Peripherally Inserted

Central Catheter (PICC)

Trouble Shooting
Chantal Miljours, RN BScN
Clinical Nurse Educator
Diagnostic Imaging Department
North Bay Regional Health Centre
 Objectives

 How and why PICC lines are inserted

 Identify catheter occlusion and trouble
shooting methods
 Identify potential causes for redness in PICC
arm and at insertion site
 Air Embolism
 Case Studies
 Purpose of Central Venous
Access Device

 To infuse fluids (allows for large volume boluses)

 No peripheral access
 To infuse TPN
 To infuse medications
 To sample venous blood (when no peripheral access
is available)
 To provide a method for hemodynamic monitoring
i.e.: right atrial and PA pressures(acute care setting)
 Blood Vessels involved in Central
Venous Therapy
 basilic
 cephalic

 axillary

 jugular

 subclavian

 innominate

These veins all lead

to superior vena cava
Central Venous Access Devices

Port-a-Cath

Hickmann Line
 Central Venous Access Devices

Short term central catheter

Peripherally Inserted Central Catheter

PICC Line Placement
PICC Line Placement
 PICC Lines
 PICC lines are inserted as a
sterile procedure in the
diagnostic imaging
department
 Both Ultrasound and
Fluoroscopy are used insert
the PICC line and confirm
proper placement
 Insertion is performed by
specially trained nurses and
placement is confirmed by
the radiologists
 STATS 2014
PICC lines 2014

356 PICC lines inserted 140

in 2014 120

100

80
 12% for TPN 60

 39% Antibiotics 40

 39% Chemotherapy 20

0
 10 % other TPN Abx Chemo Other
 Troubleshooting
 In 2014 we saw 149
3% 1%1%
patients for PICC line 5%

troubleshooting
9%
Declot
Difficulty Removing PICC

 Only 57% of these 10%

No Problem
PICC pulled out

patients required 57%

Cap changed
3 cc syringe

thrombolytics Extra saline flush

Line Kinked
14%
 CVAD Occlusions

There are 3 types of occlusions

 Complete
 Partial
 Withdrawal
 Signs of a CVAD Occlusion
 Resistance when flushing
 Sluggish flow
 Inability to infuse fluids
 Frequent occlusion alarm on infusion pump
 Infiltration or extravasion or swelling or
leaking at insertion site
 Inability to withdraw blood
 Sluggish blood return
 Complete Occlusions
 Inability to infuse or
withdraw blood or fluid
into the CVAD
 Can be mechanical,
chemical or thrombotic
 Withdrawal Occlusions
 Inability to aspirate blood but ability to infuse
without resistance
 Lack of free-flowing blood return
 Partial Occlusions
 Decreased ability to infuse fluids
 Resistance with flushing and aspiration
 Sluggish flow through the catheter
 Can me mechanical, chemical, or thrombotic
 Types of Thrombotic Occlusions

