Protocol for Insertion, care and removal of Peripherally inserted central catheters (PICC) in adult patients

PICC lines are recommended for patients in whom medium to long term venous access (> 10 days) is anticipated.

The decision regarding the insertion of a PICC line should be made by an experienced clinician at the outset of therapy and should be based upon the following.

• Diagnosis
• Length and type of therapy
• Clinical status
• Availability of venous access
• Previous PICC history
• Operator experience
• Patient preference

PICC Lines may be indicated in the following situations.

• Poor peripheral venous access in patients requiring intravenous medication, where an alternative route is not possible (i.e. oral)
• Poor peripheral venous access in patients requiring administration of irritant, vesicant or hyper-osmolar drugs.
• To facilitate the administration of chemotherapy
• To facilitate expected frequent blood sampling.
• To facilitate expected frequent transfusion of blood products.
• To facilitate ambulatory chemotherapy at home.
• Palliative care

The risk of complications associated with venous access can be minimised by selecting the smallest access device with the fewest lumens that will meet the clinical need of the patient.

PICC Lines in NHS Borders are inserted in Theatre or radiology by anaesthetists and trained nurses.    In patients should be referred by contacting the theatre coordinator on 6595.

Outpatients: A RAT form should be completed and sent with patient and their medical notes to preassessment clinic

Pre-operative

When the need for a PICC line is identified, patients should be given verbal information about PICC lines and the PICC information sheet. 

Peri-operative

The insertion is done under sterile conditions, using ultrasound guidance. The skin should be prepared with chloraprep, which should be allowed to dry. PICC insertion is done using local anaesthetic (lidocaine). Following insertion, the lumens should be flushed with 10ml 0.9% normal saline (This should be prescribed or given under PGD: Intravenous Flush Policy NHS Borders: available at http://intranet/resource.asp?uid=37081)

A biopatch and a semi-permeable occlusive dressing should be applied to the exit site e.g., Tegaderm.

The PICC line diary will be given to the patient in theatre/radiology post insertion and the PICC Line Checklist Sticker (Appendix 2) must be completed and put into the patient’s medical notes.

This includes site of insertion, external length of the lumen at insertion, x-ray to confirm placement of line completed and line is signed off as safe to use.

Post operative.

Ward staff must give the patient verbal and written instructions regarding the care of their line. They must ensure they have their PICC line discharge pack and their hand-held diary. The discharge section of the PICC Line Checklist Sticker should be completed. (Appendix 2).

1) When the line is not being used for an infusion (‘capped off’): The line should be bled and flushed using push pause technique with 10mls of 0.9% normal saline for each lumen weekly and closed using positive pressure.

2) If the line is capped off but having bolus injections of medications administered, the drug should be flushed with 10mls of 0.9% normal saline. Ensure the speed of the flush takes into account the required speed of administration of the drug. If the patient reacted to the medication on administration, withdraw the drug. (A further flush of 10mls 0.9% normal saline will be required to flush any accumulated blood). Using Push pause technique and closing with positive pressure

3) When the line is in use: 10mls of 0.9% normal saline is required after having taken a blood sample or having administered a blood product. Flush using push pause technique and closing with positive pressure.

4)Changing the needle free device Hub:  They should be changed weekly, preferably when the dressing is being changed. Carry out any bleeding and flushing of the lumen and taking of bloods prior to changing the needle free device.

Priming the Hub:

Prime by attaching a 10ml luer lock syringe of 0.9% normal saline onto the needle free device and push a small volume of normal saline into the needle free connector.

Procedure for Accessing/Flushing and Sampling from the Line:

Always ensure you get blood return when accessing a line, take 5mls of blood then discard prior to taking blood sampling except when taking blood cultures, follow blood cultures procedure.

GATHER THE REQUIRED EQUIPMENT

Equipment required for accessing/ flushing a line

• PPE
• Yellow Bag
• Hard surface disinfectant wipes
• 2 pairs nonsterile gloves
• 1 plastic procedure tray
• 5 x 2% chlorhexidine and 70% alcohol wipes
• 2 x 10 ml syringes (per lumen)
• Vygon red cap (1 per lumen)
• Blunt fill needle (1 per lumen)
• 1 Multi adaptor for blood collection
• Needle free connector if required to be changed (1 per lumen)
• 1 x10 ml vial of 0.9% Normal saline (per lumen) If changing needle free connector you need to increase to 2 x 10ml/lumen
• Appropriate blood sample tubes
• Sharps bin

Additional equipment required if taking blood cultures

• Culture bottles 1 red (anaerobic) and 1 blue (aerobic) for adults
• Sterile gloves • 2 sterile wrapped plain Monovette tubes
• 2 Monovette
• 2 Chlorhexidine wipes (2% Chlorhexidine in 70% isopropyl alcohol) for disinfection of culture bottles • ‘Record of blood culture’ sticker. (DO NOT remove bar code labels from blood culture bottles)

5) Prepare the catheter for the procedure: Clamp the line, switch off any infusions.

