Vygon Corporation

Neona
Neonataltal / Pedia
Pediatric
ediatric
Peripher all
eripherall
allyy Inser ted Centr
Inserted al Ca
Central theter
Catheter

Basic Manual
All rights reserved
2005

VYGON Corporation
1-800-544-4907
(610) 630-3350
www.vygonusa.com
PICC Excellence, Inc.
www.piccexcellence. com
info@piccexcellence.com
1-888-714-1951
(904) 264-6887

No part of this book may be

reproduced in any form without
permission of Vygon Corporation or PICC Excellence, Inc.
If you want additional books simply call and ask for more!

VYGON
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 Vygon Corporation

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Neonatal / Pediatric Peripherally Inserted

Central Catheter Training Program

About the Manual

This program is designed to provide an introduction for the

nurse, physician, or medical professional for the insertion of
Peripherally Inserted Central Catheters. All recommended
basic didactic course content is contained in this manual.
Topics include: definitions, reimbursement, legal aspects,
patient selection, anatomy, site selection, insertion techniques,
radiological aspects, care and maintenance, and potential
complications with intervention. All topics include examples
and suggestions to help the practitioner to be more successful
with the insertion procedure and care.

Prerequisites for this course, according to the Infusion

Nurses Society (INS) Standards of Practice, include licensure
through medical or nursing boards, experience with
intravenous therapy for administration, insertion of peripheral
cannula and management of these devices.

Good luck with your practice and in this first step to

gaining the skills necessary to be qualified and successful with
PICC and Midline insertions
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 Vygon Corporation

INTRODUCTION

Welcome to the training program for Peripherally

Inserted Central Catheters. You will be introduced to
Peripherally Inserted Central Catheters and Midline
Catheters, their insertion and usage. The information
found in this manual is necessary to properly insert these
devices and the specific information found herein is
necessary to be both safe and successful.

Each PICC/Midline user should become familiar with

each product insert sheet, and follow the manufacturers
instructions for use with each specific product. This
course endeavors to make you comfortable with the
procedure and provide the information you will need to
develop the knowledge and skills necessary for safe
practice with PICCs and Midlines.

The prerequisite for this course is established

competency with peripheral intravenous cannula insertion.
Consider this course the beginning of your training for
PICC and Midline insertions. The course, plus
demonstrated competency with insertion, will establish a
clinician as an independent PICC inserter.

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 Vygon Corporation

Nancy Moureau, BSN, CRNI

About the Author

Nancy Moureau, BSN, CRNI is an internationally recognized speaker on Peripherally Inserted

Central Catheters and issues concerning intravenous practice. In 1981 Nancy began her nursing
practice working in Pediatrics and Neonatal Intensive Care departments in hospitals. Nancy spent two
years working with Medical Missions in the Dominican Republic observing first hand, children and
adults with great medical needs. Entering Home Health Care nursing in 1984, Nancy has worked in all
service levels as a staff community Medicare nurse, supervisor of infusion services, director of nursing,
and branch manager of services.

Her insertion training for Peripherally Inserted Central Catheters was received at MD Anderson
Cancer Center in Houston, Texas. Nancy has been involved with multiple organizations including:the
Association for Vascular Access (AVA, formerly NAVAN), the Oncology Nurses Society (ONS), League
of Intravenous Education (LITE), National Home Infusion Association (NHIA) and the Intravenous
Nurses Society (INS) on both national and local levels. Having received her CRNI, Certification in
Intravenous Therapy, in 1987 through INS, Nancy supports specialization in nursing practice.

Current practice includes part time work in the ICU at Cobb Memorial Hospital, intravenous and
PICC insertion, consulting, educational programming and management of PICC Excellence, Inc. PICC
Excellence, Inc. is an education based company specializing in PICC, Midline and intravenous training
programs. A published author, Nancy is involved with research and literature analyses for
manufacturers, distributors, home health companies, infusion pharmacies and hospitals for PICC Lines
and other concerns dealing with vascular access education.

Nancy functions as a resource in education for PICCs and Midlines. For information or questions
contact www.piccexcellence.com or communicate with Nancy at nancy@piccexcellence.com.

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Table of Contents

1 Neonatal Peripherally Inserted Catheters.........................................................................9

2 Legal Aspects and Definitions.......................................................................................... 14

PICC Lines, Midclavicular, Midline Catheters, Dwell-Time, Osmolarity, Limitations and Risk with
Thrombosis, X-ray Tip Requirements, Standards of Care, Education Requirements, Liability
Concerns, Nurse Practice Acts, Policies and Procedures, Supervised Insertions, MD Orders,
Patient Consents, Documentation, Risk Management, Outcome Monitoring, and Reimbursement
Issues

3 Indications and Applications for Placement....................................................................19

Specific Indications for PICCs and Midlines, Contraindications with Neonates and Children, Risks
and Benefits, Disadvantages, Patient Selection

4. Growth and Development 0-18 years...............................................................................24

5. Anatomy of Pediatric/Neonatal Veins and Arteries.........................................................28

Structure of Veins, Vein Selection in Neonates, Peripheral and Central Anatomy, Dealing with
Valves, Premedications and Pain Management, Conscious Sedation, Measurement for PICCs

6. Measurements for PICCs.................................................................................................39

7. Insertion Devices and Products....................................................................................41

Devices for Insertion, Breakaway Needles, Peelaway Sheaths, Through the Cannula,
Split Cannula, Modified Seldinger Technique, Materials and Designs, Size and Gauge,
Guidewires, Selection Guidelines, Tips for Neonates, Infection Control Practices,
Universal Precautions, Sterile Technique, Supplies, Preparation for Insertion

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8. Insertion Procedure: Neonates and Children...................................................................47

Supplies and Additional Equipment for Neonates, Assistance, Patient Assessment and Education,
Confirmation of Orders, Patient Consents and History, Positioning for Insertion, Location for Best
Management, Measurements

9. Radiology Tips and Confirmation........................................................................................52

10. Needle-Free Accessing Systems.........................................................................................54

11. Care, Maintenance and Removal........................................................................................55

Flushing, Pediatric Dressings, Extension Sets and Caps, Securement for Reduced Complications,
Catheter Removal, Syringe Sizes and PSI, Declotting, Catheter Repair, Blood Drawing
Considerations

12. Complications, Assessment and Management.................................................................58

Phlebitis, Occlusion and Clotting, Venospasm and Valves, Thrombosis and Deep Vein Thrombosis,
Hemorrhage, Infiltration, Infection, Sepsis, Stuck Catheter, Stuck Guidewire, Catheter Fracture,
Breakage, Emboli, Catheter Shearing, Catheter Material Reaction, Anaphylaxis, Vasovagal
Response, Malpositioning, Migration, Nerve Damage, Arterial Stick, Cardiac Arrhythmias, Cardiac
Arrest, Anoxic Encephalopathy, Troubleshooting

13. References............................................................................................................................66

14. Resources: NANN, AWHONN, AVA, INS, CDC, FDA, ASPEN............................................ 73

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Educational Objectives

To demonstrate understanding of the definition of a

Peripherally Inserted Central Catheter by acknowledging
the Intravenous Nurses Standards of Practice and FDA
designation for terminal tip location as it applies to children
and neonates.

To state the pediatric and neonatal indications for

each: Midline and PICC lines.

To list three benefits associated with the use of PICC

lines.

To describe three main veins and three alternate veins

utilized for the insertion of these catheters for children and
neonates.

To review major anatomical features of the neonatal

vascular system.

To differentiate Neonatal PICC line products and the

two main insertion methods associated with the use of
these catheters.

To verbalize neonatal and pediatric care and

maintenance when flushing and dressing and know
procedures acceptable for use with PICC and Midline
catheters.

To recognize three potential complications associated

with use of PICC lines.

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NEONATAL PERIPHERALLY INSERTED CATHETERS
What is a PICC?
A Peripherally inserted Central
Catheter (PICC) is a long, soft,
flexible catheter, usually inserted
through the larger veins of the
anticubital fossa or upper arm and
advanced into the superior vena
cava (SVC). An X-ray placement
check is required to confirm SVC
placement before using a PICC line.
A PICC (Peripherally Inserted Central Catheter)
is a soft, flexible catheter, similar to a piece of thin
cooked spaghetti. For infants, insertion can also be
performed through scalp veins, jugular veins and
through the veins of the lower extremities. If a PICC is
inserted into the saphenous vein, the catheter will be
threaded into the Inferior Vena Cava.
PICC catheters come in different sizes and
lengths; they vary from 16-28 gauges and from 8 to
65 cm in length. A PICC line that falls short of the
Superior Vena Cava is considered to be suboptimal
placement and is called by another name. The
terminology will depend on the location of the end of the
catheter. Older terms like PCVC, PIC lines, and Long
Lines are often used to describe Periphally Inserted
Central Catheters.
Vygon Corporation
A PICC is called a midline catheter if the
terminal tip of the catheter resides in the upper extremity.
A chest x-ray is required to confirm the catheters proper
placement prior to use.
Optimal dwell-time of a PICC is unknown. The
record for the longest PICC placement is held by MD
Anderson. A PIeripherally Inserted Catheter has been
maintained in a patient for four years. Additional reports
from the Oley Foundation report the maintenance of
inserted PICCs for 5-7 years. Typically, a PICC is
recommended for therapy from 5 days to 2 months,
however; there are patients that have had a PICC for
longer durations if the patient has poor access or is a
poor surgical candidate.
The SVC (Superior Vena Cava) and the IVC
(Inferior Vena Cava) are ideal tip placement locations
due to the large flow of blood through these vessels.
They are large and allow for infusates to be diluted.
Also, due to the vessel size, the catheter tip will float in
the center of the vein and not come into contact with the
vessel wall, which will decrease the risk of vessel wall
irritation.
There are no limitations to the type of infusates
used with PICCs, and solutions such as chemotherapy,
TPN (Total Parenteral Nutrition), and antibiotics can
easily be infused through a PICC. There are also no
limitations of therapies infused through a PICC. Blood
sampling can also be performed with larger PICC sizes,
although this is not recommended with 2Fr or smaller
catheter sizes .
Meeting the overall needs of the patient while
maintaining low complication rates is one of the overall
goals when using a PICC.
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 Vygon Corporation
By placing a PICC with the tip residing in
the vena cava, decreased complications and
longer dwell times can be achieved. Two other
types of lines which are identified by their terminal
tip placement are Midclavicular lines and Midlines.
A Midclavicular line is a peripherally
inserted catheter with the tip location in the
proximal axillary or subclavian vein. The only
approved use of midclavicular lines is in serious
clinical situations where the catheter cannot reach
the vena cava due to obstruction. Home care
agencies have used these in the past because no
x-ray has been required for the tip placement; this
is no longer the case.
A NAVAN/AVA 1998 tip location consensus
paper states that no line should reside in the chest
without x-ray. Best practice now requires that all
catheters entering the chest have x-ray
confirmation.
Optimal catheter tip placement is in the
Superior Vena Cava. If the catheter falls short and
ends in the innominate vein, it should be
considered a midclavicular device. Midclavicular
devices are advanced past the shoulder region,
falling short of the junction with the jugular vein.
They are still considered peripheral placement.
Evidence exists that a higher rate of
thrombosis occurs with suboptimal midclavicular
placement. The rates vary from 15% (according to
Ryder in 1995) to 61% (according to Kearns in
1996). Midclavicular lines (when considered
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clinically necessary due to extreme need), should
be used only for those peripheral infusions with an
osmolarity of 500 miliosmoles or less and non-
irritating infusates with a pH between 5 and 9.
Due to the risk of thrombosis, it is never
recommended that a catheter tip be left in this
location except in extreme need. For pediatric
patients, the caliber of the veins is smaller and
with smaller veins there is decreased flow and
greater risk of occlusion, thrombosis, or phlebitis.
Risk is increased with Subclavian vein
access due to its more horizontal position which
results in catheter contact with the wall of the vein.
When a catheter lies on the vein wall it is likely
that irritation will result. Flow rates are lower in the
subclavian vein which reduces the buffering effect
of blood mixing with the infusate.
Perfect placement of a PICC occurs when
the catheter tip floats in the upper portion of the
lower third of the SVC near the SVC right Atrial
junction. The SVC is the appropriate tip placement
according to the INS, NAVAN/AVA, the FDA and
manufacturer guidelines. All vascular access
devices including PICCs have associated risks
but optimal tip placement reduces the potential for
complications.
Midline devices are peripherally inserted
catheters where the tip terminates 3-8 inches
above the insertion site in the proximal portion of
the extremity. Midlines are typically inserted in the
arm with the tip location in the veins of the upper
arm at the level of the axilla. The disadvantages of
using a Midline catheter are obvious when there is
a change in drug or lengthened therapy.
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Midlines are recommended for therapies
lengths of 2-4 weeks. Dwell time longer than
4 weeks should be based on the policy of the
institution and the professional judgment of the
nurse. So much time and skill goes into inserting
these catheters that in many cases, you may as
well thread the catheter to the SVC.
Pediatric patients may have alternate
midline insertion sites using the lower or upper
arm, lower or upper leg, and scalp veins (INS).
Standard midline catheter length is greater than
3 inches and the insertion site should be no more
than 1.5 inches above or below the antecubital
fossa (INS). The length of the selected catheter
should allow for appropriate placement without
alteration of tip integrity. The exception will be in
neonates.
Midline catheter use is appropriate for the
administration of fluids and medications
(500mOsm or less with a pH between 5 and 9)
and are generally administered through the
peripheral veins.
Therapies which are not appropriate for
midline catheters include continuous vesicant
chemotherapeutic agents, central formulation total
parenteral nutrition solutions or other
hyperosmolar or irritating medications or
solutions. Radiologic confirmation is not usually
necessary for midline catheter placement.
As previously stated, Midlines can be
inserted in the scalp of infants, with the tip
placement in the jugular vein. Midlines can also be
inserted in the lower extremities with the tip
placement in the knee or thigh region (i.e. the
femoral vein). The rule of thumb for Midlines is that
the catheter tip does not reside in the torso. Non-
irritating antibiotics are the most common use of
midlines with pediatrics.

