Peripherally Peripherally Inserted Central Inserted Central Catheter (PICC) Catheter (PICC) Trouble ShootingTrouble ShootingChantal Miljours, RN Chantal Miljours, RN BScNBScNClinical Nurse EducatorClinical Nurse EducatorDiagnostic Imaging DepartmentDiagnostic Imaging DepartmentNorth Bay Regional Health CentreNorth Bay Regional Health Centre

ObjectivesObjectives

How and why PICC lines are insertedHow and why PICC lines are inserted Identify catheter occlusion and Identify catheter occlusion and

trouble shooting methodstrouble shooting methods Identify potential causes for redness Identify potential causes for redness

in PICC arm and at insertion sitein PICC arm and at insertion site Air EmbolismAir Embolism Case StudiesCase Studies

Purpose of Central Venous Purpose of Central Venous Access DeviceAccess Device

To infuse fluids (allows for large volume boluses)To infuse fluids (allows for large volume boluses) No peripheral accessNo peripheral access To infuse TPNTo infuse TPN To infuse medicationsTo infuse medications To sample venous blood (when no peripheral To sample venous blood (when no peripheral

access is available)access is available) To provide a method for hemodynamic To provide a method for hemodynamic

monitoring i.e.: right atrial and PA monitoring i.e.: right atrial and PA pressures(acute care setting)pressures(acute care setting)

Blood Vessels involved in Blood Vessels involved in Central Venous TherapyCentral Venous Therapy

basilic cephalic axillary jugular subclavian innominate These veins all lead to superior vena cava

Central Venous Access Central Venous Access DevicesDevices

Port-a-Cath

Hickmann Line

Central Venous Access Central Venous Access DevicesDevices

Short term central catheter

Peripherally Inserted Central Catheter

PICC Line PlacementPICC Line Placement

PICC Line PlacementPICC Line Placement

PICC LinesPICC Lines PICC lines are inserted PICC lines are inserted

as a sterile procedure in as a sterile procedure in the diagnostic imaging the diagnostic imaging departmentdepartment

Both Ultrasound and Both Ultrasound and Fluoroscopy are used Fluoroscopy are used insert the PICC line and insert the PICC line and confirm proper confirm proper placementplacement

Insertion is performed Insertion is performed by specially trained by specially trained nurses and placement is nurses and placement is confirmed by the confirmed by the radiologistsradiologists

STATS 2014STATS 2014

356 PICC lines 356 PICC lines inserted in 2014inserted in 2014

12% for TPN12% for TPN 39% Antibiotics39% Antibiotics 39% 39%

ChemotherapyChemotherapy 10 % other10 % other

0

20

40

60

80

100

120

140

TPN Abx Chemo Other

PICC lines 2014

TroubleshootingTroubleshooting In 2014 we saw In 2014 we saw

149 patients for 149 patients for PICC line PICC line troubleshootingtroubleshooting Only 57% of these Only 57% of these

patients required patients required thrombolyticsthrombolytics

57%

14%

10%

9%

5%3% 1%1%

Declot

Difficulty Removing PICC

No Problem

PICC pulled out

Cap changed

3 cc syringe

Extra saline flush

Line Kinked

CVAD OcclusionsCVAD Occlusions

There are 3 types of occlusionsThere are 3 types of occlusions

CompleteComplete PartialPartial WithdrawalWithdrawal

Signs of a CVAD Signs of a CVAD OcclusionOcclusion

Resistance when flushingResistance when flushing Sluggish flowSluggish flow Inability to infuse fluidsInability to infuse fluids Frequent occlusion alarm on infusion Frequent occlusion alarm on infusion

pumppump Infiltration or extravasion or swelling Infiltration or extravasion or swelling

or leaking at insertion siteor leaking at insertion site Inability to withdraw bloodInability to withdraw blood Sluggish blood returnSluggish blood return

Complete OcclusionsComplete Occlusions Inability to infuse Inability to infuse

or withdraw blood or withdraw blood or fluid into the or fluid into the CVADCVAD

Can be Can be mechanical, mechanical, chemical or chemical or thromboticthrombotic

Withdrawal OcclusionsWithdrawal Occlusions Inability to aspirate blood but ability Inability to aspirate blood but ability

to infuse without resistanceto infuse without resistance Lack of free-flowing blood returnLack of free-flowing blood return