Procedure for bleeding and flushing one lumen and taking blood samples.

• Utilising Six Step Technique, for hand washing.
• Clean and dry work surface using disinfectant wipes.
• Clean aseptic tray using hard surface disinfectant wipes.
• Arrange equipment around tray.
• Put on PPE
• Re-clean hands using Six Step Technique or use alcohol gel hand rub.
• Apply nonsterile gloves.
• Open 10ml luer lock syringe. Open red vygon cap and attach to syringe ensuring the 'key parts' are not contaminated and place in tray.
• Open another 10ml luer lock syringe. Open safety needle and attach to syringe ensuring 'key parts' are not contaminated and place in tray.
• Outer wrappers, ampoules and fluid bottles which cannot be prepared in an ANTT method should be cleaned with hard surface disinfectant wipes and place in the tray.
• Wipe neck of 0.9% saline ampoule with 2% chlorhexidine in 70% alcohol wipe and allow to dry.
• Utilising one of the syringes and needles draw up 10mls of 0.9% normal saline ensuring that key parts are not contaminated and place in tray. Repeat this for the number of lumens you are accessing.
• Clean blood tubes with hard surface disinfectant wipes and place in tray
• Take tray to patient and expose the end of the line.
• Remove gloves and wash hands using Six Step Technique
• Apply new gloves (Sterile gloves if blood cultures being taken)
• If the patient is unable to assist holding the line, use a sterile sheet to lay the PICC line on in-between procedures.
• Lift the lumen and clean the needle free connector port with the2% chlorhexidine and 70% alcohol swab for 15 seconds and allow to dry for at least 60 seconds.
• Ensure the lumen does not become re-contaminated (e.g. allowing to drop back onto the patient or touching the end with hands)
• Attach the 10ml luer lock syringe to lumen ensuring 'key parts' are not contaminated. Unclamp the catheter and aspirate blood 1-2mls to discard unless taking blood cultures see sections take 10mls and retain for cultures. Clamp the catheter, remove syringe and discard in sharps box. Unless taking blood cultures, take 10mls and retain for culture bottles.
• If blood sampling is required aspirate 5mls and discard, then attach first blood tube to interlink adapter ensuring 'key parts' are not contaminated.
• Attach to the needle free port, unclamp the catheter and aspirate the desired amount. Clamp the catheter and remove blood tube leaving the adapter in-situ.
• Repeat for each blood sample required. Clamp catheter and remove multi adapter.
• Attach syringe with 0.9% normal saline ensuring ‘key parts’ not contaminated.
• Unclamp the catheter and flush line using push pause method ensuring cap is free from blood. Close the line using positive pressure.
• If changing the needle free connector, do this here. Remove the needle free connector,

clean the hub with a new 2% chlorhexidine and 70% alcohol swab and allow to dry. Attach the new needle free connector and flush with the saline syringe attached as above and prime hub.

• Re-clean end of lumen with a new 2% chlorhexidine and 70% alcohol swab ensuring any.

 residual blood is removed. Verify patients details and write on blood tubes at bedside or attach the blood test stickers to tubes.

6) Dispose of clinical waste as per BGH policy

7) Remove gloves, apron and face covering and wash hands remove PPE

8) Document procedure in nursing notes and PICC line diary.

DRESSING THE EXIT SITE

Equipment required for dressing the exit site

• Appropriate PPE
• Hard surface disinfectant wipes
• 1 pair nonsterile gloves
• 1 pair sterile gloves
• 1 dressing pack
• 1 procedure tray
• 1 chloraprep
• 1 grip-lok dressing
• 1 IV 3000/tegaderm dressing

Procedure

1. Wash your hands.
2. Clean suitable work surface with hard surface disinfection wipes
3. Clean plastic tray using hard surface disinfection wipes
4. Use appropriate PPE
5. Utilising Six Step technique, for hand washing

Open dressing pack onto tray and carefully open ensuring only touching the outer edges of the pack

9) Open all equipment and allow to drop onto sterile area of dressing pack being careful not to touch/contaminate it

10) Measure external length of the PICC line. If line more than 2cms difference than at insertion, please see complications and troubleshooting section for next steps.

