PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

POLICY PICC’s are inserted by NICU PICC Certified Physicians (PCMDs) or PICC Certified Registered Nurses (PCRNs) within the NICU. The maximum number of attempts (defined as skin and venous punctures) per PICC insertion must be limited to a maximum of three times.

Applicability: PICC insertion occurs within the Neonatal Intensive Care Unit

PROCEDURE Gather Equipment Sterile insertion tray 2”x 2” gauze Appropriate PICC device Sterile wound closure strips Appropriate introducer needle Transparent dressing Straight extension tubing as required Measuring tape Injection cap Cap and mask Sterile 0.9% NaCl 10 mL pre-filled syringe Sterile gown Sterile 0.9% NaCl or sterile water non-injection Sterile gloves vials (for rinsing of the skin) Procedural screen and “Sterile Procedure in Dexidin 2 solution (2% chlorhexidine with 4% Progress” sign alcohol) PICC securement device 4”x 4” sterile gauze Peripherally Inserted Central Catheter (PICC) Trimming tool Registry PICC consent form

PCMD and PCRN Assistant: PICC Assisting with Insertion

Prior to the insertion procedure Note Confirm physician’s order for PICC insertion and Consent form and parent’s information guide to be parental consent obtained. given to parents prior to insertion. Telephone consent acceptable if parents are unavailable for written consent. Call Radiology Department and fill out radiology Ensure that radiology is available to come for x- requisition. rays – request MIRA is possible. Obtain or write physician’s order for analgesic or sedative as indicated by infant’s BIIP score. Obtain an assistant for the procedure. The assistant is responsible to:

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Assist with the insertion procedure. Monitor the patient. Provide developmental support. Complete the BC Women’s Neonatal Intensive Care Unit (NICU) Central Catheter(s) Insertion Checklist. Assist with x-ray taking. Support and answer questions for parents. Measure PICC insertion distance to determine the External measurement can never exactly length of the catheter to be inserted. duplicate the internal venous anatomy. Tip Follow the steps under the selected insertion site location of PICCs must be confirmed by x- section and measure, in centimetres, the ray. length of the catheter to be inserted. The length of the catheter is estimated by measuring the distance from the insertion site to the desired tip location. The catheter is trimmed to allow easier dressing changes, visualization of catheter movement and reduction of infusing pressure.

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Upper limb Right side insertion Step 1: Extend right arm at 90° angle; measure from insertion site along arm and clavicle to 8. the right of the sternal border (figure 1). Step 2: Measure from right sternal border down to the third intercostal space (figure 3). Left side insertion Step 1: Extend left arm at 90° angle and measure from insertion site along arm and clavicle to the right of the sternal border (figure 2). Figure 1: Right arm Step 2: Measure from right sternal border down to the third intercostal space (figure 3). 10

Figure 2: Left arm 3.0

Figure 3: Step 2 for both arms Lower limb Right or left side insertion 22 Measure from insertion site along venous path to 1. the centre of the body to the right of the umbilicus and to just above the xiphoid process (figure 4). Figure 4: Lower limb

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Scalp 1. Right or left side insertion Step 1: Measure from intended insertion site along venous path next to the ear down to the right of the sternal border (figure 5). 10 Step 2: Measure from the right of the sternal border down to the third intercostal space (figure 6). Figure 5: Scalp step 1

3.

Figure 6: Scalp step 2

Position infant for insertion. Clean limb or scalp with soap (Cetaphil) and Follow the steps under the selected insertion site water as required prior to insertion. section and place infant in an optimal position to facilitate insertion and visualization of selected vein. Upper limb Antecubital veins Extend arm and rotate head towards insertion site with chin on shoulder to lessen the risk of catheter travelling cephalad through

ipsilateral jugular vein (figure 7). Figure 7: Antecubital veins

Lower limb Saphenous veins Extend leg to expose insertion site. Cannulation may be performed at many points along the saphenous vein (figure 8). Scalp Temporal and posterior auricular veins Turn head to the side to expose insertion site. Place a neck roll as needed to improve Figure 8: Saphenous veins visualization of vein (figure 9 & 10).