Partial OcclusionsPartial Occlusions Decreased ability to infuse fluidsDecreased ability to infuse fluids Resistance with flushing and Resistance with flushing and

aspirationaspiration Sluggish flow through the catheterSluggish flow through the catheter Can me mechanical, chemical, or Can me mechanical, chemical, or

thromboticthrombotic

Types of Thrombotic Types of Thrombotic OcclusionsOcclusions

IntraluminalIntraluminal Often cause Often cause

complete catheter complete catheter occlusionsocclusions

Develops from Develops from blood build up as blood build up as a result of a result of insufficient insufficient flushing, flushing, inadequate inadequate infusion rate, or infusion rate, or frequent blood frequent blood withdrawalswithdrawals

Fibrin TailFibrin Tail Fibrin adheres Fibrin adheres

to the end of to the end of the catheter the catheter and causes and causes more cells to more cells to be deposited on be deposited on the tailthe tail

Acts as a one-Acts as a one-way valve: way valve: fluids can be fluids can be pushed out but pushed out but with aspiration with aspiration the tail is the tail is sucked back sucked back over the over the openingopening

Fibrin Fibrin SheathSheath

Fibrin adheres Fibrin adheres to the external to the external surface of the surface of the catheter, catheter, creating a creating a “sock” over the “sock” over the cathetercatheter

Occasionally Occasionally the sheath the sheath covers the end covers the end of the catheter of the catheter and causes and causes occlusionocclusion

MuralMural Occurs when Occurs when

fibrin from a fibrin from a vessel wall vessel wall injury binds to injury binds to fibrin covering fibrin covering the catheter the catheter surfacesurface

Caused by the Caused by the catheter catheter rubbing in the rubbing in the vessel, vessel, traumatic traumatic insertion, or insertion, or poor blood flowpoor blood flow

Dual-Lumen PICC Dual-Lumen PICC (Navalist)(Navalist)

Fibrin Sheath OcclusionsFibrin Sheath Occlusions Fluid can usually be Fluid can usually be

injected, but blood injected, but blood cannot be aspiratedcannot be aspirated

Infiltration/Infiltration/extravasation can extravasation can occur when occur when medications are medications are infused up the fibrin infused up the fibrin sheath and back to sheath and back to the insertion sitethe insertion site

May cause mixing of May cause mixing of incompatible solutionsincompatible solutions

CASE STUDIESCASE STUDIES

Case Study #1: The Case Study #1: The Repeat OffenderRepeat Offender

69 year old patient receiving 69 year old patient receiving antibiotics through the PICC line is antibiotics through the PICC line is sent to DI by homecare for a sent to DI by homecare for a withdrawal occlusion. This patient withdrawal occlusion. This patient has been seen multiple times in the has been seen multiple times in the past 2 weeks.past 2 weeks.

Chemical OcclusionsChemical Occlusions Many PICC line Many PICC line

occlusions are occlusions are caused by a build-caused by a build-up of precipitate up of precipitate from antibiotic or from antibiotic or other medicationsother medications

PrecipitatePrecipitate

Troubleshooting tipsTroubleshooting tipsFirst determine there is no First determine there is no mechanical cause for the occlusionmechanical cause for the occlusion

Assess for kinks, closed clamps, or Assess for kinks, closed clamps, or change in external lengthchange in external length

Assess for clogged cap or if the cap Assess for clogged cap or if the cap is on too tight (finger tip tight)is on too tight (finger tip tight)

Assess for positional catheter:Assess for positional catheter: Reposition arm, have patient cough, put Reposition arm, have patient cough, put

patient in Trendelenberg positionpatient in Trendelenberg position

The Art of FlushingThe Art of Flushing Knowing how PICC Knowing how PICC

feels with flushing can feels with flushing can tell you what is tell you what is happening with PICChappening with PICC

Flush with 20ml Flush with 20ml Normal saline Normal saline turbulent flush to each turbulent flush to each port after each useport after each use

May require daily May require daily flushes depending on flushes depending on medication i.e. medication i.e. VancomycinVancomycin

Troubleshooting tipsTroubleshooting tips Remove any add on Remove any add on

devices such as cap or devices such as cap or y-connector and y-connector and attempt to aspirate attempt to aspirate and flush the catheter and flush the catheter directly at the hub directly at the hub with normal salinewith normal saline

Consider changing the Consider changing the dressing to ensure dressing to ensure there is no there is no twisting/kinking of the twisting/kinking of the cathetercatheter

Troubleshooting tipsTroubleshooting tipsOnce mechanical obstructions have been ruled Once mechanical obstructions have been ruled

out:out: If no blood return on aspiration, may alternate If no blood return on aspiration, may alternate

gently drawing back and then gently flushinggently drawing back and then gently flushing Try using a dry 3cc syringe to aspirate blood Try using a dry 3cc syringe to aspirate blood

returns as it exerts less negative pressure returns as it exerts less negative pressure when withdrawingwhen withdrawing

If still unable to get returns will require If still unable to get returns will require Cathflo instillation.Cathflo instillation.

