Peripherally Inserted Central Catheters: Guideline for Practice Are Only to Be Used for Individual Review and Study

PeripherallyPeripherally Inserted CentralCentral CathetersCatheters Guideline for Practice, 2nd Edition

Janet Pettit, MSN RNC NNP CNS Mary Mason Wyckoff, PhD ARNP BC CCNS CCRN NNP Publisher's note: The product is provided on an as-is basis. National Association of Neonatal Nurses, the authors, and editors neither represent nor guarantee that the content will, if followed, ensure safe and effective patient care. NANN, the authors, and the editors assume no liability or responsibility in connection with the content. The content reflects NANN's judgment regarding the state of general knowledge and practice in this field as of the date of publication and is subject to change based on the availability of new scientific information. The content is not intended to be a substitute for professional medical judgment, diagnosis, or treatment.

© 2001, 2007 National Assocation of Neonatal Nurses. All rights reserved under U.S. and international copy- right laws. First edition 2001 Second edition 2007 The content and materials of the Peripherally Inserted Central Catheters: Guideline for Practice are only to be used for individual review and study. For any other use, written permission to use or duplicate the content and/ or materials of the Peripherally Inserted Central Catheters: Guideline for Practice must be obtained. All requests for such perdition must be made in writing and addressed to National Association of Neonatal Nurses, 4700 W. Lake Avenue, Glenview, IL 60025.

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ISBN 978-0-9787636-3-3

Peripherally Inserted Central Catheters Contents Preface...... 4 Catheter migration...... 35 Acknowledgments...... 5 Catheter dislodgement...... 36 Introduction...... 6 Dysrhythmias...... 37 Definitions...... 6 Myocardial perforation, effusion, or tamponade...... 37 Peripherally inserted central catheter...... 6 Pleural effusion/hydrothorax...... 38 Midline catheter...... 6 Phrenic nerve injury/diaphragmatic paralysis...... 40 Vascular Access Device Comparisons...... 6 Catheter fracture and embolism...... 40 Peripheral IVs...... 6 Thrombosis...... 41 Umbilical catheters...... 7 Vena cava thrombosis...... 42 Midline catheters...... 7 Mechanical phlebitis...... 42 Tunneled catheters...... 7 Chemical phlebitis...... 42 Recommendations for Peripherally Inserted Central Catheter occlusion...... 43 Catheter...... 7 Nonthrombotic or mechanical occlusions...... 43 Infusate Considerations for Vascular Access Device Catheters that resist removal...... 45 Selection...... 7 Drainage from catheter or insertion site...... 46 Osmolality factors...... 7 Extremity edema...... 46 pH factors...... 8 Neurologic complications...... 46 Chemical/irritant factors...... 8 Medical Device Reporting and MedWatch...... 47 Cost considerations for vascular access device Catheter Care and Maintenance...... 48 selection...... 8 Assessment and documentation...... 48 Candidate Selection and Contraindications...... 8 Infusion tubing configuration...... 48 Educational Competency for Nurse Inserters and Medication administration...... 48 Caregivers...... 9 Infusion of fluids...... 49 Maintaining competency...... 9 Flushing...... 49 Vascular Access Teams...... 9 Management of heparin locks...... 50 Outcome monitoring...... 10 Blood sampling and administration...... 50 Equipment and Supplies for PICC Insertion Procedure..... 10 Transfusion of blood products...... 50 Potential Insertion-Related Difficulties...... 10 Catheter repair...... 51 Inability to thread the catheter through Dressing changes...... 51 the introducer...... 10 Catheter removal...... 51 Inability to thread the catheter to the Conclusion...... 52 premeasured distance...... 11 References...... 53 Use of modified Seldinger technique (MST) and poor Appendices ...... 60 peripheral venous access...... 32 Clinical Competencies for the Nurse...... 60 Malposition of catheter...... 32 Troubleshooting Guide...... 61 Bleeding...... 33 Sample Consent Forms and Parent Education Tools..... 62 Postinsertion Complications...... 33 Procedure Documentation and Maintenance Records... 64 Catheter-related bloodstream infection or PICC Order Forms...... 69 catheter-associated bloodstream infection...... 33 Tables Figures Table 1. Procedure for PICC Insertion in an Infant...... 12 Figure 1. The major veins that may be used for PICC Table 2. Relationship Between Patient Position and placement in young infants...... 13 Catheter Tip Location...... 36 Figure 2. The major veins of the arm...... 13 Figure 3. The path from the temporal and posterior auricular and external jugular veins into the central circulation...... 16 Figure 4. Access sites for entering the leg veins and venous pathway into the central circulation...... 18 Figure 5. Catheter erosion through the myocardium, leading to pericardial effusion...... 37 Figure 6. Catheter erosion at the junction of the brachiocephalic vein and the superior vena cava, which may lead to pleural effusion...... 39

Peripherally Inserted Central Catheters Preface Peripherally inserted central catheters (PICCs) are Guidelines for Prevention of Intravascular Catheter being placed with increasing frequency in infants to Related Infections from the Centers for Disease Con- enhance the delivery of care for this vulnerable popu- trol and Prevention (CDC; 2002b), guidelines specific lation. Guidelines for PICC use are needed to support to particular patient populations, and state and fed- nursing practice and promote infant safety. This eral statutes. guideline defines criteria for educational competencies This guideline is designed as a description of prac- for nurses inserting and maintaining PICCs and dis- tices currently accepted and documented by experts cusses infant selection criteria, techniques for catheter in the field of neonatal care. It also identifies gaps in insertion, identification and management of complica- existing scientific knowledge. This guideline does not tions, and strategies for daily maintenance. preclude the use of manufacturers’ recommendations This is the only guideline specific to infants with or other safe and acceptable methods for inserting PICCs. Nurses also should be aware of the Infusion and maintaining PICCs. It provides a foundation for Nursing Standards of Practice by the Infusion Nurses the specific nursing protocols, policies, and procedures Society (INS; 2006), the Position Statement related to developed by individual institutions. catheter tip location from the National Association This guideline was developed and revised by the of Vascular Access Networks (formerly NAVAN, now National Association of Neonatal Nurses (NANN) in the Association for Vascular Access or AVA; 1998), response to members’ requests.

Peripherally Inserted Central Catheters Acknowledgments Development and Acknowledgments The following contributors and reviewers are recog- This guideline was developed by NANN members nized for their assistance. and other volunteer reviewers who provided thought- Authors ful comments and editing suggestions. Janet Pettit, MSN RNC NNP CNS NANN especially thanks BD Medical Systems for Mary Mason Wyckoff, PhD ARNP BC CCNS CCRN providing an educational grant for the publication of NNP this guideline. BD Medical Systems had no substantive Reviewers review rights or input into Joan Demarest, RN the content of the guideline. Darcy Doellman, BSN RN CRNI Nancy Kadavy, MSN APRN Liz Sharpe, ARNP MSN NNP Mary Laura Smithwick, BSN RN Carol Trotter, PhD RNC NNP Cyndi Weiss, RNC

Peripherally Inserted Central Catheters Introduction 1999). These catheters may be appropriate for the The survival of an increasing number of very-low- infusion of fluids or medications with osmolalities birthweight and critically ill neonates heightens the need <600 mOsm/kg, a pH ranging from 5 to 9, and the for parenteral nutrition to support growth, as well as noncontinuous infusion of irritant or vesicant proper- reliable vascular access for administration of additional ties (similar to those that can safely be administered intravenous fluids and medications. As a result, care- through a PIV) (Dawson, 2002; Gazitua, Wilson, Bis- givers are continually being challenged to improve the trian, & Blackburn, 1979; INS, 2006; Lesser, Chhabra, methods by which they provide safe and consistent vas- Brion, & Suresh, 1996; Pettit, 2003b; Wyckoff). cular access to this vulnerable population. Vascular Access Device Comparisons Peripheral intravenous (PIV) and umbilical catheters It is important to assess the infant early during the have commonly been employed for these purposes, hospital stay and to determine the most appropriate but they have a limited dwell time (i.e., the life of an vascular access device for meeting the infant’s ongo- inserted vascular access device). In addition, the PIV ing needs. This device will allow for uninterrupted has an increased complication profile and infusate therapy, preserve the peripheral vasculature, reduce limit compared with other central venous catheters. the cost of delivering therapy, and protect the infant Surgically inserted, tunneled central venous catheters from pain associated with multiple PIV restarts (Janes, (e.g., Broviac®) have been successfully placed in neo- Kalyn, Pinelli, & Paes, 2000; Pettit, 2002). The selec- nates and infants for more than 2 decades and have tion criteria for vascular devices include length and proven to be a reliable but more costly means of pro- type of anticipated therapies, age and weight of the viding long-term access. In 1973, Shaw described a infant, diagnoses, condition of the vasculature, and novel technique for inserting a silicone catheter into current clinical condition of the infant (INS, 2006). the central veins of neonates. Since then, the practice One device will not meet the needs of every infant and of inserting PICCs has been streamlined because of some will need a few devices throughout their hospital improvements in catheter technology and insertion stay. Some infants may need more than one PICC for devices. Registered nurses (RNs) are inserting PICCs infusion or withdrawal of laboratory specimens. with increasing frequency, presenting a cost-effective approach to providing vascular access while yielding Peripheral IVs similar outcomes as physicians (Fong, Holtzman, PIVs have been indispensable for providing thera- Bettmann, & Bettis, 2001). pies to infants who require intensive care. Although historically PIVs have served as the vehicle for infus- Definitions ing most IV solutions and medications, the potential Peripherally inserted central catheter for temporary or permanent damage to the peripheral A peripherally inserted central catheter (PICC) is veins has not been sufficiently considered. A patient’s a device inserted into a peripheral vein and threaded length of therapy and type of therapy distinguishes into the central venous circulation. Although PICC is whether he or she is well-suited for peripheral or the preferred term for this device, neonatal care pro- central catheter placement. Although PIVs remain viders have historically referred to these catheters as common, the risk of complications is high (Franck, percutaneous central venous catheters (PCVCs), perc Hummel, Connell, Quinn, & Montgomery, 2001). lines, and long lines. According to the U.S. Food and Nonelective removal of a PIV due to complications Drug Administration (FDA) and other entities, the tip occurs in up to 78% of insertions and can lead to of the PICC should reside in the superior vena cava premature removal of up to 95% of devices, though 1 1 (lower /2 to /3) for upper-body insertions and the tho- variations in reporting make accurate rates difficult racic inferior vena cava for lower-extremity insertions to detect (Franck et al.). Inserting and maintaining (National Association for Vascular Access Networks PIVs in premature infants, especially those weigh- [NAVAN], 1998; FDA, 1989; Infusion Nurses Society ing <1,000 g, can be difficult due to the small size of [INS], 2006). their veins and the depletion of available sites from repeated puncture. It is not unusual for an infant to Midline catheter undergo multiple attempts at IV placement before suc- A midline catheter is a vascular device inserted into cessful cannulation, which has been shown to increase a peripheral vein and threaded to an area of greater the risk of infection (Franck et al.; Grant et al., 1997). blood flow in the proximal portion of the extremity, PICC insertion has demonstrated a reduction in pain- or it can be inserted into a scalp vein and threaded ful PIV insertion attempts by 50% in infants weighing into the external jugular vein (INS, 2006; Wyckoff,

Peripherally Inserted Central Catheters <1,250 g (Janes et al., 2000). PICCs prevent dam- has been shown to be safe and effective in infants with age to the peripheral veins (caused by the properties anticipated postoperative hospital stays of 4–7 days of many IV solutions and medications) and protect (Schwengel et al., 2004). PICCs offer neonates numer- infants from the pain and stress of frequent PIV ous advantages over other vascular access devices restarts (Pettit, 2002, 2003b). and provide a safe, effective alternative for providing required therapies. When a PICC is used appropri- Umbilical catheters ately, the risk of complications is low. For critically ill neonates and those weighing <1,000 g at birth, an umbilical catheter often is required. If ongo- Infusate Considerations for Vascular ing vascular access is necessary, a PICC is placed before Access Device Selection removing the umbilical device to avoid repeated Placement of the PICC with the tip residing in attempts at PIV access and the accompanying risk the superior or inferior vena cava provides increased of infection. Infants who weigh >1,000 g and do not blood flow with resultant increased hemodilution of require umbilical venous access should be evaluated infusates (INS, 2006; NAVAN, 1998; Racadio, Doell- for a midline catheter or PICC as the initial vascular man, Johnson, Bean, & Jacobs, 2001). This allows access device, based on diagnosis, vascular assessment, the safe delivery of more concentrated parenteral and therapeutic and nutritional needs. nutrition, increased dextrose-containing solution Midline catheters with higher caloric density, and medications (e.g., Midline catheters offer an alternative for those vancomycin, phenobarbital) known to damage the infants who do not require a PICC, but who need sev- peripheral veins with repeated use. eral days of IV therapy. Mean dwell times for midline Many substances infused into peripheral veins can catheters have been reported to be between 6 and 10 cause venous damage, including chemical phlebitis, days and up to four times as long as those of PIVs thrombosis, and infiltration or extravasation injuries (Dawson, 2002; Leick-Rude & Haney, 2006; Lesser (Camara, 2001; Gazitua et al., 1979; Irving, Simone, et al., 1996; Wyckoff, 1999). Fewer PIV restarts and a Hicks, & Verger, 2000; Kearns, Coleman, & Weh- longer life span make midlines an attractive option for ner, 1996; Kuwahara, Asanami, Tamura, & Kaneda, vascular access in select infants (Dawson; Leick-Rude 1998; Racadio et al., 2001). Trauma to the vein, as & Haney; Lesser et al.; Wyckoff). Currently, no data well as potential decrease in dwell time leading to exist to support a limit to the dwell time of a properly the development of chemical phlebitis, is related to functioning midline catheter. the composition of the infusate (i.e., osmolality, pH, chemical properties) (Wermeling, Rapp, DeLuca, & Tunneled catheters Piecoro, 1985). Chemical phlebitis presents clinically Tunneled central venous catheters (CVCs) (e.g., Bro- with the appearance of erythema within hours of viac®) historically have been associated with a higher infusing an offending agent. Development of venous rate of infection when compared with the reported thrombosis often accompanies phlebitis. Infiltration infection rate of PICCs (Chathas, Paton, & Fisher, and extravastion injuries may present with ecchy- 1990; Hruszkewycz et al., 1991; Oellrich, Murphy, mosis, blistering, and skin sloughing. Intervention Goldberg, & Aggarwal, 1991; Pandit, Pandit, Govan, and removal of the peripheral device is required to & O’Brien, 1999). More recent data support equal facilitate vein healing and possible recovery. It may infectious risks when comparing PICCs to tunneled be necessary to infuse medications or solutions that CVCs (Foo, Fujii, Harris, LaMorte, & Moulton, are known to cause venous damage into a peripheral 2001). The risks of pneumothorax and hemothorax, vein. Although this may be tolerated for short peri- as well as increased insertion-related costs, use of ods of time, it is important to ensure that the vein is anesthesia, and invasiveness of the insertion proce- large enough to enhance hemodilution and decrease dure are additional disadvantages of the tunneled the risk of severe damage to the vessel. For repeated catheter. administration of these substances, central venous Recommendations for Peripherally access should be obtained (INS, 2006; Pettit, 2002). The following factors should be considered when Inserted Central Catheter determining the appropriate route for infusing an IV Although many infants will benefit from central solution or medication. venous access achieved using a PICC, the CDC rec- ommends that patients who require more than 6 days Osmolality factors of therapy should be considered for more than a PIV Medications and IV solutions with an osmolal- (CDC, 2002b). The placement of preemptive PICCs ity <450 mOsm/kg rarely cause chemical phlebitis,

Peripherally Inserted Central Catheters whereas those with an osmolality between 450 and Candidate Selection and Contraindications 600 mOsm/kg run a moderate risk of developing Candidates for PICC insertion may include the chemical phlebitis. Medications and IV solutions with following: an osmolality >600 mOsm/kg almost always lead • premature infants, particularly those who weigh to chemical phlebitis, resulting in a decreased PIV <1,500 g because of a delay in establishing mainte- dwell time (Gazitua et al., 1979). Peripheral veins nance quantities of enteral nutrition have been shown to tolerate higher osmolar solu- • infants requiring more than 6 days of intravenous tions for shorter periods of time before developing therapy (CDC, 2002b), which may include infants with complications (Kuwahara et al., 1998). Hyperosmolar – infections requiring intravenous antimicrobial solutions routinely given to neonates include dextrose therapy concentrations ≥10%, parenteral nutrition, ampicillin, – gastrointestinal disorders, such as necrotizing cefotaxime, sodium bicarbonate, and phenobarbital enterocolitis, omphalocele, gastroschisis, and (Irving et al., 2000; Santeiro, Sagraves, & Allen, 1990; those requiring multivisceral transplants Trissel, 2006). Central venous access is recommended – respiratory insufficiency for the infusion of solutions with an osmolality >600 – congenital cardiac disorders mOsm/kg (INS, 2006; Ryder, 1995). • limb anomalies, which may limit the number of pH factors vascular access sites If the pH of the medications or solutions is <5 or • infants requiring the infusion of fluids or medi- >9, vein damage can occur when the infusate enters cations with hyperosmolar (>600 mOsm/kg), a small vein without adequate hemodilution (Fonk- nonphysiologic pH (<5 or >9), or irritating proper- alsrud, Murphy, & Smith, 1968; Roberts et al., 1994). ties (INS, 2006) Gentamicin and vancomycin are examples of acidic • infants with inadequate peripheral venous access; drugs and ampicillin and phenobarbital are alkaline PICC insertion should be considered before the drugs routinely given to infants (Hadaway & Chamal- problem occurs (INS, 2006; Oellrich et al., 1991) las, 2003; Trissel, 2006). Adults often describe pain • infants whose medical providers or parents prefer when these medications are infused into the peripheral the use of a PICC over other vascular access devices. vein; unfortunately, neonates are unable to verbalize Infants should be assessed individually, with atten- their feelings of discomfort and crying may be related tion to the risks and benefits of the procedure. There to multiple factors. are few absolute clinical contraindications to the insertion of a PICC (i.e., lack of suitable peripheral veins Chemical/irritant factors or need for vascular access). Ultrasound, transillumi- The chemical properties of some medications irritate nation, and infrared vein visualization technologies the veins, possibly leading to phlebitis and throm- may enhance venous access in situations where suit- bosis. Amphotericin B, vasopressin, resuscitation able veins are not visible. medications, dopamine, and calcium are examples of However, the existence of any of the following con- chemical irritants that can promote venous damage, ditions affects the assessment and warrants additional particularly if there is inadequate hemodilution. consideration: • uncontrolled bacteremia or fungemia (A PICC Cost considerations for vascular access could become colonized with organisms, which device selection would impede or prevent adequate treatment. No significant difference was found in the cost per Some recommend antimicrobial treatment for day of a PICC or a PIV in premature infants (Naka- 24–48 hours before an elective PICC placement. mura, Sato, & Erenberg, 1990). The cost of a midline However, the infant may require reliable vascular catheter is equivalent to that of a PIV after 3–4 days access, and a PICC may be the most appropriate of therapy. The cost of inserting a PICC has been delivery device for antimicrobial treatment.) favorably compared to that of surgical placement of a • thrombocytopenia or coagulopathy (Delayed clot- CVC (Horattas et al., 2001). The latter procedure may ting mechanisms increase the risk of prolonged require using an operating room, a skilled surgeon bleeding at the PICC insertion site.) and, often, general anesthesia, all of which increase • fracture (The condition of the veins surrounding the cost of the procedure. Most PICC insertions the fractured bone is uncertain and the presence of require less time (i.e., 15 minutes–1 hour). Identifying the fracture can hinder assessment for PICC-related the need for the PICC early in the course of treatment complications.) is financially prudent.

