complicationmanagmentofpiccs

The Management of complications in relation

to PICCs

A. MECHANICAL PHLEBITIS Mechanical phlebitis is where the movement of a foreign object within a vein is the cause of the inflammation and is the most frequent complication associated with PICCs. Occurrence is normally evident within 10 days of insertion, therefore it is crucial to observe for signs and symptoms in the early stages. Symptoms will be present around the bicep region, above the PICC. As the PICC travels within the vein towards the superior vena cava the veins become larger therefore accommodating the PICC without damage to the vein wall. The symptoms include:

o Redness o Swelling o Pain o Skin warm to touch o Venous Cord (hard, palpable vein tracking up the arm)

The above symptoms can be confused with the development of infection. Incorrect diagnosis can lead to the premature removal of the catheter or the unnecessary use of antibiotics. Management Follow Flow Chart 1 When symptoms of mechanical phlebitis are present, it is imperative that regular observation and assessment of the symptoms and of the patient is performed. It is important to assess for other causes such as thrombosis or infection. Asking the following questions will help to exclude other complications:

• Is the catheter difficult to flush • Can blood be withdrawn from the catheter • Is the arm swollen or discoloured • Is there pain in the shoulder or the neck • Is the patient pyrexial and displaying signs of infection • Is the exit site red, inflamed or is there exudate present •

If there is no evidence to suggest other complications, treatment for mechanical phlebitis will commence depending on the severity of the symptoms. The PICC can still be used when symptoms of mechanical phlebitis are present. However, if the symptoms become severe and there is no response to treatment, removal of the PICC may be considered.

M.Hughes/IVAccess/CompPICCs/2006 2

Flow Chart 1

Redness, swelling and pain above PICC. Tracking up the arm

Has the PICC been in situ for less than 12 days

No Yes

Is the patient pyrexial or are there symptoms of infection at the exit site

Consider


Mechanical Phlebitis

Symptoms of Thrombosis: Swelling of the arm, neck or shoulder Pain in the shoulder Bleeding at the exit site Discolouration of the skin Distension of the veins in the

Yes

Are there symptoms of thrombosis

Yes Treat for Thrombosis as per local policy

Are there symptoms of thrombosis

No Yes

Yes Inform Dr. and consider Infection as the cause and treat with anti-biotics.

No

Are the original symptoms of mechanical phlebitis mild

No. Moderate to severe

Yes

Consider treating with hot and cold therapy at the site of redness and observe in 3-4 days.

Inform the Dr. and Consider prescribing non-steroidal anti- inflammatory medication (unless contraindicated) and heat and cold treatment to the upper arm. Evaluate in 3-4 days, or advise pt.to report any changes in symptoms.

No

Is the patient pyrexial or are there symptoms of infection at the exit site

B. WITHDRAWAL OCCLUSION Withdrawal Occlusion (WO) can be described as the inability to withdraw blood via the catheter but it retains a capacity to infuse solutions without difficulty (Mayo 2001). The main significance of WO is that the practitioner cannot be certain that the catheter is in the vein when there is no free flowing blood return (Masoorli 2002). A satisfactory blood return is the verification that the catheter is in a vein and that the catheter is functioning correctly prior to any intravenous therapy. The most serious, though rare consequence of WO is the leakage of vesicant or irritant drugs into the surrounding tissues which can potentially cause extravasation injuries. This event is extremely rare in PICCs. WO can result from a number of causes and can be classified as non-thrombotic or thrombotic. However, it is a thrombotic event that is the major cause of WO. Non-thrombotic causes:

Thrombotic causes:

Catheter malposition (movement) Fibrin sheath Catheter tip resting close to the vein wall Fibrin tail Catheter malfunction i.e faulty valve Mural thrombus Internal catheter fracture Catheter related DVT When WO is present follow Flow chart 2 overleaf. Thrombolytic agents. Thrombolytic agents are a group of drugs which work by breaking down blood clots (clot lysis). Urokinase is the most commonly used thrombolytic agent in catheter care. A bolus dose of Urokinase may help to break down the fibrin formation at the tip of the catheter therefore preventing withdrawal occlusion. The recommended dose of Urokinase for use as a bolus lock for catheter clearance is 5,000 international units. The Urokinase needs to be prescribed by a Doctor. Saline challenge A saline challenge can be used to demonstrate symptoms of extravasation. This is accomplished by infusing 50 mls of saline into the PICC and observing the patient. However, this will NOT rule out the presence of a fibrin sheath therefore does have limitations for use.


Unable to obtain a blood sample from a PICC

Check for any signs of mechanical kinking, ensure that the arm is straight

Flush the PICC with aprox 3-4 mls of N. Saline 0.9% using a positive pressure technique

If blood return is still not possible use a 20 ml syringe containing 15mls of N. Saline 0.9% and use a ‘push pull’ method to obtain a blood return

Is there a blood return

Yes No


Discard the original 20 ml syringe. Use another 10ml syringe to waste the first 3 mls of blood from the PICC. Obtain the blood sample and flush with 15-20 mls of N. Saline 0.9%

Assess for symptoms of malposition. Consider a chest X-ray to verify tip placement and if correct placement Instill Urokinase 5,000 units into the PICC - follow the guide on page *

Flow Chart 2

If there is still no blood return attempt to instill a further dose of Urokinase

C. COMPLETE CATHETER OCCLUSION Complete catheter occlusion is when there is an inability to infuse any solution into the catheter together with the inability to aspirate any blood from it. Complete occlusion can result from a thrombotic or a non-thrombotic cause. In order to be able to diagnose and manage the occlusion effectively, it is important to verify the source of the problem. The most common non-thrombotic causes of catheter occlusions are:

• Mechanical obstruction • Drug or mineral precipitates • Lipid residue

A thrombotic complete occlusion develops as a result of a build up of blood within the catheter Management – follow the Flow Chart 3. overleaf:


No

Yes

Yes

Are you able to withdraw blood and flush the PICC

Attempt to infuse Urokinase (Dr. to prescribe) into the PICC using the 3 way tap method. See instructions overleaf.

If the probable cause is blood within the lumen of the PICC

Determine the cause of the occlusion. If TPN or precipitation of drugs is the cause inform IV Access nurse and or pharmacy department

Yes Can you flush the PICC

Inform a PICC placer or relevant specialist. Catheter removal may be indicated if occlusion cannot be cleared

No

No

Repeat the infusion of Urokinase using the 3 way tap.

Can you flush the PICC

Attempt to flush but do not use excessive force

Check for any external kinks or any damage to the PICC. Ensure the arm is straight and well supported

Unable to flush a PICC Flow Chart

3


ADMINISTRATION OF BOLUS UROKINASE INTO A BLOCKED PICC USING A 3 WAY TAP Equipment required Small dressing pack Sterile gloves (powder free) 2 x 10ml syringes Green needle Sharps bin 3 way tap Urokinase 5,000units (currently the only unlicensed prescription available is supplied in 10,000 unit vials) 2mls Water for injection Sterile alcohol wipe New injectionable bung/bionector Procedure: 1 Explain the procedure to patient. 2 Wash hands effectively and prepare equipment. Check Urokinase details in usual

way, e.g., Name; Dose; Expiry Date; Route of administration. 3 Open the dressing pack, tip syringes, needle, sterile alcohol wipe and 3 way tap

ontothe sterile field. Place vial of Urokinase and water for injection on the edge of the sterile field

4 Wash hands again or use hand rub, put on gloves and using sterile swab to hold vial, draw up 2mls of water for injection into the syringe. Again using a piece of sterile gauze, pick up the urokinase vial, use sterile alcohol wipe to clean the rubber bung of Urokinase vial and allow to dry.