Tip Verification by X-ray may be indicated for midline catheters when there is:
Difficulty threading or advancing the catheter.
Pain or discomfort after catheter advancement.
Inability to obtain free flowing blood return.
Inability to flush the catheter easily.
Difficulty removing the catheter guidewire.
Pain, discomfort, feelings of coldness, or gurgling sounds
when flushing.

To determine the osmolarity of a solution ask a Pharma-
cist. Many times this information can be found on the
solution bag. Solutions with an osmolarity of 500 mOsm or
higher are not indicated for midline catheter placement.
Solutions with a pH less than 5 or greater than 9 are very
irritating to vessels and should not be infused through
midlines. Solutions that are hyperosmolar such as TPN,
PPN, that may have an osmolarity greater than 600 or
irritating solutions such as acyclovir, with a pH of 10.5,
can be safely infused through a PICC but not a midline.
The following is a list of medications that are considered
irritants due to chemical structure, pH or osmolarity.

Acyclovir pH 10.5 Dopamine pH 2.5 Pentamidine pH 4.09

Penicillin pH 10 Doxycycline pH 1.8 Phenergan pH 4.0
Amphotericin B irritant Erythromycin irritant Potassium pH 4.0 hypertonic
Bactrim pH 10 Gancyclovir pH 11 Rocephin mixed hypertonic
Cipropraxin pH 3.3 Lidocaine Tobramycin pH 3.0
Dilantin pH 12 Morphine pH 2.5 TPN and PPN hypertonic > 600m Osm
Dobutamine pH 2.5 Nafcillin pH 10 Vancomycin pH 2.4

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Midline Issues
or
Why We Dont Infuse Everything Through The
Midline!

Midlines are just like peripheral I.V.s

but better since we do not have to
rotate them, right?

WRONG!
Midline catheters have a greater risk of
injury or damage than peripheral I.V. sites.
Vancomycin, with a pH of 2.4, will damage the
vessel wall due to the acidity of the solution. Once
the irritation begins, there is potential that more
serious complications such as chemical phlebitis
and thrombosiscan develop.
If the patient has a peripheral I.V. in place
and Vancomycin is being infused, in a very short
time some redness and pain may develop along
the track of the infusion. When this occurs the
peripheral I.V. should be removed.
If a Midline or Midclavicular catheter is in
place and pain or swelling develops it may take
longer to detect. During this time, vessel wall
damage can occur. Later, a change in circulation
is possible and clots and scarring may also
develop in the vessel. This type of injury may
prevent later access to or catherterization of the
vein. In addition, if the subclavian vein is clotted off
circulation to the extremity may be compromised.
It is more difficult to identify problems in the
early stages of phlebitis, especially with young
patients or infants. A PICC can provide the safest
way to infuse a variety of solutions.
Other examples of pH include Potassium
pH of 4, Nafcillin 10pH, and Dopamine pH of 2.5.

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The History of PICCs and Longlines
PICCs have been around longer than we
realize. The new PICCs began their
come-back in the late 80s and early 90s.
Once called Longlines, Peripherally
Inserted Central Catheters (PICCs) have found a
valuable position in the administration of
intravenous therapy. The early PICCs, known as
the Intracatheters (available in the1950s and
1960s and made of PVC), Intrasil (released by
Vycra and later purchased by Baxter) and
Centrasil (from Baxter in the 1970s and made of
silicone) had many problems. These precursors
to the PICCs were used with questionable
success in the 1960s & 1970s.
Complications related to PVC, Teflon
materials and the slotted introducers were
reported; including thrombosis, venous rupture
and a high infection rate due to limited sterile
technique with insertion. The Intracath by
Becton Dickinson is still in use. It is now made of
Vialon and it is used primarily as a short term
acute care access device.
In the 1970s, Silicone was introduced with
other innovations to vascular access devices that
have improved dwell time and outcomes. Nurses
from Texas and California assisted with
modifications to vascular access devices.
In the 1970s a new frontier was forged with
PICCs. Millie Lawson RN, at MD Anderson Cancer
Center in Houston, Texas (a hospital with one of
the longest histories of use with Longlines,
Intracaths, and then later Intrasils and PICCs)
began working with adult oncology patients and
performed some of the first research with PICCS.
This was done with a grant from Baxter and
Vygon Corporation
published through The American Journal of
Nursing in 1979.
MD Anderson now has a 4-day educational
program, Trends in Central Venous Devices,
which includes PICC insertion training. During the
1980s, Robyn Whitlock, RN at Childrens Hospital
in Oakland, CA studied Percutaneous Lines
(PICCs) by sterilizing tubing and adding blunt end
adapters to make the lines usable in the Neonatal
Intensive Care Unit.
Nurses like Millie Lawson, Robyn Whitlock,
Marcia Ryder, and Susan Markel-Poole, and many
others, helped to pioneer manufacturing changes
that have resulted in todays PICCs.
Manufacturers were influenced by the work of
these women.
Companies involved in the initial
development of PICCs were Baxter, Cook, Gesco
and HDC in the US and Vygon in Europe. In the
US, as states made decisions regarding nursing
scope of practice with PICCs, nurses began using
the devices in a variety of settings, ranging from
intensive care in the hospital to home care. PICC
use in the home gained momentum in the early to
mid 1990s with the growth of home care nursing.
They became a reliable and cost effective access
device for patients receiving I.V. therapy.
PICCs are now favored over surgically
placed tunneled CVCs due to the ease of insertion,
low risk, and low cost. Now considered within the
scope of nursing practice for insertion in all fifty
States, PICCs are used in all patient care settings.
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Legal Aspects of
Intravenous Therapy
To be qualified to insert PICCs, it is
necessary to have the educational training to learn
to insert the device safely. Education for Picc
placement includes the study of venous anatomy,
appropriate vein choice, insertion procedure, care,
maintenance and other areas of proper usage.
The knowledge you will gain from this course and
the certificate of training you will recieve will assist
in reducing liability.
Policies and procedures establish safe
practice guidelines when working with PICCs for
your institution or for your home care agency. Your
liability will be reduced when you follow up to date
policies and procedures and this will ensure that
your employer covers you in the event of litigation.
Documentation of your initial PICC training and
qualification should be maintained in your personal
records and in your employers records.
Completion of this training program does
not establish competency to insert PICCs but is a
necessary first step in your education. Your
competency is established by actually performing
supervised PICC insertions on patients. After
completing this course, try shadow or observe
someone inserting a PICC. Consider which
products they are using. Ask what the advantages
and disadvantages of each product are? Gain
experience by inserting PICCs in as many patients
as possible (most institutions require at least 3
supervised insertions for competencies).
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Supervised PICC Insertions are
necessary to document competency or safe
practice for the PICC procedure. State boards vary
on the number of supervised insertions needed for
competency. Refer to your State Board of Nursing
website for specific information concerning PICC
issues (http://www.ncsbn.org/regulation/
boardsofnursing_boards_of_nursing_board.asp).
The number of required supervised
insertions can range from 3 to 5 or more and is
determined by the requirements of the institution,
the State Board of Nursing and/or other licensing
boards, the clinicians comfort with the procedure,
the supervisors comfort level with the inserter and
the ability of the inserter to perform the procedure
in a safe manner. All clinical aspects should be
supervised until proficiency is determined to be
acceptable and competency has been validated
through a competency assessment program.
Special activities requiring a higher order of
knowledge and expertise should only be performed
by those properly trained in proper PICC procedure
and who have achieved an advanced level of
practice. According to The Intravenous Nurses
Society, PICC Draft of 1995, supervisors are
qualified if they have inserted the initial number of
PICCs to qualify to insert independently, and an
additional five insertions or a minimum total of at
least eight PICC insertions.
The purpose of a supervisor is to monitor
the maintenance of sterile technique, manage any
complications that may arise, help the inserter to
learn from his or her experience and, if possible,
help the insertion procedure to be successful
should difficulties develop. A registered nurse with
PICC insertion experience or a physician can be
considered a qualified supervisor.
 Vygon Corporation

Documentation can reduce liability because it is

considered a form of communication and can assist
with quality improvement. It becomes a legal
document that reflects the services and skills that
were performed. This document helps to
communicate information and assists with outcome
monoriting which is essential to any quality
improvement program. Documentation is also
required for reimbursement for the procedure.

Your documentation should be thourough

and complete. Keep a copy for your
reference. It is also important to document
how the infant tolerated the procedure.

Keep documentation of the procedures

you perform and the name of your preceptor. Align
yourself with a nurse or MD who is inserting
PICCs and observe them, this will help you learn
from their experience. Something new can be
learned from every insertion and from every
inserter (techniques for inserting and measuring
PICCs and catheters, etc). There are a variety of
ways to perform this procedure and everyone will
have their own technique. Always remember, it is
important to comply with INS standards.
Everyone has their own technique, but
it is important to comply with INS standards.
Standards provide a framework for safe practice.
The Infusion Nursing Society has established
minimal intravenous practices and policies for all
clinicians. Legal nursing standards for the delivery
of infusion therapy include: establishing a
framework for monitoring care given and products
INS standards originally were released in 1984,
revised several times, with the last revision in 2000.
used; providing a frame of reference that
distinguishes between malpractice, product
failure, and unfortunate medical result; and assists
in resolving ethical conflicts between the
intravenous nurses duty to the patient and to the
employer.
Adherence to nursing standards for the
delivery of infusion therapy reduces the patients
risk of unnecessary trauma or complications;
assists the medical profession by reducing the
risk of malpractice claims against the physician,
nurse or healthcare agency or organization, and
assists manufacturers by reducing risk or product
liability claims against their companies.
Legal issues with Peripherally Inserted
Central Catheters include recommended
education and documented experience, State
Nurse Practice Acts such as INS, AVA, ONS,
supervised insertions based on policies and
procedures, MD orders and patient consents (the
concept of shared liability), documentation, quality
management and annual competency, and
reimbursement issues.
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 Vygon Corporation
INS supports that
a licensed
physician or
licensed registered
nurse, who is
educated and has
demonstrated
competency, can
insert a PICC. The
RN must have
demonstrated
competency and
proficiency, have
competency in
intravenous
therapy, (including the insertion of short peripheral
catheters) and have a solid understanding of
central venous catheters. All nurses must work in
accordance with their State Nurse Practice Acts.
Each State has established the scope of
nursing practice including the insertion of PICCs
and Midlines. The Intravenous Nurses Society
Standards are a legal basis for all intravenous
practice and can be used in a court of law for any
intravenous practice issues.
Other recommendations and guidelines
from organizations such as the Center for
Disease Control, the Oncology Nurses Society,
Society for Interventional Radiology, the National
Association of Neonatal Nurses and the
Association of Vascular Access can also be used
as legal documentation of intravenous practice,
but is generally considered secondary to INS
Standards.
Continuing Education is essential to sustain and
advance nursing and is required of all nurses
(INS). All infusion policies and procedures should
be reviewed and revised annually (INS). Once a
nurse has validated initial competency, there must
be an ongoing continuum of competency. Ongoing
competency validation includes the ability to
perform the insertion safely, and knowledge of
appropriate care and maintenance strategies.
Consider annual continuing education
needs in maintaining a current, up to date
knowledge base for PICC insertions. With new
and advanced technology, it is advantageous to
keep up with the new information available. There
16
are journals that you can subscribe to (i.e. JAVA
and JIN) which will provide an excellent way to
continue and expand your knowledge.
The clinician should evaluate new products
and be knowledgable of current technology in the
clinical setting. This is important for the growth of
the infusion profession. A nurse inserting PICCs
in neonatal and pediatric patients should have
clinical knowledge and expertise with those age
groups because it is much more difficult to insert
PICCs on neonates or children. As yet, no
national certification for PICCs is available.
If you are employed by a facility or agency,
your employer should carry malpractice insurance
for each of the employees. When policies do not
exist for a specific procedure, the nurse assumes
total responsibility and the facility is not obligated
to cover the employee. The physician is the head
of the medical team, and directs therapy for the
patient via written orders.
Nurses assume much responsibility for
the administration of intravenous therapy.
Liability is shared when the physician writes
an order for the insertion of a device or the
administration of the therapy.
Consents are supported by INS. Information
concerning the device and possible alternatives
should be given to the patient and/or significant
others prior to insertion as part of an informed
consent. Information included in an informed consent
would consist of information concerning the need for
the procedure, its benefits and risks.
Documentation in the patient chart that
verbal consent was received is beneficial to reflect
that instruction was performed and consent given.
Written information should include the insertion
procedure, catheter management and potential
complications. If deemed necessary by the institution
or agency, risk management, or by State laws,
consideration should be given to an informed
consent document signed by the patient and/or a
significant other.
Patients have the right to receive information
on all aspects of their care in a manner they can
understand, as well as the right to accept or refuse
treatment.

PICCs are riskier and more invasive than
peripheral I.V.s and implied consent prior to PICC
insertion will reduce your liability. Always allow
time for questions as a means to confirm
understanding and reduce liability.
Consent is managed differently in hospitals
and agencies. Some require the physician to
provide informed consent even if the nurse is
performing the procedure. The consent transfers
some responsibility to the patient. By informing the
patient or parent of the risks involved, they are
then able to make an informed decision, accepting
or declining the need to move forward.
PICC orders must be complete.
Preprinted, standing orders are very useful. Some
institutions write information in the progress notes
on the Informed Consent Form and other
paperwork given to the family. It is always
important to list all complications. In the event of a
lawsuit, the entire patient record will be used in
court and it reflects positively on the inserter when
there is complete information.
What you write is what was done.
What you did not write, was not done.
PICC LINE INSERTION INFORMED NURSING CONSENT
AND AGREEMENT FOR TREATMENT
Date
Date
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Quality Assurance processes need
to be established to ensure patient safety,
appropriate patient selection, and clinical
competency of medical professionals.
Outcome monitoring is essential to
establish qualified professionals with
sound practices.
A Quality Assurance / Improvement Program is
a systematic process designed to improve your
organizations performance and ensure the
desired patient outcome. A program that
objectively identifies, evaluates and solves
problems associated with infusion patient
treatment modalities, should be established by the
organization (INS). INS supports that institutions
must collect outcome data on their specific patient
populations for each device and establish and
revise policies and procedures based on
outcome data.
Every person selecting, inserting, and/or
caring for these devices must be vigilant regarding
potential complications in order to establish
positive patient results. Health care professionals
should study new information as it becomes
available and critically review current literature in
order to appropriately evaluate the research
performed.
The Centers for Disease Control and
Prevention (CDC) and American Practitioners for
Infectious Control (APIC) standard for infection rate
calculation is: the Number of Infected I.V. Lines/Total
Number .o.f Patient I.V. Days x 1000 = Number of
Infected IV Lines per 1000 Patient Days.
Quality paradigm is the model used to
increase patient care services, increase the
probability of desired outcomes and also reduce the
probability of undesired outcomes given the current
state of knowledge, track the problems (i.e. phlebitis
or infection), track patterns, improvement, and
improved patient safety.
NOTE: INS Recommended education for clinicians
inserting PICCs and Midlines includes documentation of
1600 hours of clinical practice with I.V. therapy in the
previous two years. Generally, accepted training includes
the completion of a PICC course, with subsequent
successful supervised/precepted insertion of three PICC
Lines. Ongoing competency evaluation and education is
recommended for annual renewal.
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Reimbursement Information for PICCs

Can you or your organization get paid or reimbursed
for inserting PICCs? Reimbursement information for
PICC and Midline insertions and supplies is specific to
each type of care setting and each type of
reimbursement carrier.
There are Hospital Billing codes for PICCs and Midline
Insertions. CPT or Q codes can be utilized to bill
specific percutaneous insertion of central lines by a
nurse, physician or radiologist.

Some examples include:

36568 Introduction of a peripheral catheter into the vena cava. Over 5 years of age.
36569 Introduction of a peripheral catheter into the vena cava. Under 5 years of age.
36575 Repair of a peripherally inserted central catheter.
36584 Complete Replacement.
36595 Fibrin Sheath.
36596 Obstruction.
76937 Ultrasound for insertion of peripheral central venous catheter.
75998 Fluoroscopic insertion of a PICC.
36597 Repositioning or 76000.

Charges for PICC insertions
Charges for PICC insertion for neonates
range from $750 to $2500, and for children range
from $450 to $1500. Coding is helpful to allocate
funds to the proper departments to allow
justification of additional personnel, or validation of
existing personnel.
Consider establishing a specific department
in your hospital for vascular access. Allocation to that
department will establish a foundation for adequate
staff support. All billing charges must be the same
regardless of private, pediatric, adult, or Medicare.
Private insurance carriers, case managers and
managed care accounts can be billed per procedure
using the same codes. They are usually very
pleased to authorize PICC insertions, due to the
overall cost savings.
Medicaid Benefits for infants, children and
adults requiring PICC insertions vary in each
state
Medicaid Waiver Beneficiaries can receive
coverage for authorized PICC insertions and
supplies.
Medicaid HMOs may authorize insertions and
give X-ray authorization in advance!
Managed Care and Private Services for Home
Care
These are generally pre-authorized insertions.
You will need to check contracted rates and receive
X-ray authorization in advance. Billing is calculated
per insertion and you may be able to bill for failed
attempts - know your billing CPT codes.

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Indications & Patient
Selection for PICCs
Why Place A PICC?
It can be difficult to maintain a peripheral
I.V. for a toddler and a PICC will provide reliable
and continuous access. Many patients require
venous access for 5 days or more and early
referrals which identify an infant, child, or other
patient as a PICC candidate can be helpful. In a
short period of time you can virtually run out of
veins when there are repeated attempts for I.V.
restarts. Think ahead concerning the option of
PICCs before you run out of vein puncture sites.
General indications include:
Inadequate peripheral access:
Neonates and children requiring continued
I.V. therapy (5-7 days or more).
Two peripheral I.V.s equal one midline; if a
child requires 3-4 peripheral I.V.s or more
than 2 peripheral I.V.s in 24 hours, consider
a PICC line.
The need for a CVC with low platelets
indicates the need for peripheral access and a
PICC.
A PICC may be indicated for patients who may
be poor general anesthesia risk for other CVCs.
The need for the administration of Total
Parenteral Nutrition (TPN is a hyperosmolar
solution) and other solutions i.e. vesicant
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chemotherapeutic agents, and continuous
narcotics like morphine that has a pH of 2.4 (these
solutions can be irritating to a vein).
Open chest wounds, burns, an existing
tracheotomy or injuries to the chest or neck.
Dermatitis or other skin conditions which would
preclude chest access with a central line.
Infections with previous central lines
may indicate a need for CVC by peripheral
access.
Geographic location: For home care patients,
a PICC can provide reliable access for I.V.
therapies. It is a more efficient use of the home
care nurses time to have a pediatric patient at
home with a PICC versus a peripheral I.V. Overall
this therapy will allow fewer home care visits.
For Neonates specifically, in addition to the
above indications:
Neonates weighing less than 1500g.
Neonates unable to take sufficient amounts of
enteral feeding to achieve growth and whose
anticipated need for I.V. fluid is 7 or more days.
Neonates with GI disorders, on vasoactive drips,
congenital cardiac disorders or limb anomalies.
A need for reduced patient handling would
indicate a CVC rather than peripheral intravenous
cannulas (PIVs). PICCs have the lowest insertion
risk of all CVCs.
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Contraindications
Contraindications are best documented in
the patient record, reflecting the nurses and the
physicians awareness of problems or potential
problems. Knowledge of the contraindication is used
when choosing the safest type of vascular access
for the patient.
The following limitations and
contraindications require the health care professional
to consider the possible complications, and if
necessary, proceed with the PICC or Midline
insertion with caution:
Lack of antecubital or alternate peripheral veins:
Dont try to access these veins by the traditional
approach when there is no visible vein. Advanced
techniques such as ultrasound-guided PICC
placement for patients whose
vein cannot be visualized or
palpated may be necessary.
Alternate insertion sites may be
used for pediatric patients. For
example, the Scalp and
Saphenous veins.
Peripheral neuropathy,
circulatory impairment, burns,
or radiation to the insertion site
or along the intended path of the
catheter.
History of thrombosis: This
may need to be investigated further. Ask yourself, Is
the patient at risk for thrombosis? Where was the
thrombosis located? If the thrombosis was in the
right arm, you cannot place a PICC in the right arm.
Dermatitis, hematomas, or burns that would
prevent peripheral or antecubital access.
Injury or infection to the extremity: if a patient has
osteomyelitis of the left shoulder, you should not
place a PICC in the left extremity. Avoid PICCs in an
extremity with an injury or infection.
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Sepsis: if a patient has a positive blood culture, it
may be indicated to treat the patient with peripheral
antibiotics for 48 to 72 hours and confirm a negative
blood culture before a PICC is placed.
Noncompliance: if there is a history of
noncompliance or even safety issues with access
devices, a PICC may not be the most appropriate
access device for the pediatric patient. Issues like
these should be discussed with the patients primary
physician.
A higher incidence of complications can be
identified early in patients; document this type of
information in the patients record, make sure that
the physician is aware of any concerns that you may
have. Knowledge of the contraindication is used to
consider the safest type of vascular access for the
patient. Discuss this with the patient, parent or MD,
and suggest and write down any and all concerns.
Benefits
There are many benefits when using a PICC and
PICC insertions have reduced risks versus a central
line insertion performed by a surgeon because
potential complications of PICC placement are less
severe than potential surgical complications.
PICCs carry the lowest risk and are less invasive
than the insertion of other central venous catheters
or ports.
Overall, PICCs have the lowest sepsis rate of
any other type of central line. There are fewer
bacterial colonies in the arm because there are
fewer hair follicles than are found on the chest, neck
or groin. The PICC site is also further removed from
the respiratory tract.

PICCs are appropriate for placement in any
patient care setting, from the ICU to home care.
The relative ease with insertion eliminates risk
of pneumothorax that is associated with traditional
central line insertion. PICCs can be placed in
many different types of facilities and the
equipment can be easily learned.
Peripherally Inserted Centrally Placed
Catheters can be used for any type of I.V. therapy
and there are no limitations with the type of
solution that can be infused through a PICC (as
long as the tip placement is in the SVC or IVCs).
There is increased patient comfort and
parental satisfaction (because of the decreased
number of attempts) with PICCs. Also, I.V. boards
are not necessary to secure a PICC in a young
patient, allowing greater mobility. Often patients
may have several PICCs over a period of time (a
child with cystic fibrosis requires intermittent I.V.
antibiotic therapies). If a child has had a PICC in
the past, the parent may request another due to
the ease of therapy.
Reduced patient handling and stress is
especially significant with neonates.
PICCs are cost effective in terms of time and
usage: umbilical catheters and peripheral I.V.s
have a limited dwell time. Patients can be
discharged to go home sooner and a PICC can be
safely placed in an outpatient facility.
PICCs can easily be removed by a trained RN.
Peripherally Inserted Central Catheters have
numerous benefits associated with their usage
which have now become widespread. Ideally,
insertions are performed in hospitals at the beginning
of therapy, or upon discharge for home care use.
PICCs can also be inserted in a physicians office to
ease therapy and they can be used successfully in
home care to provide adequate access, in sub-acute
or in long-term care to help the staff better manage
intravenous patients.
They can also be used in outpatient clinics to
assist in procedures or for long term intravenous
services. All care settings benefit with the use of
these lines and with excellent results, positive
feedback from patients and good use of the
healthcare dollar.
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Disadvantages
Training is required
for insertion, care,
maintenance and removal
of PICC Lines, especially for
insertions and management
of lines for neonates and
children. Competency must
be established for RN
placment and care of
PICCs.
Maintaining a
consistent skill level with
pediatrics can be
challenging and placement of PICCs in children, on a
regular basis, is necessary to maintain a high
success rate. Education initially provides a higher
quality of care without the risk of a higher rate of
complications. Standards are unclear concerning
PICCs and Midlines, or the number of insertions
required to qualify a medical professional to
independently insert these catheters safely. The
general rule of thumb is three supervised insertions
with an experienced inserter.
Refer to your State Board of Nursing or
facility policies concerning PICC and Midline training
requirements. JCAHO and State agencies may
recommend that your facility establish policies that
define yearly requirements. Consider yearly updates
on competency and proficiency testing for medical
professionals practicing advanced procedures such
as the insertion of these devices. These updates
may be in the form of skill check sheets or
documented education and competency with
supervised insertions.
Phlebitis occurs in less than 5% of patients,
and is less common with infants and neonates.
Early identification and treatment with warm
compresses may resolve the problem. This early
identification is imperative to treat phlebitis effectively
and some NICU settings consider phlebitis, which
occurrs later than one week after insertion, a
potential infection, and they treat it accordingly. A
PICC may even be discontinued due to the late
onset of phlebitis. Generally speaking, phlebitis that
is treated with heat early will respond within 24
hours. If there is no resolution or the condition
worsens after 48 hours, the PICC should be removed.
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Clotting and occlusion problems can occur
frequently with PICC lines, especially in the smaller
lines used with neonates and children. Turbulent,
positive pressure, flushing techniques are needed to
maintain patency and adequate flow. Continuous
infusions which may or may not include Heparin in
the solution are necessary in the very small gauge
PICC lines (i.e. the 26g or 28g) to maintain patency.
Larger gauge PICCs are recommended when blood
is to be given or drawn regularly.
Due to the small diameter of the catheters,
the practice of routine blood return checks may
cause significant increase in catheter occlusion, risk
of breakage or infection. Positive pressure end caps
can be helpful in reducing occlusion to lines without
continuous infusions. Neonatal and pediatric PICCs
(1.1Fr, 2Fr and 3Fr catheters) are small and more
prone to breakage. Special securement devices,
such as STATLOCKs or I.V. Housetm, and other
similar devices can help reduce the problems with
breakage.
Patient Selection
Assessment of the veins to determine
whether the patient is a PICC candidate is
appropriate. It is also important to know the
patients previous compliance with other medical
regimes.
Other factors for patient selection involve
the disease process, duration of the therapy and
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determination of the best treatment. Ask the
question, Is this the best vascular access device
for this therapy and this patient? Use the
algorithm for vascular access selection, by Marcia
Ryder, based on therapy and usage.
Nursing actions and interventions with
pediatric patients are based on the childs age,
developmental tasks and previous medical
experiences. Obtaining the patients medical
history is helpful to identify past hospitalizations,
past experiences and complications with I.V.s.
This information can be obtained from the parent,
the patients chart, or medical personnel (i.e. the
Nurse). Consider other aspects such as
developmental level, age, mobility, thumb sucking
and accessibility, to determine the best site for the
child.
Due to patient mobility, it is important to
protect the PICC site. Consider safety needs,
based on the childs age. Mummy-wraps or
bundling, papoose boards and other restraints can
assist when helpers are few. Tell the child that
holding the arm still will help to place the catheter
that is needed to give the medication. Focus the
childs attention on the medication, the need to get
better and the ability to go home faster.
Assistance is needed for all children under
the age of 10 and two assistants are required
when the child is under 6. Ideally three persons
are needed to start a PICC on a child, one person
to hold, one to insert the PICC and one to comfort.
The person designated to comfort the child can be
a parent or child life specialist.
Much of your success with the PICC
insertion procedure is based on the abilities of
your holders. If you prepare the patient and/or the
parent ahead of time, it will increase your chances
for success during the PICC insertion.
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Family involvement with the PICC included in the decision to insert a PICC (NANN).
procedure can be controversial. Parents should The nurse performing the procedure needs
be given a choice of participating and be to be knowledgeable of the hospital or facility
encouraged to be present for the PICC insertion policy for informed consent , the alternatives to the
procedure. If the mother or father is comfortable procedure, and they should be responsible for
with the procedure and wants to be in the room, ensuring that informed consent has been obtained
this can be a comfort for the child. But, if the (NANN).
family is upset, causing the child to become more Document the informed consent either in
upset, this should be discussed carefully with the your nurses notes or on the form designed for
parent. Your goal is to provide a calm and consents. The more you list about the information
controlled setting for the given concerning benefits
child. and risks, the better
Encourage family protected you are for liability
members to go out and get a coverage.
cup of coffee or soft drink For children passed infancy,
until the procedure is over. preparation is necessary.
Teach the parents how to They need to know what to
hold the child with an I.V. and expect. The outward
encourage them to play and appearance of personal
interact with the child. If the protective equipment,
parent does not want to be positioning and use of and
present for the procedure, it clothing, the process of
is helpful to designate Once a decision has been made to insert a PICC, positioning and the use of
another person as a support consider the best position for the insertion of the premedications and topical
for the infant or child; this can device for the patient and for you. creams like magic cream or
be another nurse or child life Numby can be frightening. A
specialist. photo album to help the patient become more
Once a decision has been made to insert comfortable with the procedure can be helpful. All
a PICC, consider the best position for ypu and for preparation should be age appropriate.
the patient during the insertion of the device. The
patient should be either masked or positioned, Tell the child how he or she can help and
with the head to the side in what he or she is allowed to
preparation for the procedure do. Parents can also be given
(INS). Ask the question, Is some assignments. Reading a book
form of sedation necessary? If to their child or holding their
so, what appropriate hand can be benificial. Try to
premedications or anesthetic identify needlephobic, high
agents would be indicated for this anxiety patients ahead of time.
individual? and, What other Ask the parent or caregiver
supplies are necessary for the how their child has tolerated
procedure? venipuncture in the past.
Preparation should occur
Patient Education and just before the procedure and
only last a few short minutes.
Obtaining Informed
The procedure should then
Consents. begin immediately. Once the
Parents should be patient is in the room do not
informed of the risks and benefits delay. Have the tray set up and
of, and the alternatives to the ready to go.
procedure and they should be
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GROWTH AND
DEVELOPMENT
PICC insertion with infants and children
can be challenging. Knowledge of normal growth
and development can help to reduce some of the
commonly experienced frustrations with pediatric
patients. Learn to communicate with children on
their age level, stating phrases in concrete terms.
Remember that children expect truth and honesty.
The use of terms like bee sting, big stick, it wont
hurt, shot, flush, burn, and take your blood
pressure are confusing to children. Consider
each word you say and how the child may
perceive the meaning, use simple words. A
matter of fact, organized and honest approach
with children and parents can pave the way to
positive experiences with intravenous therapy.
The five stages of childhood include trust,
autonomy, initiative, industry and identity. These
correspond in infancy through adolescence. Each
stage is outlined below with an emphasis on
intravenous therapy.
Neonate and Preterm Infants: They rely on
others to fulfill their needs.
Neonates are a
special population requiring
clinicians to use a higher
level of critical thinking and
evidenced based criteria to
provide optimal care for
these babies. Special
adaptation required at the
time of birth puts these
babies at risk to have
difficulty with
thermoregulation, immunity,
skin integrity, neurological regulation with over-
stimulation and nutritional deficits.
Preparation of parents in all aspects of
care, as applicable, is part of a nurses duty when
working with this special population. Provide
comfort to the baby with a pacifier, as appropriate.
Avoid painful or stressful events immediately after
feeding to promote digestion and avoid aspiration.
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Music and the reduction of lights at specific times
can aid in comfort and healing. Maintain balanced
heat at all times. Refer to Clinical Practice
Guidelines such as the AWHONN Neonatal Skin
Care and NANN PICC Guidelines for more
detailed information.
Infants (0-12 months): Trust versus Mistrust
They rely on others
to fulfill their needs.
This child is
most secure in the
presence of a parent
due to a strong
separation anxiety
experienced at this
age. Preparation of parents in all aspects of any
procedure, as applicable, is part of a nurses duty
with infants and children. Developing a trusting
relationship with the parents will sometimes open
the way to gaining the trust of an older infant.
If possible, the PICC assessment should
be performed while the infant is content, perhaps
in the parents lap. Use of stroking, a reassuring,
soothing voice during a quick and organized
assessment with slow hand movements, can aid
in your success with the infant. Provide comfort to
the baby with a pacifier, as appropriate, and avoid
painful or stressful events immediately after
feeding to promote digestion and avoid aspiration.
Exploratory behavior begins at 6-12
months and allowing play such as peek-a-boo
will pave the way to trust during the assessment
or procedure. Pain is perceived as being present,
not in one place, but throughout the entire body of
the child. Toys or books can be used as a
distraction. Memory of pain is short for this age
group and the infant can be easily comforted
following a painful procedure. Comfort items such
as a pacifier or a security blanket are excellent
items to have for the PICC insertion procedure.
Feeding can be particularly comforting following
an upsetting event.
The parent should be informed of the need
for the PICC and what to expect during the
procedure. Prepare the parent ahead of time by
discussing how long the procedure will take,
where it will take place, and the site where the
PICC may be inserted.

Infants have greater metabolic needs.
Smaller than an adult, a child has a higher
metabolic rate. Infants less than six months of age
cannot shiver to generate heat. In infants, heat
comes from brown fat in non-shivering
photogenesis, increasing the need for energy.
Keeping the infant covered during intravenous
procedures saves vital energy. Bundling an infant
with a blanket or papoose is a good way to keep
the infant warm and feeling safe.
Attempts should be made to limit stimuli to
one type because multiple forms of stimuli will
cause increased stress on a premature infant.
Veins used for PICCs in infants include the scalp,
arm and saphenous veins. Scalp veins of choice
include the temporal and posterior auricular veins.
Rubberbands are useful in dilating small pediatric
veins in the scalp and tourniquets can be cut
smaller for younger patients.
Toddler (1-3 years): Autonomy Versus Shame
Increased mobility, self-discovery, the NO
stage and separation anxiety.
Autonomy is
the goal of every
toddler. A toddler
strives to do things
for himself or
herself and they
want to have and
maintain control.
When a toddler
cannot control a situation or is prevented from
doing for himself, he may cry, kick, scream, hit,
pinch, struggle or demonstrate his frustration by
throwing a tantrum. Egocentric in thought,
everything is me, the toddler is constantly
thinking me do it!
Some separation anxiety remains and
parents may need to stay close for the childs
feeling of security. Other security objects such as
a blanket, stuffed animal or special toy can be
comforting for the toddler. Dolls with PICCs can
be used to demonstrate the procedure and aid in
preparing the child for the upcoming event.
Assist the child in managing
uncomfortable procedures by using distraction
techniques such as toys, books or movies.
Children in this age group will listen to the tone of
your voice more than your words. Use a calm
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voice with simple words during these procedures.
Children should be given permission to
vocalize by crying during the procedure.
Sometimes, there are cultural differences in the
demonstration of emotions, tell the child how he or
she can demonstrate hurt or anger and tell them
what they can do during the procedure. Always be
prepared for extremity movement.
Prepare this age group immediately before
the procedure due to their short attention span.
Use short simple words to explain to the child
about the procedure, for example, You will be on
a special bed, and your
arm will be cleaned with
soap. Child life
specialists are
especially helpful with
this age group and they
can engage the child
with kaleidoscopes, pop-
up toys, bubbles and
other distarctions.
Toddlers are active,
mobile, curious and
place everything in their mouth. Food, dirt and
other sources of contamination are constantly
present. Creative methods can be used for
securing PICCs such as an occlusive dressing,
tape, or wraps. Limit the use of occlusive wraps,
(like Cobantm) that limit visualization of the
insertion site and increase heat to the area. In the
end, err on the side of the safest and most secure
dressing for the child.
Safety is an issue with this age group. You
may want to recommend that the young toddler
wear long sleeves to cover and hide the PICC
dressing, particularly when the child is sleeping.
Allow the toddler to help himself and the staff in all
possible ways (help with tape or choosing a color
for the wrap) but have limited or no choices. After
the procedure, a sticker can be given for a reward.
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Preschooler (3-6 years): Initiative versus
Guilt: they have fantasies and magical thought
based on their understanding and much fear
of procedures that touch or hurt and cause
any loss of blood.
The preschooler is
in constant motion,
investigating, learning and
trying to acquire new skills.
Magical thinking prevails,
complete with a make
believe friend. Consider the
presence of the friend and
ask about them while you
engage the child in
discussion. This is a
wonderful age of
creativeness and magical play. Preparing the
patient ahead of time, perhaps 1-2 hours (not too
far in advance) before the scheduled PICC
insertion, can be beneficial for this age group.
Tell the preschooler what they can do
during the procedure; suggest watching a video,
reading a book, or allow them to work with a
stuffed doll that has a PICC. Anticipation can
increase the childs anxiety and fear, try to identify
those patients ahead of time and discuss the best
plan for preparing the child with the parent. Allow
patients in this age group to see and touch the
equipment during the preparation phase.
Fear of bodily injury, loss of control,
abandonment and punishment are the greatest
concern for children in this age group. Frustration
is demonstrated with pouting, crying, words like I
hate you!, and tantrums. Children this age often
feel that the hospitalization is a punishment for
being bad. Reassure the child that they are not
being punished. Misunderstanding is frequent
because the preschooler appears to comprehend
fully but may be reluctant to speak or ask
questions.
There is a strong desire to be understood
at this age, take time to pause and listen, but dont
let them stall for time. Never underestimate the
strength of a preschool child, when upset they can
easily squirm out of any hold. Set yourself up for
success with a competent plan for managing the
patient and reducing the emotional trauma of the
event. After the procedure, be quick to wash and
26
cover the area. Band-Aids, stickers or tape with a
happy face can provide comfort. If the parents can
not stay for the procedure, assure the child that they
are near and will return soon and identify a support
person for the child who will help to comfort him.
Find out if your institution has a child life specialists.
Distraction with games, songs, and toys is
effective. Honesty with concrete statements is vital
for all children. Do not make promises like There will
only be one try... it will only take a minute or other
statements that may prove to be false. The child can
be assured that of play after the I.V. is started.
Stickers can help to take some of the pain away and
can also be used to explain what areas should not
be touched. They can also help with basic
instructions that this age group can follow. Treasure
chests with little toys are a wonderful reward when
the procedure is complete.
At this age the antecubital fossa is the
primary site for PICC placement, although
ultrasound can be helpful for upper arm access.
Premedications can also reduce the pain and fear,
but must be prearranged.
School Age (6-12 years):
Industry versus
Inferiority
At this age
children struggle with
mastering new skills and
the possibility of failure.
Self esteem is built by
successfully achieving
the skills. School age
children feel a sense of
helplessness, and a fear
of bodily mutilation. When
fear is present the child
may bargain, become
angry, regress, ignore the parent or try to delay the
procedure. Children in this age group will test limits.
Provide boundaries for their activities and tell
them what choices they CAN make and what they
CAN do. Do not allow the child to stall, be clear when
describing what will happen and when it will happen.
Use short, detailed explanations and never lie to the
child. Channeling the childs energy into helping with
small tasks, can fulfill their sense of industry and
also make them feel important.

The cildren in this age group can be
prepared ahead of time. Use concrete terms when
explaining the procedure to them and relaxation
techniques may be helpful (i.e. deep breathing or
massage). These techniques may also be
practiced ahead of time.
A Child Life Specialist can engage this age
child with board or card games, video games or
stories. Stories can be read or provided in video or
audio form. The play time should be promised as
a treat that will follow the procedure and the child
will enjoy selecting a treasure from a treasure
chest when the procedure is over.
Modesty is an issue for this age group,
keep the child covered at all times. An explanation
of anatomy and function may help to clarify
inaccurate stories from peers. Give this age group
controlled choice; for example, allow the child to
choose between two arms. In the latter half of this
age group, the child may become afraid of dying.
Reassurance is needed concerning equipment
and/or procedures and they must be reassured
that death is not a possibility. Stickers and hero
badges are still comforting after a painful
procedure.
Adolescent (13-18 years): Identity versus
Identity Confusion
Adolescents want to
establish a personal
identity through
independence and
emancipation. Illness is a
major threat to their
sense of independence
and ego. Reinforcement
and praise of
performance or
appearance may assist
this child in gaining
needed confidence.
Anger is demonstrated through grudging
cooperation, aggression, threats, and verbal
abuse. Rebellion against authority, parents and
rules may be pronounced. Identify peers with
similar conditions and encourage communication.
Telephone access is very important at this age.
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Teenagers are exceptionally modest,
fearing differences from the norm, consequently,
disfigurement, pain, disability and death are
important issues for them. Allow choices, provide
privacy, and involve the teen in their treatment plan
help them to be as independent as possible.
Involve the teen in their treatment plan. Transfer
care responsibilities to the teen and encourage
self monitoring.
Utilize humor to gain cooperation and trust.
This age group will make deals and negotiate, you
can make this work to your advantage. The teen
may attempt to stall the procedure and a
hysterical response to an injury is not unusual at
this age. The patient should be treated with calm
reassurance. Premedications are still a good
option for the teenager and lidocaine is a quick
and easy choice for most venous procedures.
Be supportive of their concerns, speak
directly to them, and use correct terminology.
Allow time for questions or discussion especially
concerning their fears. Be sure to explain all
procedures to them.
Young Adult (18-25 years): Intimacy versus
Isolation
Young adults that
are hospitalized in a
pediatric area may have
chronic conditions, such
as Cystic Fibrosis or
Cancer. The exacerbation
of the condition can
cause regression,
withdrawal, depression or
denial in the young adult.
Providing
emotional support and
reassurance can help to
regain lost confidence. Show recognition of their
greater responsibility and maturity level. The
young adult is better equipped emotionally to
manage intravenous procedures, but may
continue to need coping mechanisms to maintain
control.
27
 Vygon Corporation

Anatomy of Veins and Valves

Vein Selection for Neonates / Children

Basilic, Median and Cephalic Veins

While there are a variety of veins that can

be used with infants and children, the Antecubital
fossa is the first assessment location for PICC
access. Other veins are used for PICCs and
Midlines such as the Saphenous veins, scalp
veins, and the External and Internal Jugular veins.
Jugular veins are visible under the surface
of the skin. You can place the patient in reverse
trendelenburg position to access these veins.
There are increased risks, including the possibility
of an air embolism with a Jugular PICC
placement. With Jugular PICCs it is more difficult
to secure the catheter, especially with active
patients.
When using the Antecubital veins, the
Basilic vein is the largest and straightest vein in
the arm; it provides the most direct route of
threading for a PICC. Beginning as the Accessory
Basilic in the wrist region, the vein follows the
back of the forearm, up the inner aspect of the
arm in the region of the elbow. and grows larger
as you follow it up the arm.
The basilic vein is the first vein of choice
because it has a low incidence of phlebitis. With
infants, there can be a curve in the vein at the
Antecubital Fossa, making access difficult. The
Basilic vein is used in about 15-20% of PICC and
Midline insertions. Risk of arterial access may be
higher with attempted Basilic access. The Basilic
artery is in close proximity to the Basilic vein.
Palpate the vein prior to insertion; make sure that
you do not feel a pulse. It is important to make
sure that the introducer does not penetrate too
deeply. The Basilic vein is 8 mm in diameter and
increases in size as it becomes the Axillary vein
by the shoulder.
28

Midline catheters are not inserted into the
chest region, but remain in the proximal portion of
the extremity. The Subclavian vein is the
continuation of the axillary vein.
The Innominate veins, also known as the
Brachiocephalic veins, join together to form the
Superior Vena Cava. The left innominate vein is
longer than the right. There is a slightly higher
thrombosis rate with left sided PICC insertions.
Because of this the right Innominate vein is usually
accessed first.
Median Veins are known as the Median
Basilic or Median Cubital and Median Cephalic
veins. They are located in the center of the
Antecubital Fossa and form a V. One vein goes
toward the Basilic and the inner aspect of the arm,
while the other proceeds outward and in a more
lateral position toward the Cephalic vein. The
Median veins are used 70-75% of the time for
PICC or Midline insertions where access is made
to the Antecubital area without the aid of
ultrasound. The Median veins are often used in
infants and children.
Cephalic Veins are located on the outer
aspect of the arm and there are anatomical
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differences between the Basilic and Cephalic
veins. The Cephalic vein is small and superficial.
Beginning proximal to the thumb, the Cephalic
vein advances up the forearm along the lateral
aspect of the Antecubital Fossa. A very common
site for laboratory blood draws, this vein sits high,
with easy visibility
The Cephalic vein remains small in size
throughout its path up the arm. As it reaches the
Axillary vein, it makes a sharp turn as it joins the
vein. At this junction, approximately 10-15% of all
catheters will turn down instead of continuing up
into the Subclavian vein. For these reasons, the
Cephalic vein is considered the last choice for
PICC and Midline vein selection. Track your
complication rates with the Cephalic vein.
Consider carefully your options and
choose the best vein for the PICC insertion.
Identify a vein that is soft and bouncy;
remembering that the vein of choice is the Basilic
vein and that the Cephalic vein has catheter
malpositioning problems. The small size of the
Cephalic vein may contribute to an increased
chance of phlebitis.
29
 Vygon Corporation

Neonatal and Pediatric Peripheral Site Selection

Pediatric site selection is age specific. The Antecubital area is always preferred but due
to multiple I.V. attempts or blood sampling, the antecubital veins may not be visualized
or palpated. Age approximations for site selection are:

Temporal or Post Auricular scalp veins for
0-6 months: both veins are appropriate for
threading the PICC to the SVC. The vein that runs
in front of the ear is the Temporal vein, it is
important to make sure that there is no pulse prior
to accessing this vein. Many times the Temporal
artery is in close proximity to the vein, especially
with the left Temporal vein.
The Temporal vein is less tortuous and more
visible than the Posterior Auricular vein. The
Posterior Auricular vein is the vein that runs
behind the ear. It is important to assess the
infants activity level before a scalp PICC is
considered. If the infant is rolling over or plays
with its ears, a scalp PICC may not be the best
choice.
Overall, the scalp PICC is often considered a
last resort and parents usually prefer to have the
PICC placed in the extremities. A device known as
the IV Housetm can be helpful in covering and
securing the scalp catheter.
The Axillary vein in neonates and by
radiologists. This vein is considered to be a deep
vein accessible with ultrasound; the Axillary vein
extends from the axilla to the lateral border of the
first rib. This vein is very prominent in premature
babies. Securing the catheter can be difficult at
times due to the location of this vein and
movement of the shoulder.
Lesser and Greater Saphenous veins for
ages 0 - crawling: The Saphenous vein is a good
option for infants who are not mobile. The vein is the
longest vein located on either side of the ankle and
is typically an option for infants until they are standing
or crawling. Optimal placement is in the Inferior Vena
Cava (IVC).

30

Lesser and Greater Saphenous Veins
External Juglar veins: These veins are easily
visualized and palpated. For the placement of the
PICC into the Jugular, it is important to position the
patient in reverse trendelenburg with a roll under their
shoulders. Due to the potential of air embolism with
a Jugular PICC insertion, sedation or general
anesthesia is required. Maintaining an occlusive
dressing to this site can be challenging due to the
patients activity level.
Femoral Vein: This site is primarily accessed by
physicians because it lays so deep under the skin and
requires a deep needle stick. With the advent of
ultrasound use of this location may increase. Because
it is positioned so near the Femoral artery, access of
this vein is not without risk. Avoid use of the Femoral
vein with cardiac patients.
Popliteal vein: the Popliteal vein is easier to
see in premature rather than full term infants.
Because it is difficult to stabilize it should not be
used with cardiac patients due to possible need
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for cardiac catheterization. There is evidence that
there may be increased risk later in life involving
deep vein thrombosis in the leg.
The Femoral vein: Because it is a deep vein
it is primarily accessed by a physician, nurse
practitioner or physician assistant. If a vein is
visible, access may be possible with a small gauge
PICC or Midline (2Fr or 3Fr catheter or smaller). A
blue line under the skin will help to identify a
Femoral vein.
It is difficult to feel or palpate veins in infants
until they are older and the veins grow to
adequate size to be felt. This generally occurs
after puberty.
Application of heat, lowering the extremity
below the heart, tapping and/or rubbing lightly, and
milking the vein can all assist in improving
visualization.
For neonates, the hand, wrist region and
forearm can additionally be considered as
appropriate sites for PICC access.
Site Selection should provide the most
appropriate vascular access for the delivery of the
prescribed therapy and minimize the potential risk
of complications related to infusion therapy (INS).
Vein selection must include assessment of the
patients condition, age and diagnosis; vein
condition, vein size, location and type, and
31
 Vygon Corporation
duration of therapy. The vein must accommodate
the gauge of the catheter. Prior to insertion,
anatomical measurements are necessary to
determine the length of catheter required to insure
full advancement of the catheter and catheter tip
placement into the Superior Vena Cava. The veins
of the Antecubital Fossa are the most common
sites for peripherally inserted central access.
Veins should be differentiated from arteries by
palpation (INS).
Parents can assist during the procedure
by wrapping the childs arms and legs with towels
or diapers that are soaked with warm water.
Median Antecubital
Basilic Vein
Cephalic Vein
Saphenous Vein
32
Application of an arm-board may
immobilize the site and improve success of the
insertion. Arm-boards after insertion are not
necessary for PICCs or Midline catheters.
Dominance of hands does not play a part
with PICCs or Midlines as there is no functional
limitation. If few sites are visible, consideration
should be given to radiological placement or the
use of hand-held ultrasounds or other Seldinger
type methods of insertion. Encourage the staff that
draws blood and starts the peripheral I.V.s to save
Antecubital veins for Midlines and PICCs.
Temporal
Scalp Vein
External Jugular
Subclavian Vein
Innominate Vein
Superior Vena Cava
Inferior Vena Cava
Femoral Vein

Tips For Finding Veins
The use of rubberbands works well for
small children or infants.
Cut tourniquets to fit for older children
and rub the site rather than thumping it.
Give the patient a warm bath just before the
insertion procedure.
Warm compresses work well. Dampen a
diaper with warm water and wrap the arm or the
leg.
Midline catheters are commonly inserted
1 inches below or above the antecubital fossa
and threaded up to the shoulder. Exceptions are
made for pediatric and neonatal patients.
Insertion of midlines may be in the lower or
upper arm, lower leg or scalp veins as available.
These catheters are used for
medications/solutions with an osmolarity under
500 mOsm and a pH between 5 and 9.
Medications listed as irritating, or hyperosmolar
are not to be used with Midline because of the
risk of thrombosis, phlebitis and other serious
complications.
A Peripherally Inserted Central Catheter
which falls short of the Superior Vena Cava is
considered suboptimal placement and is
considered a midclavicular line. This placement
is not appropriate for most infusions, even if the
Superior Cava cannot be reached. Do not leave
a line in the midclavicular position but pull it back
to midline.
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Central Venous Access
Peripherally Inserted Central Catheters
(PICCs) are inserted peripherally, usually
through the veins of the Antecubital Fossa,
and advanced into the Superior Vena Cava, or
in the leg through the Femoral or Saphenous
vein into the Inferior Vena Cava; the scalp
veins, Temporal or Post Auricular; or via the
External Jugular vein. PICCs can be used for
all intravenous therapies including total
parental nutrition, vesicant chemotherapeutic
agents, irritants and all hyperosmolar
solutions.
Central Veins for the upper body
include the Subclavian, the Innominate
veins and the Superior Vena Cava (SVC).
For compliance with the Infusion Nurses
Society Standards, central placement for a
PICC is generally in the SVC or for the lower
extremities in the Inferior Vena Cava. As a
catheter travels up the arm into the Axillary
vein (16 mm for the average adult) then thru
the Subclavian vein (19mm), until it reaches
the Innominate vein (19mm).
The Innominate veins form a V in the
center of the chest under the sternum. As the
two veins join to form the SVC, the left
Innominate vein stretches to the right side of
the sternum to reach the SVC. Consequently,
the left Innominate vein is longer than the right.
For this reason, catheter measurement and
placement from the left will always be longer.
The Superior Vena Cava sits just to the right
of the sternum. Measurement for neonates
should be approximately along the nipple line.
The Innominate veins form a V in the
center of the chest under the sternum.
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 Vygon Corporation

Anatomy of Veins and Valves

Tunica Adventitia Tunica Intima
Veins are made up of three
layers: the tunica intima,
tunica media, and the tunica
adventitial. Each layer has
distinct functions relating to
PICC placement.
Tunica Media
The Tunica Intima: made up of smooth valves. Surprisingly the muscular tissue in the
endothelial cells in a single layer inside a vein, this valves is even stronger than the tissue in the
layer of cells runs the length of the vein wall and medial layer. Applying heat to the extremity will
protects it. When the endothelial layer is damaged help to relax the veins and decrease the chance of
by a difficult introducer insertion, the body re- vasoconstriction. Advancing the catheter slowly
sponds with a thrombotic cascade. The platelets will also assist with decreasing vasoconstriction.
and red blood cells begin to clump together to
form a patch covering the area of irritation. If the The Tunica Adventitial: this layer houses the
irritation continues, the patch becomes larger and capillary and nerve fibers and is the outer layer of
may develop into a phlebitis or thrombus. the vein. Although blood flows through our
This layer can also recognize any foreign vessels, little absorption of nutrients takes place at
body. Risk factors for irritation include threading this location. Vessels
too rapidly, a guidewire nourish themselves
sticking out of the cath- through the capillary
eter, and irritating solu- network. This is the
tions. All of these can layer where the pop
interrupt this layer of the is felt upon insertion.
vein and lead to the
beginning stages of The nerve fibers in
thrombophlebitis. the adventitial layer
are the same nerves
The Tunica Media: the that activate the
center layer of the vessel closure of the valves.
made up of elastic and The closer needle
muscular fibers that penetration is to a
crisscross to form the valve, the more likely the valve is to shut because
structure. This is the thickest part of the vein and the nerve conducts the impulse to close the valve.
is the part of the vessel that is responsible for Anxiety and the flight or fight response will also
vasoconstriction. Factors such as trauma to the cause the nerve to stimulate closure of the valves.
vessel wall or anxiety may be precursors to Patients with degenerative muscle diseases will
vasoconstriction. The same tissues that are in the have veins that will roll and are not supported well
medial layer are also in the structures called with this layer.