Peripherally Inserted Central Catheters • decreased venous return (Edema that presents due Each facility is responsible for establishing written to decreased venous return related to a nerve palsy criteria for qualifying employees to perform the proce- or other etiology may be difficult to distinguish dure and defining guidelines for obtaining competence from edema resulting from a PICC-related com- (FDA, 1989; INS, 2006; Masoorli, 2005). A healthcare plication. Use of another extremity or the scalp is professional who is experienced in PICC insertion preferable.) must observe an employee to verify and assess clinical • cardiac malformations requiring operative proce- competency. A minimum of three supervised success- dures (Consult with a surgeon regarding the use of ful insertions is required for independent practice. a PICC and the preferred catheter tip location.). Maintaining competency Educational Competency for Nurse Each facility is responsible for establishing criteria Inserters and Caregivers for maintaining clinical competence (INS, 1997b, RNs assuming responsibility for the placement 2006). The successful insertion of a minimum of five of PICCs should consult with their respective State PICCs per year should be required to maintain privi- Board of Registered Nursing to determine whether leges. In addition, a review of recent PICC-related the procedure is within the scope of nursing practice. literature, NICU procedures for PICC insertion and PICC placement may be considered an advanced maintenance, and outcomes of insertions by each nursing practice and therefore require development clinician performing the procedure support team of a standardized procedure requiring approval from improvement efforts and should be performed at least an interdisciplinary practice committee. Practice annually (INS, 1997b; Linck, Donze, & Hamvas, restrictions, such as limitations of veins that can be 2007; Sharpe, 2006). cannulated, vary among states and hospitals. One of the strongest predictors of long-term success PICC insertion requires specialized training in order with PICC use identified more than 20 years ago con- to improve patient outcomes by reducing device- tinues to be staff education regarding all aspects of related complications and decrease the cost of care. PICC care, management, and surveillance (Chathas, (CDC, 2002b; FDA, 1989). A two-pronged approach 1986; Linck et al., 2007; Sharpe, 2006). An increase to training consists of a didactic and a clinical com- in knowledge and self-efficacy has been demonstrated ponent. An expert in the field of neonatal vascular following targeted educational programs, along with a access who possesses current expertise in PICC place- significant decline in the rate of PICC occlusion (Ngo ment in infants should provide the didactic content. & Murphy, 2005). Knowledgeable staff members are Curriculum designed to prepare professionals for able to intervene earlier to identify problems (Chathas, placing and maintaining PICCs should be formalized 1986). Every RN caring for a patient with a PICC and minimally include (INS, 2006) must demonstrate knowledge of potential complica- • indications and contraindications for placement tions and care and maintenance strategies (Pettit, • risks-benefit analysis of the procedure 2002). Only RNs with verified competency should • applicable legal issues perform dressing changes, treat catheter occlusions, • knowledge of guidelines and standards of infusion repair catheters, and discontinue catheters due to the therapy published by professional organizations and higher risk associated with these procedures. governmental agencies Vascular Access Teams • knowledge of the anatomy and physiology of the Specially trained IV teams have demonstrated effec- venous and arterial systems tiveness in reducing catheter-related complications, • application of sterile technique particularly infections, and have proven to be cost- • patient preparation effective (CDC, 2002b; Golombek, Rohan, Parvez, • pain management Salice, & LaGamma, 2002; Schelonka, Scruggs, • use of equipment and supplies for PICC insertion Nichols, Dimmitt, & Carlo, 2006; Sherrod, Warner, • insertion technique (traditional and modified Seld- & Altimier, 2005). Using dedicated PICC teams has inger technique [MST], where appropriate) significantly improved patient safety and reduced • assessment and management of complications costs. The use of a consistent team decreases multiple • routine catheter care and maintenance (including insertion attempts, improves outcomes, and decreases troubleshooting) infection rates (Burns, 2005; Hornsby, Matter, Beets, • institutional quality improvement process for PICCs Casey, & Kokotis, 2005; Santolucito, 2001). Early vas- • documentation of the procedure, assessment find- cular access assessments are a multidisciplinary effort ings, and complications.

Peripherally Inserted Central Catheters and can be facilitated by the nursing team for iden- • patient’s weight at the time of catheter insertion tification and initiation. The majority of physicians • indication for placement may be unaware of the multitude of venous punctures • catheter specifics (brand, composition, size, num- infants will experience. Early assessment through a ber of lumens) team concept may well decrease the pain and suffering • complications occurring during insertion, dwell, or caused by short-term peripheral venous access. Noti- removal fication of the ordering of hyperosmolar medications • length of catheter dwell or other medications or solutions irritating to the • reason for removal. vein should be incorporated as part of the pharmacy Data from each inserter and the team as a whole are communication with the PICC team to facilitate early reviewed on a regular basis to identify trends in usage assessment (Santolucito, 2001; Sharpe, 2006). and outcome measures. Data should be reported per These teams may perform all PICC insertions, con- 1,000 catheter days to allow for benchmarking against duct daily surveillance of each catheter and dressing, other hospitals. perform dressing changes, troubleshoot catheter prob- To arrive at this number, perform the following lems, provide formal and informal staff education, calculation: and conduct outcome monitoring. A team concept Total number of complications x 1,000 = rate of further minimizes the use of inappropriate device Number of catheter days complications selection and inappropriate catheter tip location. per catheter day Facilities may choose to have one team responsible for PICC insertion and another educated team designated for insertion, care, and maintenance, fol- Equipment and Supplies for PICC lowing standardized protocols that have minimized Insertion Procedure complications (Golombek et al., 2002; Linck et al., Table 1, beginning on page 12, outlines each step in 2007; Rourke & Higgins, 1998). Advancing the team the process of PICC insertion in an infant. concept to include full responsibility for the PICC program is the ultimate goal. The creation of PICC, Potential Insertion-Related Difficulties stick, and run teams significantly diminishes the safety A number of problems can occur related to catheter of PICC use. These teams are not cost-effective and insertion. Those most common are addressed in this increase the risk of infection and decrease positive section. outcomes. Their only goal is PICC placement; these Inability to thread the catheter through the teams neglect to follow through on quality assurance introducer and care and maintenance (Burns, 2005; Hornsby et Once the vein is cannulated, blood return is typi- al., 2005; Sharpe, 2006). Providing staff education cally, but not always, evident. Although the catheter and competency validation, ensuring adequate staff usually is easily advanced into the vein, obstructions scheduling to perform PICC insertion, and financially can be encountered. Strategies to facilitate catheter supporting the PICC program are responsibilities of passage include the healthcare institution that elects to develop and • Ensuring that the introducer and the entire bevel support a PICC team (Sharpe). Empowering and are in the vein. If you are unsure, redirect the de- expanding nursing practice to advance the health of vice into the vessel. infants by incorporating a PICC team will decrease • Checking the angle of the introducer in the vein and complications and improve the vascular access health realigning or straightening it; move it either up or of neonates. down to prevent the catheter from contacting the Outcome monitoring vein wall. Quality improvement programs are an integral • Removing the tourniquet after the catheter has component of a hospital’s PICC program (Chathas & passed into the vein lumen. Paton, 1996; INS, 2006; Linck et al., 2007; McMahon, • Tightening the tourniquet or reapplying it to distend 2002). Data gathered through this process guide deci- the vein and allow the catheter to pass. The larger sion making to positively affect patient care (Linck et vein diameter may increase ease of catheter passage. al.; McMahon). Targeted data collection for outcome • Visualizing the location of the catheter using ultra- monitoring (procedural documentation requires addi- sound or other imaging technologies. Using ultrasound tional information) for each PICC placed should at a to visualize the catheter in the subclavian or internal minimum include jugular veins will provide further information to

Peripherally Inserted Central Catheters 10 evaluate whether the catheter is malpositioned in an 3. Partially withdraw the catheter and reinsert it fol- upward position toward the head. lowing the instructions outlined below. • Removing the introducer and catheter if these a. For insertion in the arm, elevating the shoulder or measures fail to correct the problem. moving the arm in different locations may allow the catheter to pass the obstruction (Puntis, 1986). Inability to thread the catheter to the pre- b. For insertion in the leg, elevating the pelvis may measured distance help a catheter that is stuck at the groin to advance. Vasospasm, venous valves, bifurcation of the vein, Abducting or manipulating the leg are other scarring or sclerosis of veins, venous anatomy, and measures that can be tried (Puntis, 1986). patient positioning have all been linked to difficulty c. Difficulty in threading catheters from the scalp to in threading catheters. In addition, the catheter may the jugular vein may be overcome by gently pulling be taking an aberrant route. If the catheter cannot the skin on the neck down toward the body if the be threaded more than 2–3 cm beyond the tip of the catheter is stuck anterior to the ear. If the catheter introducer, the catheter may not be within the vein. is stuck at the neck, rotate the patient’s shoulders or Establish where the catheter is located by determining gently move the head to midline, extend or flex the the length of the catheter in the patient, then follow neck (Puntis, 1986). the appropriate strategies. 4. Massaging over the vein or rolling a sterile cotton Inability to insert the catheter through the peripheral swab over a portion of the vein where the catheter circulation is stuck has been described anecdotally as beneficial 1. Remove the introducer (if needle style) to prevent (Rastogi et al., 1998). catheter damage and withdraw the catheter a few cen- 5. If the catheter has been preflushed, gently flushing timeters (depending upon the distance it is inserted). with 0.5–1 ml of flush solution while attempting to 2. Rotate or twist the catheter and reinsert. This advance can be helpful. maneuver, which can be done two or three times, 6. If you are still unable to thread the catheter, repeat can help the catheter to pass valves. step 3. 3. If the catheter fails to advance, place a tourniquet 7. If the catheter is successfully inserted to the premea- high on the extremity above the catheter tip. Venous sured depth, attempt to aspirate for a blood return. engorgement may help the catheter advance. If a blood return is not obtained, an X ray can help 4. If a stylet is present, it can be withdrawn a few determine the position of the catheter tip. centimeters. Partial withdrawal of the stylet adds 8. If the catheter remains outside the superior vena cava more flexibility to the catheter tip and can facilitate (typically in the brachiocephalic or subclavian vein) catheter advancement. The stylet can be completely despite attempts to place it within the vena cava, it removed if the catheter still will not thread. may be in an acceptable position to infuse therapies 5. Gentle flushing while threading can help the cath- that can safely be given through a PIV, if doing so eter pass valves or an obstruction. will meet the infant’s needs or as a temporary mea- 6. Other strategies: sure until a CVC can be placed. Blood return must • Massaging over the length of the vein has been be present and the catheter should flush easily. This is described as helpful in catheter passage (Rastogi, not considered a central catheter tip position because Bhutada, Sahni, Berfon, & Wung, 1998). there is an increased risk of thrombosis when catheter • Application of warm packs to promote dilatation. tips reside in the brachiocephalic and subclavian veins • Waiting several minutes to allow the vein to relax. compared with those that are located in the superior 7. If the catheter cannot be advanced, it should be vena cava (Brown-Smith, Stoner, & Barley, 1990; INS, removed. 2006; Kearns et al., 1996; Racadio et al., 2001). 9. Catheter tips that remain in the peripheral circula- Inability to thread the catheter from the peripheral into tion are referred to as midline catheters. the central circulation a. Catheters placed in the arm should have the tip If the catheter is entering the trunk of the body, the located opposite the axillary fold, not entering following should be considered: the torso and away from areas of flexion 1. Ensure that the patient is correctly positioned. For (Wyckoff, 1999). upper-extremity insertions, the arm should be at a 90° b. Catheters inserted in leg veins should remain below angle and the head turned toward the arm of insertion. the inguinal crease and away from areas of flexion. 2. Remove the needle-style introducer. c. Catheters placed in the scalp should reside in the jugular vein above the clavicle and out of the torso.

Peripherally Inserted Central Catheters 11 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 1. Determine need for a PICC and The nurse inserter should evaluate patients individually to If a suitable vein is not identified, obtain an order. verify the need, risks and benefits, and presence of a suitable the infant may be a better candidate vein. Not all infants are appropriate candidates. for another vascular access device. Verify patient identification. Follow hospital procedure to ensure compliance with patient identification procedures as outlined in the Patient Safety Goals by the Joint Commission (Join Commission, 2007). 2. Review the procedure with par- Information should include a description of the proce- The nurse performing the proce- ents and obtain informed consent dure, indications, risks, benefits, and the alternatives to the dure is responsible for ensuring (per hospital protocol and by procedure (Zonderman, 2000). Sample consent forms and that informed consent has been appropriate personnel, accord- information for parents about the procedure are included in obtained (if required and per hos- ing to state and federal statutes). the Appendix. pital protocol). Many facilities consider PICC insertion a routine procedure for the NICU and do not require a separate signed consent.

3. Select the vein to be used for The vein needs to be of sufficient caliber to accommodate Avoid using previously damaged the procedure. Figure 1 shows the the large size of the catheter and introducer. or sclerotic veins because of the major veins that can be used for increased risk of complications PICC insertion in neonates. (i.e., difficulty threading catheter, phlebitis, infection). Some hospitals and states specify If the vein is difficult to locate, consider use of a trans- Use of ultrasound requires the veins that RNs are allowed illuminator or other imaging devices, application of warm additional training to achieve to cannulate for a PICC. Only packs, or application of double tourniquets. The use of proficiency. a highly skilled inserter should “blind” technology utilizing anatomical landmarks and cannulate the external jugular, palpable veins to insert PICC catheters is rapidly becom- femoral, and axillary veins. ing obsolete. Recommendations from Agency for Healthcare Research and Quality (AHRQ) and Society of Critical Care Medicine (SCCM) have moved forward with instituting the use of ultrasound technology for the insertion of PICC catheters. These newer technological advancements provide bedside imaging during the placement of PICC catheters. The advantages incorporate exact vessel location and avoid- ance of arterial puncture. Ultrasound technology further improves the success rate and decreases the complication rate, while diminishing pain for the patient by minimizing attempts (Rothschild, 2007).

Peripherally Inserted Central Catheters 12 Figure 1. The major veins that may be used for PICC placement in young infants

Figure 2. The major veins of the arm Figures 1 and 2 ©BD Medical Systems. Used with permission.

Peripherally Inserted Central Catheters 13 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments The following veins are used for PICC insertion in neonates (Evans & Lentsch, 1999; Pettit, 2002; Racadio, Johnson, & Doellman, 1999) Veins of the arm • Basilic and median cubital basilic The basilic vein is a large vein in the arm that is straighter Disadvantages of using the basilic vein (See Figure 2.) and less tortuous than the cephalic vein in the arm. It is vein include its close proximity easily accessible, is easy to thread the catheter through, to the brachial artery and risk of requires less time for insertion, and allows a secure dress- inadvertent arterial puncture, as ing to be placed. It has a low incidence (4.7%) of reported well as possible previous venipunc- phlebitis (Nakamura et al., 1990; Neubauer, 1995). ture for lab draws. These factors make the vein a less satisfactory candidate. The most common site of malposition is the jugular vein (Lum & Soski, 1989). • Cephalic and median cubital The cephalic vein is smaller than the basilic and has a sharp The cephalic vein narrows and may cephalic vein (See Figure 2.) angle where it joins the axillary vein. It may bifurcate, with be tortuous as it ascends the arm one portion joining the external jugular vein and the other leading to an increased risk of the axillary vein (Lum & Soski, 1989). mechanical phlebitis. It may be difficult to thread the catheter past the shoulder, and the catheter may become malpositioned into the axillary vein.

• Axillary vein (See Figure 2.) Benefits of using the axillary vein include its large size, The axillary vein may be difficult which makes it easy to cannulate and thread the catheter to visualize in larger infants due to through. The size of this vein allows use of larger-size and subcutaneous fat. Its close proxim- dual-lumen catheters in many infants (Metz, Lucking, Chat- ity to the axillary artery poses the en, Williams, & Mickell, 1990; Oriot & Defawe, 1988). risk of arterial cannulation. Ensure the introducer remains out of the thorax.

Peripherally Inserted Central Catheters 14 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments Veins of the scalp and neck (A right-sided approach is preferred because it provides a near straight entry into the superior vena cava (SVC). A neck roll can facilitate catheter entry into the subclavian vein.) • External jugular vein (See The external jugular is a large, superficial vein that is eas- Positioning patients for catheter Figure 3.) ily palpable and visible. The vessel usually has not been placement and stabilizing the cath- cannulated for other purposes. To facilitate entry, place a eter after insertion can be difficult. towel roll under the shoulders to slightly hyperextend the There also can be increased risk neck, and turn the head to the side (Abdulla, Dietrich, & of catheter dislodgment, and it is Pramanik, 1990; Dolcourt & Bose, 1982; Oellrich et al., difficult to maintain a dry, intact 1991). dressing.

Leaving a few centimeters of catheter external and bringing the hub onto the upper chest for securement keeps the catheter away from for- mula and secretions and allows for easier access into the catheter. • Temporal vein (See Figure 3.) The branch of the temporal vein just in front of the ear is Carefully distinguish the temporal large and easily visualized (Racadio et al., 1999). vein from the adjacent temporal artery. Resistance to threading can occur where the catheter traverses the area in front of the ear and where it enters the subclavian vein. • Posterior auricular vein (See The posterior auricular vein is best cannulated behind the The posterior auricular vein is Figure 3.) ear. variable in size and may be tortuous. Resistance to threading can occur where the catheter enters the subclavian vein. Veins of the Legs • Femoral vein (See Figure 4.) Catheterization of the femoral vein can be accomplished by The close proximity to the femoral inserting the needle at a 30° angle 1 cm below the inguinal artery poses the risk of arterial punc- ligament and 5 mm medial to the femoral pulse (Abdulla ture. The femoral vein may be needed et al., 1990). A larger or dual-lumen catheter can be placed for cardiac catheterization, so it may into this vein due to its large size. not be an appropriate choice. Prevent- ing the insertion site from becoming Imaging technology is recommended while cannulating the contaminated with excrement may be femoral vein (Rothschild, 2007). difficult.