5 Reconstitute the Urokinase vial of 10,000 units with 2mls water for injection. Draw up 1.5mls of Urokinase solution into syringe. 1ml is the dose required for the lock and the extra .5 is used to prime the 3 way tap.

6 Prime the 3-way tap with the Urokinase solution. With a sterile swab, remove the bionector from end of the PICC and attach 3-way tap to the end of the PICC. Close the 3 way tap to the patient.

7 Attach the syringe containing the Urokinase to one access point of 3-way tap and one empty syringe to other access point. i.e urokinase at 3 oclock and the empty syringe at 6 oclock.

8 Turn off tap to Urokinase (3 o’clock), pull gently back on empty syringe (6 o’clock) to create vacuum in catheter to approximately 8-9mls and hold the plunger at 8 mls whilst turning the closed position onto the empty syringe. A small amount of Urokinase will then be drawn into vacuum. Remove empty syringe and expel air from empty syringe.

9 Repeat every 5 minutes until all Urokinase solution is inserted into line. This can take up to 20 minutes to complete.

10 Apply the new bionector or bung to the end of Catheter and leave the Urokinase insitu for 60-120 minutes, then withdraw the Urokinase lock. Attempt to withdraw blood. If


blood withdrawal is possible flush with 15-20 mls saline as per normal protocol. If blood return is not possible repeat the injection of bolus urokinase.

11 Dispose of equipment according to hospital procedure, and document clearly in patient’s notes.

(If procedure unsuccessful on first attempt, procedure may be repeated once after 1 hour) (If the procedure is unsuccessful after two attempts, try again in 24hrs and leave the urokinase lock insitu for 12 -24hrs) (If the procedure is still not successful – remove the line.)


D. TORN/SPLIT PICC.

PICC lines are made of silicone, a very soft pliable material with a thick wall to enhance durability. It is however possible for the PICC to develop tears, pinholes or leaks with time or with improper handling. Tears and splits can occur at any site along the length of the PICC but it is more common that damage takes place close to the exit site or on the external part of the line. Signs and symptoms:

1) Leakage from the PICC when flushing 2) Unexplained fluid under the dressing or along the external part of the catheter. 3) White powder around outside of line (if 5FU chemotherapy infusing) 4) Separation of the connector from the catheter.

Management – follow the Flow Chart 4. overleaf If there has been leakage of chemotherapy around the split, the arm must be washed with copious amounts of saline (maintaining sterility around exit site


The PICC leaks from the exit site

The PICC leaks from a portion on the external part of the PICC

The PICC will require withdrawal prior to repair. Taking care to withdraw the minimum amount of line.

No

Is the tip of the PICC correctly placed in the SVC

Dr. to request a chest X-ray to verify tip placement of the PICC

Contact a PICC placer or relevant specialist practitioner to assess the possibility of performing an exchange over a wire or alternatively remove the PICC depending on location of the PICC and therapy needs of the patient

Yes

The PICC will need to be repaired. See guidelines for repair: Overleaf.

Remove the dressing and carefully flush the PICC whilst observing the external portion of the PICC and the exit site

Leaking at the site of the PICC

Flow Chart 4

Use the PICC as normal


PROCEDURE FOR REPAIRING A TORN//DAMAGED SINGLE LUMEN PICC This procedure should not be performed unless the practitioner has received specific training in PICC repair. Equipment needed

• Small dressing pack (containing powder free sterile gloves) • 1 sterile stitch cutter • PICC repair kit • 10ml syringe • Green needle • bionnector • 10ml 0.9% Sodium Chloride • Steri strips • Occlusive dressing • Sterile alcohol wipe

Procedure (N.B. If connected to chemotherapy pump, this should first be disconnected and capped off in the appropriate chemotherapy area where cytotoxic safe handling equipment is easily available) 1 Explain procedure to patient 2 Support patients arm on a pillow ensuring arm is horizontal at 90 degrees to the body. 3 Wash hands effectively and prepare equipment 4 Open dressing pack, tip PICC repair kit, syringe, needle/s, stitch cutter, steri strips,

occlusive dressing and bionnector onto sterile field

5 Open 10ml 0.9% Sodium Chloride and place on trolley outside sterile field 6 Carefully remove old dressing and steri strips except the steri strip closest to where

the PICC exits the patients skin. 7 Wash hands effectively and put on sterile gloves 8 Using the green needle and 10ml syringe, draw up 10ml 0.9% Sodium Chloride using

swab from pack to hold ampule 9 Prime PICC repair kit sections. Place sterile dressing towel or bag from pack onto

patients arm under PICC line


10 Clean needle-free connector with sterile alcohol wipe and allow to dry. Flush 2mls

0.9% sodium chloride into PICC line to identify precise ruptured area.

11 Using a sterile swab hold PICC line firmly and cut above rupture with stitch cutter.

Attach PICC repair kit by

a Inserting blue cuffed repair piece over PICC line (blue to blue) b Hold PICC catheter push steel pin on grey piece of repair kit into blue catheter

up to hilt.

c Finally line up the grooves in each piece and click firmly together.

12 Attach new bionector and flush well under positive pressure using a pulsating turbulent flush. Establish no further leak

13 Remove old steri strip and apply new steri strips and dressing 14 Dispose of equipment as per policy. Wash hands

15 Document in medical notes and record in PICC diary, stating reason for repair.


E. DEEP VENOUS THROMBOSIS Deep venous thrombosis (DVT) is a condition which may present in the deep veins of the upper or lower extremities. Catheter-related DVT involves the veins of the upper extremity, usually the subclavian vein, the axillary vein and the Superior Vena Cava. This condition is referred to as Upper Extremity Deep Vein Thrombosis (UEDVT). Management – follow Flow Chart 5. overleaf It is important that if the PICC remains in situ, careful and frequent assessment of the patient and the PICC should take place to detect any deterioration in symptoms or function. When a clinical decision is made to remove the PICC, care must be taken when removing the device due to the risk of a pulmonary embolus. The catheter should be removed in a suitable area with access to oxygen and suction and the nurse should be aware of the correct management of a patient in respiratory distress (Hadaway 2002).


Consider Thrombosis

Attempt to aspirate blood and flush the PICC with 20mls N.Saline 0.9%

Observe for the following symptoms: • Bleeding at exit site • Discolouration of the arm

(cyanosis) • Pain in shoulder • Protruding veins in the chest or

neck

Does the patient experience any pain during the flushing procedure

The patient has a swollen arm, hand or neck

Flow Chart 5

Yes No

15

Follow Flow Trust Policy for the management of a suspected Thrombosis

• Chest X-ray to verify tip placement

• Doppler Ultrasound • Review catheter function • Ensure line is giving blood

Positive result: Complete a thrombosis nursing assessment sheet and review on a regular basis. Remove if line not functioning or if tip out of position (post anticoagulant therapy).

If symptoms persist or become worse, remove the PICC after 3-4 days of anticoagulant therapy.

Ensure that the SPR or Consultant is aware of the diagnosis and treatment.

Explore the possibility of internal catheter fracture. Dr. to request linogram. Inform PICC placer or relevant specialist practitioner

Do not use line

M.Hughes/IVAccess/CompPICCs/2006

F. CATHETER TIP MALPOSITION The optimal position for the tip of a Central Venous Catheter (CVC) is the lower third of the Superior Vena Cava (SVC) (Vesley 2002). When the tip of the catheter moves from the desired position, the movement is referred to as catheter tip malposition (Wise, Richardson and Lum 2001). Signs and Symptoms It important to remember that malposition of a CVC can be symptom free. There are however some symptoms to observe which may require investigating:

o Sensation in the neck during flushing ‘ear gurgling’ o Chest pain o Difficulty aspirating blood o Inability or difficulty infusing fluids via the catheter o Visible reflux into the catheter (blood within the catheter) o Visible movement of the external portion of the PICC

If there is a suspicion that the external measurement of the PICC is longer than at the time of placement, follow the guidelines below:

• Observe for any damage to the catheter • Review the post insertion measurement if available and compare

Management – follow Flow chart 6. overleaf Under what circumstances should the line be removed?

