INSERTION OF PERIPHERALLY INSTERTED CENTRAL CATHERTER (PICC) USING ULTRASOUND AND MODIFIED SELDINGER TECHNIQUE PURPOSE To provide direction on how to safely insert a peripheral catheter into the central venous system for short or long term venous access while conserving veins and morbidity. Early identification of patients requiring therapy as indicated below will minimize discomfort related to multiple venous access attempts, preserve veins for future use and to reduce delays in and provide uninterrupted therapy. INDICATIONS Home or hospital Intravenous (IV) therapy exceeding 5 days in duration Total Parenteral Nutrition administration, osmolality more than 600 mOsm Vesicant/irritant medication administration, infusates with a pH less than 5 or greater than 9. Lack of vascular access NOTE: Please ensure that the online request for NON-SURGICALLY INSERTED CENTRAL CATHETER has been submitted prior to commencing procedure POLICY STATEMENTS PICCs are inserted by Physicians and PICC Certified Registered Nurses (PCRN) Maximum number of attempts (skin and venous punctures) by PCRN per PICC insertion must be limited to two (2) times per inserter to a maximum of 4 attempts. Patients requiring conscious or deep sedation for the procedure must follow Pre-Anesthesia and Procedural Sedation Fasting Guidelines CC.08.05 Anesthesia is informed of the need for a PICC insertion along with the name, age and diagnosis of the patient, isolation status (if applicable) and the medication that the patient is to receive. SITE APPLICABILITY PICCS may be inserted in: Interventional Radiology (IR) IV Team/PICC Program to bring request to radiology and IR triage Operating Room(OR) Healthcare provider inserting the PICC MUST change into OR scrubs, hat, booties and mask and enter the OR suite through the central corridor. ONLY equipment necessary for the PICC insertion is brought into the operating room. Recovery Room PICU/NICU PICU at the bedside NICU as per BCW policy/procedure (Policy NN.11.26D) BCCH Inpatient Units At the bedside or in the treatment room CV BCCH Child and Youth Health Policy Manual Draft Date: February 23, 2016 Page 1 of 14 INSERTION OF PERIPHERALLY INSTERTED CENTRAL CATHERTER (PICC) USING ULTRASOUND AND MODIFIED SELDINGER TECHNIQUE PRACTICE LEVEL/COMPETENCIES Registered Nurses must be approved to complete formal PICC insertion training and complete a PICC Inserter Skill competency checklist with supervision annually. DEFINITIONS Maximum sterile barrier (MSB) precautions: wearing a sterile gown, sterile gloves, and cap and using a full body drape (similar to the drapes used in the operating room) during the placement of CVCs, PICCs, or guide wire exchange. PRECAUTIONS Maintain ASEPTIC technique throughout the procedure TWO healthcare providers are required to carry out this procedure to maintain aseptic technique ALL patients must have an established peripheral IV in place PRIOR to PICC insertion if patient requires anesthesia support for the procedure. A NEW administration setup and bag of fluid must be hung with each newly placed line to prevent contamination and decrease risk of sepsis PICC 3 Fr and larger catheters may be used for blood sampling. EQUIPMENT MSB Harmonized PICC insertion tray bundle or CHG Transparent dressing or other if required for skin Procedure tray, add 3ml syringe, 26 g 5/8 needle, sensitivity blunt fill needle, transducer cover with gel, sterile tourniquet, PICC Catheter tray Measuring tape Additional Inducer needle (if required) Cap and mask Straight extension tubing (as required) Sterile gown, additional as needed Sterile cap (Max plus) one per lumen Sterile gloves Sterile 0.9% NaCl (normal saline) pre-filled syringe “Sterile Procedure in Process” sign for door Heparin 10 unit/ml pre-filled syringe Patient Assessment, PICC procedure checklist, Lidocaine 1% vial Consent form, sedation record, X-ray requisition Alcohol/Chlorhexide swab Large prep swabs 5.2 ml (2% chlorhexidine with PICC insertion record and database document 70% alcohol, bottle of solution if using procedure Patient information handout and satisfaction survey tray) 4x4 sterile gauze 2x2 sterile gauze Ultrasound machine with vascular probe and gel Wound closure strips Navigation tool (Sherlock TLS) with device cover CV BCCH Child and Youth Health Policy Manual Draft Date: February 23, 2016 Page 2 of 14 INSERTION OF PERIPHERALLY INSTERTED CENTRAL CATHERTER (PICC) USING ULTRASOUND AND MODIFIED SELDINGER TECHNIQUE PROCEDURES Prior to Insertion Rationale 1. CONFIRM physicians order for PICC insertion 2. COMPLETE consultation for PICC insertion. To obtain history, determine pain management and Assessment will include patient age, history facilitate safe insertion of PICC. Confirm lab values of previous vascular access; level of anxiety, are appropriate for procedure: CBC, platelets, INR vein selection assessment by ultrasound. (international normalized ratio) MUST be discussed Patents with a history of previous difficult with Physician. If on antithrombotic medications, PICC insertions, thrombosis, severe anxiety may need to be placed on hold as per Physician or lack of vascular veins visible by orders. Initial assessment will determine if patient is ultrasound will be referred to Radiology. appropriate for PICC RN insertion. 3. Determine room LOCATION where PICC Follow appropriate booking for location e.g. OR, IR will be inserted. PICCs may be inserted in in- etc. Patient’s room is considered a “safe zone from patient areas, specific location to be procedures” thus invasive procedures are ideally determined. performed in treatment rooms. 4. Identify patient using two patient-identifiers, Explaining the procedure to the patient/family will procedure verification process and explain help to gain trust, cooperation and reduce anxiety. procedure to patient and/or family Give patient/family teaching handouts as appropriate. 5. Obtain consent for PICC insertion and/or Ensures that the procedure has been explained to confirm form has been signed the patient/family 6. Provide pharmacological and/or non- Use appropriate pain assessment tools as pharmacological interventions for painful or necessary. anxiety provoking procedures. Individual age appropriate comfort measures may These may include: contribute to minimizing pain and anxiety and Positive verbal encouragement and optimizing cooperation. feedback Position patient for comfort Distraction and relaxation techniques Encourage parental participation Child life involvement Application of topical anesthetic, as per procedure Follow Procedural Sedation Guidelines (CC.08.01) 7. Identify need for assistance for the The assistant is responsible to: procedure. If so, contact Child Life and Assist with the insertion procedure arrange for someone to be present. Assist with navigation device and/or X-Ray Support and answer questions for parents Bedside nurse to assist in preparing the patient: bath if possible prior to the Bedside RN in addition to PICC assistant procedure and assist in monitoring and holding the patient during the procedure if required. CV BCCH Child and Youth Health Policy Manual Draft Date: February 23, 2016 Page 3 of 14 INSERTION OF PERIPHERALLY INSTERTED CENTRAL CATHERTER (PICC) USING ULTRASOUND AND MODIFIED SELDINGER TECHNIQUE Prior to insertion Rationale POSITION patient in a supine position or elevate Placing the arm lower than the heart facilitates a head of bed to 15 degrees with the selected arm natural pathway for the PICC and decreases the risk abducted at 45-90 degree angle from the body. Pad of air embolism. under arm as necessary for visualization. ASSESS vasculature: apply ultrasound gel to Basilic, cephalic and brachial veins are the veins of potential insertion sites, use ultrasound to assess choice in the upper arm. The basilic vein is the vein patient’s veins to determine patency, shape, of choice for SVC placement (whenever possible) pathway and size. due to its anatomical relationship to the central venous system. MEASURE and document vein size to determine Catheter size should not exceed 50% of vein size appropriate catheter size and is optimally 30% of vein size (see Appendix A) The mid-arm fascia applies tissue tension and CONFIRM selected insertion site is avoiding areas stabilizes the basilica and brachial veins providing a of flexion (antecubital fossa and axilla) and mark more ideal needle insertion point. Avoiding areas of with appropriate marker. flexion provides better dressing adherence and maintenance to decrease potential complications of infection, thrombosis and bleeding. ENSURE appropriate monitoring is in place, and Equipment includes electrocardiograph leads and emergency equipment is available (if applicable). monitor plus oximeter for patients receiving Give oral sedation if indicated. See sedation sedation. guideline CC.08.01 Monitoring facilitates early identification of complications related to sedation (if required) or the procedure be performed A chest x-ray is required to confirm catheter tip Have assistant CALL Radiology Department and placement. For children < 1 yr, refer to Policy REQUEST digital portable X-Ray. COMPLETE NN.11.26G (PICC radiographic confirmation) required requisition and send to radiology. For SUPERIOR VENA CAVA placement (SVC): To determine length of PICC catheter to be inserted for proper tip location (SVC or IVC). Three Step Standard Method for Neonates/ Infants: 1. Begin at insertion site 2. With the arm at 45 degree angle, measure to right sternoclavicular notch 3. Turn and measure to first intercostal