The risk of leg swelling has been reported to be as high as 15.6% (Foo et al., 2001).

Peripherally Inserted Central Catheters 15 Figure 3. The path from the temporal and posterior auricular and external jugular veins into the central circulation Figure 3 ©BD Medical Systems. Used with permission.

Peripherally Inserted Central Catheters 16 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments • Greater saphenous vein (See The greater saphenous vein is a large, easily visible vein on The greater saphenous vein is the Figure 4.) the medial aspect of the leg beginning near the ankle and longest vein in the body, containing extending up the leg. Cannulation may be performed at 7–15 valves that must be trans- multiple sites along the vein. Some report a higher inci- versed. It is not an appropriate dence (9%) of phlebitis (Neubauer, 1995). choice for infants requiring cardiac catheterization via the femoral vein. Edema of the leg may occur due to placement of the PICC. The edema is usually mild, and the circulation to the leg is not compromised. • Lesser saphenous vein (See The lesser saphenous vein is a small, tortuous vein best Positioning the infant may be Figure 4.) reached from the lateral aspect of the leg. awkward. This vein joins the popliteal vein at the back of the knee. The lesser saphenous vein is not an appropriate choice for infants requiring cardiac catheterization via the femoral vein. • Popliteal vein (See Figure 4.) The popliteal vein is easily visualized in the premature Access may be difficult with the infant, but it is less so in full-term infants. increase in muscle tone seen with advancing gestational age. Stabi- lizing the catheter after insertion may be difficult. The popliteal vein is not an appropriate choice for infants requiring cardiac catheterization via the femoral vein. 4. Measure the length of the cath- Inserting the catheter to a premeasured depth helps to There is variability in venous eter to be inserted. ensure the desired placement within the SVC or inferior pathways among individuals and For upper-body insertion, mea- vena cava (IVC) and prevents complications associated with measurement will not exactly pre- sure from the insertion site along malpositioning of the catheter. dict internal placement (James, the course of the vein, to the right Bledsoe, & Hadaway, 1993). of the sternal border, to the third intercostal space. If insertion is through an arm vein, extend the arm at a 90° angle for measuring. For lower-extremity insertion, measure from the insertion site along the course of the vein, to the right of the umbilicus and up to the xiphoid (Serrao, Jean-Louis, Godoy, & Pra- do, 1996).

Peripherally Inserted Central Catheters 17 Figure 4. Access sites for entering the leg veins and venous pathway into the central circulation Figure 4 ©BD Medical Systems. Used with permission.

Peripherally Inserted Central Catheters 18 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 5. Assemble the following equip- Efforts should be made to provide latex-free and di-(2-ethyl- ment and supplies before the hexyl) phthalate (DEHP)-free products to minimize the risk procedure. Many of the supplies to healthcare providers of an allergic reaction and the risk are available packaged as commer- of such an allergy developing in infants. cially prepared kits. General equipment and supplies • Sterile gown • Hair cover • Face mask • Protective eyewear • Sterile gloves (two pairs), powder and latex-free • Restraints or swaddling device (optional) • Limb board and tape (optional) • Imaging devices, such as a trans- illuminator, infrared technology, or ultrasound and sterile sleeve or glove (if applicable) Catheter equipment and supplies • 1.1 to 2 F (28- to 23-gauge) catheter, with sufficient length to achieve appropriate catheter tip placement for infants weighing < 2,500 g • 1.9 to 3 F (26- to 20-gauge) catheter, with sufficient length to achieve appropriate catheter tip placement for infants weighing ≥ 2,500 g • Introducer needle or cannula, in a size appropriate for the catheter, utilize safety-engineered introducers, if available (INS, 2006) Modified Seldinger technique (MST) supplies (if applicable) in addition to the previously listed supplies • 24-gauge peripheral intravenous device • Flexible guidewire, size 0.12– 0.15, approximately 15 cm in length • #11 surgical blade • Sheath dilator

Peripherally Inserted Central Catheters 19 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments These items may be available in a manufacturer-supplied kit • Tape measure • Sterile tourniquet • Antiseptic solution (e.g., chlorhexidine gluconate or povidone iodine) • Sterile water or saline pads • Three sterile 4” x 4”, lint-free gauze sponges • Sterile tape measure for trimming catheter (optional) • Sterile tape or skin-closure tape strips • Semipermeable transparent dressing or 2” x 2” gauze and non- occlusive tape • Two or three surgical drapes (one may be fenestrated) • Flush solution, which may include a heparinized saline solution, concentration per unit protocol (usually 0.5–1.0 units heparin/ml) or sodium chloride. (Throughout the document, “flush solution” is the term used to indicate either solution.) • One or two 5–10-ml syringes (per manufacturer’s recommendation) • Needles or needleless supplies for drawing flush solution into syringes or prefilled syringes that are sterile on the outer surface and labeled. • Nontoothed forceps • Scissors • Catheter-trimming device (optional, per manufacturer’s recommendations) • Extension set (T-connector, straight connector, or multilumen device) with luer-lock and closed-end adapt- er. The extension set should be lipid resistant and free of DEHP. Some catheters are manufactured with an integrated extension set and do not require a separate extension set. • Water-soluble radiocontrast media (optional; may be needed for small catheters, catheters containing lower amounts of radiopacity, or when infants have extensive cardio- pulmonary disease and when the catheter cannot be visualized radiographically)

Peripherally Inserted Central Catheters 20 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 6. Select catheter. Some infants require a double-lumen catheter or more than Catheters with tip terminations one PICC at a time. One may have the tip located in the within the same vessel can become SVC and the other in the IVC. entangled and be difficult to remove. The catheter should be selected that meets the infant’s therapeutic needs. Catheter material • PICCs are currently made of silicone or Both materials have been used suc- polyurethane. cessfully for many years, and both • The smallest catheters (28-gauge) are only made of are biocompatible. Catheter mate- polyurethane. rials are judged by their structural • Catheters made of both materials have been success- integrity, resistance to kinking, fully used in infants. structural rigidity for easy inser- • The choice of catheter material is personal because tion, low thrombogenicity, low little current data support the superiority of either. bacterial adhesion, long-term sta- bility, inertness to surrounding cells and tissues, and chemical inertness to infusate and mechanical irrtita- tion (DiFiore, 2005). The major significant difference lies in the tensile strength of the catheter material. Polyurethane has high tensile strength allowing thinner catheter walls and a larger internal lumen, whereas silicone (Silastic) requires thicker walls with resultant smaller inner diameter (DiFiore, 2005). Number of lumens • Single- or dual-lumen devices are available. A meta-analysis of 15 published • A dual-lumen device is appropriate for an infant studies concluded that multilu- receiving total parenteral nutrition, multiple medi- men central venous catheters may cations, or volume resuscitation. be associated with a slightly higher Size risk of infection when compared • Determining factors include the infant’s weight, with single-lumen catheters; how- the size of the vein, the type of fluids to be infused, ever, this relationship diminishes rate of infusion, and the need for blood sampling when only high-quality studies or administration. that control for patient differences • Place the smallest size catheter that will meet the are considered. The slight increase infant’s needs (INS, 2006). in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters (Dezfulian, Lavelle, Nallamothu, Kaufman, & Saint, 2003).

Peripherally Inserted Central Catheters 21 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments Presence of stylet • Stylets provide additional body to the catheter to Stylets have been used in neonatal facilitate insertion. PICCs for more than 20 years and • Stylets are increasingly available in polyurethane are standard in pediatric and adult and silicone catheters (DiFiore, 2005; Tingey, PICCs without substantiated risk 2000). of an increase in morbidity or mortality (Catudal, 1999; Loughran, Edwards, & McClure, 1992). 7. Select the preferred style of Break-away needles may be smaller than cannula-style The insertion technique for a introducer. devices and may facilitate entry into smaller vessels with less break-away needle is similar to Some manufacturers offer trauma. that for a butterfly needle. There a choice for use with their is a risk of catheter damage if this catheters. device is used inappropriately. Current choices from manu- A peel-away cannula is more like a facturers include peel-away traditional IV catheter, and nurses cannulas, break-away needles, or are comfortable with the insertion butterfly needle. technique. There may be less risk of Safety-engineered introducers catheter shearing with this device. should be used to prevent needle- stick injuries and exposure to blood-borne pathogens if offered by the manufacturer (INS, 2006) 8. Manage pain. Provide developmen- PICC insertion causes pain. Infants requiring a PICC often Medication should be administered tally supportive care throughout the are unstable and easily agitated. Movement of the infant and its effectiveness ensured before procedure. Use swaddling, pacifiers, during the cannulation procedure can lead to unsuccessful the procedure begins. Monitor for and visual stimulation as appropri- venipuncture or catheter damage. respiratory depression and other ate (Walden, 2001). side effects. Document procedural The infant needs to remain quiet when using the modified sedation per hospital policy. Topical Consider premedicating the infant Seldinger technique to prevent catheter and vein damage. anesthetics can cause vasocon- with an analgesic. Topical anesthe- striction in a small percentage of sia (e.g., EMLA or LMX4 creams) Parents or a caregiver may soothe the infant during the patients. may be appropriate for some procedure. infants (Walden, 2001). 9. Apply hair covering and mask. 10. Perform hand hygiene, using an alcohol-based waterless cleanser or antimicrobial soap and water. 11. Open equipment and prepare Creating a large sterile field reduces the risk of contamina- Restrict traffic near the ster- a sterile field. tion of supplies and allows the inserter adequate space to ile field to reduce the risk of work. contamination.

Peripherally Inserted Central Catheters 22 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 12. Perform hand hygiene, then don Maximal sterile barrier precautions, including the use of It is preferable to use powder-free sterile gown and gloves. hair covering, face mask, sterile gown and gloves, and large gloves to reduce the potential for sterile drapes have been shown to reduce the risk of infec- reactions. Rinsing powder-contain- tion by six to seven times over the use of sterile gloves and ing gloves is not acceptable due to drapes alone (CDC, 2002a; Maki, 1994; Raad et al., 1994). clumping of residual powder.

Latex-containing gloves may lead to latex reactions in infants (NANN, 2003).

Consider using goggles. Standard precautions protect the caregiver against infec- There is minimal splashing of tious exposure from the patient. blood when breaking the insertion device in the small catheters. 13. Prepare the catheter. Flush catheter. This step removes air from the internal lumen before • Attach a 5–10-ml syringe, per insertion. the manufacturer’s recommendation, to the catheter and flush. • Flushing is required for catheters containing a hydrophilic-coated stylet in order to retract and remove the stylet. • This step cannot be performed with all catheters, depending on their configuration.

Trim catheter Theoretic benefits of trimming excess catheter include the FDA (1994) guidelines state that • Excess catheter length can following: the trimmed tip should be squarely be trimmed to the measured • facilitating assessment of the external portion of (not bevel) cut and should closely insertion length if allowed by catheter to ensure the same amount is present as approximate the original tip. manufacturer. was left external upon insertion • Follow manufacturer’s direc- • decreasing the risk of catheter migration Manufacturers fashion the catheter tions for trimming, including tip by cutting with a blade. This use of scissors, scalpel, or cut- • decreasing resistance to flow within the catheter may result in a straight or slightly ting blade. • decreasing potential damage to the external portion irregular cut surface (Pettit, 2006) of the catheter • creating a smoother catheter tip on some catheters, dependent upon method Potential risks of trimming the catheter include Whereas the method of trimming • trimming too short (scissors, scalpel blade, or cutting • creating an irregular catheter tip depending upon tool) may alter the smoothness of catheter and trimming method catheter tip, data linking this to • presence of fragments remaining on trimmed end a patient complication, such as (Trotter, 2004) phlebitis or thrombosis, are lack- ing (Parvez, Parmar, & Chan, 2004; Pettit, 2006; Trotter, 2004)

Peripherally Inserted Central Catheters 23 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments Stylet management Flexible stylets facilitate threading of the catheter; can The concern that stylets may • If a stylet is used, it should increase success in threading into the vena cava; and reduce increase the risk of phlebitis or be retracted 0.5–1 cm from the risk of coiling, reversing direction, or catheter shearing vascular perforation is not sup- the catheter tip and secured with a break-away needle (Catudal, 1999). ported by available data (Catudal, to ensure that it remains 1999; Loughran et al., 1992). within the lumen of the If the stylet has been trimmed in catheter. error, catheter damage can occur • Stylets should never be and a new catheter should be used. trimmed or allowed to extend beyond the catheter tip. 14. Position the patient and Abducting the arm makes the venous course straighter and restrain as needed. facilitates entry into the axillary and subclavian veins. Turn- Arm insertion: Abduct the arm ing the head narrows the angle between the jugular and to a 90° angle, with the patient’s subclavian veins, making it difficult for the catheter to enter head turned toward the arm. the jugular vein. Axillary vein insertion: Abduct the arm 100°–130° or place the infant’s hand by the head and puncture parallel and inferior to the artery. Femoral vein insertion: Position the infant “frog legged”; insert the introducer at a 30° angle 1 cm below the inguinal ligament and 5 mm medial to the femoral pulse (Abdulla et al., 1990). 15. Tape the extremity, as need- Fixing the extremity to a limb board can help stabilize the Prestabilizing the extremity can ed, to a limb board to prevent vessel and decrease patient movement. make adequate prepping difficult excessive movement during the and increase the risk of infection. insertion. 16. Prep the insertion site and A large prepped area reduces the risk of contamination. PI and CHG have been shown to surrounding skin with chlorhex- The hand or foot may be wrapped in sterile gauze or glove cause local skin reactions in some idine gluconate (CHG) or and a large portion of the extremity prepped. This meth- neonates and PI has been linked povidone iodine (PI) per facility od of prepping provides access to a larger portion of the to systemic effects (Branemark & prococol (CDC, 2002b; Clark et extremity, reducing the incidence of contamination, and Ekholm, 1967; Lineaweaver et al., al., 2004; Linder et al., 2004). allows entry into alternate sites without reprepping if the 1985). CHG (alcoholic and aque- original insertion attempt is unsuccessful. ous formulations) should be used with caution in very-low-birthweight infants due to reports of skin erythema and breakdown (Andersen, Hart, Vemgal, & Har- rison, 2005). Povidone Iodine PI should be removed from the skin Begin at the insertion site and after the procedure to prevent tissue prep in a circular motion for 30 damage, absorption, and thyroid seconds and allow to dry at least suppression (AWHONN & NANN, 2 minutes. 2001; Linder et al., 1997; Parravi- cini et al., 1996).

Peripherally Inserted Central Catheters 24 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments Chlorhexidine Gluconate There are many products containing CHG available with There is no evidence of sustained Apply the solution by moving the aqueous or alcohol bases and containing different concen- toxicity with CHG remaining on applicator using a back-and-forth trations of CHG. One neonatal study compared 0.5% CHG the skin, although the aqueous for- and side-to-side motion for 30 in 70% alcohol to 10% PI on peripheral intravenous sites mulation needs to be removed due seconds and allow to dry (at least and noted less skin colonization with use of CHG (Garland to its soapy consistency to allow 30 seconds) (Medi-Flex, 2007). et al., 1995). the dressing to adhere (AWHONN & NANN, 2001; Malathi, Mill- Change gloves if contamination er, Leeming, Hedges, & Marlow, occurs. 1993; Mullany, Darmstadt, & Tiel- sch, 2006).

Trace serum levels have been detected following bathing and umbilical cord care with 1% or 2% chlorhexidine, particularly in preterm newborns. Potential for absorption may be reduced with aqueous formulation (Mullany et al., 2006). Studies have utilized a variety of concentrations for multiple interventions and tens of thousands of neonates worldwide have received CHG for umbilical cord care, bathing, and maternal vaginal lavage prior to birth without reported adverse effects (Mullany et al., 2006). 17. Place a sterile drape underneath This step provides a large sterile field to prevent the catheter and above the insertion area. or supplies from becoming contaminated and is a compo- Cover as much of the infant as nent of maximum sterile barrier precautions (CDC, 2002b) can be safely done while ensuring the ability of adequate observation. 18. Apply a sterile tourniquet (for This step is performed to dilate the vessel to enhance If the tourniquet is placed on an an extremity insertion). For insertion. Large veins may not require a tourniquet for unprepped area of the extremity, insertion into a scalp or axillary insertion. apply a new pair of sterile gloves. vein, apply digital pressure prox- Monitor the extremity to prevent imal to the insertion site. arterial occlusion from a restrictive tourniquet.

Peripherally Inserted Central Catheters 25 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 19. Insert the introducer bevel up at Blood return may not be visible with some introducers. If a 15°–30° angle into the skin you think you have cannulated the vein, try advancing the a few millimeters before antici- catheter. pated entry into the vein.

Hold the skin taut below the level of insertion to prevent the vein from rolling. A 30° angle is recommended for insertion into the femoral vein (Abdulla et al., 1990).

20. Observe for blood return. When A blood return usually is obtained due to the large size of A vein can be cannulated without the vessel is cannulated, a blood the introducer, but it may be absent in some infants and in blood return. Observe the color, return may be observed or a low perfusion states. Sometimes it is not evident until the speed of flow, and pulsation of “pop” may be felt. catheter is advanced. blood to detect arterial cannu- When the blood returns, lower the lation. If in doubt, obtaining a introducer until it is parallel with blood gas through the catheter may the skin, and gently insert it a few be helpful. Additionally, contrast millimeters farther to ensure that injection or ultrasound may be the entire bevel is within the vein. definitive. 21. Remove the tourniquet after Tourniquets distend the vein and when removed the vein Removal of the tourniquet may the introducer is well within contracts. If the introducer tip is not entirely within the cause some infants to move and the vein and blood return is lumen or close to the wall it may retract with tourniquet may cause the introducer and cath- evident. removal leading to extravascular placement. eter to become dislodged. 22. Using nontoothed forceps, Slow, controlled insertion can prevent venous irritation thread the catheter through the and the development of phlebitis (Hadaway, 1998). It also introducer needle in 0.5–1-cm allows the catheter to float into the central circulation with increments to the premeasured the flow of blood. To minimize trauma to the vessel, thread- length. ing the catheter should take at least 30–60 seconds. 23. To facilitate insertion, flush Flushing may help the catheter advance past obstructions There is little benefit to flushing a with saline or heparinized and valves in veins. It can be attempted when the catheter is catheter containing a stylet because saline while threading the cath- within the vein and appears to be stuck. only minimal flow can be achieved. eter if obstruction is realized. 24. Remove the introducer. Apply Digital pressure over the vein prevents the catheter from Applying pressure too close to the digital pressure to the vein of being withdrawn with the introducer. The introducer needs tip of the introducer may cause insertion a few centimeters above to be away from the insertion site to be removed from the catheter damage. Keep the intro- the tip of the introducer to hold catheter. ducer parallel to the catheter to the catheter in position, and prevent catheter damage. slowly remove the introducer until it is outside the skin several centimeters. Alternatively, hold the catheter in place with forceps while withdrawing the introducer. Initially, hold behind the introducer and then switch to close the skin as soon as the introducer is removed.