34

Dealing With Valves
Assessment of the quality of vein sites, the
presence of valves and the emotional state
of the patient prior to insertion, can improve
your overall success with the insertion of
PICCs and Midlines. (Neonates do not
have competent valves)
Valves are present in most veins
throughout the body and can create problems for
PICC insertions. Fortunately, they present less of
a problem in pediatric patients. Neonates and
children up to age 10 have immature valves still in
the developmental stages consequently, these
children usually do not have valve issues. If there
are valve problems they are generally connected
with catheter threading difficulty due to small or
rolling veins.
The number of valves in a vein varies
depending on the type of vein and the age of the
patient. The Basilic vein has 4-8 valves; the
Cephalic vein has 7-10 valves, and the
Saphenous veins have 7-15 valves. Fewer valves
are present as you approach the Vena Cava.
It is best to use a strategy to avoid valves.
Assess the patient for anxiety before the
procedure and then take steps to manage any
overt anxiety with premedications po, topical
creams or injectable anesthetic. Difficulties with
valves are significant when they impede the
threading of Peripherally Inserted Catheters,
Midlines, Midclavicular or PICC lines.
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Valves are present in larger vessels to
regulate blood flow. They can be palpated by
feeling for a round knot in the vein and can be
seen with fluoroscopy if contrast is injected.
Management of valves focuses on three
issues: the location of the valves, assessment of
the anxiety level of the patient and the use of
premedication as needed.
Valves close in the presence of anxiety
or pain and pain management is important for
all ages; it can assist with valve management.
Premedications useful with children include:
Valium (over age 6) or Chloral Hydrate. Use of
topical or injectable anesthetic agents such as
EMLA cream (AstraZeneca Pharmaceuticals,
www.emla-us.com) or L-M-X 4 (Ferndale
Laboratories, www.ferndale.com) for full term
infants or older children can reduce insertional
pain and some anxiety. Conscious sedation may
be needed when initial efforts to manage the
patient are ineffective. Morphine and other
narcotics can also be used to limit the pain
caused by these procedures. In older children,
pain can cause the activation of valves and
impede the threading of the catheter.
Check blood return and then gently flush.
This will open the valves and can encourage
threading of a catheter.
Warm heat can also assist with opening
or relaxing valves. Apply heat with a warm
washcloth on the upper arm, shoulder or upper
leg. This may assist with the threading of the
catheter.
Choose the most appropriate vein for
the PICC. This may decrease threading
problems relating to valves. Patient
assessment is important as you determine if
the patient would benefit from sedation.
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 Vygon Corporation
Management of Valves
Vasoconstriction
Tunica Media
When a valve is hit upon insertion, stop
threading the catheter. Try to relax the patient or
the vein by having the patient perform slow, deep
breathing. Check for blood return if possible. Apply
heat to the upper extremity, this may assist with
relaxing and dilating the valve. When blood return
is present, gently flush; if possible, gently pull the
catheter back through the peel away introducer
1-2 cm. Never attempt to do this with a
breakaway needle insertion. Gently flush the
catheter with 1-3 mL of normal saline and then
attempt to thread the catheter again.
With infants and children threading the
catheter requires patience and must be done
slowly. Milking and/or massaging of the vein
toward the heart to empty it of blood and then
allowing it to refill can sometimes aid in threading
the catheter. This technique is particularly helpful
with Saphenous veins.
Premedications are frequently necessary
for the insertion of PICCs for pediatric patients for
the following reasons:
It can be difficult to control the movement of
an infant or child.
Patient concern over the pain of the
procedure. (Effectiveness of topical anesthetics
should not be overlooked.)
When accessing a deep vein or if there is
only be one vein that can be accessed.
(Premedications can create the best
circumstances for insertion)
When a larger introducer is required. (More
pain is associated with larger introducers.)
36
Reducing the trauma of a procedure can
be accomplished easily with forethought and
preparation. A child may have a prolonged
hospitalization or a serious illness and has
already experienced multiple invasive procedures.
Premedication, child life experts, games,
distraction techniques or conscious sedation may
all benefit a young patient undergoing a procedure
but, premedications and/or conscious sedation
are not necessarily or appropriate for all
insertions. Improper use of premedications can
cause an increased risk of untoward reactions
and should only be used after careful
consideration of the possible complications.
Distraction Therapy
Additional methods can help control a
childs movement and result in a less traumatic
experience. Music, games, movies and tape
players with headsets work well to provide
adequate distraction during the procedure for
school-age children.
Quick, organized, and efficient use of time
when working with young children is paramount to
success. Adequate assistance to manage their
movement is also very important. Have the room
set up prior to the patients entrance to decrease
their anxiety.
Oral distraction for the youngest patients in
the form of pacifiers, a sucrose pacifier (Sweet-
Ease, by Childrens Medical Ventures/Respironics
www.childmed.com), the Super Soothie pacifier
and WubbaNub pacifier, Wee Thumbie, Freddy
Frog, and the Snoedel Doll for comfort and
positioning can be helpful.
 Vygon Corporation

Conscious Sedation

Conscious Sedation in some situations is vital to

the success of a PICC insertion. Conscious sedation is
administered in an appropriate setting to minimize the
potential risk of complications. Conscious sedation is
recommended for children that are unable to be still for
30 to 60 minutes. Toddlers most commonly recieve
conscious sedation.
Intravenous conscious sedation requires a
physicians order and is provided only in a controlled
practice setting. Common indications for the use of
conscious sedation are to produce sedation, relieve
anxiety, and impair memory during short-term,
therapeutic, diagnostic, and surgical procedures, such
as endoscopic procedures. A controlled practice setting
requires a physician to be in attendance, resuscitative
equipment and medications, cardiac monitoring
equipment, pulse oximetry, continuous patient
observation, and post procedural monitoring as the child
recovers from sedation. Know what to do if there is
respiratory compromise and confirm that equipment is
quickly available and ready for use (i.e. oxygen, suction
etc).
Patient consent for sedation must be obtained
prior to the procedure. Specific agents used to achieve
intravenous, conscious sedation may include Meperidine,
Diazepam, Midazolam (Versed), Morphine and/or
Fentanyl. Conscious sedation can reduce the trauma of
intravenous procedures for children while increasing the
potential for success with PICC lines.
Versed can be given po, I.V. or even I.M.
effectively taking away the memory of the event. A
pediatric dose of Versed is 0.1 mg/kg IV/IO (over 1-2 min/
max dose 4 mg). It cannot be used in the home.
Chloral hydrate po can be given in the home,
possibly at dose. The child may fall asleep in about 20
minutes but will wake up once you start the procedure
and they continue to have tactile responses.

37
 Vygon Corporation

COMMON PREMEDICATIONS: AGE SPECIFIC

Valium EMLA Lidocaine Normal Other

Saline
Pre-
Apply mini- 0.1 cc - 0.2 cc 0.1 cc 0.5 cc Antihistamines
Medications marshmellow Intradermal / SQ Bleb Intrasal
size cover with Intraderma / lSQ Versed
transparent Conscious Sedation
dsg L-Max4
(called Elamax)

Older Children YES YES YES YES YES

NO YES NOT USUALLY Depends on

use other 60 minutes Can be mixed with the Child
pre-medications 2 hour peak Sodium Bicarbonate Deadens nerve endings,
Children (PO relaxants Magic Cream! to reduce burning. should be Bacteriostatic.
Versed LMX only takes Can be given thru Benzl Alcohol numbs
lollypops 30 minutes iontophoresis like the nerve endings
Benedryl) Numby Stuff

Generally
Neonates not treated with
pre-medications

EMLA or L-M-X4
EMLA cream or L-M-X 4 can be used
successfully to decrease pain. Both creams have
lidocaine and EMLA has prilocaine. Application of
the cream directly on top of a vein can reduce its
size so place a small amount of the cream (the
size of a nickle) just below where you plan to
access and then stabilize the vein by tunneling the
introducer. The cream can then be applied in
several spots. Topical creams can be used with
infants greater than 37 weeks gestation. They
come in small tubes that are 5-15 grams. L-M-X4
takes less time to reach full anesthetic action,
about 30 minutes.
Lidocaine
Lidocaine injectable form, can be buffered to
decrease the stinging sensation. Use 0.9mL of 1%
Lidocaine and 0.1 of sodium bicarbonate. The
Lidocaine can be injected where the topical
anesthetic cream has been already applied.
Bevel down with Lidocaine or Bacteriostatic normal
saline, injecting a wheal, this tends to work best.
38
Smaller gauge
needles (27 gauge)
work very well. The
typical dose is
.3-.5mL for children. If
you use too much or get
too close to the vein, it
may constrict or
disappear.
Numby Stuff
Numby Stuff electrodes teamed with
IONTOCAINE (a brand of Lidocaine, 2% HCI with
1:100,000 epinephrine topical solution) will provide
clinically effective dermal anesthesia up to 10 mm
depth in as little as 10 minutes. Through
iontophoresis Lidocaine is electrically absorbed
through the skin reaching effective levels of topical
anesthetic in a very short period of time. Numby
Stuff is ideal prior to procedures that might
otherwise be painful. (Numby, IOMED, Inc; Salt
Lake City, UT, 1-800- 621-3347 www.iomed.com )
 Vygon Corporation

Measurements for PICCs

The Standard Three Step Method

For Neonates and Children: To determine For Inferior Vena Cava use, measurements
the catheter length for PICC insertion for approximate the level of the diaphragm (about 3
neonates and infants use the following finger widths above the umbilicus). Never trim a
formula and method: catheter shorter than 12 cm, it may become too
short and floppy. This method will ensure proper
catheter measurement for the smallest patients.
Total catheter length =
Insertion length + a
portion of the catheter
remaining outside of
the body

The Standard Three Step

method assures
success:
1. Choose the insertion
site

2. Stretch the arm out

45-90o from body, Locate
the clavicular region near
the sterno-cleido notch
3. At the first intercostal
space, following down
toward the sternum (one
finger breadth),
approximating the nipple
line.
For Children: (under 80 pounds):
1. Locate the insertion site and stretch the arm
out 45-90o from body.
2. Place your finger at the Midclavicular region.
3. For children over 80 lbs find the 3rd intercostal
space on the RIGHT side of the body. This sight
will determine the proper catheter length for the
PICC.

Description of the Neonates and Infants
Measurement Method: Follow the above
description omitting the third intercostal. Insert
one finger breadth near the RIGHT side of the
sternum at the head of the clavicle. From the left
side begin a 45o-90o arm insertion sight to the
midclavicular area, come across to the head of
the right clavicle. Measure down one finger
breadth (to approximately the first intercostal
space) slightly above the nipple line.
For ages 0-2 years, the catheter length site
should be located one finger breadth down from
the head of the RIGHT clavicle.
For ages 2-4 years, locate the sight two
finger breadths below the head of the RIGHT
clavicle
For ages 4-8 years and weighing up to 100
lbs, measure three finger breadths down.

39
 Vygon Corporation

Use good judgment based on the size the
patient and your approximation of the nipple
line. The insertion site should be slightly above
the nipple line.
Description of the PICC Measurement
Procedure for children over 80 pounds:
Locate the best part of the vein and below that site
1 or 2 cm place the end of the tape measure at the
actual insertion site, not on the best part of the
vein. Stretch the arm out 45o-90o from the body;
pull the tape measure toward the midclavicular
region.
Feel for the clavicle, where the
sterno-cleido-mastoid notch is located. Hold the
tape and release the arm. Turn the tape measure,
so no wrinkling occurs. Feel for the first
intercostal space, just under the RIGHT clavicle,
move toward the sternum, following the space.
Using three fingers, starting with the index
finger place the finger under the clavicle, then find
the second and third intercostal spaces. The third
intercostal space is over a mammary gland and
should be slightly tender. Pull the tape measure
to the third intercostal on the right.
Double and triple check as needed for
accurate measurements. Look at your x-ray
placement checks to further improve your
accuracy. The extra 1-2 cm will help secure the
catheter to the securement device.

Important Points to Remember When Measuring PICCs

External measurements are estimates, but certain practices can
improve your accuracy of measurements and final tip placement.

To improve accuracy, dont walk the tape measure up the arm.