Intraluminal Fibrin Tail Fibrin Sheath Mural

 Often cause  Fibrin adheres to  Fibrin adheres to
 Occurs when fibrin
complete catheter the end of the the external surface from a vessel wall
occlusions injury binds to
 Develops from catheter and causes of the catheter,
more cells to be creating a “sock” fibrin covering the
blood build up as a
result of deposited on the over the catheter catheter surface
insufficient tail  Occasionally the
 Caused by the
flushing, catheter rubbing in
inadequate infusion  Acts as a one-way sheath covers the
rate, or frequent valve: fluids can be end of the catheter the vessel,
blood withdrawals pushed out but with and causes traumatic insertion,
aspiration the tail is occlusion or poor blood flow
sucked back over
Dual-Lumen PICC (Navalist)
 Fibrin Sheath Occlusions
 Fluid can usually be
injected, but blood
cannot be aspirated
 Infiltration/
extravasation can occur
when medications are
infused up the fibrin
sheath and back to the
insertion site
 May cause mixing of
incompatible solutions
CASE STUDIES
 Case Study #1: The Repeat
Offender
 69 year old patient receiving antibiotics
through the PICC line is sent to DI by
homecare for a withdrawal occlusion. This
patient has been seen multiple times in the past
2 weeks.
 Chemical Occlusions
 Many PICC line
occlusions are caused
by a build-up of
precipitate from
antibiotic or other
medications
Precipitate
 Troubleshooting tips
First determine there is no mechanical cause
for the occlusion
 Assess for kinks, closed clamps, or change in
external length
 Assess for clogged cap or if the cap is on too
tight (finger tip tight)
 Assess for positional catheter:
 Reposition arm, have patient cough, put patient in
Trendelenberg position
 The Art of Flushing
 Knowing how PICC
feels with flushing can
tell you what is
happening with PICC
 Flush with 20ml Normal
saline turbulent flush to
each port after each use
 May require daily flushes
depending on medication
i.e. Vancomycin
 Troubleshooting tips
 Remove any add on
devices such as cap or
y-connector and attempt
to aspirate and flush the
catheter directly at the
hub with normal saline
 Consider changing the
dressing to ensure there
is no twisting/kinking of
the catheter
 Troubleshooting tips
Once mechanical obstructions have been ruled out:
 If no blood return on aspiration, may alternate
gently drawing back and then gently flushing
 Try using a dry 3cc syringe to aspirate blood
returns as it exerts less negative pressure when
withdrawing
 If still unable to get returns will require Cathflo
instillation.
 Consider radiography to determine malposition of
the catheter tip
Case #2: What Do You See?
 Case #2
 Patient sent to ED with a blocked PICC line, home
care nurse unable to flush or get venous returns
 Upon assessment in ED blood noted backed up in
catheter hub. Cathflo instilled overnight in ED for
complete occlusion.
 Patient to return in am for follow up assessment in am
with DI Nurse.
 Case# 2
 What is missing?
 What is wrong with
this PICC?
 Solution
 When questioned about the missing clamp, the
patient states “ the nurse cut it off because it was
digging into his skin”
 Do Not Remove any clamps that is attached a CVAD
 RISK OF AIR EMBOLISIM
 Patient required new PICC line insertion
 If unsure about type of CVAD device look it up or
consult with DI nurse.
 CVAD 911 Emergency!
 Damaged PICC line,
hickmann line or any
central line
 RISK FOR AIR
EMBOLUS
 DVT
 Air Embolism
 Venous air embolism can occur during time
CVC insertion, while catheter in place or at
time of removal
 Air can easily get into vascular system when
needle or catheter open to atmosphere
 As little as 200ml of air can be fatal
 Signs and Symptoms
Air Embolism
 Sudden complaints of dyspnea
 Respiratory distress
 Coughing
 Chest pain
 Tachyarrhythmia's
 Cardiovascular collapse
 Treatment for Air Embolus
 Lay patient on left side
 Trendelenberg position
 100% oxygen
 Call 911
 Supportive measures ( i.e. fluid resuscitation)
Case #3 :What Do You See?
 CASE: 3
 65 year old woman with breast cancer is
receiving chemo through a PICC line in the
right basilic vein
 CT tech unable to get blood returns from PICC
 Pt had states had a recent fall on the ice
injuring her right shoulder
 Upon further exam noted distended veins
 Case #3: Deep Vein Thrombosis
 The patient had an obstrutive DVT in her right arm
from the basilic vein to the subclavian vein
 Sent to ER for treatment of DVT
 PICC line pulled and reinserted after DVT resolved
“70-80% of thrombotic events occurring in
superficial and deep veins of upper extremity are
due to the presence of intravenous catheters”
 DVT
 An extraluminal thrombus can
progress to a deep vein
thrombosis (DVT)
 Fibrin build-up from the vein wall
to the catheter may cause
blockage of blood flow in the
vein
 This can lead to SVC syndrome -
when the SVC is completely
occluded and venous return
cannot empty into the right heart
to be oxygenated
 This is an emergency!
 DVT
 Pt may experience
redness to arm localized
or can extend up arm
 Swelling to arm or
hand(compare to non
PICC line arm.
 May experience pain to
arm chest neck
 No fever noted
Vein Measurement
Thrombus to Vein
Case Study # 4: The Quick Draw
 60 year old female with hx of breast cancer,
presented to ED with a fever .
 Urine culture came back positive and admitted
to hospital for urosepsis and was started on
antibiotics
 No blood culture drawn from PICC
 PICC line pulled and tip sent for culture, came
back negative
 Case # 4
 Patient starting to improve on antibiotics
 A febrile now
 Limited peripheral veins due to lymph node
involvement
 Important to establish if patient has a true
Catheter Related Blood Stream Infection
(CRBSI) in order to decide whether to salvage,
exchange, or remove the catheter.
 Systemic Antibiotic Therapy is
NOT required for the following:
 Positive catheter tip in absence of clinical
signs of infection
 Positive blood cultures obtained through a
catheter with negative cultures through a
peripheral vein
 Phlebitis in the absence of infection, the risk of
CRBSI usually low
 CRBSI –catheter removal
 Severe sepsis
 Hemodynamic instability
 Endocarditis or evidence of metastatic infection
 Erythema or exudate due to suppurative
thrombophlebitis
 Persistant bacteremia after 72hrs of antimicrobial
therapy to which the organism is suseptible
 Difficult PICC line Removal
 This usually due to venous spasm
 Sometimes PICC lines can be difficult to
remove especially if catheter too big for size of
vein
 Ask patient to relax arm
 Apply warm compress
 After these measures the PICC line usually
comes out easily
Case #5:What do you see?
 Contact Dermatitis
Dermatitis
 Dermatitis presents as reddened irritated skin
at the site
 Always allow antiseptic (ie. Chlorhexidine) to
dry completely before applying dressing
 Consider changing dressing to IV3000

