Hospital of the University of Pennsylvania NURSING. Insertion of Peripherally Inserted Central Catheter (PICC) and Midline Catheter (MLC)

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1 Page 1 of 11 KEYWORDS: Central Catheter Sterility REFER TO: 4B Nursing Management of the Patient with a Central Venous Access Device HUP Consent to Health Care Services SCOPE Registered Nurses (RNs) who have completed requirements to establish competency in the insertion of Peripherally Inserted Central Catheters (PICC) or Midline Catheters (MLC). Requirements include: A. Documentation of attendance at a basic PICC insertion course or individualized training session about PICCs. B. Documentation of demonstrated competency with PICC catheter insertion by Nurse Manager. A minimum of five successful insertions is required. RNs who have completed requirements for competence in PICC insertion using a peel-away sheath introducer are deemed competent to place MLCs using a peel-away introducer. RNs who have demonstrated competency in PICC insertion using a modified Seldinger technique are deemed competent to place MLCs using the modified Seldinger technique. PRODUCT DESCRIPTION AND INDICATIONS PICCs and MLCs are supplied in two ways: an open ended catheter and a closed ended or valved catheter (groshong PICC and MLC). The insertion procedure for an open-ended catheter is different from the procedure for a closed-ended or valved catheter. This policy and procedure addresses the use of open-ended catheters only. PICCs are best suited as intermediate-term central venous devices for therapy durations of 2-12 weeks. With optimal care, PICCs can last for a longer period of time. Patients requiring therapy durations greater than 12 weeks are generally better served with a tunneled catheter or a port. Subclavian and jugular triple lumen catheters can stay in the patient 7-10 days. If a femoral line has been placed it should be removed as soon as a new line is placed. PICCs should primarily be used as long term (>2 weeks) devices and in most cases, after acute issues in patient care are resolved (i.e., infection suspicion, after infectious disease consults, cardiac surgeries, in which cases PICC would only remain in place acutely). If patient requires central venous access because of limited peripheral venous access or may be receiving irritant of vesicant drugs and duration will be short term (<2 weeks) or plan is unclear, a triple lumen catheter should be utilized. Midlines should only be inserted for short term use (<1 week) if peripheral catheters are unsuccessful. Otherwise, they should be used for patients who require venous access for 1 week or greater, but not central venous access. Please see attached PICC Insertion Protocol.

2 Page 2 of 11 Clinical judgment must be utilized in deciding the PICC size and number of lumens. When clinical situations permit, smaller catheters are preferred over larger catheters and single lumen catheters are preferred over double lumen catheters. PICC placement is not an emergency procedure. PICCs may remain in place indefinitely if no complications arise. MLCs are indicated for short-term (approximately 1-4 weeks) peripheral access to the peripheral vascular (not central line) system for selected intravenous therapy and blood sampling (see contraindications). Midlines may remain in place for up to 4 weeks if no complications arise. For blood therapy it is recommended that a 4 French or larger catheter be used. PICC and MLCs are made from specifically formulated and processed medical grade materials for reliable long term (greater than 30 days) and short term (less than 30 days) vascular access. PICCs are an effective vascular access device in adults, children and infants. Patients who may benefit from a PICC or MLC include (but are not limited to) those with chronic disease, limited venous access, receiving vesicant/irritant drugs, needing antibiotic therapy, etc. with therapy durations appropriate to the device. PICC lines have been an accepted technology since 1975, with extensive published research. CONTRAINDICATIONS PICCs and MLCs are contraindicated whenever: The patient s body size is insufficient to accommodate the size of the inserted device. The patient is known or suspected to be allergic to materials contained in the device. Past irradiation of prospective insertion site. Although usually avoided, history of venous thrombosis is not a contraindication of line placement. Local tissue factors that will prevent proper stabilization and/or access. The patient has end stage renal disease with creatinine 3, or a functioning renal transplant regardless of creatinine. In addition to the above contraindications MLC placement is contraindicated for patients requiring any of the following: Solutions with final glucose concentrations above 10 percent. Solutions with protein concentrations above 5 percent. Continuous infusion of vesicants. WARNINGS Polyurethane PICC and MLC only: Use of ointments can cause failure of the device.