DO hold the tape at the insertion site and stretch it to the midclavicular, flat against the arm.
Do keep the arm stretched out at a 45o angle from the body.
Remember: the Superior Vena Cava is always to the right of the sternum.
Remember that external measurements are estimates, never exact. Strive for greater accuracy!
Gravity can help drop the PICC into the SVC, away from the Jugular, consider using a pillow to support,
this will help with the threading of the catheter to the SVC.

Dont overshoot intentionally. It is difficult to maintain a catheter with excessive external length,
especially during dressing changes. DO strive to place the terminal tip in the SVC. An X-ray is
always required to confirm placement in the SVC.
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 Vygon Corporation

Insertion Devices and Products

There are a large number of PICC and With practice, patience, and concentration, you
Midline products on the market today. The can master this procedure.
difference is determined by the the type of
introducer; breakaway needles, peel away sheath Breakaway needles have advantages and
introducers, and needle access with the Modified disadvantages.
Seldinger Technique. They are sharp
The Modified and advance
Seldinger Technique through the skin
(MST) is an advanced with a cleaner
practice for the insertion cut making it
of PICCs. The easier to access
sharpness and design of veins. This type
the needle is an of needle must
important factor in be used with
Premicath and Nutriline
using a Split Cannula selection. Introducers caution when
come in a variety of advancing a Premicath: Polyurethane 1.1 Fr 28G or
Nutriline Polyurethane 2 Fr catheters with
colors but the technique of insertion will remain catheter through Splitting needle and Integral Extension.
basically the same. There are safety introducer the bevel.
needles available for most of the products as well. Access the vein straight in then let go.
Proper technique when using the peel Grab the catheter with the forceps and begin to
away sheath introducer insures that the plastic thread. Once a catheter has been advanced
introducer and the needle remain locked together. through the bevel of the needle it must not be
This allows a smooth transition, without drag. To pulled back because it can be sheared off when
access the vein, lay introducer flat and advance pulled against the sharp edge of the needle bevel.
through the skin and into the vein. Advance the Shearing can result in a hole or complete catheter
cannula gently and remove the needle. You should emboli; the piece typically travels to the pulmonary
see adequate blood return. bed. Fragmentation of a catheter usually
Observe the blood flow for color and becomes a legal case.
adequate flow. Be sure that it is not bright red and
not pulsating! Begin threading
the catheter with forceps. Size Product and Catheter Material
Preferably the forceps should Application Size
be rubber or silicone shod to
avoid damage to the catheter.
1.1 - Premicath / Nutriline / ECC: 28 - 20G Polyurethane
A small tear in the catheter 3 Fr Neonates less than and Silicone
can lead to subsequent 2500G 1.1 - 2 Fr
complications. greater than 2500G
The process of 1.9 - 3 Fr
accessing the vein by laying
the introducer flat before 3 Fr Lifecath: 22 - 20G Polyurethane
advancing, can be technically Pediatric Patients and
difficult, especially when veins Small Adults
are small. Needles are often
used with neonates because 4 Fr Lifecath: 18G Polyurethane
of the ease of use and Older child
because it is easier to access Adult
their smaller veins.
41
 Vygon Corporation

Breakaway needles are most often used with silicone, and

neonates due to their ease of use and easier allows thinner
ability to access the vein. catheter walls,
Other factors with PICC and Midline and greater flow
products include the size, length, material, and rate capabilities
hub type. The smallest gauge and shortest length (NANN).
cannula that will accommodate the prescribed Polyurethane is
therapy should be used (INS). durable, strong,
Premicath: Polyurethane 1.1 Fr
Please refer to the Instructions for Use catheter 28G, or Nutriline 2 Fr
and x-rays well.
clinical insert sheet which accompanies the catheter 24G, and Splitting The smallest
product to become familiar with each particular Needle or NeoCath Split size is 1.1 Fr.
catheter. With babies and children catheter Introducer and Integral Extension Because of
trimming is frequently necessary; it is very difficult thinner walls,
to manage a catheter that is too long, especially the inner lumen diameter can be larger than the
during dressing changes. Catheter sizes vary inner lumen of silicone catheters of the same
from a 1.1 Fr single lumen to 7 Fr triple lumen outer diameter. This is an important factor with
PICC. The 7Fr triple lumen is suitable for adult smaller gauge catheters.
application only. For children, 2-3Fr size catheters Due to the strength of polyurethane these
are the most common size. catheters have a lower frequency of
There are multiple devices to choose from. fragmentation. In the past the use of polyurethane
How do you decide which type and size to use? catheters has been questioned for use with
What are the access needs of the patient? There neonates due to their stiffness. However, newer
is no need to put a dual lumen PICC in a patient formulations of polyurethane are much softer than
unless their fluid needs are high. There are older, stiffer catheters. Because of higher flow
advantages and disadvantages with all types of rates and softer more durable polymer
catheters. formulations, polyurethane is now used for all age
Materials: groups with lower risk and excellent success.
Silicone is soft, Catheter guidewires are called stylets and
flexible, comfortable, their use is optional. Guidewires or stylets are
and can be easily generally not used in the neonatal population but if
trimmed. However, they are used
silicone catheters for the initial
tolerate less insertion the
pressure than wire is pulled
Epicutaneos (ECC Silicone polyurethane and back out of the
and Polyurethane 2 Fr catheter rupture easily PICC as the
with a Compression Hub). The (NANN). PSI limits on catheter
catheter threads through the
Butterfly needle. silastic catheters are advances into
lower due to lower the chest. The
burst pressures because the silastic is so soft. LifeCath: 3 Fr and larger PICCs stylet assists
Never forcefully flush a catheter. Syringe are manufactured in with threading
size can contribute to a rupture if any resistance is polyurethane, come single lumen by making the
present, (1cc syringes can easily rupture a or dual lumen. Insertion is catheter stiffer.
catheter and are not recommended for any PICC accomplished through a Stylet use is
product). See the care and maintenance Peel-apart cannula Introducer. questionable
instructions on the IFU for problems with syringe with neonates due to their soft veins and the risk
issues. Syringes no smaller than 10cc are of perforation; this is an area that has not been
recommended for use with PICCs. well researched and consequently level of risk is
Polyurethane is 2-10 times stronger than unknown.

42
 Vygon Corporation

Tips That Will Help When

Choosing The Correct Size Catheter

Place the smallest size catheter to get the job done. Larger catheters can increase
complications, especially thrombosis. A patient must have adequate veins for the catheter
size you intend to use.

A 2Fr catheter = zero gravity flow, and a pump must be used for infusion. (There are some
institutions that draw blood from 1.9-2 Fr polyurethane catheters.) Occlusion is a potential
complication when drawing blood from small gauge catheters. These typically come with a
22g introducer needle.

A 4Fr catheter is recommended by most manufacturers for blood sampling. This typically
comes with a 17g introducer. This size PICC will also allow large volumes of infusion.

43
 Vygon Corporation
Infection Control & Universal Precautions
For Insertion
Handwashing is the cornerstone
for aseptic technique practiced
by all medical professionals in
their effort to decrease the risk of
bacterial contamination.
Handwashing prior to a
PICC procedure requires a 5 minute
scrub and should be performed
before, immediately after all clinical
procedures and upon removal of
gloves. Single-use soap scrub
packets or waterless products are
also recommended in situations
where running water is
compromised. (INS)
Treat the PICC procedure as
you would any surgery, using
maximum drapes, taking special
care in the application of gloves and
immediately managing any episodes
of contamination. Be conscious that
a one year.
Follow all sterile principles
during insertion. Maximum barrier
protection is recommended by the
CDC for all Central Line insertions.
Children need to be educated prior
to the procedure to avoid treir fear
of the monster garband all ages
will want to watch what you are
doing. Mask them if possible but do
not impede them from watching.
Nurses who insert PICCs should be very knowledge-
able about and competent with sterile technique.
Use a sterile gown, mask, eye shield, gloves,
and head cover (INS).
Create maximum barriers and use full draping
after the skin is prepped with large drapes.
Sharps containers, and waste protection must
be available.
44
Sterile principles include:
Always apply gloves in a sterile
manner.
Remember the difference
between sterile verses non-sterile.
Consider a one to two inch
border around the drapes as
contaminated
Stay within the center of the
sterile field, keep your hands above
your waist and out in front at all
times.
Never turn your back on your
sterile field.
Warn the patient or parent not to
touch the sterile field.
Change your gloves after the
patient is prepped and draped.
The sterile field is not
established until the patients arm is
prepped and draped. Cover the
hand or other body parts with extra
drapes as necessary.
A Peripheral-Midline insertion site
should be aseptically cleansed with
an antimicrobial solution prior to
cannula placement.
Insertion of a PICC requires the use
of sterile technique, including a
sterile gown, gloves, mask, head
cover and a large sterile drape (i.e.
maximum barrier precautions, INS).
Gloves: After the nurse puts on sterile
gloves and whenever the gloves contain talc they
should be rinsed with a sterile water or normal
saline solution to avoid powder adherence. After
the initial preparation and completion of drapes,
gloves should be changed again prior to catheter
placement (INS). It is also recommended that
gloves should be talc and latex free.

Supplies needed for a
PICC or Midline
insertion include:
A catheter, specify brand and lot number in the
documentation. It is generally advisable to have
two catheters available in the event that one is
accidently contaminated.
An Insertion Kit (the catheter and insertion kit
may be combined) Be sure to check the contents
of the kits. You may need some of the items
mentioned below if they are not included in the
kits. It is not uncommon that supplemental items
are required.
Personal Protective Equipment (sterile gown,
eye shield, mask, gloves, hair and shoe covers,
as applicable). Flushes, saline (preservative free
for neonates), and Heparin may be required as
well.
4-6 pairs of Gloves (talc free preferred).
An extension set.
Injection cap, or needleless cap.
Gauze 4x4s.
Extra drapes.
An extra Introducer
Vygon Corporation
Chlorhexidine (Chloraprep). Guidelines
recommend chlorhexidine or povidone-iodine and
alcohol as skin decontaminants for neonates, but
indicate that iodine solutions be removed with
sterile saline solution or water to prevent
absorption. Chlorhexidine has been found to have
minimal to no absorption through the skin. Apply
Chlorhexidine for 30 seconds or with two
consecutive wipings as shown below for
disinfectant use (AWHONN Neonatal Skin Care).
Normal Saline for rinsing gloves if they are not
talc free.
1cc syringe for intradermal doses, as needed.
Premedications (some need to be given po 30
minutes in advance, EMLA, 60 minutes or LMX, 30
minutes in advance).
Adhesives top the list of threats to the integrity
of neonatal skin and studies listed below invite the
further development of least-disruptive adhesives.
Lund C, Osborne J, Kuller J, Lane A, et al. Neonatal skin care:
clinical outcomes of the AWHONN/NANN evidence-based clinical
practice guideline.
JOGNN. 2001;
30(1): 41-51.
Lund C, Kuller J,
Lane A, Lott W, et
al. Neonatal skin
care: the scientific
basis for practice.
JOGNN. 1999;
28(3): 241-254.
Gerard JS, Buck
RK, Maloney P,
Durkin DM, Toth-
Lloyd S, Duffy M,
Szocik P, McAuliffe TL, Goldmann D. Comparison of 10%
providine-iodine and 5% chlorhexidine gluconate for the
prevention of peripheral intravenous catheter colonization in
neonates: a prospective trial. Pediatr Infect Dis J 1995 Jun;
14(6):510-516.
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 Vygon Corporation

Four Devices for Insertion of PICCs or Midlines

1 2 3 4
Splitting Needle Butterfly Needle Split Cannula Peel-apart Cannula
Premicath or Nutriline Epicutaneo (ECC) Introducer (ALL) Introducer
Nutriline/LifeCath

