PC Places in the Heart Peripherally Inserted Central Catheters

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					                                       PC 847
                    Places in the Heart:
Peripherally Inserted Central Catheters
                                        6.0 A A

                                 Sophia Rodgers
                                   Monty Foster
                         Rozalinde Christodoulos
                                   Jansen Helm
                                 Toni McFadden

         Saturday 5/16 9:00 AM - 5/16 4:30 PM
Places in the Heart: Peripherally Inserted Central Catheters

Sophia Rodgers, Monty Foster, Toni McFadden, Jansen Helm, Rozalinde Christodoulos

Level: Expert

Content Description
In recent years, peripherally inserted central catheters (PICCs) have gain great popularity as a mean of
central venous access especially in the ICU setting. They are much safer, have less complications and can
be left in much longer than acute care catheters. This session will prepare bedside and advance practice
nurses on the insertion of PICCs. The morning session will consist of the didactic portion of the course.
Anatomy, indications, contraindications, potential complications, and legal aspects will be discussed. The
procedure will also be demonstrated in detail emphasizing steps of insertion. Moreover, the theory and
demonstration on the use of the ultrasound venous access device will be discussed. In the afternoon,
participants will be divided into small groups for hands on demonstration on the insertion of PICCs using
ultrasound guidance. They will also learn how to repair, maintain, and declot the catheters. This course is
limited to 48 participants.

Learning Outcomes
At the end of this session the attendee will be able to:
1. Describe the anatomy of the upper extremity and chest
2. Demonstrate the insertion of PICC
3. Demonstrate the use of ultrasound venous access device

Summary of Key Points
1. Locate the veins in the arm and chest
   a. Basilac, cephalic, brachial, axillary, subclavian, innominate, SVC
2. Explain the potential complications associated with PICC insertion and post insertion
   a. Infection, embolus, DVT, hematoma, bacteremia, nerve injury
3. Describe the indication and contraindication for PICC insertion
   a. Indications: long term IV access, CVP monitoring, TPN
   b. Contraindications: DVT, infection

BARD Access Device Manual
Hind, D., et al. Ultrasonic locating devices for central venous cannulation: metal analysis. British Journal of
Medicine, 2003, 327 (7411): 361
McGee, D.C. & Gould, M.K. Preventing complications of central venous catheterization, NEJM, 2003, 348
(12), 1123-1133
Mey, U., Glasmacher, A, et al. Evaluation of an ultrasound guided technique for CVC via internal jugular
vein in 493 patients. Support care cancer, 2003, 11(3), 135-6.

    Places in the Heart:                                                 HouseKeeping
Peripherally Inserted Central
     Catheters (PICCs)

                          Supplies generously provided by
                              Bard Access Systems

               Objectives                                                      Objectives
• Define Peripherally inserted central                       • Explain the care and maintenance of
  catheters (PICC)                                             PICCs
• Identify clinical indications and                          • Demonstrate PICC insertion using
  contraindications for PICC placement                         microintroducer method under ultrasound
• Locate and select veins for PICC insertion                   guidance
• Describe and demonstrate use of the
  portable ultrasound

                                                            March Market Data
 History & Definitions of PICCs                                          $136MM; 15% CAGR

• History of PICCs                                                           BD, 4%
                                                                                      Angio, 0.02
• Definitions of PICCs                                            Cook, 5%                     Bos Sci, 10%
  – PICC – percutaneously inserted central                   Arrow, 7%

                                                                                         BAS, 72%

                                                                                         Source: 3Q05 IMS Data
            Anatomy of the Arm and Chest
            Physiology of Blood Flow                           Anatomy of the Arm and Chest
                                                               Physiology of Blood flow

                                                              How do you tell the difference
                 Vessel Flow Rates
                                                            between a deep & superficial vein?
•   Digital & metacarpal veins of the hand10 ml min         • Answer:
•   Lower forearm vein cephalic & basilac20-40 ml min
                                                              – Deep veins have accompanying arteries,
•   Cephalic upper arm vein               40-90 ml min
                                                                superficial veins do not.
•   Basilac upper arm vein                90-150 ml min
•   Axillary vein                         150-350 ml min    • Based on the above definition, which arm
•   Subclavian vein                       350-800 ml min      veins are deep and which are superficial?
•   Innominate vein                       800-1500 ml min
•   Superior vena cava                    2000 ml min
     Deep vs Superficial Veins                         Indications/Advantages of PICC
                                                       • Indications of PICCs              • Advantages
• Clots in the deep veins are called deep                  – long term peripheral                – Decreased risk of phlebitis
  venous thrombosis (DVT)                                    access to the central
                                                             venous system
                                                                                                 – Lowest incidence of
• Clots in the superficial veins are called                – Infusion of TPN,                    – Reduced risk of infiltration
                                                             hyperosmolar, blood,                – Cost effective
  thrombophlebitis                                           vasoactive, drugs with high
                                                             or low pH                           – Can be used to measure
                                                           – Poor peripheral access                CVP
                                                           – Blood sampling                      – Avoidance of multiple
                                                                                                 – Can be used for patients
                                                                                                   with coagulopathy

            Contraindications                          Osmolarity, Osmolality, drug pH
• Bacteremia                                           • Hypotonic                    • Normal body pH
• Patient’s vein size insufficient to accommodate      • Isotonic                       7.4
  size of device                                                                      • Drug pH
                                                       • Hypertonic
• Known or suspected allergy to materials                                                  –   Vancomycin 2.4
  contained in the device                                                                  –   Doxycycline 1.8-3.3
• Past irradiation of the prospective insertion site                                       –   Dopamine 2.5-5
• Venous thrombosis or vascular surgical                                                   –   Ceftriaxone 6.6-6.7
  procedure at the placement site                                                          –   Acyclovir 10.5-11.6
• High fluid volume infusion                                                               –   Phenytoin 12
• Skin infections                                                                          –   Bactrim 10
                                                                                           –   Blood 7.384

                                                                       Device Selection
                                                       • Conventional Peripheral – 72 hours
                                                       • Midline – Up to 4 weeks
                                                       • PICC – Up to 1 year
                                                       • Subclavian-Jugular-Acute Care – 3 to 7
                                                       • Tunneled CVC – Up to 6 weeks
                                                       • Chest or Arm Port - > 1 year
                                                           Institute for Healthcare
                      VAD Infection Rates                  Improvement (IHI)
Device Type                    Studies      BSI per 1000
                                            IV Days         Central Line Bundles
PICCs                          9            0.4%               Insertion:
Peripheral IVs                 13           0.6%                 Hand Hygiene
                                                                 Maximal barrier precautions
(Tunneled) Cuffed 22                        1.0 %                Chlorhexidine kin antisepsis
CVC                                                              Optimal catheter site selection, with
                                                                 subclavian vein as the preferred site
CV Ports          26                        0.2 %

Acute Care                     66           2.2 %
Dr. Maki U of Wisconsin

  Institute for Healthcare
  Improvement (IHI)
                                                                        Types of Material
       Central Line Bundles                                • Silicone
            Maintenance                                      – Advantages
                  Daily review of line necessity             – Disadvantages
                  Dedicated lumen for TPN
                                                           • Polyurethane
                  Accessing the lumens aseptically
                  Check entry site for inflammation with
                                                             – Advantages
                  every change of dressing                   – Disadvantages

                    Non-valved vs Valved
  • Valved (Groshong®)
  • Non-valved catheter (Open-ended)
                                                              Power Injectable PICCs
        Positive Pressure Ports
                                                         • History
                                                           – Problems with power injection through
                                                             vascular access devices
                                                           – No central lines marketed for power injection
                                                           – No central lines tested per FDA guidelines to
                                                             be marketed for power injection
                                                           – MAUDE- “Manufacturer and User Facility
                                                             Device Experience Database”

  MHRA Medical Device Alert
• United Kingdom ‘s FDA
  – Medical device alert issued 2/25/2004                All open-ended polyurethane
    • Risk of CVC rupture during contrast
                                                         PICCs have Central Venous
  – Recommendations:
    •   Use a peripheral IV for power injection               Pressure Monitoring
    •   Avoid tunneled catheters
    •   Use largest lumen in multi-lumen device
    •   Limit flow rate to maximum to 2 ml/sec
    •   Flush the device and examine for damage before
        and after injection
                                                     • Q - PICCs are longer catheters than the CVC catheters
                                                       used for CVP monitoring. How will this affect the CVP
                                                     • A – Extensive 3 testing has shown that there is not a
                                                       significant reduction in signal due to the longer catheter
                                                     • Q – PICCS are narrower catheters than the CVC
                                                       catheters. Will this result in reduced CVP signal?
                                                     • A – No. PICCS give strong CVP signals that are not
                                                       reduced by the narrower catheter size.

• Q – Kinks in the catheters can reduce the CVP
  signal. How prone to kinking are catheters?
• A – PICCs are kink resistant. This is due to the
  reverse taper design.
• Q – Is the procedure for CVP monitoring any
  different in using a PICC versus a CVP
• A – No, the procedure for CVP monitoring is
  exactly the same.