Consider radiography to determine malposition Consider radiography to determine malposition of the catheter tipof the catheter tip

Case #2: What Do You Case #2: What Do You See?See?

Case #2Case #2 Patient sent to ED with a blocked PICC Patient sent to ED with a blocked PICC

line, home care nurse unable to flush or line, home care nurse unable to flush or get venous returnsget venous returns

Upon assessment in ED blood noted Upon assessment in ED blood noted backed up in catheter hub. Cathflo backed up in catheter hub. Cathflo instilled overnight in ED for complete instilled overnight in ED for complete occlusion.occlusion.

Patient to return in am for follow up Patient to return in am for follow up assessment in am with DI Nurse.assessment in am with DI Nurse.

Case# 2Case# 2 What is missing?What is missing? What is wrong What is wrong

with this PICC?with this PICC?

SolutionSolution When questioned about the missing When questioned about the missing

clamp, the patient states “ the nurse cut it clamp, the patient states “ the nurse cut it off because it was digging into his skin”off because it was digging into his skin”

Do Not Remove any clamps that is Do Not Remove any clamps that is attached a CVAD attached a CVAD

RISK OF AIR EMBOLISIMRISK OF AIR EMBOLISIM Patient required new PICC line insertionPatient required new PICC line insertion If unsure about type of CVAD device look If unsure about type of CVAD device look

it up or consult with DI nurse.it up or consult with DI nurse.

CVAD 911 Emergency!CVAD 911 Emergency! Damaged PICC Damaged PICC

line, hickmann line, hickmann line or any line or any central line central line

RISK FOR AIR RISK FOR AIR EMBOLUSEMBOLUS

DVTDVT

Air EmbolismAir Embolism Venous air embolism can occur Venous air embolism can occur

during time CVC insertion, while during time CVC insertion, while catheter in place or at time of catheter in place or at time of removalremoval

Air can easily get into vascular Air can easily get into vascular system when needle or catheter system when needle or catheter open to atmosphereopen to atmosphere

As little as 200ml of air can be fatalAs little as 200ml of air can be fatal

Signs and Symptoms Signs and Symptoms Air EmbolismAir Embolism

Sudden complaints of dyspneaSudden complaints of dyspnea Respiratory distressRespiratory distress CoughingCoughing Chest painChest pain Tachyarrhythmia'sTachyarrhythmia's Cardiovascular collapseCardiovascular collapse

Treatment for Air Treatment for Air EmbolusEmbolus

Lay patient on left sideLay patient on left side Trendelenberg positionTrendelenberg position 100% oxygen100% oxygen Call 911Call 911 Supportive measures ( i.e. fluid Supportive measures ( i.e. fluid

resuscitation) resuscitation)

Case #3 :What Do You Case #3 :What Do You See?See?

CASE: 3CASE: 3 65 year old woman with breast cancer 65 year old woman with breast cancer

is receiving chemo through a PICC line is receiving chemo through a PICC line in the right basilic veinin the right basilic vein

CT tech unable to get blood returns CT tech unable to get blood returns from PICCfrom PICC

Pt had states had a recent fall on the Pt had states had a recent fall on the ice injuring her right shoulderice injuring her right shoulder

Upon further exam noted distended Upon further exam noted distended veinsveins

Case #3: Deep Vein Case #3: Deep Vein ThrombosisThrombosis

The patient had an obstrutive DVT in her The patient had an obstrutive DVT in her right arm from the basilic vein to the right arm from the basilic vein to the subclavian veinsubclavian vein

Sent to ER for treatment of DVTSent to ER for treatment of DVT PICC line pulled and reinserted after DVT PICC line pulled and reinserted after DVT

resolvedresolved““70-80% of thrombotic events occurring in 70-80% of thrombotic events occurring in

superficial and deep veins of upper superficial and deep veins of upper extremity are due to the presence of extremity are due to the presence of

intravenous catheters”intravenous catheters”

DVTDVT An extraluminal thrombus An extraluminal thrombus

can progress to a deep can progress to a deep vein thrombosis (DVT)vein thrombosis (DVT)

Fibrin build-up from the Fibrin build-up from the vein wall to the catheter vein wall to the catheter may cause blockage of may cause blockage of blood flow in the veinblood flow in the vein

This can lead to SVC This can lead to SVC syndrome - when the SVC syndrome - when the SVC is completely occluded and is completely occluded and venous return cannot venous return cannot empty into the right heart empty into the right heart to be oxygenatedto be oxygenated

This is an emergency!This is an emergency!

DVTDVT Pt may experience Pt may experience

redness to arm redness to arm localized or can localized or can extend up armextend up arm

Swelling to arm or Swelling to arm or hand(compare to non hand(compare to non PICC line arm.PICC line arm.

May experience pain May experience pain to arm chest neckto arm chest neck

No fever notedNo fever noted

Vein MeasurementVein Measurement

Thrombus to VeinThrombus to Vein

Case Study # 4: The Case Study # 4: The Quick DrawQuick Draw

60 year old female with hx of breast 60 year old female with hx of breast cancer, presented to ED with a fever .cancer, presented to ED with a fever .

Urine culture came back positive and Urine culture came back positive and admitted to hospital for urosepsis and admitted to hospital for urosepsis and was started on antibioticswas started on antibiotics

No blood culture drawn from PICCNo blood culture drawn from PICC PICC line pulled and tip sent for PICC line pulled and tip sent for

culture, came back negativeculture, came back negative

Case # 4Case # 4 Patient starting to improve on antibioticsPatient starting to improve on antibiotics A febrile nowA febrile now Limited peripheral veins due to lymph Limited peripheral veins due to lymph

node involvementnode involvement Important to establish if patient has a Important to establish if patient has a

true Catheter Related Blood Stream true Catheter Related Blood Stream Infection (CRBSI) in order to decide Infection (CRBSI) in order to decide whether to salvage, exchange, or remove whether to salvage, exchange, or remove the catheter.the catheter.

Systemic Antibiotic Systemic Antibiotic Therapy is NOT required Therapy is NOT required

for the following: for the following: Positive catheter tip in absence of Positive catheter tip in absence of

clinical signs of infectionclinical signs of infection Positive blood cultures obtained Positive blood cultures obtained

through a catheter with negative through a catheter with negative cultures through a peripheral veincultures through a peripheral vein

Phlebitis in the absence of infection, Phlebitis in the absence of infection, the risk of CRBSI usually low the risk of CRBSI usually low

CRBSI –catheter removalCRBSI –catheter removal Severe sepsisSevere sepsis Hemodynamic instabilityHemodynamic instability Endocarditis or evidence of metastatic Endocarditis or evidence of metastatic

infectioninfection Erythema or exudate due to suppurative Erythema or exudate due to suppurative

thrombophlebitisthrombophlebitis Persistant bacteremia after 72hrs of Persistant bacteremia after 72hrs of

antimicrobial therapy to which the antimicrobial therapy to which the organism is suseptibleorganism is suseptible

Difficult PICC line Difficult PICC line RemovalRemoval

This usually due to venous spasmThis usually due to venous spasm Sometimes PICC lines can be Sometimes PICC lines can be

difficult to remove especially if difficult to remove especially if catheter too big for size of veincatheter too big for size of vein

Ask patient to relax armAsk patient to relax arm Apply warm compressApply warm compress After these measures the PICC line After these measures the PICC line

usually comes out easilyusually comes out easily

Case #5:What do you Case #5:What do you see?see?

Contact DermatitisContact DermatitisDermatitisDermatitis Dermatitis presents as reddened Dermatitis presents as reddened

irritated skin at the siteirritated skin at the site Always allow antiseptic (ie. Always allow antiseptic (ie.

Chlorhexidine) to dry completely before Chlorhexidine) to dry completely before applying dressingapplying dressing

Consider changing dressing to IV3000Consider changing dressing to IV3000 Consider changing antiseptic solution to Consider changing antiseptic solution to

povidone-iodine solutionpovidone-iodine solution

Case #6 :Case #6 : What Do You What Do You See?See?

PICC Line Site problemsPICC Line Site problemsInfection vs DermatitisInfection vs Dermatitis Dermatitis presents as reddened Dermatitis presents as reddened

irritated skin at the siteirritated skin at the site Infection presents as redness, Infection presents as redness,

swelling, warmth, and possible swelling, warmth, and possible purulent drainage at site?purulent drainage at site?