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Note: Shave hair adequately to expose vein and surrounding area for dressing.

Figure 9: Temporal vein Figure 10: Posterior auricular vein

Insertion Procedure Note Gather Equipment and supplies Select a catheter and preferred introducer Consider the number of infusions to assess the according to the catheter size. number of lumens required. Select a catheter size appropriate to the infant’s weight and vein size. PICC insertion can be uncomfortable. Assistant Manage Pain. should be present to provide Provide developmentally supportive care prior to developmental care. If medication is and during the procedure. administered effectiveness should be monitored. Document BIIP scores before, Consider analgesia as appropriate during and after procedure. Put on cap and mask. Scrub hands and arms up to elbows for one minute using antiseptic soap; dry hands with sterile towel. Put on sterile gown and gloves. Assistant prepares and assists with gowning. Organize equipment within sterile insertion tray. Assistant opens insertion tray and adds necessary supplies. Prepare the catheter This step removes internal air from lumen before Flush catheter (if no stylet attached). insertion. Attach a 10ml syringe to the catheter and flush. Catheters with a stylet insitu cannot be flushed. Leave the pre-filled NS syringe attached to the PICC. Trim the catheter The catheter length is trimmed to avoid coiling on the skin. Withdraw wire from catheter. Benefits of trimming include: Trim catheter to measured length plus 1–3cm for Decreasing the risk of catheter migration. securement Decreasing potential damage to external portion Cut the distal end squarely with the V-cutter by of catheter. lifting the blade using the blade handle. Decreasing resistance to flow within the catheter Thread the catheter through the appropriate sized and decreasing risk of occlusion. Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

opening until the chosen marking is in the centre of the trimming tool. Document trimmed length of catheter.

Hold one side of the trimming tool and the top before pressing. Press down in one steady motion to cut the catheter ensuring that a black mark is left at the end to increase accuracy in checking measurements. Inspect the line end for a smooth cut surface.

Stylet Management If a stylet is used it should be retracted 0.5 to Flexible stylets facilitate the threading of the 1.0cm from the catheter tip and secured so catheter and reduce the risk of coiling and that it remains within the lumen of the reversing direction. catheter.

Stylets should never be trimmed or allowed to extend beyond the catheter tip.

Prep the insertion site Assistant cleans the limb with the dampened 4x4 Stabilize insertion site to facilitate cleaning. gauze. Use new dry 4x4 gauze to hold the Dampen 4”x 4” sterile gauze with Dexidin 2 limb to facilitate further cleaning. solution and squeeze out excess Dexidin.

Hand this gauze to assistant

Cleanse site with Dexidin for 30 seconds. Allow For infants ≤ 1000gm: to air dry for 60 seconds. Cleanse site for 30 seconds A large prepped area reduces the risk of Allow solution to dry on skin for 60 seconds contamination. Remove residual solution using sterile NS prior to PICC insertion. NICU Skin Antisepsis protocol. Drape around insertion site. Ensure continual monitoring of infant under the drapes. Apply tourniquet to limb as needed. Application of tourniquet to scalp is contraindicated due to the potential of causing increased intracranial pressure. Visualize vein and insert introducer bevel at 15° to Hold skin taut below level of insertion to 30° angle. stabilize vein and prevent the vein from rolling Watch for flash back of blood into the chamber of the introducer. Once blood flash back is

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

seen release tourniquet, if used. Use the index finger of the opposite hand to stabilize introducer. Remove needle. Use non-toothed iris tweezers and thread the catheter through the introducer cannula in 0.25 to0.5cm increments to reach desired measurement (figure 11).

If resistance is felt with threading, attempt the Figure 11 following techniques: 1. Advance in 0.25 - 0.5 cm increments Advancing too much at a time when Repositioning threading can cause the catheter to buckle Advance in 0.25 cm increments and lead to vessel irritation or mechanical Flush to dilate the vessel and open valves phlebitis. Massage the vein toward the heart Apply warm compress 2. Flush to dilate the vessel and open valves Flushing may help dilate the vein and allow the catheter to advance past the valves.

3. Massage the vein Massage the vein toward the heart to empty it of blood then allow to it to refill. This can also aid in threading.

4. Apply Warm Compress Warm compress will dilate the vessel allowing for increased blood flow, which can aid in insertion. Stabilize catheter position at desired measurement. When a 24 gauge Jelco ® (figure 12) is used as Apply pressure to the vein proximal to the an introducer, withdraw the Jelco cannula introducer cannula above the insertion site. so it sits outside at the skin level. Withdraw the introducer cannula from vein.

Figure 12: Jelco The hub of the PICC is fitted into the hub of the Jelco and secure as a unit in the following way (figure 13a to c): Snug fit the two pieces together

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Slide a single wound closure strip (sticky side up) under the wings of the Jelco then cross tape over wings on top of the hub of the PICC (chevron method) Position as a unit to prevent pressure areas

Figure 13a Figure 13b

Figure 13c Split the introducer and peel it away from the If the catheter has not threaded to the desired catheter. length, remove the introducer and complete catheter advancement into vein (figure 14).

Figure 14 1. Pull back gently on the syringe to confirm blood return and then flush to clear. 2. Maintain pressure with gauze to stop bleeding . If bleeding continues beyond 30 minutes at insertion site for one minute before securing post-insertion call physician. catheter to the skin.

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Temporarily secure PICC until confirmation of Figure 15 catheter tip placement by x-ray with these steps: . Place an “X” with trimmed wound closure strip over the insertion site (figure 15). Do Wound closure strips not use chevron technique. to secure

Figure 16 Secure with wound closure strip. Avoid kinks, coiling catheter over itself or over an area of limb flexion. Do not overlap or use excessive wound closure strips (figure 16).

. PICC insertion site and catheter are to be kept sterile by a temporary dressing (e.g., 4”x4” gauze or transparent dressing) when inserter leaves the infant for x-ray taking and reading (figure 17a to 17d). Figure 17a Figure 17b

Figure 17c Figure 17d

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

3. Intermittently flush PICC with 0.5ml Normal Saline to maintain patency when waiting for x-ray. Alternatively, attach D10W with heparin 1 unit/mL and infuse at 1 mL/hr until placement is confirmed by x-ray (figure 18). Ensure sterility is maintained during flushing.

Figure 18

4. Call radiology technician to bedside to take Maintain sterile field and attire during x-ray taking. x-ray. Assistant is responsible to do x-ray with the radiology technician and to bring up x- ray for viewing. . PICC Radiographic Confirmation, Appendix G and see PICC placement flow charts to guide decision making in PICC tip placement and adjustment upon x-rays. 5. Proceed with completing the steps for PICC dressing when catheter tip location is confirmed by x-ray to be in an ideal or acceptable location. Transparent dressings are placed over the insertion site. Do not encircle the Figure 19 transparent dressing around limb or place gauze under the dressing. .

If a stabilization device is used: A stabilization device may be used to hold the Ensure skin site is clean and clear of hair “butterfly wing” hub of the PICC. (especially for scalp site). Snap the PICC hub onto the posts of the device. If Place stabilization the device has arrow they should be device with pointed in the direction of venous flow “arrows” towards the heart (figure 20). Remove device backing and secure to skin. Place Figure 20 transparent dressing over the device site (figure 20). . Always snap PICC hub onto the posts Any extra catheter should be arranged with a slight before adhering the pad to the skin. curve at it exits the skin. This minimizes NOTE: the risk of tension causing outward PICC dressings are not changed on the same day

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

migration or allowing inward migration with of PICC insertion with the exceptions: movement. The PICC requires adjustment based on follow up If several centimetres of catheter are external place x-rays the curve as above and coil the remaining Bleeding at the insertion site compromises the length ensuring there are no kinks or integrity of the dressing and may act as a bends. Avoid laying the catheter over itself. medium for bacterial growth if left on the skin. Attempt to stop bleeding before dressing. Bleeding at the PICC insertion site is expected because the introducer used for insertion is larger than the PICC itself. 6. Set-up PICC in preparation for initiation of infusions with these steps: . Add primed sterile injection cap onto the hub of the PICC . If the distance of the hub of the PICC from skin is ≤ 10cm, add straight extension tubing onto PICC (figure 21) Hub ≥ 10cm Straight extension . Do not use a limb board to secure a PICC tubing not because it can result in decreased range of motion or contractures in the extremity. In the case of excessive bleeding a limb board can be used to assist with a pressure Figure 21 dressing for a maximum of 1 – 2 hours.

Post Insertion Procedure Note Dispose of sharps and other used equipment into appropriate containers. Remove gloves and gown. Wash hands and remove mask and cap. Documentation Note PICC Insertion Registry The PICC Registry is kept on the clipboard until Complete all details of insertion on the registry and removal. Any adjustments made to the have two signatures once placement in line are to be documented. confirmed after the final x-ray Arterial, CVC and PICC Nursing Assessment and To be kept on the clipboard for daily use until Maintenance Tracking. PICC removal. BC Women’s NICU Arterial and CVC Insertion Keep on clipboard while PICC in situ and then file Registry. under operative procedures in patient chart.

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Complete x-ray annotation. Document any changes on each x-ray. Assistant Provides BC Women’s Neonatal The checklist is a way to ensure sterility is not Intensive Care Unit (NICU) Central compromised during insertion. Catheter(s) Insertion Checklist. Arterial and CVC and PICC Nursing Assessment Document the procedure in the nursing notes if and Maintenance Tracking Log by the more detail is required. bedside nurse. Keep Tracking Log on clipboard while PICC in situ and the file under operative procedures in patient chart.

REFERENCES Neonatal Policy Peripherally Inserted Central Catheter Policy (PICC)

Neonatal Policy PICC Assisting with Insertion

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Gustafson, R. (2010). Best practices for the care and maintenance of Argyle neonatal peripherally inserted central catheters. Covidien. Mansfield, MA.

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Kelly, R. E., Croitoru, D. P., Nuss, D., Flemmer, L. S., & Bass, W. T. (1997). Choosing venous access in the extremely low birth weight infant: Percutaneous central venous lines and peripherally inserted catheters. Neonatal Intensive Care, September/October,10(5), 15-18.

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Neonatal Policy PICC Radiography

NANN Peripherally Inserted Central Catheters: Guideline for Practice, 3rd edition Neonatal Policy Skin: Antiseptic Protocol Neonatal Policy Arterial and Central Venous Catheter Registry Neonatal Policy NICU Central Catheters Insertion Checklist Neonatal Policy Arterial and CVC Daily Maintenance Tracking Log Neonatal Program. (2016). Neonatal Intensive Care Unit central venous catheters…the basics. A self instructional learning package. Vancouver, Women’s Hospital of British Columbia.

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Pettit, J. (2007). Technological advances for PICC placement and management. Advances in Neonatal Care, 7(3), 122-131.

Pettit, J. & Wyckoff, M. (2007). Peripherally inserted central catheters. Guidelines for practice (2nd ed.). Glenview, IL: National Association of Neonatal Nurses.

Sawatzky-Dickson, D. (2009). Peripherally inserted central catheters in neonates. Unpublished workbook.

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Sharpe, E.L. (2008). Tiny patients, tiny dressings. A guide to the neonatal PICC dressing change. Advances in Neonatal Care, 8(3), 150-162.

Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC): INSERTION PROCEDURE

Trotter, C. W., (1996). Percutaneous central venous catheters in neonates: A descriptive analysis and evaluation of predictors for sepsis. Journal of Perinatal and Neonatal Nursing 10(2), 56-71.

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