                                                               Through the intact cannula
       Vein Access Techniques
•   Breakaway needle technique
•   Through the Cannula
•   Peel-Away sheath (Safety Excalibur)
•   Modified Seldinger (Microintroducer)
Through the intact cannula   Through the intact cannula

Through the intact cannula   Peel-away Sheath Technique
                                   Safety Excalibur

Peel-away Sheath Technique   Peel-away Sheath Technique
      Safety Excalibur             Safety Excalibur
        Peel-away Sheath Technique
              Safety Excalibur

    Insertion of PICC using Modified               Insertion of PICC using Modified
       Seldinger (Microintroducer)                    Seldinger (Microintroducer)
•   Step 1:   Assessment & Education/Consent
•   Step 2:   Anatomical Measurement           •   Step 6: Anesthesia
•   Step 3:   Sterile Field                    •   Step 7: Cannulation
•   Step 4:   Site Prep                        •   Step 8: Catheter advancement
•   Step 5:   Draping                          •   Step 9: Securement & dressing
                                               •   Step 10: Radiographic verification

          Insertion Site Preparation                  Set Up Sterile Field & Supplies
       Draping the Patient
                                      Anesthetizing the Insertion Site
                                      • Check for patient allergy
                                      • Anesthetize the venipuncture site
                                      • Insert the needle at a 15-to 25-degree
                                      • Inject the lidocaine intradermally
                                      • Avoid entering the vein
                                      • Withdraw the needle—wait 5 to 10

MicroIntroducer--Modified Seldinger     MicroIntroducer--Modified Seldinger

MicroIntroducer--Modified Seldinger     MicroIntroducer--Modified Seldinger
MicroIntroducer--Modified Seldinger   MicroIntroducer--Modified Seldinger

MicroIntroducer--Modified Seldinger   MicroIntroducer--Modified Seldinger

MicroIntroducer--Modified Seldinger   MicroIntroducer--Modified Seldinger
MicroIntroducer--Modified Seldinger   Advancing the PICC

  PICC Securement & Dressing
        What is ultrasound?                                      What does
                                                                 tissue look
                                                                  like under

 How does ultrasound transmit and              Basilic Vein

 •Vein visualization &                    Reduced complication rates
 cannulation                                •Hematomas
 •Vessel patency                            • Arterial sticks
 •Lower complication                        • Multiple venipunctures
 •Reduced referrals
 •Needle guide
 •Bedside use
 •Above the antecubital
 fossa access

    How does ultrasound guidance
  challenge traditional vascular access
            clinician skills?
•Look at screen--not
•Rely on instrument
•Learn to multi-task
•Patient positioning
may differ
         Features of the System:

                                    How do we
                                    know which
                                    one is a vein
                                     and which
                                     one is an

                                       Give 2 reasons for observing
                                          pulsatile flow in a vein

                                   • Presence of an AV fistula
The vein winks                     • Severe right sided congestive heart failure
 at you when

 The artery                        Ultrasound                          0.5 cm

pulsates and                       System                              1.0 cm

  does not                         provides                            1.5 cm

collapse with                      depth                               2.0 cm

  pressure.                        markings for
                                   guide            Each white mark
                                   selection        represents 0.5cm
Ways to Optimize an US Image
• Plenty of ultrasonic gel
• US probe 90º to image
• Ascertain depth of screen is appropriate   The vein will
                                             dimple as the
                                             needle enters

  What you will see on the screen

                                              Demonstration of Insertion
                                              Using Modified Seldinger
PICC placement via x-rays

Can you tell if the placement
        is correct?
        Sherlock Tip Locator

                                                    Catheter/Wire Embolus
     Complication Management
• Air Embolism
  – Caused by entry of a bolus of air into the
    vascular system.
• Catheter/Wire Embolus
  – Occurs when a portion of catheter or wire is
    broken in the vein and enters the circulatory
           Catheter/Wire Embolus                              Complication Management
• Prevention                                               • Arterial Puncture
  –   Inspected PICC for defects before use
                                                             – Prevention
  –   Avoid forceful flushing
                                                                • Palpate the artery before introducing the introducer
  –   Do not pull catheter back through needle
  –   Do not force PICC removal if resistance felt              • Immobilize the patient’s arm and vein
  –   Avoid inserting PICC over joint flexion                   • Consider image-guided placement (Site-Rite)
  –   Roll the PICC to facilitate removal
  –   Do not hold pressure at the site until PICC is out
  –   Have tourniquet available when removing PICC line

      Complication Management                                  Nerve Injury and Irritiation

• Cardiac Dysrhythmias
  – Prevention
       •   Baseline heart rate and palpate radial pulse
       •   Cardiac monitoring during PICC insertion
       •   Prevent right atrial tip placement
       •   Accurate and repeated measurement of external
           catheter length

