Nurse led PICC line insertion procedure (G071)

NHS Ayrshire & Arran guidelines

NHS Ayrshire and Arran

Objectives

The aims of these guidelines are:

To provide comprehensive guidance on the insertion of PICCs in adult patients.
To support and encourage the use of PICCs as an alternative to traditional central vascular access devices.

Audience

This guidance is applicable to nurses who:

have undertaken a University accredited advanced vascular access course.
completed supervised practice.
are deemed competent by an appropriate practitioner.

Introduction

The peripherally inserted central catheter (PICC) is a central vascular access device (CVAD) which is placed via the antecubital fossa using either the basilic or cephalic vein, the tip of the catheter must lie in superior vena cava (preferably lower third). PICCs can be open-ended or valved and management of the catheter is different in both cases. Using correct management techniques the catheter can remain insitu for many months.

Guideline information

Inclusion criteria

Placement of a PICC should be considered for patients who meet the following criteria:

Delivery of intravenous therapy with a duration of more than 2 weeks.
Delivery of chemotherapy.
Delivery of irritant or vesicant intravenous therapy.
Delivery of total parental nutrition (TPN)

Referral

Referral for PICC placement can be undertaken by a Medical Referrer or a Clinical Nurse Specialist who has been entitled by the Department of Medical Imaging to act as a referrer for this procedure.

The referrer must ensure that the nursing staff caring for the patient has undertaken organisational training on the care and maintenance of CVADs. If not both the referrer and charge nurse of the ward need to be informed.

Following referral

Patient will be sent an out patient appointment by the x-ray office including a PICC line information booklet.

The PICC line insertion nurses will explain the procedure to the patient and obtain written consent for PICC line insertion and review recent blood results.

Equipment required for PICC line insertion

Cleaned dressing trolley.
Venous access pack.
Scissors.
Micro-introducer kit.
100mls bag 0.9% saline.
Contrast media visipaque 270.
Lidocaine 1%.
Biopatch.
2% chlorhexidine in 70% alcohol (Chloraprep)
1 transparent semi-permeable dressing.
Sterile gown and gloves.
Tourniquet.
Medcomp PICC 4F/5F.
Hepsal 10iu/ml to lock line.
Short connecting tubing.
Securacath/griplock.
Bionector and curos cap.

Procedure for insertion of PICC lines

	Procedure	Rationale
1.	Perform procedure in a designated clean area e.g. operating theatre clinical room.	To facilitate optimum infection control practice.
2.	Check patient identity and check patient’s blood results including coagulation screen and platelets.	Ensure correct patient and check blood results are within correct parameters.
3.	Check patient and veins suitable for PICC placement.	Is this the most appropriate device for the patient?
4.	Explain and discuss procedure to patient. Assess the patient’s level of anxiety and give appropriate reassurance. Obtain written informed consent.	To help relieve patient’s anxiety and satisfy medico – legal requirements.
5.	Position the patient comfortably on the x-ray table. Ensure doors are shut.	Maintain patient’s privacy and ensure comfort.
6.	Extend the patient’s arm 90 degrees to their body and place the tourniquet on the arm.	This gives the approximate length of catheter to be inserted
7.	Use ultrasound to identify a suitable vein.	To visualize optimum vein.
8.	Hands should be thoroughly washed, using a technique, which aims to cover all surfaces of the hands. The use of a surgical scrub is recommended. Hands should be rinsed in running water before and after applying the cleansing agent and dried well with a sterile towel. Alternatively, an alcohol hand rub can be used on visibly clean hands.	To comply with EPIC guidelines on hand hygiene.
9.	Put on sterile gown and apply well-fitting sterile gloves.	To comply with EPIC guidelines.
10.	The scrub nurse will open insertion pack and create sterile field using drop technique. The floor nurse will open other equipment required using the same technique.	To prevent contamination of sterile field and maintain asepsis.
11.	Ask assistant to open PICC line and drop sterile inner pack onto sterile field.
12.	Prime the PICC with 0.9% saline.	To lubricate the hydrophilic stylet in the catheter.
13.	Arrange sterile supplies and draw up 2mls Hepsal 10iu/ml (to lock line after insertion)
14.	Ask patient to raise arm to enable sterile towel to be placed under arm.
15.	Clean 10-15cms around the intended insertion site in concentric circles with 2% Chlorhexidine in 70% alcohol. Clean in circular motion working outwards. Allow solution to dry. For patients with a history of chlorhexidine sensitivity povidone iodine with an alcohol base of at least 70% is recommended.	To comply with EPIC 2 guidelines on CVC insertion.
16.	Place fenestrated drape over top of patient’s arm and a large patient drape to cover patient.	To create a sterile field.
17.	Using ultrasound, identify the vein and inject lidocaine 1% intra-dermal and perform venepuncture using a micro-introducer cannula and insert the guidewire. Remove the cannula and insert peel away sheath.	To gain venous access.
18.	Release tourniquet. Remove wire and attach connecting tubing to peel away sheath to inject contrast for venogram. If there is a known allergy to contrast media- DO NOT carry out this step.	To release pressure within the vein. To confirm access is in a vein.
19.	Place measuring wire and cut to desired length. Remove dilator from peel away sheath and insert PICC over the wire into peel away sheath.
20.	Use fluoroscopy to confirm tip position, adjust as is necessary and remove peel away sheath. Apply gentle pressure on catheter and remove the guide wire slowly.	To check tip position.n Removing guide wire fast may damage catheter.
21.	Position of the line should be verified by the duty radiologist. NB: Do not use line until position checked.	To check tip position.
22.	Aspirate for blood return and flush with 0.9% sodium chloride.	To check patency of device.
23.	Lock with 2ml Hepsal 10iu/ml. Attach bionector & Curos cap. Fix the catheter in place using the fixation method of choice, securacath/Griplock.	Ensure the catheter does not move and prevent damage to the catheter.
24.	Clean the area and place a biopatch around the catheter and cover with a transparent semi-permeable occlusive dressing. If there is oozing of blood from the venepuncture site cover the dressing with a small cling bandage.
25.	Dispose of equipment appropriately.	Dispose of sharps and clinical waste in accordance with Trust policy to maintain safe environment for patients /colleagues.
26.	Document the procedure in the patient's notes.	To meet medico-legal and NMC requirements.
27.	Ensure patient is booked for renewal of dressing and line check 24 hours post insertion with district nurse.