Does patient have a fever?Does patient have a fever? Does patient have any swelling to arm?Does patient have any swelling to arm?

What do you See?What do you See?

PICC Line InfectionPICC Line Infection Send to ER with signs of sepsis (ie. Send to ER with signs of sepsis (ie.

Fever, chills, tachycardia, hypotension)Fever, chills, tachycardia, hypotension) Rule out other sources of infectionRule out other sources of infection Obtain cultures – draw blood culture Obtain cultures – draw blood culture

from PICC line (do not discard a waste from PICC line (do not discard a waste sample) and consider swab for C&S if sample) and consider swab for C&S if site infection notedsite infection noted

Administer antimicrobialsAdminister antimicrobials Do not necessarily pull the PICC!Do not necessarily pull the PICC!

PreventionPrevention Good hand hygieneGood hand hygiene Ensure to “Scrub the Ensure to “Scrub the

hub” with Chlorehexidine hub” with Chlorehexidine for minimum 30sec prior for minimum 30sec prior to accessing devicesto accessing devices

Wear sterile gloves and Wear sterile gloves and mask (pt should wear mask (pt should wear mask as well) anytime mask as well) anytime opening dressing.opening dressing.

Removal of unnecessary Removal of unnecessary CVC should be regularly CVC should be regularly assessed.assessed.

Leaking at PICC siteLeaking at PICC site If leaking at site is If leaking at site is

present when present when flushing or infusing flushing or infusing through CVADthrough CVAD

Send to DI for Send to DI for catheter-o-gram (to catheter-o-gram (to rule out a hole in rule out a hole in the catheter)the catheter)

Doppler studies (to Doppler studies (to rule out thrombosisrule out thrombosis

Case 4: Pain in the neckCase 4: Pain in the neck A 59 year old man with a PICC line in the A 59 year old man with a PICC line in the

right basilic vein presents with a right basilic vein presents with a withdrawal occlusion.withdrawal occlusion.

Has also been complaining lately of a Has also been complaining lately of a constant “wooshing” sound in his right earconstant “wooshing” sound in his right ear

The patient has been vomiting lately due to The patient has been vomiting lately due to chemo treatmentchemo treatment

Chest xray done to confirm proper Chest xray done to confirm proper placement…placement…

PICC line malpositionPICC line malposition PICC line must be removed and PICC line must be removed and

reinsertedreinserted If PICC pulled out more than 2cm from If PICC pulled out more than 2cm from

original position, tape it in current original position, tape it in current position do not pull it out completelyposition do not pull it out completely

Do Not Do Not attempt to push catheter back attempt to push catheter back into positioninto position

Do not use PICC until tip placement Do not use PICC until tip placement confirmed by chest X-rayconfirmed by chest X-ray

Cracked PICCCracked PICC If there is a crack or a hole present, If there is a crack or a hole present,

determine locationdetermine location Fold catheter over on itself and Fold catheter over on itself and

cover with tegaderm or other film cover with tegaderm or other film dressingdressing

Close catheter clamp if there is oneClose catheter clamp if there is one Send to hospital right awaySend to hospital right away

Cap on TOO TightCap on TOO Tight

Crack more visible with cap on

Crack faintly visible with cap off

Prevent Damage to PICCPrevent Damage to PICC

Never put steri-strips over picc line, Never put steri-strips over picc line, always make sure they are underneath always make sure they are underneath the line or on top of white wingthe line or on top of white wing

Do not force fluid into PICC if resistance Do not force fluid into PICC if resistance is metis met

Ensure clamps are open before Ensure clamps are open before attempting to flushattempting to flush

Do not over tighten capDo not over tighten cap

Broken PICCBroken PICC If the end of the catheter If the end of the catheter

breaks off grab CVAD (to breaks off grab CVAD (to prevent it from migrating prevent it from migrating internally)internally)

Fold catheter over, Fold catheter over, cleanse catheter, tape cleanse catheter, tape securely to arm, and send securely to arm, and send patient to hospital right patient to hospital right away with the external away with the external portion of the catheterportion of the catheter

Monitor for air Monitor for air embolismembolism

Broken PICCBroken PICC If catheter disappears inside vein:If catheter disappears inside vein:

Apply tourniquet to upper arm close to Apply tourniquet to upper arm close to axillaaxilla

Place patient in Trendelenburg positionPlace patient in Trendelenburg position Call 911Call 911 Monitor for air or obstructive embolismMonitor for air or obstructive embolism

QUESTIONS ???QUESTIONS ???