      Complication Management                                 Complication Management
• Difficult Catheter Advancement                           • Catheter Malposition
  –   Vessel stenosis/sclerosis
                                                             – Cephalic Vein access may be associated with
  –   Valves
                                                               a higher incidence of insertion malposition
  –   Vessel bifurcation
  –   Repeated Venipunctures                                 – Basilic vein access most commonly leads to
  –   Cold Patient                                             an internal jugular vein malposition
  –   Dehydration
  –   Anxiety
  –   Patient Positioning
  –   Anesthetics
  –   Vasospasm
     Secondary or Post-Insertion
                                                  Suspected Catheter Infection
         Catheter Migration
                                                • Dr. Dennis Maki study documents a
                                                  PICC infection rate of <1% based on
                                                  a reduction of colonization of the skin
                                                  of the antecubital space
                                                  – The extremities are cooler and drier than
                                                    the trunk of the body
                                                  – The Antecubital Space is well away from
                                                    oral and endotracheal secretions and

                                                          Complication Management
    Complication Management                                       Phlebitis
                                                     Intravenous Nursing Society Phlebitis Scale (Standards 2000 )
                                                              Grade                       Clinical Criteria
• Phlebitis
  – Chemical                                                     0              • No sym s

  – Mechanical                                                   1              • Erythem at access site with or
                                                                                  without pain
  – Bacterial                                                    2              • Pain at access site with erythema
                                                                                  and/or edem  a
                                                                 3              • Pain at access site with erythema
                                                                                  and/or edem  a
                                                                                • Streak form ation
                                                                 4              • Pain at access site with erythema
                                                                                  and/or edem  a
                                                                                • Streak form ation
                                                                                • Palpable venous cord>1 inch in
                                                                                • Purulent drainage

    Catheter Difficult to Remove                               Catheter Occlusion
• Never apply aggressive traction to a           • Causes
  “stuck” catheter. Because of the thin-            – Thrombotic (58%)
  walled, small diameter of a PICC, forceful          • thrombus
  traction usually results in shearing of the         • fibrin
  catheter, commonly at the area of spasm.
    Earlier intervention increases rate of
          restored catheter function
                                                                                            Catheter Occlusion
                                                                                   • Causes:
                                                                                     – Nonthrombic
                                                                                       • Catheter malposition
                                                                                       • Drug Precipitate
                                                                                       • Lipids

    COOL-2 clinical trial (Cardiovascular thrombolytic to Open Occluded Lines-2)

                                                                                             Catheter Occlusion
            Catheter Occlusion

• Thrombotic occlusions are prevented
  by proper flushing technique and
• Non-thrombotic occlusions are
  avoided by proper administration of
  incompatible drugs.

              Damaged Catheter                                                                 Hematoma
• Prevention
   – Use clamps on clamping sleeves
     provided on silicone catheters
   – Avoid the use of scissors or other sharp
   – Use only small-bore needles (22-25
     gauge) w/needle length 1 inch
   – Administer medications without force
   – Use 10cc syringes when administering
          Infiltration/Extravasation                          INS Extravasation Grading Scale 2000

• Prevention                                                  Grade      Criteria
  –   Avoid areas of multiple venipunctures
  –   Dilute all medications as indicated                     0          No Symptoms
  –   Secure the catheter
                                                              1          Skin blanched-edema <1”
  –   Avoid the use of high-pressure infusion pumps
  –   Only qualified RNs should administer a vesicant         2          Skin blanched-edema 1”-6”
  –   Check patency before flushing
  –   Monitor insertion site routinely for edema              3          Skin blanched-edema >6”
  –   Educate the patient to report any feelings of burning
                                                              4          Skin blanched-gross edema

                               Declotting using
                               3 way stopcock

        Care & Maintenance
         Blood Aspiration
• Draw up 10ml normal saline
• Stop any IV fluids
• Insert needleless adapter of empty 10ml syringe
  into injection cap
• Pull back syringe plunger
• Disconnect syringe and discard
• Clean injection cap
• Obtain blood sample.                                                          Positive Pressure
• Flush the catheter with 10ml normal saline                                        Flushing
• Always change caps after each blood draw                                            Only use
                                                                                    10 cc syringe
Dressing Changes
        Repair of Ruptured Port

                                                 PICC Discontinuation/

     Outcomes Monitoring
• “A valid measure of quality specifically
  identifies an aspect of care where
  there is a known problem and
  describes the extent of the problem.
  Quality measures are definitive end
  points that do not require future
  investigation in order to make
  judgments about quality of care.”

                   Legal Issues                             Legal Issues

   •State Regulations regarding PICC Line    •State Regulations regarding PICC Line
   or midline placement                      or midline placement
                                             •Nursing qualifications
               Legal Issues                             Legal Issues

•State Regulations regarding PICC Line   •State Regulations regarding PICC Line
or midline placement                     or midline placement
•Nursing qualifications                  •Nursing qualifications
•Nursing competency                      •Nursing competency
                                         •Patient Consent

               Legal Issues

•State Regulations regarding PICC Line
or midline placement
•Nursing qualifications
•Nursing competency
•Patient Consent

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