11) Remove gloves and re-clean hands

12) Re-apply sterile gloves 1

13) Remove clear dressing

14) Use chloraprep, squeezing both ends to open and allow the sponge to be soaked with the cleaning liquid

15) Place soft round sponge end onto exit site and move in upwards and downwards movement across whole area inclusive of grip-lok dressing (the grip-lok dressing will get wet)

16) Whilst awaiting to dry, peel off the grip-lok dressing ensuring not pulling on the line

17) Once all dried, secure the picc line into the new grip-lok dressing and then secure to the skin.

18) Apply new dressing over the exit site.

19) Put date and time onto dressing and document in diary

20) Dispose of all equipment as per NHS Borders policy and remove PPE. Clean plastic tray inside and out using hard surface disinfectant wipes.

21) Wash hands

22) Document in patients PICC diary.

Patient Preparation

1 Explain the procedure to the patient.

2 Listen to any anxieties or fears and take action to alleviate stresses.

3 Ensure patient is comfortable.

4 Assess the catheter and skin for signs of potential problems.

5 Check the length of the PICC line and ensure it matches the documented length in the patients handheld diary. If it has moved by >2cm from insertion DO NOT USE THE LINE and look at section 16 (Complications and troubleshooting) on what to do.

6 Prepare the catheter for the procedure: Clamp the line, switch off any infusions.

1. Prepare the prescribed fluid and prime the administration set, ready for connection to the patient.
2. Re-clean needle free connector with 2% chlorhexidine in 70% alcohol wipe and allow to dry for at least 60 seconds.
3. Attach prepared primed line to needle free connector ensuring it is not contaminated.
4. Unclamp catheter and giving set and commence infusion.

At end of infusion:

1. Clamp catheter and giving set.
2. Disconnect giving set and flush with a 10ml flush using push pause and positive pressure to close

Changing IV Giving Sets

 It is preferable to avoid routine replacement as this will increase the risk of introducing infection into the catheter, leave in situ, if possible, for routine antibiotics. Administration sets should be changed every 24 hours except in the following circumstances.

Transfusion of blood products

• Replace the infusion set at the end of transfusion
• Replace between different types of blood products (e.g. platelets/red cells) Lipid Feeds
• Change every 24 hours

Do not take blood cultures unless there is clinical evidence of infection. If the cultures are required to detect a line infection, a separate sample should be taken from each port of the line as well as from a peripheral vein.

An 10ml blood sample is required for each bottle of the pair.

No blood should be discarded – Take specimens for blood culture before other specimens. Follow procedure for bleeding line.

Put on sterile gloves and then undertake Blood cultures as per procedure.

Dressing Change: Dressings

• Formal dressings require a strict aseptic non touch technique (ANTT)
• The entry site should be cleansed with Chloraprep
• The written information given to patients tells them not to get in a bath, do not submerge lines, shower with waterproof cling film covering
• If signs of allergy to dressing (erythema around edge of dressing/itch), please change to using IV 3000 dressing
• Please be aware allergy to biopatch also possible, cease to use this if allergy suspected

 When to change the dressing/biopatch

• Change weekly or, sooner if soiled; blood stained; if the edges are curled or, if adhesion is impaired due to clammy skin.

Lines must be removed as soon as there is no longer a clinical need for them.

Other reasons for line removal include.

• Proven and unresolved infection
• Faulty or fractured device
• Proven thrombosis
• Unresolved occlusion
• Unresolved phlebitis or thrombophlebitis
• Extravasation
• End of treatment/no longer required. Prior to removing the line every effort should be made to discuss with the clinical team responsible for on-going care of the patient.