3 Page 3 of 11 Intended for single patient use. Do not reuse. Any device that has been contaminated by blood should not be reused or re-sterilized. Acetone and tincture of iodine should not be used. After use, this product may be a biohazard. Handle and discard with universal and blood body fluid precautions in mind (state, federal, local laws and regulations and accepted medical practice). CONSIDERATIONS A. PICCs and MLCs are commonly inserted into (but not limited to) the basilic, cephalic, accessory cephalic, brachial and median cubital veins of the upper arm. B. The most preferred vein for access is the basilic, then the brachial, followed by the cephalic. C. Catheter Tip Locations: PICCs: for PICCs, optimal catheter tip location is in the lower third of the superior cava, ideally at the caval-atrial junction (CAJ). MLC: the tip of the midline lies in the veins outside of the SVC. D. Radiographic confirmation of catheter tip location: PICC: Radiographic confirmation or other FDA approved means of confirmation of the PICC tip location is required prior to initiation of infusion therapy. E. A prescriber s order is needed for PICC and MLC insertion. F. Informed Consent: Registered Nurses from the Venous Access Program may obtain informed consent for PICC insertion. PRECAUTIONS A. Follow universal precautions when inserting and maintaining catheters. B. Use maximum barrier precautions when inserting a PICC or MLC. C. Use aseptic technique whenever the catheter lumen is opened or connected to other devices. D. The fluid level in the catheter will drop if the connector is held above the level of the patient s heart and opened to air. To prevent a drop in the fluid level (and thus air entry) while changing injection caps, hold the connector below the level of the patient s ear before removing the injection caps. E. Pre-insertion screening criteria: PICCs and Automatic Internal Cardiac Defibrillator (AICDs): If a patient is a candidate or potential candidate for and AICD or has an AICD in place, insertion into the left arm is contraindicated. RNs should consult the referring physician regarding potential for AICD placement if the patient is on intravenous inotropic therapy. If the patient already has an AICD, PICC placement in the right arm is permitted.

4 Page 4 of 11 PROCEDURE If patient has a history of mastectomy or lymphectomy, the PICC will be placed in the opposite arm. If the patient has a double mastectomy the patient can be referred to IR. PICC: Patient will be referred to Interventional Radiology for Small Bore Central Catheter placement if: Creatinine > 3 mg/dl The patient is a candidate for renal transplant or has a history of renal transplant, regardless of creatinine. Note: MLCs will NOT be utilized in this patient population. A. Prior to beginning the placement procedure: 1. Examine the package carefully before opening to confirm its integrity and that the expiration date has not been passed. Do not use package if it is damaged, opened, or the expiration date has passed. Inspect kit for inclusion of all components. B. To avert device damage and/or patient injury during placement: 1. Avoid accidental device contact with sharp instruments, which may cause mechanical damage to the catheter material. Use only smooth edged atraumatic clamps or forceps. C. Avoid perforating, tearing, or fracturing the catheter when using a stylet. D. Do not use catheter if there is any evidence of mechanical damage or leaking. E. Avoid sharp or acute angles during implantation, which could compromise the patency of the catheter lumen(s). F. Do not place suture material around the catheter as sutures may damage the catheter or compromise catheter patency. G. Do not cut the stylet inside the catheter. H. Prior to insertion withdraw the stylet approximately ½ inch distally from the tip catheter to prevent accidental contact between stylet and the vein wall. I. After placement, observe the following precautions to avoid device damage and/or patient injury: 1. Damage to the catheter may lead to rupture, fragmentation and possible embolism requiring surgical removal. If the catheter is damaged it should be clamped with an atraumatic clamp or kinked closed if a clamp is unavailable until the catheter can be replaced or repaired. Please notify Venous Access Program or IR immediately to replace the damaged catheter. 2. Use only leur-lock connections for accessories and components used in conjunction with this device. 3. If signs of extravasations exist, discontinue infusion. Begin appropriate medical intervention immediately.

