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: Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016 Page 1 of 14 Refer to online version – Print copy may not be current – Discard after use 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. Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016 Page 2 of 14 Refer to online version – Print copy may not be current – Discard after use 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 Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016 Page 3 of 14 Refer to online version – Print copy may not be current – Discard after use 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). Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016 Page 4 of 14 Refer to online version – Print copy may not be current – Discard after use 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 Page 5 of 14 Refer to online version – Print copy may not be current – Discard after use 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 Policy NN.11.26D Neonatal Program Policy & Procedure Manual Effective Date: 13-Jul-2016 Page 6 of 14 Refer to online version – Print copy may not be current – Discard after use 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.