 Prior to removal:

Check Full Blood Count (as long as done within the last week). If platelets <50 check with medical staff prior to removal

Equipment Require for Removal

• Plastic Apron
• Non-sterile gloves
• Hard surface disinfection wipes
• Dressing pack
• Sterile gloves
• 1 plastic procedure tray
• 1 chlorhexidine 2% and alcohol 70% wipe
• Mepore dressing
• If removing due to infection also require: Universal container; Sterile scissors

1. Explain procedure to patient
2. Utilising Six Step Technique, wash hands and pat dry with paper towels
3. Clean suitable work surface with hard surface disinfectant wipes
4. Clean procedure tray with hard surface disinfectant wipes and place onto clean work surface.
5. Collect all required equipment beside the tray
6. Repeat hand washing
7. Put on PPE
8. Open dressing pack onto tray
9. Carefully open the pack from the outer edges, being careful not to contaminate
10. Open the other packs onto the sterile area, being careful not to contaminate
11. Position patient in a supine position with the PICC arm extended at a 45-to-90-degree angle from the torso
12. Remove the non-sterile gloves, wash hands
13. Put on the sterile gloves
14. Place the sterile drape and ask the patient to lift their arm and place underneath arm and PICC area
15. Remove the dressing and gently open the griplock dressing, being careful not to move the PICC line
16. Take a hold of the PICC line at the exit site, ask the patient to take a breath in and hold (valsalvar manoeuvre)
17. Remove the PICC line, pulling straight out, ask the patient to breathe out (if there is any resistance on removal DO NOT force it. Call for assistance.
18. Place the PICC line onto the sterile drapes, whilst putting pressure on the exit site with gauze swabs. Maintain pressure for 2-5 minutes.
19. Apply mepore dressing, occlusive dressing water resistant to the site
20. If the line is removed due to infection, cut the end of the PICC line into the universal container and send to the lab for culture and sensitivity
21. Sit the patient up, ensuring they feel well and monitor the site
22. Dispose of all equipment as per NHS Borders policy and remove PPE. Clean plastic tray using hard surface disinfectant wipes.
23. Wash hands

24. Label the PICC line tip and document in the notes and PICC line diary and return to Dr Heather Mathews (Anaesthetic Consultant). 

All PICC line care should be documented in the 'Patient hand-held diary' which is designed to assist with communication and promote best practice regarding   PICC line care and will be used to assist with audit.

In-Patient Care

Complete the diary each time you access the line and also record any issues that occur when accessing the line at other points in the day.

Out-Patient Care

Complete the diary when the patient attends for PICC line care When the line is removed the diary should be returned to Heather Matthews (Anaesthetic Consultant).

Main contacts for advice:

Critical Care outreach team on bleep 6321

Oncology Patients contact Acute Oncology on bleep 3041.

Outreach bleep 9am-9pm bleep 6321

Refer to medical registrar.

NEVER try to aspirate with anything smaller than a 10ml syringe If aspiration is still unsuccessful, with normal saline 0.9%, in no less than a 10ml syringe, attempt a small flush using push pause technique, exerting gentle pressure. If this is successful, continue to administer the rest of the saline flush using push pause technique and try aspiration again.

Patient leaflets/records associated with this procedure.

The following leaflets can be obtained from Borders Macmillan Centre, Main theatres.

• Patient PICC line information leaflet
• Patient held record, PICC line diary. Intranet CARS system

Sources for Advice

Outreach Team Borders General Hospital Bleep 6321

Borders Macmillan Centre Bleep 68331

Referral Letter for Insertion/Removal of PICC Line

Picc Line Check list

Difficulty Bleeding and Flushing PICC Line

Procedure for Administration of Activase Cathflo (Alteplase)

Always contact Outreach Team prior to administration

• Ask Doctor to prescribe Actilyse Cathflo.
• Reconstitute the content of an injection vial to a final concentration of 1 mg alteplase per ml: 2.0 mg in a volume of 2.0 ml. If patients bodyweight <30kg dose should be 1mg/1ml alteplase only.
• Follow steps 1- 23 for Procedure for bleeding and flushing one lumen and taking blood Samples. Then follow instructions for priming the needle free connector.
• Clamp Catheter. Remove existing needle free connector.
• Clean lumen with 2% chlorhexidine in 70% alcohol swab.
• Attach 10ml syringe, unclamp line and remove dead air space from lumen and then re-clamp.
• Unclamp line and instil Actilyse Cathflo
• Re-clamp line and replace needle free connector
• Leave for 30 minutes and then try to bleed line if unsuccessful repeat procedure and leave for a further 90 minutes.

If unable to bleed the line after 60 minutes repeat procedure from step1 again. If bleeding and flushing is still unsuccessful Depending on results it may be necessary to remove line, this requires to be discussed with the patient’s Consultant.