use preserved 0.9% sodium chloride solution, limit the volume to 30 mL/day in adults and don't use this solution in neonates or pediatric patients.1 To prevent cross-contamination and infection, use single-use, labeled syringes of flush solution.
If you use heparin for flushing, keep these pointers in mind:
* Use the SASH (saline, administer medication, saline, heparin) protocol when giving medications incompatible with the heparin flush.2
* If your patient needs multiple infusions, monitor the number of heparin flushes in 24 hours to prevent systemic anticoagulation.
Obtaining blood specimens
Risks associated with drawing blood specimens from a PICC include infection and catheter occlusion or rupture if the PICC isn't flushed properly afterward. For patients with severely compromised venous access, though, the PICC may be the only option for drawing blood specimens.
Follow your facility's policy for obtaining blood specimens. No matter which method you use, stop all infusions before drawing blood and don't reinfuse the discard sample. After you've obtained blood specimens, generously flush the PICC with 10 to 20 mL of preservative-free 0.9% sodium chloride solution.3
Troubleshooting catheter occlusion
If you have trouble flushing a PICC, it may be occluded. Thrombotic catheter occlusions are caused by the buildup of fibrin or coagulated blood inside the PICC's lumen or at its tip. Follow your facility's policy and protocol for obtaining an order for a fibrinolytic agent such as tissue plasminogen activator (t-PA) and instilling it.
Nonthrombotic occlusions could be mechanical, such as a kinked or malpositioned catheter, unreleased clamps, or clogged in-line filters. You can fix these occlusions without pharmacologic intervention.
Other causes of nonthrombotic occlusions include precipitate from chemically incompatible medications infused through the same lumen or a buildup of fat emulsion residue. For these types of occlusions, a trial instillation of t-PA may be recommended first to rule out a thrombotic occlusion. If that doesn't work and the health care provider strongly suspects the occlusion is caused by precipitate or emulsion residue, she may order an infusion of hydrochloric acid, sodium bicarbonate, or ethanol in an effort to restore catheter patency.4 A chest X-ray or venogram may be needed to evaluate unresolved PICC occlusions. Never inject against resistance, which could cause catheter rupture.
Removing the PICC
When the health care provider orders discontinuation of a PICC, have the patient lie in bed. Apply slow, steady traction to remove the catheter. The patient should perform Valsalva's maneuver as the catheter exits. Immediately cover the exit site with an antiseptic ointment, gauze, and sterile occlusive dressing. This initial dressing should remain in place for 24 hours. The site should be reassessed daily and a new occlusive dressing applied until epithelialization occurs.2,4
Inspect the catheter after you remove it, to be sure that it's intact and that the length matches the documented insertion length. If there's a discrepancy, immediately notify the health care provider.
If you meet resistance when removing the PICC, don't force it. Instead, secure the catheter and apply a warm, moist compress to the insertion site and upper arm. This may ease the venospasm and vasoconstriction that are impeding catheter removal. If you still feel catheter resistance after these interventions, secure the catheter and notify the health care provider.3
By knowing why PICCs are used and how to prevent or manage occlusions, you can help your patient experience safe, effective, and trouble-free infusion therapy.
1. Infusion Nurses Society. Infusion Nursing: Standards of Practice. 29(1S):S1-S92, January/February 2006. [Context Link]
2. Infusion Nurses Society. Policies and Procedures for Infusion Nursing, 3rd edition. Norwood, Mass., Infusion Nurses Society, 2006. [Context Link]
3. Hankins J, et al. Infusion Therapy in Clinical Practice, 2nd edition. Philadelphia, Pa., W.B Saunders Co., Inc., 2001. [Context Link]
4. Hadaway L. Technology of flushing vascular access devices. Journal of Infusion Nursing. 29(3):129-145, May-June 2006. [Context Link]