5 Page 5 of Do not infuse against resistance. Follow standard institution policy/procedure to clear an occluded catheter. 5. Caution should also be used performing peripheral phlebotomies at or above the insertion site of a PICC or MLC as damage to the catheter could occur. J. Insertion Instructions: 1. Verify prescribers order. 2. Review patient s medical history, contraindications to device placement, and indications to device placement, allergies, and labs. Consult with ordering physician and/or IR attending physician as necessary. 3. Verify patient s identity using two unique identifiers. When placing the lines at the bedside, perform TIME-OUT with either primary RN, another floor RN, charge RN, CNS, or nurse manager prior to start of procedure. 4. Explain procedure to patient and family. Obtain informed consent or insure that informed consent is documented in the medical record. 5. Prepare a clean work area and gather supplies. 6. Wash hands with an antimicrobial soap prior to beginning the insertion procedure. 7. If necessary, wash the intended cannulation site with anti-infective soap and water. 8. Position the patient supine with the arm to be accessed away from the trunk of the body at a 90 degree angle. Have patient practice turning his/her head toward the insertion arm and dropping chin to the shoulder. 9. Determining catheter insertion length and total catheter length: a. PICCs: For PICCs with intended catheter tip placement in the SVC with optimal placement in the caval-atrial junction, catheter insertion length is determined by measuring from the planned insertion site to the right clavicular head, then straight down the chest to the third to fourth intercostal space. b. MLCs: For MLC only (peripheral placement), catheter insertion length is typically 20 cm. RN may use professional judgment for MLC length depending on patient size. 10. Wash hands again with antimicrobial soap; gown (sterile) mask and put on first pair of sterile gloves. 11. Utilizing maximum barrier precautions, place a sterile poly-lined drape under the arm to be cannulated, sterile drapes over the patient s chest and sterile drapes outlining the insertion site. 12. Establish a sterile field for all supplies and place all supplies on the sterile field. 13. Remove catheter from the tray and examine it along the entire length to ensure the stylet is straight. 14. Draw up 10 ml of 0.9% normal saline and irrigate the catheter directly through the priming hub. Treat each lumen of a duel catheter as thought it were a separate catheter. 15. Modification of Catheter Length: a. Retract the stylet approximately ½ inch distal to the proposed total catheter length. Using a scalpel or sterile scissors, carefully cut the catheter according to manufacture s instructions. Inspect cut surface to assure there is no loose material.

6 Page 6 of 11 b. Caution: Do Not Cut Stylet. If stylet cut discard PICC or MLC and replace with a new device. 16. Site Preparation: a. Using aseptic technique prep the insertion site using antiseptic solution. Using friction, apply chlorhexidine solution. Allow aseptic solution to air dry (i.e., do not blow or blot dry). b. Apply for a minimum of 30 seconds. 17. Discard used supplies, remove prep gloves, apply tourniquet above the intended insertion site and put on a new pair of sterile gloves. 18. Position sterile towels over the anticipated puncture site and over the tourniquet. The tourniquet must be released through the drape without compromising the sterile field. 19. Prepare ultrasound equipment according to manufacturer s labeled use and directions. 20. Locate the vessel using ultrasound guidance. 21. Local Anesthesia: a. Mandatory for peel-away sheaths used with catheters >4 French or if using a modified Seldinger insertion technique. b. Use of injectable, intradermal anesthetic: draw 3 ml of injectable anesthetic (lidocaine hydrochloride 1% solution buffered with sodium bicarbonate 10:1 solution). With needle bevel up insert needle intradermally at intended venipuncture site. Aspirate to confirm there is no blood return. Inject 3 ml of anesthetic to form wheal at cannulation site. Remove needle, engage safety mechanism and discard syringe in appropriate puncture resistant container. Monitor patient response. TECHNIQUE FOR PICC AND MLC INSERTION USING A MODIFIED SELDINGER TECHNIQUE A. Remove introducer needle cover or a gauge IV cannula cover. B. Prepare ultrasound equipment according to manufacturer s labeled use and directions. C. Place sterile cover filled with sterile gel over ultrasound probe, according to manufacturer s labeled use and directions. D. Apply additional sterile gel to intended venipuncture location. E. Locate desired vein on ultrasound monitor. F. Insert needle. G. Use direct venipuncture procedure to insert catheter. H. Observe for brisk blood return.