 Consider changing antiseptic solution to

povidone-iodine solution
Case #6 : What Do You See?
 PICC Line Site problems
Infection vs Dermatitis
 Dermatitis presents as reddened irritated skin
at the site
 Infection presents as redness, swelling,
warmth, and possible purulent drainage at site?
 Does patient have a fever?

 Does patient have any swelling to arm?

What do you See?
 PICC Line Infection
 Send to ER with signs of sepsis (ie. Fever,
chills, tachycardia, hypotension)
 Rule out other sources of infection
 Obtain cultures – draw blood culture from
PICC line (do not discard a waste sample) and
consider swab for C&S if site infection noted
 Administer antimicrobials
 Do not necessarily pull the PICC!
 Prevention
 Good hand hygiene
 Ensure to “Scrub the hub”
with Chlorehexidine for
minimum 30sec prior to
accessing devices
 Wear sterile gloves and mask
(pt should wear mask as well)
anytime opening dressing.
 Removal of unnecessary
CVC should be regularly
assessed.
 Leaking at PICC site
 If leaking at site is
present when flushing
or infusing through
CVAD
 Send to DI for catheter-
o-gram (to rule out a
hole in the catheter)
 Doppler studies (to rule
out thrombosis
 Case 4: Pain in the neck
 A 59 year old man with a PICC line in the right
basilic vein presents with a withdrawal
occlusion.
 Has also been complaining lately of a constant
“wooshing” sound in his right ear
 The patient has been vomiting lately due to
chemo treatment
 Chest xray done to confirm proper placement…
 PICC line malposition
 PICC line must be removed and reinserted
 If PICC pulled out more than 2cm from
original position, tape it in current position do
not pull it out completely
 Do Not attempt to push catheter back into
position
 Do not use PICC until tip placement
confirmed by chest X-ray
 Cracked PICC
 If there is a crack or a hole present, determine
location
 Fold catheter over on itself and cover with
tegaderm or other film dressing
 Close catheter clamp if there is one
 Send to hospital right away
 Cap on TOO Tight

Crack more
visible with
cap on

Crack faintly visible

with cap off
 Prevent Damage to PICC

 Never put steri-strips over picc line, always

make sure they are underneath the line or on top
of white wing
 Do not force fluid into PICC if resistance is met
 Ensure clamps are open before attempting to
flush
 Do not over tighten cap
 Broken PICC
 If the end of the catheter
breaks off grab CVAD (to
prevent it from migrating
internally)
 Fold catheter over, cleanse
catheter, tape securely to
arm, and send patient to
hospital right away with the
external portion of the
catheter
 Monitor for air embolism
 Broken PICC
 If catheter disappears inside vein:
 Apply tourniquet to upper arm close to axilla
 Place patient in Trendelenburg position

 Call 911

 Monitor for air or obstructive embolism

QUESTIONS ???