Peripherally Inserted Central Catheters 26 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 25. Release the break-away needle This step removes the introducer from the catheter and Prevent catheter damage by keep- or peel-away cannula per the allows the required length of catheter to be inserted. ing the introducer and catheter manufacturer’s guidelines. parallel. 26. Apply pressure to the puncture Bleeding can persist for several minutes due to the large size Persistent, difficult-to-control site until the bleeding stops. of the insertion device and the smaller size of the catheter. bleeding is unusual. In such cases, coagulopathy or arterial puncture should be considered. 27. Ensure that the catheter is at The catheter may slip out slightly during removal of the the premeasured length. Adjust introducer. Reinsert it as needed. as necessary. 28. If a stylet is present, remove it Rapid removal can lead to catheter damage. If the catheter bunches or ripples slowly over a period of 30–60 near the insertion site, it is neces- seconds. sary to slow down. If the stylet cannot be removed (possibly due to a curve in the vein), the catheter can be pulled back 1 cm and removal attempted. If a hydrophilic-coated stylet is in place, the catheter must be flushed to activate the lubricant before the stylet is removed. 29. Aspirate for a blood return Blood return indicates vascular placement. Lack of blood Radiographic verification may and flush the catheter. If blood return or inability to flush may indicate malposition. assist in identifying tip location, return is not present, withdraw which may provide guidance to the catheter slightly and aspi- repositioning efforts. rate. Continue this maneuver until a blood return is present or the catheter is pulled back to the extremity or scalp. Attempt to reinsert the catheter to the premeasured depth. 30. Attach the luer-lock extension Extension sets applied at the time of insertion may be All connections should contain set, if an integrated extension considered part of the catheter and not routinely changed luer locks to prevent inadvertent set is not part of the catheter (CDC, 2002b). disconnection, with the poten- design. tial for embolus, hemorrhage, or occlusion. Extension sets prevent stress to the catheter hub from repeated disconnection or IV tubing changes. 31. Temporarily secure the catheter The catheter is lightly secured until radiographic verifica- Maintain the sterile field while to the skin with sterile tape or tion of the tip position. Temporary taping prevents having waiting for verification of tip skin-closure tape. to remove the dressing (and risking skin damage) to reposi- location. If an X ray cannot be tion the catheter if necessary. Allowing tape or skin-closure performed in a timely fashion, con- tape to remain on the catheter over time has been linked to sider applying the dressing. catheter damage (Frey, 1999). The infant and the catheter should be carefully monitored until the catheter is dressed.

Peripherally Inserted Central Catheters 27 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 32. Keep the catheter patent by Catheters with small internal lumens (27 and 28 gauge) Maintain sterility during flushing. flushing it intermittently with are more prone to clot without frequent flushing or use of a 0.5 ml flush solution in a 5–10- positive or neutral displacement device prior to the infusion Pulsatile flushing has been anec- ml syringe; or attach a positive of fluids. dotally described as a method of or neutral displacement device enhancing catheter patency. until the position is verified. Refer to the manufacturer’s recommendations for minimum Flush using a pulsatile (short syringe size that can be safely used. bursts or start-stop) technique.

33. Verify the location of the cathe- Radiographic or another imaging modality is required Positioning the infant for the inserter tip with a chest radiograph. for verification of the catheter-tip location (FDA, 1989; tion and subsequent X rays to verify If the insertion site is in the arm, NAVAN, 1998). catheter tip location should be include a portion of the upper consistent to prevent misinterpreta- arm and neck. If it is in a lower Tips for enhancing tip visualization tion of catheter migration due to extremity, include the abdomen. • Positioning the infant for a lateral oblique view of positioning. For scalp insertion, include the the chest (right side elevated at a 10°–15° angle) skull. The catheter tip must be can enhance visualization of the catheter because There is little data to suggest the adequately visualized before the the PICC is not superimposed over the mediastinal optimal position to place the infant catheter is used. structures. This technique has been credited with in for the X ray. Suggestions for enhancing agreement among physicians on catheter infant and catheter tip positiong tip location when compared to the anterior-pos- include terior view in adults (Harako, Nguyen, & Cohen, • Positioning the infant in a man- 2004) ner that would make the catheter • Overpenetrating the radiograph can allow better at its deepest location or plac- visualization of the catheter. If using computed ing the infant in the position that radiography, adjust the contrast or use the invert is most likely to be maintained feature. during the infant’s day (Nadroo, Glass, Lin, Green, & Holzman, • To determine whether the catheter has coiled within 2002). the peripheral or central veins, the part of the vein near the insertion site can be included in the radio- • Positioning the infant for the post graphic assessment. insertion X ray to allow maximal • A lateral X ray may be beneficial in locating the inward movement of the catheter catheter tip, particularly if malpositioning is sus- (Nadroo et al., 2002). pected based on the AP view or clinical findings (Coit & Kamitsuka, 2005; Royer, 2001; Stark, • Maintaining the catheter tip 1 cm Brasch, & Gooding, 1984). outside the cardiac reflection in a premature infant and 2 cm in a term infant has been suggested (Nowlen, Rosenthal, Johnson, Tom, & Vargo, 2002).

Peripherally Inserted Central Catheters 28 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments PICC catheters are radiopaque, Many catheters contain enough barium or bismuth for The contrast medium should be but some, depending on manufac- visualization without additional contrast enhancement. injected slowly, instilling enough to turer and size, may be difficult to Contrast media can be instilled if the catheter tip cannot be slightly overfill the catheter. The X see on radiograph and require the adequately visualized without them. Certain water-soluble, ray can be taken after 3–5 seconds. instillation of additional contrast nonionic contrast solutions may not cause tissue damage This allows time for the blood- (Odd, Page, Battin, & Harding, if the catheter tip is extravascular. However, some contrast stream to wash excess contrast away 2004). Catheters are difficult to solutions do, and they should be checked carefully before from the catheter tip so that the tip visualize in infants with opacified instillation. can be accurately identified. With- lungs. Water-soluble, nonionic con- draw the contrast after the X ray. trast media may be used to enhance catheter visualization. Suggestions supporting routine use of contrast to visualize the catheter tip focused on lack of visibility and were brand specific and cannot be applied to all catheters due to individualized radiopaque properties (Cartwright, 2004; Odd et al., 2004; Reece, Ubhi, Craig, & Newell, 2001). There is a lack of agreement to support the use of contrast as a routine measure and the use of contrast does not guarantee precise localization of a catheter tip in all situations (Bagchi, Nycyk, & Bodic- oat, 2002; Odd et al., 2004).

1 34. Place the catheter tip in the SVC A catheter tip in the lower /3 of the SVC lies parallel to Placement in the right atrium is or thoracic IVC (FDA, 1989; the vessel wall, so the risk of thrombosis and infection against manufacturers’ recommen- INS, 1997a, 2006; NAVAN, is reduced (NAVAN, 1998). The SVC is much shorter in dations for use. The FDA (1989) 1 1998). This position has been neonates than in adults, so identifying the lower /3 is chal- states that only pulmonary artery described as the T3–T5 level, but lenging. Outside the vena cava, the catheter tip is subjected catheters should be left in the it varies depending on radio- to smaller diameter vessels, curvature of the vein, and heart due to the risk of dysrhyth- graphic technique and infant venous valves; these increase the likelihood of the catheter’s mias, perforation, tamponade, and anatomy. Both the INS and AVA contacting and damaging the vessel wall. Chemical irrita- death. Catheter tip locations in the 1 recommend the lower ½– /3 of tion (caused by the infused fluid or medication) is more brachiocephalic and subclavian the SVC as the ideal tip location likely in these smaller diameter veins. Exposure of the sub- veins are not considered central, for upper body insertions. Dif- endothelial layer of the vein due to mechanical or chemical due to the decreased diameter and ficulty in defining this location irritation can lead to thrombosis, thrombophlebitis, and lack of laminar blood flow in these and the risk of the complications infection (Hadaway, 1998; Kearns et al., 1996; Racadio veins and increased risk of com- related to the catheter migrat- et al., 2001). A 60% rate of subclinical thrombosis of the plications (INS, 1997a; NAVAN, ing in the right atrium in infants axillary, subclavian, and brachiocephalic veins has been seen 1998; Racadio et al., 2001). have led to the more general SVC with catheter tips residing in these veins in adults (Kearns et location.The appropriate IVC tip al.). In a small study of pediatric patients, Stringer and col- placement is not well defined, but leagues (1992) found a slightly shorter survival time and a current data suggest a tip loca- 15% incidence of thrombophlebitis when catheter tips were tion between the right atrium and in the brachiocephalic and subclavian veins rather than the the diaphragm, described as T8– vena cava. They recommended elective replacement of these T10 (Racadio et al., 2001; Serrao catheters after 10 days. et al., 1996). The catheter should lie parallel to the vessel wall. 35. Reposition the catheter, if If a sterile technique has been maintained and repositioning Verify the new catheter tip location necessary. can be accomplished in an efficient manner, the catheter can by radiographic means after all be advanced if necessary. Otherwise, the catheter may only repositioning efforts. be withdrawn to reposition it.

Peripherally Inserted Central Catheters 29 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments 36. Remove PI and aqueous CHG skin PI can be absorbed through the skin, leading to elevation of prep with sterile water or saline iodine levels and hypothyroidism (Linder et al., 1997; Parravi- (AWHONN & NANN, 2001). cini et al., 1996). The formulation of aqueous CHG prevents adherence of dressings if not removed. There is currently no data to support removal of CHG contained in an alcohol base. 37. Secure the catheter to the skin. The dressing is intended to secure the catheter to the skin Attempt to stop bleeding prior to A slight curve should be placed and reduce the potential for infection. One study in neo- dressing to decrease blood remain- in the catheter as it exits the skin nates supported the use of semipermeable transparent ing on the skin, which serves as a to prevent applied tension from dressings for this purpose (Zenk et al., 1993). medium for bacterial growth. causing outward migration or allowing inward migration with Dress in a manner that promotes movement. visualization of the catheter and insertion site to facilitate assessment and promote catheter security. Some manufacturers have specific recommendations for securing their catheter. Tape or skin-closure tape applied directly on the catheter tubing have been reported to cause catheter damage (Frey, 1999). Secure to allow visualization of amount of catheter external to infant and the insertion site (Pettit, 2002). If several centimeters of catheter are external, place the curve as directed above and coil catheter while preventing kinks or bends in the catheter.

Securement devices are available for some PICCs. Sterile skin barriers made of Prevention of skin damage is critical to prevention of hydrocolloid can be placed under infection. the catheter hub to prevent skin breakdown from contact with a rigid catheter hub or T-connector. The catheter hub should be Catheter securement depends on adequate fixation of the secured to the infant using the device to the patient. method described by the manufacturer. If not specified, adhere hub or disk to the skin with sterile tape or skin-closure strips.

Extension sets (i.e., T-connector) should be attached to the skin with tape to prevent catheter dislodgement.

Peripherally Inserted Central Catheters 30 Table 1. Procedure for PICC Insertion in an Infant (continued) Step Considerations Precautions/Comments Apply the dressing to the cath- There are a variety of transparent dressings. Those shown The dressing should not be com- eter and hub. The choice of to be superior have the ability to keep the skin drier by pletely wrapped around the dressings includes transparent allowing more moisture vapor to pass. They are more com- extremity, as this may lead to semipermeable or gauze and fortable and allow visualization of the insertion site. venous stasis and edema. tape. The dressing should cover the insertion site, catheter, and Gauze or impermeable tape placed under or on top of this Accumulation of moisture or hub of the extension set, if this dressing creates a gauze-and-tape dressing. Although pre- blood on the skin may increase col- is a separate device. ferred by some, they are bulky, prevent visualization of the onization of microorganisms. insertion site and catheter, and may require more frequent manipulation of the dressing to check the insertion site Infants who have oozing of tis- and require routine changing. sue fluid or persistent bleeding are at risk for catheter migration. Antimicrobial ointments should not be applied to the For persistent bleeding, a topical insertion site (CDC, 2002b). hemostatic agent (e.g., Surgicel®, Gelfoam®) may be placed under the dressing. Hydrocolloid or karaya wafers may be placed under the dressing of infants who have oozing from the skin, and the catheter and dressing placed on top. 38. Document the procedure on the A formal procedure note should be prepared. The bedside Initiation of a data collection tool medical record. The following caregivers should have immediate access to this information for outcome monitoring is recom- should be recorded: to allow assessment of catheter tip placement and monitor- mended following each insertion. • indication ing for complications. Responsibility should be assigned • consent and parent education for ongoing monitoring of each • patient identification PICC at least daily for the need to • skin prep solution remain indwelling. Each shift the • vein of insertion catheter should be evaluated for • brand, type, size, number of signs of malfunction and the integ- lumens, and lot number rity of the dressing and cleanliness • initial length of catheter (i.e., of the site. length trimmed, inserted, and external) • style and size of introducer • presence of stylet • radiographic location of catheter tip • type of dressing used • infant’s tolerance of procedure • number of attempts at cannulation • complications encountered • procedural medications administered with therapeutic response • MST specifics • Imaging technology used for insertion • Catheter tip location verified radiographically • Name of clinician performing procedure

Peripherally Inserted Central Catheters 31 Use of modified Seldinger technique (MST) • Catheters inserted into the scalp can enter intracra- and poor peripheral venous access nial veins or tissue and thoracic veins (Anderson, Some infants have veins that are difficult to can- Graupman, Hall, Sweeny, & Lam, 2004). nulate, making the traditional methods of insertion Identification challenging. Although alternative techniques have Suspect a malposition if been used in older patient populations, they are rela- • the catheter is difficult to thread or won’t thread to tively new in the NICU. Using the following technique the premeasured depth (Aladangady, Roy, & Cos- requires training and practice protocols, and in some teloe, 2005; Baker & Imong, 2002) states it requires approval of the facility and state • a blood return is not easily obtained boards of nursing. • the catheter flushes with resistance Using an MST (also referred to as micropuncture) • the stylet is difficult to remove or is bent upon allows a smaller introducer to be used (Frey, 2002). A removal. small gauge, short PIV catheter is initiated following An X ray may provide definitive evidence that a strict sterile technique as set up for the PICC place- catheter is malpositioned. ment. Following cannulation, the needle is removed and a short guidewire is inserted a few centimeters Management beyond the tip of the PIV while remaining in the Techniques for successfully repositioning a malposi- peripheral circulation. The peripheral catheter is tioned catheter include the following: removed over the wire. • Repositioning or partially withdrawing the catheter After the skin is anesthetized, a small nick is made and attempting to reinsert it (done only at the time to allow the introducer to be inserted. The PICC of insertion and requires sterile technique to have introducer or a larger sheath or sheath dilator is been maintained). To prevent catheter shearing, inserted over the guidewire. Once in place, the guide- the catheter must not be withdrawn until the needle wire and dilator (if used) are removed. The PICC is introducer is removed. placed through the introducer/sheath and advanced • Using the MST to incorporate a guidewire ex- into the proper position. The introducer/sheath is change and facilitate appropriate positioning. separated and removed (Frey, 2002; Pettit, 2007; Ste- Alternatively, a catheter exchange procedure phenson & Khan, 1993; Valk, Liem, & Geven, 1995). through a cannula-style introducer has been de- Using ultrasound technology in combination with the scribed (Pettit, 2007). MST can improve the chances of achieving venous • Using patient repositioning maneuvers (Nadroo et access in patients and decreasing pain and should be al., 2002) considered. – For basilic vein insertions with the catheter tip in the jugular vein, abduct the arm at the shoulder Malposition of catheter and extend the elbow as far as possible to pull the When the PICC does not terminate in the appropri- catheter into a more peripheral location. Follow ate location within the vena cava it is considered to be these maneuvers by adducting the arm and malpositioned. flexing the elbow to reinsert the catheter. Etiology – For cephalic vein insertions with the catheter • vein used for catheter insertion tip in the axillary vein, adduct the arm and • insertion technique, particularly rapid threading of extend the elbow as far as possible to withdraw the catheter the catheter into a more peripheral location. • venous anatomy Abducting the arm and flexing the elbow will reinsert the catheter. Location of malposition • Repositioning the patient to allow gravity and • Catheters inserted into the basilic vein most com- blood flow to help the catheter travel to the supe- monly are malpositioned into the internal jugular rior vena cava (James et al., 1993) vein. – Raise the head of the bed (if the catheter is in the • Catheters inserted into the cephalic vein most internal jugular vein) (Lum & Soski, 1989). commonly are malpositioned into the axillary and – Place the infant on the ipsilateral side with the basilic veins. head of the bed elevated (if the catheter has • Catheters inserted through the saphenous or other entered the contralateral brachiocephalic vein) leg veins (particularly on the left side) may enter (Lum & Soski, 1989). the ascending lumbar vein (Clarke, Wadhawan, Smyth, & Emmerson, 2003; De & Imam, 2005). Peripherally Inserted Central Catheters 32 – Catheters that are curled back into the axillary • Excessive bleeding can be caused by an inadvertent vein can flow to the superior vena cava if the arterial puncture. Differentiate the vein from the infant is placed on the contralateral side with the artery before attempting the insertion. head of the bed elevated (Lum & Soski, 1989). • If oozing or bleeding persists, investigate the cause • If the PICC is looped back on itself and is in a deep (i.e., vigorous movement of extremity, coagulopathy). vein (e.g., subclavian, jugular), or is in a large vein such as the internal jugular vein, it can enter the Postinsertion Complications superior vena cava with fluid infusion, gravity, and The incidence of major complications associated the aid of venous return to the heart (Frey, 1995; with PICC use is low. The majority of catheters Lum & Soski, 1989; Tawil, Eldemerdash, Hathlol, & are removed electively at the conclusion of therapy Laimoun, 2006). (Cartwright, 2004; Evans & Lentsch, 1999; Linck • Gentle flushing through the catheter has been anec- et al., 2007). A variety of complications have been dotally described as facilitating repositioning. associated with PICCs and there is an increased risk Further considerations may include of complications in units where the procedure is • repeating X rays within 24 hours to assess catheter performed infrequently (Garden & Laussen, 2004). position. A reduction in complications was noted when the • infusing the line with fluids that can be given in a procedures for insertion and catheter care were stan- PIV or heparin locked until it is properly positioned dardized and nurses became more experienced in to avoid vascular injury. Achieving maintenance rate inserting and maintaining the catheters (Rourke & to the infusion may be beneficial in catheter reposi- Higgins, 1998; Sherrod et al., 2005). Compliance with tioning (Tawil et al., 2006). central line policy and care regimen was positively • discontinuing using the catheter if its position is not linked to a specialized education program (East & appropriate (Tawil et al., 2006). Jacoby, 2005). Although most complications are minor and eas- Prevention ily treated, some can be life threatening and require • Select a vein for insertion knowing risks of mal- prompt action. Mechanical problems, including occlu- position. sion, leaking, and dislodgment, along with infection • Position the infant to facilitate successful insertion. are the most commonly identified complications. (Refer to positioning the infant in “Insertion Pro- Many case reports of infection, however, do not cedure.”) distinguish the catheter as the source of the infec- • Insert the PICC slowly, allowing the blood return- tion (Trotter, 1996). Complications can be related to ing to the heart to carry the catheter with it to the insertion technique, routine care and maintenance vena cava. procedures, or patient-specific problems (Pettit, 2002, Bleeding 2003a). Serious complications often are related to Oozing from the insertion site is common during improper catheter tip location (Cartwright, 2004; De the 24 hours after insertion because of the large size & Imam, 2005; Nowlen et al., 2002). The complica- of the insertion device. tions encountered most commonly or associated with • Apply pressure on the puncture site for at least 5 serious sequelae are addressed here. minutes following insertion and until bleeding has Catheter-related bloodstream infection or stopped. catheter-associated bloodstream infection • A sterile piece of gauze can be applied under the A catheter-related bloodstream infection (CRBSI) is dressing to the side of the catheter to wick blood defined as “bacteremia or fungemia in a patient who away from the site. Placing gauze under the dress- has an intravascular device and ≥1 positive result of ing can contribute to moisture accumulation and culture of blood samples obtained from the periph- therefore requires a dressing change within 48 eral vein, clinical manifestations of infection (e.g., hours (INS, 2006). fever, chills, hypotension), and no apparent source • If there is persistent oozing, a hemostatic agent for bloodstream infection (with the exception of the (e.g., Surgicel®, Gelfoam®) can be applied under catheter). One of the following should be present: a the dressing to promote adherence and to prevent positive result of semiquantitative (≥15 cfu per cath- catheter migration. eter segment) or quantitative (≥10² cfu per catheter Prevention segment) catheter culture, whereby the same organism • Use the smallest introducer available to minimize (species and antibiogram) is isolated from a catheter the size of the insertion hole. segment and a peripheral blood sample; simultaneous

Peripherally Inserted Central Catheters 33 quantitative cultures of blood samples with a ratio of Risk factors greater than 5:1 (CVC versus peripheral); differential Premature infants, particularly those with a birth- time to positivity (i.e., a positive result of culture from weight <1,000 g, are at higher risk of infection a CVC is obtained at least 2 hours earlier than a posi- because of deficiencies in their host defense mecha- tive result of culture from peripheral blood” (CDC, nisms and the number of invasive procedures to which 2002b; Mermel et al., 2001). they typically are subjected. Additional risks for The term catheter-associated bloodstream infection CRBSI may include (CABSI) is intended as a surveillance definition for • PICC insertion or care by relatively inexperienced use in benchmarking performance and directing qual- staff (Puntis et al., 1991; Sherrod et al., 2005) ity improvement activities (Ryder, 2005). • catheter repair (Golombek et al., 2002; Neubauer, Sepsis appears to be the most consistently reported 1995) serious problem associated with PICCs. The incidence • multiple manipulations of catheter (Neubauer, figures of CRBSI reported in the literature vary due 1995) to inconsistent use of diagnostic criteria and reporting • contamination of the catheter hub (Salzman et al., (Trotter, 1996). Comparing rates is difficult because 1993; Sitges-Serra et al., 1997) of inconsistencies in the definition of CRBSI; the • long catheter dwell time (i.e., >3–6 weeks) (Chathas insertion, care, and maintenance procedures; and the et al., 1990; Golombek et al., 2002). population of infants included. Treatment A retrospective study of infants matched by birth- There are no controlled clinical trials to provide weight and admission date concluded that PICCs do data about the appropriate management of CRBSI not lead to a greater number of CRBSIs than PIVs in infants (Mermel et al., 2001). Controversy exists (Parellada, Moise, Hegemier, & Gest, 1999). These regarding treatment decisions with infants who data have been confirmed in a randomized, compara- require vascular access devices to survive. Based on a tive trial of very-low-birthweight infants (Janes et al., retrospective review of infants who had a variety of 2000). Equal numbers of infants developed bactere- CVCs and developed bacteremia without an identi- mia in the group with a PICC and the group with a fied source, removing the PICC with a CRBSI of PIV. More recently, infants weighing <1,000 g were Gram-negative rods, Staphylococcus aureus, or Can- matched by weight, gestational age, gender, and Clini- dida could improve a patient’s outcome (Benjamin et cal Risk Index for Babies (CRIB) scores to evaluate al., 2001; Karlowicz, Hashimoto, Kelly, & Buescher, success during insertion and short- and long-term 2000). Successfully treating infants having four or catheter complications (Liossis, Bardin, & Papageor- more positive blood cultures for coagulase negative giou, 2003). Infants in the treatment group received Staphylococcus without removing the CVC is unlikely IV fluids and medications via a PICC while the con- (Karlowicz, Furigay, Croitoru, & Buescher, 2002). trol group was managed with PIVs. Placement of a The literature reports that the following are alterna- PICC was successful in the majority of cases and car- tives to be used based on a case-by-case assessment of ried a significantly lower risk of infection than those each infant: infants in the control group managed with PIVs. • Treat the infection with antimicrobials through the Etiology catheter and repeat a blood culture after 48 hours. CRBSI is an inherent risk with the use of any If it is positive, consider removing the catheter vascular access device. This multifactorial nature (Klein & Shahrivar, 1992; Maki & Crnich, 2003; of infection can be due to migration of skin flora Ramanathan & Durand, 1987). from the insertion site along the catheter tract and • Discontinue the catheter without attempting to colonization of the catheter (CDC, 2002b). Other clear the infection (there is the potential for in- mechanisms of catheter colonization include con- effective treatment when attempting in situ tamination of the catheter hub, contamination of the therapy, especially with systemic fungal infections) catheter at the time of insertion, administration of (Maki & Crnich, 2003). A new catheter often can contaminated infusates, and hematogenous seeding be placed, if necessary, after 24–48 hours of effec- of the catheter from a distant site of infection (CDC, tive therapy. 2002b; Salzman, Isenberg, Shapiro, Lipsitz, & Rubin, Prevention 1993; Sitges-Serra et al., 1997). Recommended strategies for preventing CRBSI include • using a central line bundle, such as that recommended by the Institute for Healthcare Improvement (IHI)

Peripherally Inserted Central Catheters 34 that includes five key components: hand hygiene, Catheter migration maximal barrier precautions upon insertion, Etiology chlorhexidine skin antisepsis, optimal catheter site • In vivo and ex vivo reports commonly document selection, and daily review of line necessity with movement or migration of the catheter at any time prompt removal of unnecessary lines (IHI, 2007). while in situ. • Ensuring staff competency in inserting and main- • The movement of PICCs within the body may taining a catheter (Linck et al., 2007). occur spontaneously or as the result of patient • Limiting the number of staff members who insert movement, as outlined in Table 2. Movement may catheters. cause a catheter shift to a more peripheral or cen- • Using standardized protocols for maintaining tral location (Brandt, Foley, Fink, & Regan, 1970; PICCs (Golombek et al., 2002; Linck et al., 2007; Lang-Jensen, Nielsen, Sorensen, & Jacobsen, 1980; Rourke & Higgins, 1998). Lingenfelter, Guskiewicz, & Munson, 1978; Nad- • Using maximum sterile barrier precautions for roo et al., 2002). catheter insertion and sterile technique for dress- • A catheter can migrate further inside or outside the ing changes (CDC, 2002b; INS, 2006; Maki, 1994; body if the dressing is not secure (Frey, 1999). Raad et al., 1994). • Difficulty in securing external jugular insertions • Practicing appropriate hand hygiene before the cath- has led to increased migration (Goutail-Flaud et eter is inserted and when entering the PICC. al., 1991; Nadroo et al., 2002). • Using PI or CHG for skin disinfection prior to catheter insertion and with dressing change (Anderson et Risk factors al., 2005; AWHONN & NANN, 2001; CDC, 2002b). Patients at higher risk for migration (based on • Dressing the insertion site with a sterile, occlusive ma- reports primarily from adults) include those who terial. If dressing integrity is lost, change the dressing experience the following (Hadaway, 2005; Jacobs & (CDC, 2002b; Zenk et al., 1993). A multidimensional Zaroukian, 1991; Lum & Soski, 1989): strategy to decrease CRBSI that included weekly • increased thoracic pressure dressing changes showed a statistically significant de- • high-frequency ventilation crease in CRBSI (Aly et al., 2005). • frequent vomiting • Eliminating stopcocks from tubing and instead us- • severe coughing ing capped injection ports that must be vigorously • extreme physical activity cleaned with alcohol prior to entry (Bouza et al., • rapid infusion of fluid or forceful flushing. 2003; Casey et al., 2003; Pettit, 2002; Sitges-Serra et Signs and symptoms al., 1997; Yebenes et al., 2004). Catheter migration may be asymptomatic although • Exercising meticulous care when using the catheter or reported symptoms can include changing IV tubing. • pain and irritability based on the catheter location • Minimizing entry into the line. A closed medication and infusate system (entry restricted to once every 24 hours) used • erythema or edema of shoulder, neck, or arm (for as a component of a multidimensional strategy to de- arm-inserted catheters) crease CRBSI was found to significantly decrease the • change in catheter function (difficulty flushing or incidence of CRBSI (Aly et al., 2005). withdrawing) (Hadaway, 1998; Pettit, 2003a) • Providing continuing education and monitoring staff • change in length of external catheter segment compliance with hand hygiene and care regimes. Fol- (Pettit, 2003a) lowing up with subsequent reporting and feedback to • symptoms specific to a particular complication staff (Kilbride et al., 2003). (i.e., dysrhythmias due to catheter migration into • Antibiotic lock strategies have demonstrated a reduc- the heart or pericardial or pleural effusion, which tion in CRBSI in a small clinical trial (Garland, Alex, are described under “Complications”). Henrickson, McAuliffe, & Maki, 2005). • Removing the PICC as soon as a vascular access de- Treatment vice is not required. The optimal time for removing a • Obtain radiographic verification of the catheter tip PICC remains unclear. Previous reports have suggest- location (Pettit, 2003a). ed 3–6 weeks as a common interval between insertion • Refer to strategies identified in “Malposition.” and the appearance of CRBSI (Chathas et al., 1990; • Patient repositioning maneuvers have been shown to Golombek et al., 2002). successfully adjust PICCs in some instances (Nadroo et al., 2002).

Peripherally Inserted Central Catheters 35 – For basilic vein insertions Table 2. Relationship Between Patient Position and Catheter Tip Location with catheter tip in the jugular vein, abduct arm at Catheter Insertion Site Infant Position Resultant Tip the shoulder and extend the Movement elbow as far as possible to Cephalic vein Abduction of arm Inward migration pull the catheter into a more Adduction of arm Outward migration peripheral location. Follow Basilic and axillary veins Abduction of arm Outward migration these maneuvers by adducting the arm and flex the elbow to Adduction of arm Inward migration reinsert the catheter. Antecubital insertion Flexion of arm Inward migration – For cephalic vein insertions Extension of arm Outward migration with catheter tip in the External jugular Full lateral neck flexion Inward migration axillary vein, adduct the arm Catheters traversing neck Neck flexion Inward migration and extend the elbow as far as possible to withdraw the Leg vein insertion Leg flexion Inward migration catheter into a more peripheral Leg extension Outward migration location. Abducting the arm Note. From “Mechanism of perforation of the heart with the production of and flexing the elbow will hydropericardium by a venous catheter and its prevention,” by R. L. Brandt, W. J. Foley, reinsert the catheter. G. H. Fink, and W. J. Regan, 1970, American Journal of Surgery, 119, 311–316; “Primary • Determine whether it is safe to and secondary displacement of central venous catheters,” by T. Lang-Jensen, R. Nielsen, M. B. Sorensen, and E. Jacobsen, 1980, Acta Anasthesiologica Scandinavica, 24, 216– leave the catheter in its current 218; “Displacement of right atrial and endotracheal catheters with neck flexion,” by A. position; doing so may not be ac- L. Lingenfelter, R. A. Guskiewicz, and E. S. Munson, 1978, Anesthesia and Analgesia, ceptable, especially if the patient is 57, 371–373; and “Changes in upper extremity position cause migration of peripherally symptomatic. inserted central catheters in neonates,” by A. M. Nadroo, R. B. Glass, J. Lin, R. S. Green, and I. R. Holzman, 2002, Pediatrics, 110, 131–136. • Consider removing the catheter or performing a catheter exchange if Prevention the tip is outside the appropriate location in the vena Migration may not be preventable due to dynamic cava. Pulling the tip back into an acceptable location forces within the body. Strategies that minimize the and using it as a midline or peripheral IV also may be risk of migration include an option. If the catheter is retracted to a midline tip • maintaining the security of the catheter with intact location only solutions and medications that can safe- dressing (Frey, 1999) ly be infused into a peripheral vein should be used. • verifying the catheter tip location upon insertion, Complications repositioning, and an ongoing basis (FDA, 1989) Complications that can arise from catheter migra- • verifying the position of the extremity or head on tion include the following: radiograph. This can alter the catheter tip position • thrombosis (Racadio et al., 2001) (Nadroo et al., 2002). • dysrhythmias • vascular perforation or extravasation (Pigna, Catheter dislodgement Bachiocco, Fae, & Cuppini, 2004) Inadvertent partial or complete removal of the cath- • myocardial perforation, effusion, tamponade eter from the body is termed catheter dislodgement. (Little, Petty, & Beeram, 2004; Nadroo et al., Etiology 2002). • Loss of secure dressing (Hadaway, 2005) • pleural effusion (Pigna et al., 2004) • Catheters are retracted during a dressing change • neurologic abnormalities (Refer to discussion of (Hadaway, 2005) neurologic complication for symptomatology.) • Excessive bleeding or drainage at the insertion site Adults and children have reported hearing water- prevents catheter securement (Pettit, 2003a) like sounds when catheters migrate into the jugular • Extension set and tubings are not secured to the vein. The infusate may be directed against the flow infant (Frey, 1999) of blood and can allow infusion into smaller veins • Tension placed on catheter and dressing (Pettit, 2003a), or into the intracranial venous sinuses and create particularly excess catheter remaining external (Frey, neurological problems (Hadaway, 2005) 1999) • catheter knotting, looping • pain.

Peripherally Inserted Central Catheters 36 Treatment • If dysrhythmias occur without an identified etiolo- • Radiographically verify tip location to determine gy, verify the catheter tip placement by radiograph safety of leaving catheter indwelling (Pettit, 2003a). or another imaging technique. • Remove catheter or perform a catheter exchange if Prevention new tip location is unsatisfactory (Pettit, 2003a). • Measure the patient to determine the correct Prevention length of the catheter to be inserted. • Maintain the security of the catheter with an intact • Verify and maintain the catheter tip location in the dressing. vena cava and outside the heart. • Consider using specially designed catheter secure- • Maintain a secure dressing to prevent catheter ment devices. migration. • Avoid using ointment under the dressing. Myocardial perforation, effusion, or tamponade • When performing a dressing change, remove the Myocardial perforation occurs anytime during cath- old dressing by pulling toward and not away from eter dwell—the median time of occurrence is 3 days the insertion site. postinsertion. Based on retrospective data, however, • Secure extension tubing to the infant. effusion may occur at any time during catheter dwell Dysrhythmias (Nowlen et al., 2002). This review also identified cath- Atrial and ventricular dysrhythmias can occur if eter tips to be predominantly within the pericardial the catheter enters either chamber of the heart. Pac- silhouette at the time the effusion was identified. Peri- ing tissue may also be present in the lower segment cardial effusion, tamponade, and death can result if of the superior vena cava. the symptoms are not readily identified and the pericardial effusion drained (Cartwright, 2004; Garden & Identification Laussen, 2004). Heightened awareness of this poten- • Monitor the heart rhythm during insertion, and tial complication may decrease mortality (Nowlen et slightly withdraw the catheter if dysrhythmias occur. al.). (See Figure 5.)

Figure 5. Catheter erosion through the myocardium, leading to pericardial effusion Figure 5 ©BD Medical Systems. Used with permission.

Peripherally Inserted Central Catheters 37 Proposed etiologies 1. Stop the infusion of fluid and notify the medical More data are required to determine the precise eti- care provider (Pettit, 2003a). ologies, but those reported include 2. Immediately obtain a chest X ray (which may show • myocardial damage as the catheter tip contacts the a widened mediastinum or enlarged heart, but cardiac muscle with each contraction, becoming not the effusion because the pericardial fluid is a fixed with resultant thrombus or causing a direct similar density to that of the heart) or an echocar- myocardial perforation (Nowlen et al., 2002) diogram and locate the catheter within or near the • osmotic injury due to infusion of hyperosmolar heart. An echocardiogram is the preferred method fluid directly contacting the myocardium leading to because it facilitates viewing the effusion, but it diffusion injury (Nowlen et al., 2002) may not be readily available (Little et al., 2004). • rapid injection of fluid (Nowlen et al., 2002) 3. Attempt to aspirate blood from the catheter while • erosion of catheter through the lower portion of awaiting the imaging study (Little et al., 2004; the superior vena cava just outside the heart and Nowlen et al., 2002). If the aspirate appears con- infusion of fluid into the pericardial space (Collier, sistent with the infusate, continue to aspirate until Blocker, Graff, & Doyle, 1998). as much fluid as possible is removed (Little et al.). If the fluid cannot be retrieved by direct aspiration Risk factors from the catheter, pericardiocentesis may be neces- Factors that can increase the risk include sary. The infant’s condition may require life-saving • catheter tip residing within heart (Nowlen et al., intervention (i.e., pericardiocentesis) before the 2002) radiologic procedure can be accomplished. • catheter angulation, curvature or looping allowing 4. Withdraw the catheter to the appropriate posi- contact with myocardium when catheters reside in tion in the vena cava; removal of the PICC is not the heart (Cartwright, 2004; Darling et al., 2001) required (Nowlen et al., 2002). • displacement of the catheter into the heart due to 5. Follow up with an X ray or ultrasound because movement of the extremity, head, or neck (Lingen- effusion can reoccur (Little et al., 2004). felter et al., 1978; Nadroo et al., 2002) • faulty catheter securement allowing migration Prevention (Pettit, 2003a). To help prevent myocardial perforation, effusion, or tamponade the following steps should be taken: Signs and symptoms • Maintain the catheter tip in the appropriate location Signs and symptoms can vary in severity, with some in the vena cava (FDA, 1989; Nadroo et al., 2002). infants being asymptomatic, and may be due to the • Dress the catheter securely to prevent possible mi- rate and volume of infusion and the size of the infant. gration and trim the catheter to the length required Symptoms may include the following (Little et al., 2004; for the infant to facilitate assessment (Pettit, 2003a). Nadroo & Al-Sowailem, 2001; Nowlen et al., 2002; • Verify during each nursing shift that the correct Schulman, Munshi, Eastman, & Farina, 2002): length of catheter is outside the body (Pettit, 2003a). • tachycardia or bradycardia • Obtain an X ray at periodic intervals to detect • narrow pulse pressure migration (FDA, 1989). Ensure that the extremity • hypotension containing the PICC or head is in the same posi- • muffled heart tones tion with each X ray (Nadroo et al., 2002). • dysrhythmias • weak peripheral pulses Suggested, but unproven, strategies to consider • respiratory distress • Position the infant for the postinsertion X ray to • poor color or extreme pallor allow the maximal inward movement of the cathe- • poor response to resuscitation ter (Nadroo et al., 2002). Refer to the radiographic • resistance to external cardiac compressions assessment of tip location located in the insertion • sudden cardiovascular or respiratory compromise procedure for these strategies. • pulseless electrical activity. • Maintain the catheter tip 1 cm outside the cardiac reflection in a premature infant and 2 cm in a term Identification and treatment infant (Nowlen et al., 2002). Rapid identification and treatment are critical for survival (Schulman et al., 2002). If myocardial perfo- Pleural effusion/hydrothorax ration, effusion, or tamponade are suspected or occur Pleural effusion has been reported when catheter tips the following management strategies should be used: reside in the right atrium, inferior or superior vena cava,

Peripherally Inserted Central Catheters 38 Figure 6. Catheter erosion at the junction of the brachiocephalic vein and the superior vena cava, which may lead to pleural effusion Figure 6 ©BD Medical Systems. Used with permission. braciocephalic and subclavian veins, and a small branch McGettigan & Goldsmith, 1996) of the pulmonary artery. This complication occurs • Superior vena cava thrombosis leading to chylo- infrequently, is typically unilateral, and has been report- thorax (Amodio et al., 1987; Kurekci, Kaye, & ed to occur due to a variety of factors. (See Figure 6.) Koehler, 1998). Etiology Risk factors • Perforation of a central vein during or after cath- • The left brachiocephalic vein inserts into the superior eter insertion (Mupanemunda & Mackanjee, 1992; vena cava at an acute angle. Left-sided insertions in Seguin, 1992) the upper body may place the infant at increased risk • Catheter tip or thrombus blocking the opening of if the catheter does not complete the curve from the the thoracic duct or migrating into the lymphatic brachiocephalic vein to the superior vena cava and vessels, leading to retrograde flow (McDonnell, is left with the tip at this junction. If left in the bra- Qualman, & Hutchins, 1984) chiocephalic vein, the catheter’s movement may allow • Catheter tip against the vessel wall or malposi- contact with the vein wall or the infusate may be di- tioned or migrated into a small vessel and not into rected at the vein wall without the benefit of adequate the vena cava (Pigna et al., 2004; Ryder, 1993) hemodilution, leading to erosion and subsequent ef- • Erosion of the vessel due to contact with the cath- fusion (Mukau, Talamini, & Sitzmann, 1991). eter can result in pleural effusion or hydrothorax • A large catheter placed in a small vessel allows the (Ellis, Vogel, & Copeland, 1989) catheter to remain in contact with the vessel wall • Mechanical and chemical irritation, which can act and can lead to erosion of the vessel’s inner layer synergistically to erode the vessel (Ellis et al., 1989) and infiltration into the mediastinal or pleural • Infusion of hyperosmolar solutions leads to os- space. Placement outside the vena cava increases motic injury and vascular leakage without catheter this risk (Marino, Aslam, Kamath, Rosenberg, & perforation of the vein (McDonnell et al., 1984; Rajegowda, 2006).

Peripherally Inserted Central Catheters 39 • Thrombus formation at the catheter tip results in a Phrenic nerve injury/diaphragmatic paralysis decreased dilution of hyperosmolar solutions, necro- This infrequently reported complication has been sis of the wall, and leakage of fluid. The leakage of seen with catheter tips that reside in the subclavian concentrated solutions draws large amounts of fluid vein (D’Netto & Bender, 2001; Williams, Hunter, into the pleural space (McDonnell et al., 1984). Kanto, & Bhatia, 1995). Signs and symptoms Etiology The signs and symptoms can vary with the size of The specific mechanism of action is speculative, but the effusion, rate of fluid accumulation, size of the the reported cases include infant, and degree of venous damage. Some effusions • extravasated fluid from the catheter tip residing in occur slowly or they can be obscured with preexisting the subclavian vein causes irritation of the underly- cardiorespiratory disease (Ellis et al., 1989). Signs and ing phrenic nerve (Williams et al., 1995) symptoms include • thrombosis and the resulting engorgement of the • respiratory distress with decreased breath sounds subclavian vein, which compresses the phrenic over the affected lung (Marino et al., 2006; Pigna et nerve (D’Netto & Bender, 2001). al., 2004) Symptoms • soft-tissue swelling (McGettigan & Goldsmith, • Respiratory distress 1996) • Persistent elevation of the diaphragm on X ray • absence of blood return from the catheter (this may (D’Netto & Bender, 2001; Williams et al., 1995) also be due to other causes). Diagnosis Identification Radiologic imaging (e.g., X ray, ultrasound, fluoros- • Radiologic imaging studies confirm the diagnosis copy) can be used to diagnose phrenic nerve injury and of pleural effusion and hydrothorax. Chest X rays diaphragmatic paralysis (D’Netto & Bender, 2001). reveal opacification of an affected lung with the ultrasound demonstrating pleural fluid. The injection of a Prevention contrast agent may demonstrate entry into the lym- To prevent phrenic nerve injury and diaphragmatic phatic system. paralysis, the catheter tip should be located in the • Blood may not be aspirated from the catheter. superior or inferior vena cava (INS, 2006; Kearns et al., 1996; NAVAN, 1998; Racadio et al., 2001). Management • Stop the infusion of fluid through the catheter. Catheter fracture and embolism • Notify the medical care provider. Etiology • Obtain imaging studies (e.g., chest X ray, ultra- This multifactorial complication has several pro- sound). posed etiologies, with fracture being identified on the • Attempt to withdraw infiltrated fluid back through internal or external portion of the PICC. the catheter (Seguin, 1992). • Shearing of the catheter can occur during inser- • Thoracentesis to remove effusion fluid may be tion if the catheter is withdrawn while the insertion required (Marino et al., 2006). needle is in place or if the infant moves significantly • Some pleural effusion and hydrothorax resolve during the insertion and damages the catheter themselves spontaneously without catheter removal (Ochikubo, O’Brien, Kanakriyeh, & Waffarn, 1996; (Spriggs & Brantley, 1977). Pigna et al., 2004) • Monitor for reaccumulation with radiologic imaging • Catheter fracture from high pressure created us- studies. ing small volume syringes for infusion or flushing Prevention against resistance (Catudal, 2002; Chow et al., 2003) • Maintain the catheter tip in the appropriate position • Removal of the catheter using force (Miall, Das, within the superior or inferior vena cava. Brownlee, & Conway, 2001) • Ensure the catheter lies parallel with the vein wall • Disconnection of the catheter from the original or a (Duntley, Siever, Korwes, Harpel, & Heffner, 1992; repaired hub (Hwang et al., 1997; Trotter & Carey, Goutail-Flaud et al., 1991; NAVAN, 1998). 1998) • Break in external segment of the catheter secondary to securement failure or force is also a cause (Frey, 1999)

Peripherally Inserted Central Catheters 40 Signs and symptoms Thrombosis Symptomatology varies depending upon the loca- Etiology tion of the fracture and the presence of embolus. Some The intact venous endothelium is nonthrombogenic. infants remain asymptomatic with the fracture or Damage to the intimal layer of the vessel exposes the catheter embolus being identified radiographically or subendothelial layer of the vein, allowing adherence clinically based on the assessment of the length of the of platelets and activation of the extrinsic and intrinsic external catheter segment (Pigna et al., 2004). coagulation cascade. Vascular trauma, inflammation Other symptoms include of the vessel wall, alteration in coagulation, and stasis • fluid leaking from the insertion site (Chow et al., of blood flow can cause the endothelial injury (Jacobs, 2003; Hadaway, 2005) 2003). Left-sided arm and scalp insertion catheters may • inflammation or swelling along the catheter pathway fail to make the transition from the brachiocephalic (Hadaway, 2005) vein to the superior vena cava, leading to vein damage • difficulty flushing or withdrawing blood (Catudal, (Mukau et al., 1991). Catheter tips residing outside the 2002; Chow et al., 2003) vena cava can lead to an increased risk of thrombosis • respiratory distress (Racadio et al., 2001).The incidence of thrombosis • cardiac dysrhythmias. varies due to the lack of a standardized method of diag- Treatment nosis, but is higher in smaller children. Clinical diagnosis If the catheter snaps during withdrawal of thrombosis is made in approximately 1% of patients • Apply digital pressure over the vein or apply a tour- with all CVCs, but diagnosis by ultrasound and venog- niquet to the involved extremity to prevent further raphy shows an overall risk of thrombosis in 20% of migration into the central circulation (Wall & Ki- patients with CVCs (Garden & Laussen, 2004). erstead, 1995). The tourniquet should not be tight Signs and symptoms enough to occlude arterial flow. Most of the signs and symptoms are silent, but may • Keep the patient immobile. include the following (Jacobs, 2003): • Obtain radiographic verification of the location of • prominent superficial or collateral vessels the catheter fragment. • edema or discoloration of the extremity in which the Catheters kept in the peripheral circulation can be catheter is located (Clark, 2004) removed by venotomy. Catheters embolizing to the cen- • unexplained fever (Jacobs, 2003) tral circulation may require removal by interventional • unexplained thrombocytopenia (Jacobs, 2003) radiology, cardiology, or surgical procedures (Chow et • chylothorax, which may be the only sign of a supe- al., 2003; Linz, Bisset, & Warner, 1994). rior vena cava thrombosis (Garden & Laussen, 2004; Prevention Kramer, Taylor, Garfinkel, & Simmons, 1981) To prevent catheter embolism • unexplained cardiorespiratory decompensation, par- • Assess the need for analgesia or sedation for the insertion ticularly with hypoxia, is suggestive of pulmonary procedure. embolus or pericardial effusion (Garden & Laussen, • If catheter repositioning is needed at the time of insertion, 2004; Jacobs, 2003) do not retract the PICC through the introducer needle to • discoloration or pain in affected limb (Clark, 2004; prevent catheter shearing. Garden & Laussen, 2004). • Maintain the catheter securely under the dressing, while Prevention preventing tension to the catheter. Ensure connecting tub- • The catheter tip should be located appropriately ing (i.e., T-connector) is also connected to patient. (Racadio et al., 2001). • Monitor catheter repair sites diligently. Consider exchang- • The catheter size should be appropriate for the size ing the catheter for a new PICC rather than repairing. of the vessel to be cannulated. An appropriately sized • Avoid forceful infusion through the catheter using syringes. catheter facilitates blood flow around the catheter and • Don’t flush if resistance is encountered. allows adequate dilution of the infusate, preventing • Only healthcare professionals with demonstrated clinical irritation of the venous wall (Jacobs, 2003). competency should remove PICCs. • Powder-free gloves should be used for catheter inser- • Remove the catheter gently, while holding the catheter at tion to decrease the risk of tissue reactions. the point of insertion rather than the hub, and do not use • Secure the catheter to prevent vessel damage, stimula- force. tion of the coagulation cascade, and thrombosis secondary to migration.

Peripherally Inserted Central Catheters 41 Vena cava thrombosis • use of a large-gauge catheter in relation to the size of Superior and inferior vena cava thrombosis is subclin- the vein (Mazzola et al., 1999) ical in most instances. This condition can be diagnosed • catheter tip outside of the vena cava (Racadio et al., using ultrasound or a venogram. Many of the etiologies 2001) are inclusive of those outlined under “Thrombosis.” • cephalic vein insertion (Mazzola et al., 1999; Neu- bauer, 1995) Signs and symptoms • saphenous vein insertion (Neubauer, 1995) Signs and symptoms can include the following • inadequately secured catheter (Mazzola et al., 1999) (Carey, 1989): • manipulation of the PICC during insertion (Mazzola • edema of the upper extremity, neck, and head et al., 1999) (superior vena cava thrombus) • inexperienced clinicians placing the catheter have • edema of the lower body and limbs (inferior vena been anecdotally associated with a more rapid inser- cava thrombus) (Edstrom & Christensen, 2000) tion, which may foster contact with the vein intima. • dilation of veins on the skin (collateral circulation) • respiratory distress Treatment • cardiac murmur The need for and type of treatment for phlebitis • central nervous system disturbances (superior vena remains unclear. Some consider this a benign condi- cava thrombus) tion with spontaneous resolution (Evans & Lentsch, • full fontanel (superior vena cava thrombus). 1999; Rastogi et al.,1998). Treatment options include • applying warm compresses over the vein every 4 hours Treatment until the phlebitis is resolved (Frey, 1999; Pettit, 2003a) The treatment of superior vena cava thrombosis • elevating the involved extremity and administer a varies depending on its severity. A variety of treat- gentle range-of-motion exercise if the infant has little ment options have been proposed though there is spontaneous activity. no consensus about which is the preferred method. With early identification and treatment, phlebitis Treatment options may include the infusion of a usually resolves itself within 24–72 hours (Frey, 1999; thrombolytic agent via the PICC or an alternative vas- Mazzola et al., 1999; Pettit, 2003a). If there is no cular access device, anticoagulation, surgical removal improvement or if the phlebitis advances after 24 hours of the thrombus, transcatheter recanalization, or cath- of therapy (as indicated by a red streak, palpable cord, eter removal with supportive care (Clark, 2004; Ries, or purulent drainage), discontinuing the catheter should Zenker, Girisch, Klinge, & Singer, 2002). be considered (Camara, 2001). Mechanical phlebitis Prevention Etiology • Maintain the catheter tip within the vena cava Mechanical phlebitis is an inflammatory reaction of (NAVAN, 1998; Racadio et al., 2001). the vein associated with placement and the ongoing • Frequently monitor (observation and palpation) the dwell of a catheter within the vein. The constellation of vein of catheter insertion to allow for early identifi- symptoms vary and may inlcude pain at the insertion cation and treatment. site or along the track of the vein, enema, erythema, • Slowly and gently insert the catheter (Hadaway, 1998). palpable venous cord, and purulent drainage. Mechani- • Use the smallest catheter capable of delivering the cal phlebitis is most commonly reported during the required therapies (Frey, 1999; INS, 2006). first 72 hours to week following catheterization, but it • Avoid using the cephalic vein (Mazzola et al., 1999; may occur at any time during the catheter dwell time Neubauer, 1995). (Camara, 2001; Mazzola, Schott-Baer, & Addy, 1999). • Saphenous vein insertions may carry an increased The incidence, clinical symptomatology, treatment, and risk for phlebitis (Neubauer, 1995). outcomes are not well defined in neonates. Symptoms of • Secure the catheter to prevent movement (Mazzola phlebitis have also been referred to in the neonatal litera- et al., 1999; Pettit, 2003a). ture as erythematous tracking or cording. • Avoid touching the catheter with gloves containing powder. Risk factors Risk factors for mechanical phlebitis include the Chemical phlebitis following: Chemical phlebitis is most commonly associated • rapid or traumatic insertion, which can damage the with PIVs and midline catheters, but can be associated intima of the vein (Hadaway, 1998) with an improperly positioned or functioning PICC.

