1. INDICATION:          To provide long-term venous access and improve nutrition parenterally.

2. EQUIPMENT:

• Sterile gown

• Powder-free sterile gloves

• Surgical hat and mask

• X-ray plate

• Catheter and introducer kit

• Heparin 3 units/ml mixed with sterile saline

• Insertion kit containing:

  • 3-3cc syringes with heparinized normal saline (sterile)

  • 1-1cc syringe (empty)

  • Steri-strips, 2 packs

  • 2 Transparent Semi-permeable membrane dressings (Opsite 3000)

  • Sterile water

  • Cotton balls, gauze, tourniquet

  • Sterile foam adhesive dressing

  • Sterile non-adhering dressing

  • Sterile towels

• Chlorhexadine skin cleanser

• Betadine swab sticks

• (Chlorhexadine swab sticks should be available soon to replace the chlorhexadine skin cleanser and betadine swabs)

  Clave: a. use clave with positive pressure plus forward fluid displacement.  No clamp is required   (eg. CLC2000 from ICU Medical)

  b. use clave with positive pressure, no clamp is required   (eg. BD Posiflow from Becton, Dickinson)

  c. do not use clave with negative backflow, clamp is required   (eg Alaris Medical)

3. PROCEDURE:

1. Have informed consent on chart.

2. Write orders for fentanyl IV/IM for procedure, restraint order, and chest x-ray requisition

3. Verify the identification of the patient by checking the ID band on the infant with the signed Consent Form.

4. Estimate length of insertion by measuring with a tape measure externally.

5. Restrain infant in open bed warmer with cardio-respiratory-saturation monitor.

6. Prepare arm, shoulder, and axilla with chlorhexadine solution for three minutes and rinse.(omit this step when the chlorhexadine swabs are available)

7. Wash hands and don sterile garb.

8. Prepare arm, shoulder, and axilla with betadine using sterile technique. Smaller infants may need their hands and wrists prepared if the dressing is estimated to extend over a large portion of their smaller arm. (use chlorhexadine swabs when available)

9. Drape the infant with sterile towels.

10. Rinse betadine from area, rinse powder from gloves with sterile water.

11. Prepare sterile tourniquet and cut steri-strip packs in half.

12. Flush introducer needle and catheter with heparinized normal saline, tighten blue hub.

13. Place tourniquet above insertion site and clamp with hemostat.

14. Insert needle into vein, establishing blood return.

15. Thread catheter through the needle, using iris forceps, until the catheter is past the tip of the needle.

16. Remove the tourniquet and advance the catheter to the predetermined depth.

17. Holding catheter securely, remove needle from the skin.

18. Loosen the blue hub and remove catheter from the hub. Slide the needle off the catheter.

19. Reinsert catheter into the blue hub and re-tighten. Observe for position of the washer located inside the blue hub. It should remain flat to attain a seal.

20. Aspirate to confirm blood return in the catheter, flush with heparinized saline.

21. Secure catheter with a steri-strip and call for x-ray.

22. If catheter tip cannot be adequately visualized due to opacification of the lungs on x-ray, a water-soluble contrast medium may be indicated.  Conray 30, 0.26cc should be injected into the catheter slowly. Wait 5 seconds to allow any excess contrast to be taken away. Take AP chest x-ray that includes the arm and shoulder. The arm position during x-ray should be at the baby’s side since this is the position of comfort when at rest. It is important to remember that extending the arms above the head may increase the depth of the catheter tip. If the catheter tip is located in the right atrium on subsequent x-rays while the arms are extended above the head, repeat the x-ray with the arms at the sides before undressing the PICC and pulling back the catheter.

23. Remove contrast from the catheter, if possible, by aspirating with a syringe until blood is pulled back to the clear connector. Disconnect the blue hub from the catheter and flush out the blood and contrast from the clear tubing. Flush the clear tubing with heparinized saline and reconnect to the catheter. Flush the catheter with heparinized saline solution and maintain positive pressure.

24. Adjust the catheter position as indicated. If the catheter is inserted further, repeat the x-ray. If the catheter is withdrawn more than one centimeter, repeat x-ray. If contrast is used for the x-ray, repeat step "22" for contrast removal.

25. Clean any blood from site prior to dressing. Apply steri-strips over the catheter at the insertion site. Loop external catheter and anchor with steri-strips.

26. Place adhesive foam dressing or non-adhering dressing under the blue hub connection to protect the skin

27. Secure catheter and blue hub connection with Opsite. Turn back the clear tubing while maintaining a gentle loop proximal to the blue hub. Place Opsite over the loop and the dressing beneath, enclosing the entire site. Avoid circumferential dressings. Reinforce the exit site of the clear tubing with non-sterile tape to decrease traction on the Opsite and to maintain integrity of the dressing.

28. Flush the clave with heparinized saline and attach to the end of the extension tubing. Remove and discard the clamp on the clear tubing, since it will be unnecessary with the use of a positive pressure clave. The clave will remain with the PICC for the entire insertion time to maintain a closed system during changes of TPN and IV tubing. Prior to changing the IV tubing or attaching a flush syringe, the clave should be cleansed with betadine, and allowed to dry for 30 seconds. The betadine should be removed with alcohol to prevent sticky build up. Remove syringes from the clave to maintain positive pressure.

29. If new TPN will not be available within two hours of the PICC insertion, the current fluids will be used. Draw the fluids into a syringe from the buretrol, using sterile technique, and infuse the fluids with a medication infusion pump and extension tubing until the new TPN arrives. If the current fluids are not heparinized they may be run until the new heparinized TPN arrives.

1. Change the bifusion/two-way connector and the quadfusion/four-way

connector every 72 hours with the buretrol change. Place a clave on the

intralipid port. At this site either a positive pressure clave (eg BDPosiFlow or

CLC2000) or a non-positive pressure clave (eg. Alaris) may be used. This will

keep the system closed when IL are changed every 24 hours. When the

buretrol and connector are changed every 72 hours, the IL clave will be

discarded with the buretrol tubing. The PICC clave will remain intact on the

PICC for the duration of the PICC.

Note: Practice prior to March 2001 had been to change Intralipid tubing every 24 hours. Close surveillance of the nosocomial infection rate in the subsequent 6 months should reveal whether the new practice of changing IL tubing every 72 hours is safe as well as practical.

2. Documentation for insertion should include: permit from parents is on the

chart, skin preparation, sterile drapes, sedation amount, initial insertion depth,

adjustment of insertion depth, insertion site, state that the catheter was not cut

prior to insertion, comment on blood loss, sterile dressing applied, how infant

tolerated the procedure, any complications, comment on the correct placement

confirmed by xray and if contrast was used.

 

Please also record the lot number of the PICC line that was placed in the patient.

4. COMPLICATIONS:

• Infection

• Bleeding at the insertion site

• Occlusion of the catheter

• Superior vena cava syndrome

• Pericardial effusion

• Pleural effusion

• Perforation of the vessel with subsequent extravascular infusion of IV solutions