Vascular - PICC & CVC

Question 1

PICC - Peripherally Inserted Central Catheter

Answer 1

• form of IV access, may be used for a prolonged time, up to 30 days
• peripheral veins used - cephalic, basillic, brachial, catheter tip rests in distal superior vena cava or cavoatrial junction
• can be used for deliverry of blood and blood products, and to measure central venous pressure, chemotherapy, extended antibiotic therapy, TPN
• lower rates of complications or infection than CVC
• less restrictive than CVC lines

Question 2

PICC - Insertion

Answer 2

• under sterile conditions, inserted by radiologists under fluroscopic guidance
• patient preperation
  
  • ID confirmed, consent form signed
  • patient well hydrated
  • completed post-op checklist
  • clotting profile performed, anticoagulants ceased
  • any allergies documented
• must have xray to confirm location

Question 3

PICC - Post Insertion

Answer 3

• observations (in progress notes)
• insertion site
  
  • every 30mins for 2 hours, 4 x day for 24hrs, then once per shift
  • observe for redness / oedema of site
  • pressure dressing - for first 24hrs - if saturated by blood / drainage, change
• upper arm circumference
  
  • measure 7cm above antecubital fossa, increased circumference may be due to phlebitis, catheter migration or infiltration
• catheter patency
  
  • inability to aspirate, infuse, absence of flashback of blood on aspiration, pain / discomfort reported by patient

Question 4

PICC - Complications & Management

Answer 4

• complications
• catheter occlusion
  
  • patient positioning, gentle flushing, aspiration of clot / fibrin, do not remove, contact medical staff & document
• bleeding
  
  • apply pressure to site, minimal bleeding expected in first 24hrs, contact med staff, docment, replace dressing
• leaking catheter
  
  • contact med staff, if due to catheter fracture, repair using aseptic technique
• air embolism, thrombophlebitis or mechanical phlebitis
  
  • inflammation caused by catheter itself or occlusion? document S&S, contact med staff, elevate arm, warm compress
• infection (local or catheter related)
• catheter migration & cardiac arrhythmias

Question 5

PICC - Dressings

Answer 5

• maintain dry, intact dressing
• aseptic technique when changing dressing, sterile gloves, sterile drapes
• use of gauze under transparent dressing if excessive ooze
• changed 24hrs post insertion or anytie dressing becomes soiled, wet, or no longer occlusive
• never raise arm above head when insertion site uncovered (risk of air embolus)

Question 6

PICC - Dressing Technique

Answer 6

• inspect site - exudate, oedema, tenderness
• hand hygiene wash, open dressing pack, prepare equipment
• don non-sterile gloves, remove dressing & securing device
• aseptic hand wash for 60 secs using chlorhex
• don sterile gloves
• place sterile towel under patients arm
• clean insertion site in spiral pattern, inner to outer, x 6
• stabilise catheter using the securing device
• gauze may be placed under catheter insertion if ooze present
• place transparent dressing over insertion site, write date / time on it
• document - date of dressing change, appearance of insertion site, length of catheter as per markings, report any adverse events

Question 7

PICC - Removal

Answer 7

• done by RN / EN
• removed in entirety using aseptic technique
• apply dressing technique to removal of dressing
• to decrease risk of air embolism instruct patient to perform valsalvas maneuver during removal
• grasp catheter near insertion site, remove while applying constant parallel force, do not stretch catheter, inspect to ensure intact
• apply gauze dressing, apply pressure to site
• if required, cut last 3cm off PICC line & place in labelled specimen jar

Question 8

PICC - Removal Problems

Answer 8

• resistance felt on removing catheter
  
  • inject normal saline into catheter while slowly withdrawing the PICC, apply heat pack over site & catheter tract to minimise vasospasm
• catheter breaking during removal
  
  • promptly attempt to secure any remaining visible catheter
• place transparent dressing over site & point of fracture
• call med staff immediately, send to diagnostic imagining as requested
• document in notes

Question 9

CVC - Central Venous Catheter

Answer 9

• form of longer term venous access (7-10 days), longer than standard IV, but less than PICC
• indicated for
  
  • haemodynamic monitoring (CVP)
  • administration of drugs likely to cause phlebitis
  • administration of TPN
  • lack of peripheral venous access
  • secure IV access for inotropes & resuscitation
• single lumen or triple
  
  • distal port - CP monitoring, largest lumen & closest to r) atrium, viscous fluids, colloids, medications
  • medial port - TPN / other medications if no TPN running
  • proximal port - blood sampling - less contamination from infused substances

Question 10

CVC - Insertion Sites

Answer 10

• subclavian (most common)
  
  • least rate of infection, but most considerable risk of complications during insertion
• internal jugular
  
  • superficial access but most risk of complications
• femoral
  
  • highest rate of infection but easy access with no immediate life threatening structures in the way

Question 11

CVC - Management & Dressings

Answer 11

• potential risk of complications during insertion, patient monitored (ECG, NIBP, SpO2), monitored in high acuity department
• perpare patient as per PICC, immediate xray upon insertion to determine tip positions
• dressings performed weekly or on replacement or if excessive ooze present (sandwich or single occlusive)
• removal as per PICC

Question 12

Portacath

Answer 12

• surgically inserted port resevior with silicone hub for needle insertion & attached catheter extending along a large vein to the cavoatrial junction
• surgically implanted, appears as bump under skin on upper right chest
• completely internal so can swim / shower, low infection risk as skin disinfected & small needle used
• used to administer chemotherapy agents, antibiotics, TPN, blood & blood products