Peripherally Inserted Central Catheters 42 • With a peripheral catheter tip (i.e., in the extremity 2005; Racadio et al., 2001). Catheter occlusions can be or scalp) this form of phlebitis has a rapid onset. partial (i.e., the catheter is sluggish to flush), one-way • Erythema is seen within hours of infusing medica- (i.e., the catheter can be flushed but blood cannot be tions or solutions that are irritating to the vessel, aspirated), or total (i.e., the catheter cannot be flushed were improperly mixed or diluted, were rapidly ad- or aspirated through). Thrombotic occlusions repre- ministered, or contain particulate matter. sent the most common etiology. • Formation of a fibrin sheath surrounding the cath- Etiology eter may allow fluid to exit into a vein smaller than Thrombotic occlusions, which account for the major- the vena cava, which can lead to chemical phlebitis. ity of catheter occlusions, are due to (Jacobs, 2003) Risk factors • fibrin or clot formation inside or outside the lumen • Indwelling portion of the catheter is damaged and • venous thrombosis from injury to the vessel wall contains holes. (The damage may occur during • large catheters with insufficient venous flow around insertion, flushing against resistance, or infusing them, which creates turbulence and increases the with pressure that exceeds the burst strength of risk of thrombus. the catheter.) The properties of the infusate may Risk factors lack adequate hemodilution, which leads to venous • Improper flushing technique, which leads to an damage. inability to create positive pressure within the cath- • A fibrin sheath forms around the tip and propa- eter with heparin lock or blood refluxing into the gates along the length of the catheter. Infused fluid catheter (Hadaway, 2006) follows the path of least resistance and exits into • Failure to adequately flush before and after medi- the sheath. If the sheath covers part of the catheter, cation administration the symptoms are seen at the end of the sheath. If the sheath covers the entire catheter, the fluid exits Nonthrombotic or mechanical occlusions around the catheter insertion site. Etiology • Catheter tip in a location with adequate hemodilu- • Incorrectly set pump occlusion alarm tion leading to chemically induced vessel irritation • Closed clamps on tubing and erosion (Sztajnbok & Troster, 2002). • Kinks or bends in catheter tubing Signs and symptoms • Infant’s position (i.e., flexion of extremity contain- The symptoms are similar to those of mechanical ing PICC) phlebitis. Risk factors • Pain during and after infusion can indicate chemi- • failure to adequately flush before and after medica- cal phlebitis. tion administration or incompatable solutions • Chemical phlebitis due to a fibrin sheath or hole • calcium-phosphate imbalance of total parenteral in the catheter can be diagnosed by means of a nutrition (TPN) contrast injection into the catheter, venogram, or • lipid residue ultrasound. • fungus infection (e.g., Malassezia furfur) (Azimi et Treatment al., 1988; Nguyen, Lund, & Durand, 2001) • Chemical phlebitis due to tip location (non-vena Signs and symptoms for all types of catheter occlusion cava) warrants catheter removal. Signs and symptoms include the following (Had- • If chemical phlebitis is caused by a fibrin sheath, away, 1998): the catheter should be removed or the fibrin sheath • sounding of pump occlusion alarms can be treated using a thrombolytic agent. (Review • visible clots, particulate matter, or lipid clumps in the risks and benefits of this treatment before pro- the catheter ceeding.) • change in ability to aspirate or flush the catheter Catheter occlusion • pain during infusion and fluid exiting the catheter Most cases of catheter occlusion are due to improper insertion site (due to a fibrin sheath). flushing or catheter locking protocols, but may also Identification be due to infusate characteristics and compatibilities, The cause of catheter occlusion should be sought fibrin sheath formation, catheter tip location, and pos- by reviewing the etiologies of each type of occlusion sibly low rates of flow through the catheter (Hadaway, and the patient’s history with the catheter and recent

Peripherally Inserted Central Catheters 43 infusates (Flurkey, 1994; Holcombe, Forloines-Lynn, 4. Open the stopcock to the syringe containing & Garmhausen, 1992; Jacobs, 2003; Pettit, 2002; Shul- the clearing agent, and the agent will be gently man et al., 1986). drawn into the catheter. • The catheter should be inspected under the dress- 5. Close the stopcock to the patient to allow the ing for kinks and bends and secured to prevent cleaning agent to dwell within the catheter for bends or movement (Pettit, 2002). the prescribed time. • An X ray may determine whether the catheter is 6. Verify the catheter patency by assessing for malpositioned or bent internally. blood return. • The hub and the external portion of the catheter 7. If patency is achieved, aspirate the clearing should be checked for leaks and assessed for mal- agent and blood from the catheter, flush the positioning and migration (Pettit, 2002). catheter well with saline, and begin infusion of • Contrast injections through the catheter, veno- prescribed fluids. gram, or ultrasound can be used to detect Clearing agents thrombotic occlusions (Jacobs, 2003). In cases of thrombotic occlusion, thrombolytic agents Management (e.g., tPA) have to be instilled into the catheter accord- The etiology determines the course of treatment. ing to the manufacturer’s recommendations (Blaney • Repositioning may be required if the catheter is et al., 2006; Deitcher et al., 2002; Hartmann, Hussein, lodged against a vessel wall. Trowitzsch, Becker, & Hennecke, 2001; Lee, 2002). – The infant can be moved from side to side or Using tPA to treat vascular thrombus in neonates has from prone or supine. been frequently described, but less so for catheter-related – If the catheter is in an extremity, the arm or leg thrombus (Torres-Valdivieso et al., 2003). can be repositioned. Abducting or extending the For occlusions related to calcium-phosphate pre- arm can alleviate a catheter bend. cipitate, parenteral nutrition, and acidic drugs, 0.1 N • The catheter can be removed and a new one insert- hydrochloric acid (HCl) may clear the blockage (Breaux, ed if needed. In general, this is necessary for fungal Duke, Georgeson, & Mestre, 1987; Duffy, Kerzner, occlusion (Mermel et al., 2001). Gebus, & Dice, 1989; Shulman, Reed, Pitre, & Laine, • Remove the blockage by instilling a “clearing agent.” 1988; Zenk, Sills, & Koeppel, 2003). An amount equal Some of these agents return the precipitate into solu- to the catheter volume is instilled into the catheter. tion by creating a favorable pH balance. Most reports After 20 minutes, the HCl is withdrawn. If patency of success have been anecdotal. Tissue plasminogen has not been restored, the procedure can be repeated activator (tPA) has been used in neonates and is the once or twice. approved thrombolytic agent used for catheter clear- Sodium bicarbonate (1 mEq/ml) has been reported ance in children and adults (Deitcher et al., 2002; to clear alkaline drug-related occlusions by restoring Torres-Valdivieso et al., 2003). A protocol should be the alkaline environment and allowing the precipitate in place and staff should be trained in the procedure. to regain solubility. An amount equal to the catheter The risks and benefits of the procedure must be ex- volume is instilled into the catheter. After 20 minutes, amined to determine whether the catheter is essential the sodium bicarbonate is withdrawn. If patency has for care. The volume of the clearing agent instilled not been restored, the procedure can be repeated once should approximate the catheter volume (or be slight- (Goodwin, 1991). ly more in the case of a thrombolytic) to minimize For lipid occlusions, 70% ethanol, which breaks down entry into the bloodstream (INS, 2006). lipid, is instilled in an amount equal to, but not exceed- • Catheter-clearing agents can be instilled into the cath- ing, the catheter volume and is allowed to dwell for 1–2 eter using one of these techniques: hours. The ethanol then is withdrawn. If patency has – Gentle push: Use for catheters with partial not been restored, the procedure can be repeated once occlusion. (Pennington & Pithie, 1987; Zenk et al., 2003). – Negative pressure using a three-way stopcock: Prevention 1. Attach the stopcock to the hub of the catheter. • Heparinization of infusion fluid reduces the risk of 2. Using a 10-ml syringe, aspirate until enough thrombotic occlusions (Shah et al., 2007). (Refer to resistance is felt to indicate the presence of a “Infusion of Fluids” for more information.) vacuum within the catheter. • Consider the minimum infusion rate orders based 3. Attach a 10-ml syringe containing the clearing on NICU outcome data reporting rate of throm- agent.

Peripherally Inserted Central Catheters 44 botic catheter occlusion (Evans & Lentsch, 1999). vein or a lump is visible or palpated and resistance • The flushing method must be monitored. Use pul- is encountered (Filan, Woodward, & Ekert, 2005; satile movements (i.e., short bursts) when flushing. Frey, 1999). • Ensure compatibility of medications and coinfus- • Fibers (i.e., lint) attached to fibrin may cause re- ing solutions (Hadaway, 2005). sistance to removal (Filan et al., 2005; Miall et al., • Create a positive or neutral pressure within the catheter 2001). when heparin locking (refer to the heparin-locking Procedure procedure). Several approaches to discontinuing catheters resis- • Flush before and after giving medications or changing tant to removal have been described in the literature, solutions to prevent drug incompatibility and precipi- but two methods appear to be favored, both of which tate formation (Hadaway, 2005). may take several days to complete, but are not guar- • Promptly respond to occlusion alarms on the infusion anteed to be successful. pump. • Apply warm compresses along the tract of the vein • Ensure TPN components are balanced. for 20–30 minutes, then attempt removal (Rothkopf et Assessment after clearing al., 2000). If the PICC still cannot be removed, one to Possible complications related to the clearing agent two additional attempts to remove the catheter during and the procedure include the following: the following 12–24 hours are reasonable. Continue to • catheter damage apply intermittent warm compresses, then attempt re- • leakage moval. This method has less potential to cause catheter • fever as a reaction to HCl (Breaux et al., 1987) breakage than the following method (Camara, 2001; • thrombolytic-induced bleeding (Hartmann et al., Frey, 1999; Marx, 1995; Wall & Kierstead, 1995). The 2001; Torres-Valdivieso et al., 2003). catheter and surrounding skin should be prepped with an antimicrobial agent and a sterile dressing applied to Catheters that resist removal secure the catheter between removal attempts. Catheters infrequently resist removal at the conclusion • An alternative method involves applying gentle trac- of therapy. Most catheters can be removed over time tion to the catheter, then securing the catheter to the (some take a few days to remove) and do not require site. The process is repeated every few hours until the surgical intervention. Aggressive traction should never catheter is removed. Removal can take a few days. be applied during removal due to the risk of catheter There are case reports of catheter breakage using this breakage and venous damage. method (Bautista et al., 1995; Gladman et al., 1990; Etiology Miall et al., 2001). • Venous spasm caused by mechanical irritation of • Evaluate catheter location radiographically if the cath- the vein by catheter movement or patient anxiety eter is not removed within approximately 4 hours to accounts for the majority of cases. The catheter may determine further strategies for removal. be partially removed with the tip typically being in • Other measures that can be considered, based on sus- the peripheral circulation before resistance is en- pected cause, include countered (Camara, 2001; Marx, 1995). – placing a tourniquet on the extremity above the • Thrombus may trap part or all of the catheter with- catheter tip to dilate the vein in the vein during the removal process (Bautista, Ko, – flushing through the catheter (Marx, 1995) & Sun, 1995; Camara, 2001; Rothkopf et al., 2000). – rotating the extremity (Marx, 1995) Thrombus may be associated with infection (e.g., – massaging the skin overlying the vein (Camara, 2001) Staphylococcus epidermidis, Malassezia furfur) and – infusing vasodilators, which have been used the catheter may become adherent to the vein wall in pediatrics and adults but not discussed in (Bautista et al.; Gladman, Sinha, Sims, & Chiswick, neonates (Marx, 1995; Miall et al., 2001) 1990; Kim, Cohen, Ramachandran, & Glasscock, – using nonsteroidal antinflammatories, which have 1993; Nguyen et al., 2001; Rothkopf et al.). been used in children and adults (Marx, 1995) • Phlebitis and thrombophlebitis (Marx, 1995) may – using relaxation techniques (Miall et al., 2001) contribute to resistance. – obtaining a radiograph to rule out knots in the • The presence of a fibrin sheath can cause resis- catheter and an ultrasound to rule out thrombus tance. The catheter may be partially removed as etiology for resistance (Nguyen et al., 2001) before the sheath assumes an accordion appear- – infusing a thrombolytic agent (Edstrom & ance and is seen in the peripheral portion of the Christensen, 2000; Hartmann et al., 2001;

Peripherally Inserted Central Catheters 45 Rothkopf et al., 2000) • Do not pull the catheter back through the needle – removing the catheter using interventional or introducer. surgical techniques (Bautista et al., 1995; Miall et • Cautiously remove break-away needles. al., 2001). • Secure the catheter and extension tubing to the pa- • If catheter breakage occurs, grasp the external seg- tient to prevent stretching and breakage. ment of the catheter to prevent embolism. Management • If embolism occurs, compress the vein containing If a leak occurs because of a catheter fracture, pre- the catheter with your hand or a tourniquet to trap vent embolization of the catheter (refer to “Catheter the catheter within the peripheral circulation. Place embolism”). Determine if the catheter can be repaired the infant on the right side to trap the catheter or exchanged for a new catheter (Camara, 2001), or if within the right heart (Camara, 2001). removal is necessary. Prevention Extremity edema • Indentify proper PICC tip location within the vena Throughout the catheter dwell, mild to gross edema cava. surrounding the insertion site or in the extremity may • Use infusates that are appropriate for tip location. be identified. • Use lint-free products during the procedure. • Use a no-touch technique when manipulating the Etiology catheter This condition can be caused by the following factors: • Remove the catheter slowly without forcing or • restrictive dressing stretching it. • bend in the extremity • Implement strategies to prevent a hospital-acquired • dependent positioning infection. • decreased movement • thrombus Drainage from catheter or insertion site • catheter that is too large for the size of the vein so Drainage at the insertion site may be a normal that it restricts adequate venous return serous fluid or a leak in the catheter due to catheter • extravasation of infusate. damage or a fibrin sheath surrounding the catheter. Treatment Etiology The treatment is based on the cause. • Leaks can be caused by excessive pressure created • Redress and straighten the extremity (possibly us- by syringes, sharp objects (e.g., clamps, introduc- ing a limb board for a short period of time) or ers) piercing the catheter, and the catheter having elevate the extremity (Serrao et al., 1996). been flushed when resistance was felt. • Measure the circumference of the proximal portion • Leaks can signify a catheter obstruction (Pettit, of the extremity and compare to the opposing ex- 2003a). tremity until the edema improves. • Leaks can be seen at the catheter hub or external • Obtain a venogram or ultrasound if thrombus is portion of the catheter, usually due to damage. suspected. • Fibrin sheath formation along the catheter allows • If the edema is mild and stable without compro- fluid to follow the path of least resistance back mising the health of the extremity, the catheter may down the catheter. Fibrin sheaths can cover the be left in place if it is monitored vigilantly. tip of the catheter or travel part or all of the way • If the edema is progressive or if the extremity is down the catheter to the entrance site. Ultrasound compromised, consider removing the catheter. or contrast injection can diagnose fibrin sheaths. • Drainage can occur because of decreased skin tur- Neurologic complications gor at the insertion site. The most commonly reported neurologic symptoms stem from catheters placed via veins in the lower Prevention extremities. Catheters placed through the scalp or arm To prevent leaks veins have rarely been linked to complications and will • Use techniques to minimize catheter damage (i.e., not be discussed in this document (Anderson et al., do not apply clamps or sharp objects to the cath- 2004). PICCs inserted via a leg or femoral vein pose eter or hub, use the appropriate syringe size and a risk of entering the ascending lumbar veins rather pressure when infusing, do not flush when resis- than the inferior vena cava. The ascending lumbar tance is encountered). veins drain the vertebral venous plexus into the com-

Peripherally Inserted Central Catheters 46 mon iliac vein. Infusion through a catheter in this Waffarn, 1999; White, Montes, Chaves-Carballo, location can result in venous stasis, and pressure and Presberg, & Young, 1987) fluid transmitted to the spinal cord, thereby leading • Death (Lavandosky et al., 1996) to a variety of neurologic complications (Clarke et al., • Radiographic findings 2003; Vidwans, Neumann, Hussain, Rosenkrantz, & – left-sided insertion that fails to cross the midline Sanders, 2000). Migration of the central venous cathe- to enter the inferior vena cava and appears to ter or redistribution of the infusate into the ascending overlay the spine (Carrion et al., 2001; Chen et lumbar vein is thought to occur in infants who are al., 2001) experiencing an increase in intra abdominal pressure – a bend or hump in the catheter at the L4-5 level (i.e., abdominal distention, necrotizing enterocolitis, on AP view, particularly on left-sided insertions repaired congenital diaphragmatic hernia) (Kelly, and when the catheter is threaded to or beyond Finer, & Dunbar, 1984; Lussky, Trower, Fisher, Engel, the level of L3 (Carrion et al., 2001; Chen et al., & Cifuentes, 1997; Odaibo, Fajardo, & Cronin, 1992; 2001) Zenker et al., 2000). – a marked posterior deviation of the catheter at L4-5 on a lateral view (Chen et al., 2001; Vidwans Risk factors et al., 2000) • Left-sided insertions pose a higher risk of entering – a 360˚ curl or loop in the catheter in the inguinal the ascending lumbar vein because of the angle of region prior to advancement up the ascending entry from the common iliac vein (Carrion et al., lumbar vein (Chedid et al., 2005; Schoonakker & 2001; Chen, Tsao, & Yau, 2001). Harding, 2005) • Difficulty advancing the catheter to a premeasured – posterior deviation of the catheter through depth also represents a risk for malposition and the spinous processed in the lateral radiograph neurologic complications (Carrion et al., 2001; (Schoonakker & Harding, 2005) Chen et al., 2001). • The rapid insertion technique has been anecdotally Prevention linked to catheter malposition. • Maintain a high index of suspicion throughout • Catheters allowed to reside in the femoral, iliac, treatment. Experienced personnel should me- or lower portion of the inferior vena cave have mi- ticulously assess the radiograph for the catheter grated into or near the ascending lumbar vein or location. Observe the length of the catheter from produce venous thrombus and lead to retrograde the leg to the tip for subtle clues of malposition. flow into the ascending lumbar vein (Mah, Fain, (Chedid et al., 2005; Chen et al., 2001; Vidwans et Hall, & Wood, 1991). al., 2000). • If malposition is suspected, obtain a radiograph Signs and symptoms from the lateral perspective. The catheter present- • The infant may be asymptomatic, particularly if ing anterior to the spinal column is typically in the the malposition is identified on insertion X rays inferior vena cava, while the catheter deviating pos- (Chedid, Abbas, & Morris, 2005; Lussky et al., teriorly may be in the ascending lumbar vein (Chen 1997). et al., 2001; Coit & Kamitsuka, 2005; Schoonakker • Lack of blood return has been noted from some & Harding, 2005; Vidwans et al., 2000). catheters, particularly upon insertion (Lavandosky, • A contrast injection through the catheter may highlight Gomez, & Montes, 1996). the area of malposition, however, there is some con- • Resistance when the catheter is inserted (Carrion et cern that this may lead to irritation or damage (Chen al., 2001) et al., 2001; White et al., 1987). The instillation of a • Sepsis-like symptoms such as unexplained respira- contrast agent has failed to identify all malpositioned tory distress and lethargy (Chen et al., 2001; Clarke catheters (Chen et al., 2001; Lussky et al., 1997). et al., 2003; Mitsufuji, Matsuo, Kakita, & Ikuta, 2002) Medical Device Reporting and MedWatch • Parenteral nutrition retrieved following lumbar When a medical device causes or contributes to the puncture or markedly abnormal levels of glucose, death of a patient, federal law requires that a report protein, or lipid obtained be made to the FDA and the manufacturer within • Seizures, flaccid quadriplegia, or neurologic deficits 10 working days (Lowe & Scott, 1996). Other device (Bass & Lewis, 1995; Chen et al., 2001; Lavan- complications that require reporting to the manufac- dosky et al., 1996; Mitsufuji et al., 2002; Rajan & turer within 10 working days include the following:

Peripherally Inserted Central Catheters 47 • serious injury caused by the device Hourly assessment and documentation should cover • if the patient was at risk of dying at the time of the visual inspection of the site, from the insertion point adverse reaction or if it is suspected that continued along the course of the vein to the tip location and use of the product would cause death the quantity of fluid infused by the infusion pump • if the adverse reaction caused a significant or (Pettit, 2002, 2003a). permanent change in bodily function, physical ac- The use of blood pressure cuffs or tourniquets tivity, or quality of life should be avoided on an extremity with a PICC • if using a medical product required medical or sur- because of the risk of vessel or catheter damage. gical treatment to prevent impairment. Infusion tubing configuration The facility is responsible for adhering to reporting The configuration of the infusion tubing is integral requirements and faces substantial penalties for failing to the efficient and safe use of the PICC. Infants may to report. The goal of reporting is to improve patient require a continuous infusion of one or more fluids care by identifying problems unforeseen at the time of along with continuous or intermittent medication the initial FDA product review. administration. When assembling the infusion tubing, Catheter Care and Maintenance requirements for all infusates must be considered to All nurses who care for infants with PICCs must be ensure the appropriate number of injection ports are knowledgeable about effective management to prolong the available for set-up and to prevent unnecessarily enter- catheter’s dwell time and prevent complications and injury ing the catheter at a later time. to the infant. Using a team of caregivers with trouble- • Infusion tubing should be assembled using clean shooting expertise and the ability to change dressings and technique, however, using sterile technique is a part repair catheters has been found to enhance success with of the successful multidimensional efforts to de- PICCs (Golombek et al., 2002; Rourke & Higgins, 1998). crease CRBSI (Aly et al., 2005). Few care regimens, however, have been subjected to scien- • All infusion tubing connected to the PICC should tific scrutiny and those outlined identify recommendations be luer-locked. for practice. Where one clear choice is not available, several • To minimize entry into the PICC and decrease the risk options are identified. Each patient care unit should have of contamination, intermittent injection tubing (used protocols available to address the following areas. for medication administration) should remain attached to the primary administration set and not Assessment and documentation removed after each injection (Aly et al., 2005). A The following factors related to the PICC should closed medication system (i.e., entry restricted to be monitored and documented in the medical record once every 24 hours) used as a component of a during every shift and more frequently as necessary: multidimensional strategy to decrease CRBSI was • site (i.e., color, appearance, temperature, presence found to significantly decrease the incidence of of drainage, bleeding, edema, erythema). The area CRBSI (Aly et al.). along the course of the vein should be palpated for • Eliminate stopcocks from tubing and instead use pain or venous cord. capped injection ports, which must be vigorously • catheter (i.e., the amount outside the body, config- cleaned with alcohol before entry (Bouza et al., uration of the catheter, presence of kinks or bends, 2003; Casey et al., 2003; Pettit, 2002; Sitges-Serra leaking of fluid from catheter tubing, precipitate in et al., 1997; Yebenes et al., 2004). catheter or tubing) • patency (i.e., the ability to infuse fluid or flush, and Medication administration the presence of a blood return if evaluated) Providing medications through the PICC is a • dressing (should be intact around edges and hold desired feature of the device. Safety with this pro- the catheter in place in the center of the dressing; cess is integral to the successful dwell of the catheter. no part of the catheter, except the hub, should pro- The long, narrow catheter configuration provides an trude from the dressing) opportunity for mixing of incompatible infusates. • infusion pump occlusion alarm setting Care must be exercised when following the established • infusion tubing (i.e., security of connections, pre- principles of medication administration. cipitate in tubing) • Flush thoroughly before and after the administra- • complications specific to the known location of the tion of medications (if this is not contraindicated catheter tip (i.e., a tip in the subclavian vein near based on infusate). the shoulder or midline catheter can lead to development • Ensure medication is compatible with other infusates. of edema and erythema over the site).

Peripherally Inserted Central Catheters 48 • If a PICC is heparin locked, flush the PICC before Volume of flush injecting medication, and flush with saline before • Data are not available to suggest the appropriate instilling heparin back into the catheter to prevent volume to instill with each flushing action. precipitation. • At least twice the catheter volume and any add-on • Consider using a closed medication delivery system devices, such as T-connectors, has been suggested and as described by Aly and colleagues (2005). is reasonable (INS, 2006). This is approximately 1 ml. Infusion of fluids Syringe size • Fluids should be heparinized to prevent thrombotic For safe practice, do not rely on syringe size alone catheter occlusion and extend catheter survival when delivering medications or solutions; consider all (Shah et al., 2007). No increase in heparin-induced of the factors mentioned below. thrombocytopenia or hemorrhage was identified Syringe size dynamics with the addition of 0.5 U/kg/hr of heparin. • Follow the catheter manufacturer’s recommenda- • Catheter lumens smaller than 26 gauge are difficult tions about the minimum syringe size for manual to maintain patency without a continuous infusion infusion (most specify a 5- or 10-ml syringe). of fluid. • Use a technique to infuse that will be within the • Fluids should be administered by an infusion pump. maximum pressure limits (i.e., pounds per square • There are no data to suggest a minimum amount inch [psi]) for the catheter and does not create of hourly flow is required to maintain catheter pa- catheter damage. tency, though some have suggested 2 ml/hr (Evans • The smaller the syringe, the greater the pressure that & Lentsch, 1999). This may differ depending on the is exerted. Using normal hand pressure to deliver a infusion characteristics of individual pumps, length solution from a full 1-ml syringe can generate more of catheter dwell, flushing protocols, and the size of than 300 psi and a full 10-ml syringe will generate the catheter. Hospitals should monitor the occlusion less than 40 psi (Conn, 1993; Macklin, 1999). risk as defined in their outcome data to determine • The greater the force applied on the syringe plunger, the effect of infusion flow rate on occlusion. the greater the pressure delivered to the catheter. Even the largest syringe can deliver excessive pres- Flushing sure if great force is applied (Macklin, 1999). Maintaining patency of these small-bore catheters • Applying too much pressure on the catheter and requires meticulous care to prevent occlusion due to flushing when resistance is felt can lead to the thrombus or precipitate. fracture or embolization of the catheter (Catudal, Frequency 2002; Pigna et al., 2004). A PICC should never be • Flush before and after administering potentially forcefully flushed if resistance is felt. incompatible solutions and medications. • Syringe pumps also can exceed the catheter’s burst • If routine blood sampling is desired, consider strength when small-volume syringes are used. flushing with 1 ml twice a day to enhance patency. Check with the syringe pump’s manufacturer. • Flush as needed to assess catheter patency. Catheter Material PICCs made of polyurethane have greater tensile Flush solution strength than those made of silicone. This makes • Both sodium chloride and diluted heparinized saline them more resistant to damage due to applied pres- solutions (dextrose solutions may be used if medica- sure and may allow for use of syringes smaller than tion is incompatible with saline) have anecdotally 10 ml (DiFiore, 2005). been described and preferred use is facility specific. Cathether patency • Solutions should be obtained from a single-use vial • Completely patent catheters outside the body or syringe (CDC, 2002b; Joint Commission on Ac- offer no resistance to flow, and fluid will exit creditation of Healthcare Organizations [JCAHO], without increasing pressure inside the catheter. 2003). Multiuse containers as well as flush syringes • Once a catheter is inserted into the body, com- manually filled by nurses have been associated with plete patency cannot be ensured, especially when an increased risk of contamination. The syringe resistance to flushing is encountered, is sluggish, should be used one time and discarded (Mattner & or no blood return is appreciated. Gastmeier, 2004; Worthington et al., 2001). • The smallest neonatal catheters offer some resistance to flushing because of the minute size of the internal lumen.

Peripherally Inserted Central Catheters 49 Management of heparin locks samples from 24 or 26 gauge or 1.9 F PICCs are sur- Catheter lumens larger than 28 gauge or 1.9 F may facing and warrant further investigation. allow heparin locking. Saline locks for PICCs have • Catheter lumens smaller than 26 gauge are prob- not been studied in the small-size catheters used in ably too restrictive to allow this practice. Evidence infants and are not an acceptable option for maintain- supports this practice through a 3 F PICC without ing patency at this time. Anecdotal reports suggest a significant increase in occlusion or other catheter- limited success maintaining catheter patency with hep- related complications (Knue, Doellman, Rabin, & arin locking most PICCs used in the NICU (Evans & Jacobs, 2005). Lentsch, 1999). • The values of some tests may not be accurate when the blood has been drawn through the PICC (i.e., Heparin concentration blood glucose when dextrose-containing solutions The concentration of heparin reported to be effec- are infusing, coagulation studies due to heparin in tive varies from 1 to 10 U/ml (Evans & Lentsch, 1999). the catheter, therapeutic drug levels due to residual Greater success has been found using the 10 U/ml con- drugs present in the catheter). centration (Evans & Lentsch, 1999). • A second PICC may be considered to be strictly Flush volume used for blood sampling. • There are no data to suggest the most appropriate To draw blood specimens volume to instill with each flushing action. 1. Perform hand hygiene and apply clean gloves. • At least twice the catheter volume and any add-on 2. Pause the infusion pump. devices, such as T-connectors, has been suggested and 3. Place a sterile 4 x 4 under the injection port and is reasonable (INS, 2006). This is approximately 1 ml. prep with alcohol using vigorous friction prior to • Do not completely depress the plunger when each entry. flushing to prevent reflux into the catheter at the 4. Flush with at least 0.5 ml of saline. conclusion of the procedure (Hadaway, 2006). 5. Withdraw at least two times the catheter and exten- Frequency sion set volume to clear catheter of infusates. (For • Heparin locks should be flushed every 6 hours most neonatal PICCs this averages 1 ml.) Cap syringe. (Evans & Lentsch, 1999). 6. Obtain a specimen. • Flush with normal saline before and after giving 7. Reinfuse blood withdrawn to clear catheter if the medications and incompatible solutions to prevent infusate contains heparin (otherwise microclots reactions leading to precipitation and lock with may be present in this syringe). heparinized saline (10 units heparin/ml) (Evans & 8. Flush the catheter well with normal saline using at Lentsch, 1999). least twice the volume of the catheter and exten- • Using a pulsatile method (i.e., short bursts or sion set (INS, 2006). This is approximately 1 ml. start-stop technique) creates turbulence within the Remove residual blood from injection port. catheter and has been anecdotally linked to en- 9. Resume infusion. hanced clearing of substances and blood residing 10. Perform hand hygiene. within the catheter (Pettit, 2002). 11. Document the amount of blood drawn and the • Prevent blood reflux into the catheter following test obtained. flushing or locking by using one of the following Troubleshooting techniques if difficulty is encountered methods: obtaining specimen – Withdraw the syringe from the injection port or • Use a small-volume syringe for aspiration, which clamp the extension set as you infuse the last 0.5 ml. creates less pressure on the catheter during the – For valve-style injection ports, clamp the tubing withdrawal of blood and facilitates sampling. while injecting the last 0.5 ml of flush. • Reposition the infant so that the catheter tip is not – Use a positive or neutral displacement device against the vessel wall. attached to the hub of the catheter or extension • Flush with a small amount of normal saline. set to create positive pressure. Tranfusion of blood products Blood sampling and administration Some manufacturers and some NICUs allow trans- Withdrawal of blood specimens through a PICC fusion of blood products through 26 gauge and larger carries a theoretical risk of catheter occlusion. Anec- PICCs in neonates. There are limited reports of effi- dotal reports of success in reliably obtaining blood cacy for the practice. Interruption of other infusates,

Peripherally Inserted Central Catheters 50 increased frequency of entry into the catheter, and in the following situations: potential for occlusion are important concerns. • Transparent dressings should be changed when they no longer adhere to the catheter or skin or they are Catheter repair damp or soiled (CDC, 2002b; Zenk et al., 1993). Catheter repair may be considered in cases of damage • Dressings with gauze and tape, a transparent dressing to the hub or a portion of the catheter outside the body. with gauze placed underneath, or an occlusive tape During repair the damaged segment of the catheter will on top require changing every 48 hours (CDC, 2002b; be removed along with the catheter hub and a new hub INS, 2006). will be provided. A catheter that has been broken or leak- • Fluid or bleeding at the insertion site indicates the ing for a period of time may be contaminated and is not need for a dressing change (INS, 2006). a candidate for repair. Follow the manufacturer’s recom- Dressing changes require sterile technique. At a mini- mendations and instructions for repair (some may not mum, face masks and sterile gloves should be worn by recommend repair). The need for and viability of repair those making contact with the area of skin or the cath- can be assessed by the following means: eter under dressing. If contamination of the catheter is • Determine whether replacing the catheter is a better possible or a long segment of the catheter is external, option, depending on the length of therapy remain- consider using sterile drapes and a sterile gown. Assis- ing and the infusate properties. tants should wear a face mask. Securement devices under • Assess the potential for placing another catheter if the dressing should be removed and the site cleaned with other venous access sites are available. an antimicrobial agent prior to placing a new dressing. • Another option is exchanging a damaged catheter for a new one rather than repairing it (Fabian, 1995; Pet- Catheter removal tit, 2007). Performing this procedure requires special Personnel removing PICCs should be educated in the training. appropriate techniques for reducing serious complica- Perform repairs according to the manufacturer’s tions. The infant should be calm both before removal is directions in a sterile manner, using maximum sterile attempted and during the process. Removal is performed barrier precautions. as follows: 1. Gently remove the dressing by pulling it toward the Risks insertion site (pulling it away will remove the cath- • If the catheter does not remain secured to the new eter along with the dressing). hub, embolization of a catheter has been noted fol- 2. Remove the catheter using a slow, steady motion. lowing the repair. The security of the connection Grasp the catheter, not the hub, as the removal between the catheter and hub needs to be routinely progresses. Always pull from the insertion site (this assessed (Trotter & Carey, 1998). allows better control and earlier identification of • Infection can occur if the catheter has become tension). Rapid removal and application of pressure contaminated before or during the repair process to the vein over the site can allow the catheter to (Evans & Lentsch, 1999). contact the vein wall and stimulate vasoconstriction Dressing changes (Camara, 2001; Marx, 1995). A secure dressing holds the catheter in place and 3. Measure the length of catheter removed and prevents migration in and out of the body (Frey, 1999; compare it to the length that was inserted. If the Neubauer, 1995). Dressing-change practices have not removed length of the catheter is less than the length been subjected to formal evaluation in neonates, except that was inserted, notify the medical care provider for one small study using transparent, semipermeable immediately, as embolization may have occurred. polyurethane dressing (Zenk et al., 1993). Most NICUs 4. Document the length removed, the appearance of change dressings only when dressing integrity is lost, the site, the patient’s tolerance of the procedure, which is supported by low rates of infection (Cartwright, and any complications during removal. 2004; Evans & Lentsch, 1999; Trotter, 1998). Reports of 5. Cover the insertion site with sterile dressing. routine, weekly dressing changes are surfacing as com- 6. If resistance to removal is encountered, STOP. Do ponents of bundles designed to decrease the incidence of not attempt to remove a catheter by applying tension CRBSI, though there have been no randomized clinical to the device. Redress the site using a sterile technique trials to support this practice (Aly et al., 2005). In light and refer to strategies outlined under “Catheters that of the potential for damage to the stratum corneum layer resist removal.” Pulling against resistance can damage of the skin and dislodgement of the catheter when the the vein wall and weaken the integrity of the catheter dressing is removed, a dressing change is recommended leading to catheter fracture and possible embolism.

Peripherally Inserted Central Catheters 51 Conclusion standard of care for many infants who require intra- Maintaining vascular access is critical for the venous therapy to reduce stress and pain and to survival of an increasing number of extremely low- promote the delivery of medications and solutions birthweight infants. Improved technology, advanced into the most appropriate vessel. PICCs should be training, and appropriate use have made PICCs a used as a first line of treatment rather than a last life-saving device for infants. Utilization of PICCs resort. offers a cost-effective approach to care and minimizes NANN endorses appropriate training for health- pain, stress, and risk of infection associated care providers in the insertion and maintenance of with multiple PIV insertions. PICCs can be used PICCs as a means of ensuring optimal outcomes. not only during hospitalization, but also facilitate early discharge by allowing home-based infusion therapy. These catheters should be considered a

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Peripherally Inserted Central Catheters 59 Appendix A. Clinical Competencies for the Nurse (continued) COMPETENCIES Step Verbalize Demonstrate Competency Clinical competencies for PICC Inserter 1. Identify the indications for use of a peripherally inserted central catheter. 2. Identify possible contraindications or special considerations for use. 3. Explain to the family the procedure, risk, and benefits and potential complications. 4. Choose the best accessible vein based on the infant’s diagnosis and assessment. 5. Demonstrate and correctly measure the length of catheter to use for the selected insertion site. 6. Assess need for analgesia and obtain order if warranted. 7. Position and prepare infant, including swaddling, to facilitate restraint and comfort. 8. Select catheter with appropriate size and number of lumens for the size of the selected vein and the infant’s identified infusion needs. 9. Prepare catheter a. Flush b. Trim catheter based on required measured insertion length c. Demonstrate care of stylet during trimming process 10. Select appropriate catheter introducer and demonstrate insertion and removal technique. 11. Discuss and demonstrate PICC insertion per procedure including the rationale for decisions. 12. Flush the catheter using a pulsatile technique. 13. Identify catheter tip placement on radiograph. 14. Demonstrate sterile technique during insertion. 15. Demonstrate dressing stabilization of the catheter and added tubing during the initial application of the dressing. 16. Document the procedure and placement according to facility guidelines. Clinical competencies for the RN caring for the infant with a PICC 1. Demonstrate how to assess and maintain catheter placement. 2. Maintain strict aseptic technique for all catheter management, including tubing changes, medication delivery and blood sampling. 3. Demonstrate how to heparin lock the catheter. 4. Demonstrate how to flush the catheter using pulsatile technique.

Peripherally Inserted Central Catheters 60 Appendix A. Clinical Competencies for the Nurse (continued)

Step Verbalize Demonstrate Competency 5. Apply sterile technique during a dressing change. 6. Demonstrate technique for obtaining blood specimens via PICC. 7. Discuss the complications that can occur while a PICC is in place. 8. Demonstrate sterile technique and stabilization of the catheter during the application of the dressing and added tubing. 9. Describe how to instill a clearing agent into an occluded catheter. 10. Describe and demonstrate catheter removal. 11. Discuss the treatment necessary to remove a . retained catheter 12. Identify the complications that can occur as a result of PICC placement or while the catheter is indwelling along with possible intervention and prevention strategies. a. Phlebitis b. Bleeding c. Migration/dislodgement d. Infiltration (peripheral; pleural, pericardial, peri- toneal leakage) e. Occlusion f. Catheter-related bloodstream infection 13. Document all interventions for PICC lines according to facility guidelines.

Appendix B. Troubleshooting Guide

Problem Assessment Considerations/Possible Solutions Sounding of pump occlusion alarm • Tubing clamped or pinched • Patient position • Catheter kinked, either externally or internally Catheter can’t be flushed • Assess external catheter for kinks/bends • Check minimum infusion rate • Determine if injection port occluded Vein at insertion site is red and hard • Evaluate for and treat if mechanical phlebitis Extremity with catheter is puffy • Dressing too tight • Vascular thrombus within extremity • Dependent positioning Catheter can’t be removed • Refer to strategies for catheters resistant to removal

Peripherally Inserted Central Catheters 61 Appendix C. Sample Consent Forms and Parent Education Tools

Peripherally Inserted Central Catheters 62 Peripherally Inserted Central Catheters 63 Appendix D. Procedure Documentation and Maintenance Records

Peripherally Inserted Central Catheters 64 Peripherally Inserted Central Catheters 65 Peripherally Inserted Central Catheters 66 Peripherally Inserted Central Catheters 67 Peripherally Inserted Central Catheters 68 Appendix E. PICC Order Forms

Peripherally Inserted Central Catheters 69 Peripherally Inserted Central Catheters 70 Peripherally Inserted Central Catheters 71