• When the tip of the PICC is in the jugular vein • When the tip of the PICC is not in the SVC (i.e in the Subclavian vein or Brachial vein)

and vesicant treatment is given via the PICC • When the tip of the PICC is in a small tributary vein

If a patient is receiving therapy that is not toxic to the vein, for example Normal Saline infusions, it is possible that a PICC that has migrated out of the SVC can be used. The PICC can be used as a mid-line or a mid-clavicular line. Advice from pharmacy or a PICC placer should be sought in this instance.


Flow Chart 6 Symptoms of Catheter

Malpositioning are present

Compare the external measurement with the original measurement at placement in the notes. Ensure that there has not been any other alterations in the length of the PICC since PICC insertion.

Measure the external part of the PICC. Measure all you can see which is blue.

No Continue to use the PICC

Has there been movement in the PICC since placement

The tip of the line is in the right atrium

Refer to PICC placer or relevant specialist practitioner.

Dr. to request a chest Xray. Review the position of the tip of the PICC

The tip of the line is in the mid or lower SVC

Use the PICC as normal. Observe for any symptoms of thrombosis

The tip of the PICC is in the upper SVC or out of the SVC

Withdraw the PICC the desired length. Trim the PICC if necessary

Yes


G. EXIT SITE INFECTION Management – follow Flow Chart 7 below

18

Yes

Cleanse the exit site with chlorhexidine in alcohol and leave to dry

Consider early signs of infection

Cleanse the site with chlorhexidine in alcohol

Assess for symptoms of systemic infection: Rigors and pyrexia. If present, inform Dr., take blood cultures from the PICC and from a peripheral vein and consider treatment with intravenous antibiotics.

Evaluate symptoms. If there is redness, exudates, swelling and pain at the exit site within 2 cm of exit site, inform Dr. and treat with oral antibiotics

No

Collect swab from site

Yes

Is there exudate at the site

Consider exit site infection

No

Is the redness associated with swelling and pain at the site

Redness at the exit site of the PICC Flow Chart 7

Advise patient to report any exacerbation of the redness or any other symptoms: pain, swelling or exudate

M.Hughes/IVAccess/CompPICCs/2006

H. ALLERGY TO DRESSING Management - Follow Flow Chart 8 below:

Consider - allergy to the dressing

No

Consider Infection as the cause.

Yes

Redness and soreness beneath the PICC dressing

Is there any discoloured exudate at the exit site No

Apply cavilon barrier to the skin beneath the IV 3000 dressing

No

Are the symptoms moderate to severe

Is there swelling at the PICC site and a larger opening of the skin at the exit site

Take a swab

Review the Patient within 4 days

Apply a Duoderm dressing beneath the PICC. Refer to guidelines overleaf:

Yes

Consider Granuloma and re-dress twice weekly to prevent exudates from excoriating the skin

Consider Granuloma or infection

Yes

Flow Chart 8

Review the patient within 5 days. Consider changing the dressing to an alternative if symptoms persist


I. PAIN Management – Follow Flow Chart 9 below:

Pain in the shoulder, neck or chest

Consider

Migration of the tip of the catheter into a location other than the SVC

Damaged PICC Thrombosis

Extravasation

Dr. to order a chest X-ray to determine tip position

Flush the PICC with Saline and observe for any symptoms

Flow Chart 9

If in doubt Dr. to order a lineogram

Review patient for other symptoms of thrombosis flow chart 5


complicationmanagmentofpiccs

Documents