7 Page 7 of 11 I. Insert guidewire via needle into vein. Gently advance approximately cm into vein lumen to ensure adequate guidewire purchase. NOTE: The guidewire should never be forcefully advanced into the vein. J. Release tourniquet aseptically. K. Remove needle over guidewire, leaving the guidewire in place. NOTE: Always maintain control of the guidewire to prevent accidental guidewire embolization. When the needle or introducer is removed, grasp the guidewire at the insertion site to remove the needle from the wire. L. Using a surgical blade, perform a dermatotomy alongside the guidewire making sure not to puncture or cut the guidewire or vein. Keep scalpel blade pointing toward the ceiling, not toward the patient s skin. Lift the skin slightly using the guidewire to prevent accidental entry into the vein, especially with thin patients where the vein is superficial. Dermatotomy is optional depending on practitioner preference. M. Take dilator introducer and thread over the guidewire to the insertion site. NOTE: The dilator introducer must not be advanced into the skin until the guidewire extends well past the introducer hub and is controlled by the practitioner. Attempting to advance the introducer without control of the wire could cause embolization of the wire. N. Advance dilator over the wire into the vein using a slight corkscrewing motion. 1. If resistance encountered the insertion site should be assessed. The dermatotomy may not be large enough to permit passage of the introducer and may need to be enlarged or performed. 2. Venous spasm may also cause difficulty advancing the introducer especially if resistance is felt after the introducer enters the skin. Allowing the vein to rest for a few seconds may resolve advancement resistance. O. If resistance is still encountered, the vein may be progressively dilated. Disassemble the introducer and advance only the dilator portion over the wire into the vein. Remove the dilator portion, reassemble the introducer and attempt to thread the introducer into the vein. Diligent guidewire control is required. P. Remove dilator and wire from peel-away sheath. Q. Establish blood return. Assess character of blood return to ensure an artery was not inadvertently cannulated. R. Thread the catheter through the sheath slowly. S. Continue advancing the catheter to measured point for PICC or MLC tip position. When the catheter is advanced to approximately the midclavicular region ask the patient to turn head toward affected extremity with chin placed downward towards clavicle. Continue advancing catheter to the predetermined point.

8 Page 8 of 11 T. Difficulty advancing the catheter: 1. If there is difficulty advancing the catheter the following steps may resolve advancement issues: a. Stop advancing the catheter. Ensure there is a brisk blood return. If no blood return is obtained, apply a small amount of negative pressure by drawing back on the syringe plunger. Slowly remove catheter until a brisk blood return is obtained. Flush the catheter with 0.9% NSS. b. Wait one or two minutes to allow potential venous spasm to resolve. Attempt to readvance. c. Reposition the patient s arm through the range of motion and/or turn palm up or down. Attempt to re-advance the catheter. d. If resistance is still encountered flush the catheter and attempt to advance while flushing the catheter. e. If resistance is still encountered pull the catheter back to where there is blood return advance a 70cm guidewire into the catheter (floppy tip first) and readvance the catheter with the guidewire. Remove guidewire when catheter fully advanced and blood return noted. U. Slide the peel away sheath away from the skin, split it and peel it away from the catheter. V. Disconnect the T-lock from the catheter luer connector. Stabilize the catheter position by applying light pressure to the vein distal to the insertion site. Slowly remove the T-lock and stylet. 1. Caution: Never use force to remove stylet. Resistance can damage the catheter. If resistance or bunching of the catheter is observed, stop stylet withdrawal and allow the catheter to return to normal shape. Withdraw both the catheter and stylet together approximately 2 cm and reattempt stylet removal. Repeat this procedure until the stylet is easily removed. W. Aspirate for blood return and flush each lumen of the catheter to ensure patency. 1. To reduce potential for blood backflow into the catheter tip use a positive pressure flushing technique. 2. When checking for blood returns do not allow blood to enter the cap. If blood does enter, change cap. X. Suture line in place with two sutures and place transparent dressing or secure catheter with proper securement device. Y. Verify placement (PICC only) radiographically. Z. Prior to initiation of therapy radiographically confirm that the catheter tip is in the SVC ideally near the caval-atrial junction (PICC only). AA. Discard expended equipment in appropriate receptacles using universal precautions.