Potential complications of PICC placement

Nursing assessment	Nursing interventions
Air embolus (very rare) Symptoms: Chest pain, dyspnoea, air hunger, tachycardia, hypotension, confusion, restlessness.	Immediately place patient into a left lateral, steep Trendelenburg position. Notify doctor, initiate oxygen and remain with the patient. Attach cardiac monitor and pulse oximeter if available. BP, pulse and respiration rate every 15 minutes. If an outpatient, transfer patient to ward as soon as possible.
Arterial puncture Symptoms: Bright red colour blood flashback, pulsatile blood flow.	Withdraw cannula immediately. Apply pressure at cannulation site for at least 5 minutes. Elevate limb and observe for haematoma. Refer to doctor to assess if further action needed.
Bleeding	Excessive bleeding for more than 24 hours after PICC catheter insertion requires further investigation for coagulation status. Apply moderate pressure dressing and change sterile dressing when applicable.
Cardiac arrhythmia Symptoms: chest pain, palpitations, dyspnoea. On checking, patient demonstrates irregular heart rate.	Potential need to reposition PICC tip to middle to lower third of superior vena cava to allow normal arm movements. Confirm tip placement by X-ray. Secure catheter securely to prevent internal and external migration of line. Check pulse and BP every 15 minutes. Attach cardiac monitor if available.
Catheter malposition or migration Symptoms: Referred pain in jaw, ear, teeth or shoulder.	During catheter placement, turning the patient’s head toward the insertion side while advancing the catheter can reduce the risk of entry into the internal jugular vein. Spontaneous migration may occur during coughing, sneezing or vomiting. PICC tip verification by x-ray should be obtained before using catheter.
Venous spasm Symptoms: Inability to advance catheter despite successful cannulation.	Venous spasm can be avoided by ensuring that arm & axilla are warm, patient is well hydrated and comfortable. Consider use of mild sedative for anxious patient. In the event of spasm during placement, application of heat to the arm can reduce venous spasm. Flushing line with 0.9% normal saline whilst placing line. Leave catheter insitu.
Catheter in incorrect position on chest x-ray	Leave catheter insitu. Do not use catheter. Re x-ray in 24hrs time to see if catheter has migrated into correct position. If catheter remains in incorrect position, re-refer to PICC service.

Equality and diversity impact assessment

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.,

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline; however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

Last reviewed: 31/08/2023

Next review date: 31/08/2026

Author(s): McMahon S.

Version: 2.5

Approved By: Imaging Governance Group

Internal URL: http://athena/cgrmrd/ClinGov/DraftGuidance/G071%20-%20Nurse%20Led%20PICC%20Line%20Insertion%20Procedure.pdf

References

Pratt RJ; Pellowe CM; Wilson JA; Loveday HP; Harper P; Jones SRLJ; McDougall C; Wilcox MH (2007), Epic 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection.