Peripherally Inserted Central Venous Catheters (PICCs)

Peripherally inserted centralvenous catheters (PICCs)Use, care, and managementMEDICAL

The reference for this pocket guide is the 2016 InfusionTherapy Standards of Practice.1This pocket guide addresses the following topics: Flushing Blood sampling Site assessment Dressing changes and securement Needleless connectors Potential complicationsNote: The following information is intended to serveas a quick reference tool. For complete instructionsand guidelines on the use, care, and management ofperipherally inserted central venous catheters (PICCs),please consult your facility’s policy documentation, thedevice’s Instructions for Use (IFU), and the appropriateguiding organizations and societies.2

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FlushingKey points for flushing* Flush and aspirate for a blood return prior toeach infusion. Flush after each infusion in order to clearmedications and/or nutrients from the line and flushthem into the bloodstream. Flush with preservative-free 0.9% sodium chlorideusing a 10 mL syringe with a minimum volume equalto twice the internal volume of the catheter system. Flush using a pulsatile technique to completely clearthe catheter of any residue. Never forcibly flush a PICC. Resistance to flushingmay indicate partial or complete occlusion. Discard the flushing syringe after a single use.*Verbatim instructions from pages S77-78 of the 2016Infusion Therapy Standards of Practice.4

Key steps for flushing1. Follow appropriate handhygiene and personal protectiveequipment (PPE) protocols.2. Perform a vigorous mechanicalscrub of the needlelessconnector, using a disinfectingagent that aligns with yourfacility’s policy, for a minimumof 15 seconds to disinfect itprior to each PICC access.3. Aspirate the PICC for a positiveblood return.4. Prior to each Luer attachment,repeat the scrub of theneedleless connector,and allow it to dry.5. Flush with preservative-free0.9% sodium chloride toclear the catheter of allblood residues.6. Repeat the scrub of theneedleless connector, andallow it to dry.7. Reinitiate infusion therapyas prescribed.Flushing5

Blood samplingKey steps for blood sampling1. Verify the patient’s identity using two identifiers. Mark theblood collection vials with patient-specific information.2. Follow appropriate hand hygieneand PPE protocols.3. Stop all infusions.4. Perform a vigorous mechanicalscrub of the needleless connector,using a disinfecting agent thataligns with your facility’s policy,for a minimum of 15 seconds todisinfect it prior to each PICCaccess, and allow it to dry.Note: When drawing blood, use either a syringe or avacuum vial container system. Follow the procedure forthe vacuum vial system according to the manufacturer’sinstructions, flushing when necessary, and proceed tostep 9 after you have obtained samples.5. If you are using a syringe, flush briskly using a pulsatiletechnique. Leave the syringe attached. Clamp and unclampthe catheter as needed to accessthe fluid path while preventingair intake.6. Withdraw 5 mL of blood, detachthe syringe, and discard the initial5 mL of blood. For multilumenPICCs, use the largest lumen; for PICCs with staggeredlumen exit sites, use the lumen that is farthest from thepatient’s heart.2 Note: Do not discard the initial 5 mL ofblood when obtaining blood for culture.6

7. Disinfect the needleless connectoras directed in step 4, and allow itto dry. Attach an empty, volumeappropriate syringe.8. Using the empty syringe, slowlywithdraw the required amount ofblood for the number of vacuumvials for your specimens. Thendisconnect the syringe from thecatheter, attach a transfer deviceto the syringe, and fill the vacuumvials. Gently invert the vial contentsand blood. Discard the usedsyringe and transfer device asone unit. Note: Never remove therubber stopper from the vials asa method to decrease the risk ofblood exposure, accidentalneedle stick injury, or error insample analysis.9. Disinfect the needleless connectoras directed in step 4, and allow itto dry.10. Attach a new flushing syringe,and flush with 10-20 mL ofpreservative-free 0.9% sodiumchloride, until all blood is clearedfrom the catheter.11. If the original connector wasremoved or has visible blood,attach a new, sterile, and primedneedleless connector, and flush.12. If necessary, restart the infusionsthat were stopped in step 3.Blood sampling7

Site assessmentKey steps for performing a site assessment1. Follow appropriate handhygiene and PPE protocols.2. Assess the dressing to makesure that it is clean, dry, andintact. Change the dressing asneeded, and label it with eitherthe date that the dressingchange was performed orshould be repeated, based onyour facility’s policy.3. Assess the PICC catheterskin junction site andsurrounding area forredness, tenderness,swelling, and drainage byvisual inspection andpalpation through theintact dressing.4. Assess the external lengthof the PICC and comparethe length to the previousmeasurement. If the lengthhas changed, the PICC maynot be safe to use untilthe tip position has beenconfirmed.8

5. Measure the circumferenceof the arm in a consistentlocation. Identify and recordthe location and othercharacteristics, such aspitting or nonpitting.Compare this to the baselinemeasurement of thecircumference of the arm inorder to detect possiblecatheter-associated venousthrombosis.6. Check that the catheter isworking properly. If bloodreturn or flushing is inhibited,see the “Potential complications”section at the end of this guide.7. Check the needlelessconnector for the presence ofblood. If residual bloodremains after flushing, replacethe needleless connector.See the “Needleless connectors”section on pages 14-17 for thesteps for changing the needlelessconnector.Site assessment9

Infusion system assessment checklistIn addition to performing a site assessment, inspect the infusionsystem for the following:Correct infusateClarity of the infusateIntegrity of the systemPrescribed flow rateExpiration dates of the infusateand the administration set10

PICC necessity checklistThe CDC, INS, SHEA, and IHI recommend the immediateremoval of a PICC after it is no longer necessary.1,2,3,5To decide whether or not a PICC is still necessary, the INSproposes asking these four questions:Have any intravenous medications been administeredwithin the last 24 hours? Were these pain medications only?Are there alternative therapies that could be used, orcan the patient be switched to oral medications toeliminate the need for the PICC?Does the patient require frequent blood draws?Is the patient eating and drinking adequate amounts?Site assessment11

Dressing changes and securementFunctions of PICC dressing and securement Keeps the site clean and dry Protects the site from trauma Provides a barrier to prevent bacteria fromcontaminating the insertion site Prevents the catheter from dislodgingKey steps for dressing changes and securement1. Follow appropriate hand hygieneand PPE protocols.2. Position the patient with thearm extended and head turnedaway from the site, or havethe patient wear a mask.3. Perform a site assessment.4. Remove the dressing by pullingup and toward the insertion siteso that you do not accidentallypull or dislodge the catheter.5. After the dressing is removed,release the catheter from thesecurement device.6. Properly discard the dressingand the securement device.Remove the gloves and washyour hands.7. Open the assembled suppliesand establish a sterile field.8. Put on sterile gloves.12

9. Cleanse the insertion site. Followyour facility’s policy when youselect the disinfecting agent.10. Apply the sterile, suturelesssecurement device to secure thecatheter, and apply a new dressingto cover the entire area aroundthe insertion site, including thesecurement device. Use gauzeif needed.11. Measure the external length ofthe catheter, and compare thelength to the previousmeasurement. If the length haschanged, the PICC may not besafe to use until the tip positionhas been confirmed.12. Change the needleless connector,and flush the lumen(s), assessing forblood return and function inaccordance with your facility’s policy.See the “Needleless connectors” section on pages 14-17for the steps to change the needleless connector.13. Document the dressing change, including the stepstaken in the site assessment.Dressing changes and securement13

Needleless connectorsKey points for needleless connectors Disinfect needleless connectors before and after eachentry into the device per the manufacturer’s IFU and yourfacility’s policy. Use an aseptic, no-touch technique to change theneedleless connector. Only access needleless connectors with a sterile device. Avoid using a needleless connector when rapid flow ofinfusate is required. Follow the manufacturer’s IFU for the appropriate sequenceof catheter clamping and final syringe disconnection inorder to reduce the amount of blood reflux into thePICC lumen.14

Perform a vigorous mechanical scrub of the needlelessconnector, using a disinfecting agent that aligns with yourfacility’s policy, for a minimum of 15 seconds to disinfect itprior to each PICC access, and allow it to dry.Note: At the time of this publication, the INS and theCDC have not yet specified a required time fordisinfection; however, evidence suggests that a scrubof at least 15 seconds is effective in reducingmicrobial contamination.4 Standardizing the type of needleless connector within yourfacility may reduce the risk for confusion about these stepsand improve outcomes.Needleless connectors15

Needleless connectorsKey steps for accessing needleless connectors1. Follow appropriate hand hygiene and PPE protocols.2. Open a disinfectant prep pad.3. Grasp the hub of the PICC in your nondominant hand.4. Use your dominant hand to vigorously scrub theneedleless connector, using a twisting motion, for aminimum of 15 seconds.5. Allow the needleless connector to dry.6. Access the needleless connector with the syringe or IVtubing, opening the clamp, if necessary.7. Wash your hands again when you are done.Key steps for changing needleless connectorsThe reference for this content is the CDC’s Basic InfectionControl and Prevention Plan for Outpatient Oncology Settings.51. Follow appropriate hand hygiene and PPE protocols.2. Perform a vigorous mechanical scrub of theneedleless connector, using a disinfecting agentthat aligns with your facility’s policy, for a minimumof 15 seconds to disinfect it prior to each PICCaccess, and allow it to dry.3. Remove and discard the old needleless connector.4. Attach the new, flushed needleless connector to thecatheter hub by using aseptic technique.5. Wash your hands again when you are done.16

Additional reasons to change the needleless connector If the needleless connector is removed for any reason If blood or debris is within the needleless connector Prior to drawing laboratory blood culture samples fromthe catheter If the needleless connector becomes contaminated Per your facility’s policy According to the manufacturer’s IFUNote: The needleless connector must be thoroughlydisinfected before every access.Needleless connectors17