9 Page 9 of 11 BB. Report any complications that occurred during placement and expected patient criteria to monitor to the primary nurse, the referring physician, and an IR attending as appropriate. MANAGEMENT OF PRIMARY (INSERTION) CATHETER MALPOSITION A. If the catheter cannot be visualized on the initial chest x-ray, repeat the x-ray. B. Primary malposition alternative tip location (catheter tip resides in the brachiocephalic, IJ, EJ, azygus, subclavian, or axillary vein): 1. Consult referring physician. As appropriate, the physician will provide authorization to utilize the catheter with an alternative tip location. Document this authorization in the medical record noting the time, date, and physician s name. a. Relay information to primary RN. b. Consult IR as needed or directed by the referring physician. 2. Attempt bedside repositioning by pulling back the PICC several centimeters, advancing a inch, 7cm floppy tip, 70cm-long guide wire through the PICC, the readvance the PICC. A repeat chest radiograph is then obtained. If the PICC remains malpositioned the patient is referred to IR for repositioning or exchange as appropriate. C. Other malpositions: Discuss with referring physician and consult IR as directed. DOCUMENTATION A. Progress Notes: Date, time of insertion, medical record number; indicate if the catheter is a PICC or MLC. Catheter brand, gauge, number of lumens, length of entire catheter, catheter length remaining outside of the insertion site, expiration date and lot #. Name of the insertion vein, l right or left arm, insertion complications (if any). Contraindications to use of line (if any). Any specific care and maintenance recommendations. Consent Form Procedure Specific Consent Form. Informed consent. Time out performed and documented on progress note. REFERENCES Am J Kidney Disease 30: S150-S191, 1997 (suppl 3). Gorski, L., & Czaplewski, L. Peripherally Inserted Central and Midline Catheters for the Home. Home Healthcare News 2004; Infusion Nurses Society. Infusion Nursing Standards of Practice, Journal of Infusion Nursing, 2011 volume 34 number 1S S 37-S48.

10 Page 10 of 11 Trerotola, S.O., Thompson, S., Chittams, J., & Vierregger, K. S. Analysis of Tip Malposition in Peripherally Inserted Central Catheters Placed at Bedside by a Dedicated Nursing Team. J Vascular Interv Radiol, 2007, REVIEWS/APPROVALS HUP Venous Access Team Medical Director: Interventional Radiology Supersedes: Catheter (PICC) and Midline Catheter (MLC), 08/29/08; 08/31/11 Effective Date: October 31, 2011 Disclaimer Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission.

11 Page 11 of 11 Attachment PICC Insertion Protocol Purpose: To avoid unnecessary PICC insertions, thereby limiting risk of blood stream infections and DVTs, inefficient use of resources, and unnecessary pain/anxiety for patient. Criteria for PICC Placement: IV access required for 2 weeks or more for irritant or vesicant medications (i.e., vancomycin, dilantin, TPN, chemotherapy). Patient requiring TPN for more than 2 weeks. Patient requiring prolonged central IV access >2 weeks. Patient requiring central IV access in order to be discharged home. Criteria for Midline Placement: IV Access required and peripheral access exhausted. o Is the patient ordered IV meds, fluids? Patient will need the line for 2-4 weeks. o If treatment anticipated to be shorter than two weeks, consider a peripheral. PICC Placement is NOT appropriate for the following purposes: Blood draws. CT or MRI injection or other diagnostic procedures. Replacing a TLC < 7-10 days old. Patients needing central access for <2 weeks (consider IJ, SCTLC). Pt. needing just IVF (MLC is indicated if peripheral exhausted). Patients with a creatinine >3 and/or renal transplants will be referred to IR by the PICC team for a small bore central catheter.

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