46

Insertion Procedure: Neonates and Infants
Based on NANN Peripherally Inserted Central
Catheters Guideline for Practice 2001.
1. Determine the need for a PICC and obtain an
order and signed informed consent form from the
parents. Consent can
be written or verbal if
you have a witness.
Consideration for timing
and stress
management is very
important with
neonates. Do not
schedule multiple
Obtain an order and signed
Informed Consent form from the procedures and/or
patient, parents or other guardian. manipulations for a
baby back to back.
Stressors must be eliminated for optimal growth and
healing.
2. Evaluate the patients vein choices; not all
infants are candidates for PICCs. If unable to locate
aan appropriate vein, the infant may be a better
candidate for another type of device (NANN).
Assess and select the vein for suitability. Introduction
of a PICC is generally via the Basilic, Median Cubital,
or possibly the External Jugular, Saphenous,
Temporal, Post Auricular vein, or performed by a
physician to the Femoral vein. The vein should be
bouncy, soft, and visible with no recent venipuncture.
3. Choose a catheter that is appropriate to the
needs of the infant and vein chosen. Dual lumen
catheters should only be used with veins that will
accommodate a 4 Fr catheter. Some infants require
more than one PICC at a time. One may have a tip
located in the Superior Vena Cava and the other in
the Inferior Vena Cava (NANN).
4. Select the insertion device;
either a steel splitable butterfly needle
or a Peel-apart split cannula.
5. Measure the arm using the three-
step method (see page 39): Insertion
site midclavicular nipple line.
Measure the arm using the
Three-Step Method
Vygon Corporation
For the Superior Vena Cava: Insertion Site:
Make sure approx 1 cm or more is left out (the
total length of the catheter should never be shorter
than 12 cm).
For a Midline catheter: Measure for the length
of the catheter, up to end of extremity but not into
torso.
For scalp vein insertions follow the line of the
vein.
For Saphenous vein insertions measure
from the insertion site up the leg to the groin and
then above the level of the diaphragm/xiphoid,
approximately three fingers above the umbilicus,
near nipple line. Tear or mark the tape measure to
help remember the measurement.
6. Collect the supplies: A universal precaution
mask with eye protection, a sterile gown and head
cover are required. Have extra gloves available.
You will also need a catheter kit, an insertion kit,
an extra introducer, (one introducer for each stick)
gloves, a tourniquet, a tape measure, adequate
drapes to cover the bed, gauze, extension set,
and a needleless injection cap. Shoe covers are
optional. Read the packages to ensure contents
are what you expect. Open a package in advance
to become acquainted with the contents and the
devices.
Collect and organize your supplies. Read the packages.
7. Consider premedication; either topical or
injectable. PICC insertion causes some pain and
infants requiring PICCs are often
unstable and easily agitated. Increased
stress increases oxygen needs and
variation in temperature control.
Movement can also reduce the
success of the procedure and can
result in multiple attempts. Pacifiers,
47
 Vygon Corporation
sucrose pacifiers and visual stimulation can all
reduce the stress of the procedure.
8. Proper patient positioning is vital. Position
the bed, the warmer and the baby for best lighting
and access. Bundling with a
blanket is an excellent way to
keep the neonate warm and is
needed if the baby is active
with much extremity
movement. Position the arm
out 45o-90o from the body, and
place the leg in a comfortable
froggy style. Arrange to have
an assistant; one person
should concentrate on the
Apply a head covering
baby at all times. The and mask. Then wash
assistant can help with the your hands.
tourniquet, positioning and
restraining the extremity while monitoring the vital
signs and alarms. Arrange a suitable table for
insertion, away from the patient. The table for the
supply set should be at least 2 feet by 4 feet.
9. Apply the head covering, the mask and
wash hands using the five minute scrub. Be sure
you have removed all jewelry and watches.
10. Open the equipment and establish a
sterile field. Open the supply packages in a
sterile manner, do not touch corners on sterile
side. Establish a large field with adequate space
for organization, and organize your supplies so
you can see everything.
11. Don the sterile gown and sterile gloves,
place the drapes over the table keeping your hands
on top at all times. Use of sterile gowns requires an
assistant to tie the neck and reach for the front ties to prepping. Prep the entire arm, leg or a large area
secure them in the back. It is impossible for the
PICC inserter to maintain sterility while tying their
own gown. When a glove change is
needed pull the gown cuffs down over
fingers as you remove the gloves and
then put on new sterile gloves. After the
new sterile gloves are on and whenever
the gloves contain talc rinse with a
Apply a fenestrated drape or
sterile water or normal saline solution to sterile towels over the area.
avoid powder adherence (INS).
48
12. Drop all extra supplies onto the sterile
field (the extension set, injection cap, extra
drapes, etc.) Centrally position the supplies. Develop
a routine for placement of your supplies on the sterile
tray, making your task easier. Also consider your body
mechanics; if you are right-handed, you may want the
tray on your right side, next to the bed. (Children less
than 6 can use sterile cloth towels or a fenestrated
oval eye drape with a smaller hole, add these items
as needed).
13. Prepare the catheter. Draw up the flushing
solution, flush catheter, trim and perform all other
needed steps prior to prepping the patient.
Prepare the flushing syringes, pre-flush the
extension sets and the catheter. Flush with at
least 1cc of fluid through the catheter. Make sure
the catheter is intact and will advance through the
insertion device. Measure the catheter with a
sterile tape measure.
Catheter markings are
either every cm or
every 5 cm. Apply the
previously determined
Measure catheter with a sterile measurement of the
tape measure.
patient, and add the
1-2 cm the amount that will remain out of the skin.
Never cut the catheter shorter than 12 cm, less
than this will be too difficult to manage and can
easily dislodge. Cut the catheter, as needed, with
a straight cut. If no trimming is required, confirm
the amount to be left out of the skin and coil it
under the dressing.
14. Have an assistant position the baby and
hold the extremity. Lay a sterile towel under
intended extremity and have extra sterile towels
available. Follow your institutions policy for
around the insertion site with one chlorhexidine
wand. Use a back and forth, gentle, scrubbing
action, and allow drying time. Clean
3 inches above and below the site
for the PICC. Alcohol and betadine
can be used per your institutions
policy.
15. Apply a fenestrated drape or
sterile towel over area, extra

drapes can cover the exposed body areas and
extend the sterile field. Always overlap the drapes.
16. After the initial preparation and completion of
drapes, change your gloves according to
procedure prior to the catheter placement (INS).
Always have extra gloves available.
17. Tourniquet application. Have an assistant
apply pressure, a
rubber band or a
tourniquet. If needed
apply the tourniquet
and change your
gloves. Do not apply
the tourniquet until it is
Have an assistant apply pressure,
needed to dilate the a rubberband or a tourniquet.
veins. Place the
catheter close to the extremity. You may want to
apply heat above the insertion site to help dilate
the vein and relax the valves.
18. Insert the introducer. Hold the device with
your fingers on finger pads. Only one device
should be used for each cannulation attempt
(INS). Pull the cover off. (Follow the
manufacturers guidelines for insertion techniques
specific to each product). Insert the introducer
using 15o-30o angle through the skin just below the
anticipated entry point into the vein. Hold the skin
taut just under and to the side of the vein. (see
below)
19. Observe for blood return. Use a slow, stop
and start motion to locate the vein. If there is
difficulty with blood return or a clotted introducer
consider pre-filling the introducer with a very small
amount of heparin.
NeoCath Split Safety
Insertion Technique:
Lift off catheter following
the threading completion.
Split Catheter Tube (PUR)
Needle Hub (PC)
Needle protective housing activated
Winged Hub (PUR)
Vygon Corporation
20. Hold and stabilize the introducer with one
hand (on one wing) while reaching for forceps and
the catheter with the other hand. The catheter should
be within easy reach to the side of your dominant
hand. If using a Peel-apart Cannula or a Split
Cannula advance the cannula a bit more and then
remove inner needle.
21. Thread the catheter with forceps with a slow
controlled advancement, using .5-2 cm increments
with each stroke. Remove the tourniquet after the
catheter has been advanced 4-5 cm. Flush with
Heparinized saline while threading and thread to the
determined length. Positioning the head to the same
side used for the catheter insertion is optional and
avoids inadvertant jugular placement. The best way
to advance the catheter is to do so while gently
flushing.
22. Gently remove the insertion device using
digital pressure above the insertion site. Pull the
introducer back onto the catheter. Either pinch and
break the splitable needle, slide off the butterfly, and
lift off the split cannula introducer. If you are using a
peel-apart cannula introducer, swing the wings
together then up, then down and peel apart. Apply
pressure at the puncture site as needed until
bleeding stops. Verify that the catheter is at the
premeasured length or thread it in the appropriate
amount.
23. Remove the guidewire, if present. Remove
wire slowly over 30-60 seconds (NANN). For older
children have them perform the Valsalva maneuver
whenever opening the catheter system. Attach the
hub and extension tubing to the epicutaneos catheter
while holding the rod and catheter in the hub. Twist
into place.
49
 Vygon Corporation

24. Aspirate for blood return. If there is difficulty Insertion Tips

with blood return, withdraw the catheter slightly and
check for blood return through aspiration while
withdrawing the catheter. When blood return is
attained, attempt to readvance the catheter while
flushing gently and advancing it to the predetermined
length.
25. Secure the catheter and apply a temporary
dressing until after the x-ray confirmation is
complete. Keep the catheter patent by flushing it with
heparinized saline intermittently with a
5-10 cc syringe. Flush with a push, stop, push, stop,
pulsatile technique.
Apply a heel warmer or moist heat to the
extremity prior to insertion of the PICC.
Keep a low angle for insertion of the
introducer device.
Insert the introducer slightly below the best
part of the vein.
Use skin tautness and/or traction to stabilize
the vein.

Maintain alignment with the vein. Use parallel

alignment and go straight into vein, it will be less
likely to roll.

If you follow these simple insertion tips they will

Secure the catheter and apply temporary dressing until after X-ray
confirmation is complete.
26. Verify the terminal tip location by X-ray,
including the insertion site in the film. In the Vena
Cava you must be 100% certain of proper placement
before the catheter can be used (NANN). The use of
contrast may be necessary for questionable tips.
Reposition the catheter if necessary and secure it
with dressing following your facilitys protocol for
central line dressing.
help you achieve a successful PICC insertion.
Remember; practice, practice, practice and
observe other nurses when they insert PICCs.
There are different ways to achieve a successful
insertion, not just one way! If you are experiencing
success with PICC insertions be consistent with
your technique.
Develop a routine.
Body mechanics are important.

27. Speak with the patient and the parent after

the procedure.

28. Document the length of the catheter in the skin

and the length out of the skin, the vein accessed and
which extremity recieved the PICC, the date, the
manufacturer of the PICC, size, lot number, X-ray
confirmations, your name, primary physician and
phone numbers. List the indication for use of the
PICC, the prepping solution used, and any
premedications used. Documentation should also
include, tolerance of the procedure, estimated blood
loss, any problems or difficulties such as threading
problems, flushing performed, and the number of
attempts required for insertion.
50
 Vygon Corporation

Review of Procedure Check for blood return and flush.

Use this simple exercise to review. Close your

Change your gloves.
eyes and visualize the entire procedure, step
by step, in your mind. Visualization helps to
establish long-term procedural memory
making the process easier to remember when
it is time to perform the insertion.

Create a sterile field.

Position the extremity. 1

Prep the site.

Drape the site and change gloves.

2
Prepare and flush the catheter and apply the
tourniquet. An assistant should help with this.

Palpate the vein.

Insert below the vein, drop the device flat and

advance 0.5cm, observe blood flow and thread the 3
catheter.

Have the catheter and forceps next to you.

Get into your routine, body mechanics are
important.

Release the tourniquet once the catheter is

threaded at least 5 cm.
4
Straighten the arm, tuck the chin to the
extremity in which you are accessing the vein. If
you thread the catheter too fast venospasm and
vein irritation may result.

Remove the introducer when threading is

5
complete, typically after you thread 10-15 cm.

After removal do not place the tape directly on

the catheter. Securement devices such as the Insertion through a Peel-apart cannula Introducer.
StatLock tm.help to decrease movement and in Lifecath: 3 Fr and larger PICCs in Polyurethane
and out pistoning of the catheter. and silicone,and single or dual lumen.

51
 Vygon Corporation
Radiological Tips
PICCs must be confirmed by X-ray
prior to use.
According to the Intravenous Nurses
Society Standard of Practice, Peripherally Inserted
Central Catheters (PICCs) must be confirmed by
X-ray prior to use, and tip placement must be
documented. Correct catheter tip placement
should be located in the Vena Cava.
Radiographic confirmation of the catheter
tip location should be obtained prior to the initiation
of prescribed therapy.(S55,#55). The radiologic
confirmation of Midclavicular and Midline catheters is
determined by your facilitys policies and procedures,
considered optimal by INS.
PICC lines can best be seen on an X-ray with a modified
shoulder film.
52
PICC lines are radiopaque, some more
than others. Larger catheters, dual lumen and
those with tungsten or closed ends are easier to
visualize and PICC lines can benefit from small
density adjustments to enhance visualization.
X-ray visualization is also enhanced when a
guidewire is left in place. Guidewires are generally
not recommended for use in neonatal insertions
due to the risk of perforation.
Chest x-rays are the norm for radiological
confirmation of PICCs. The chest is not the focus,
but the catheter and the terminal end is the priority.
When chest x-rays are used, contrast dye may be
needed to provide 100% certainty of terminal tip
placement. X-rays performed in outpatient or
hospital radiology departments have sufficient
detail. Portable X-rays, especially those with digital
chest X-ray settings may not have the definition
needed for PICC placement checks. Mobile X-ray
is available in many areas for use with home
insertions, check your phone directory.
PICC lines can be seen best on an X-ray with
a modified shoulder film, also known as a rib
visualization or sternal technique. This places the
focus on the PICC Line and its terminal end. The
shoulder film is performed on the same side as
the PICC insertion, where the focus is more
toward the sternum. A slight 10o-15o oblique angle
will further enhance the Mediastinum, offsetting
the Superior Vena Cava for better viewing,
especially with airways and cardiac leads
obstructing the view of the SVC. Adjustment in
settings is required for small children and
neonates. Be specific when informing the
radiologist about the PICC (i.e. 3Fr PICC in right
Basilic vein, please check for SVC tip placement.
If a catheter tip placement is difficult to visualize,
you may need to inject a small amount of
contrast.)
Specific radiological settings for average
adults include:
Average Average General
Male Female Setting
KV 65 - 75 55 - 65 60
MA 100 - 200 100 100 - 200
SEC 0.5 - 1.0 0.2 - 0.5 0.5

If confidence in locating the terminal tip is
not 100%, contrast is recommended. Use of
medium or fast contrast can be used providing
less exposure and less detail. A small volume of
contrast is all that is required for PICC lines,
usually less than 1 cc flushed during the X-ray
process. Water-soluble radiographic contrast
medium mixed with isohexol is used when there is
concern over adverse events. The ability of a
radiology department to adapt and adjust settings
for maximum visualization can reduce overall
liability related to improper placement.
Certainty of terminal tip placement in the
Superior Vena Cava must be 100% with each
insertion. Nursing follow-up to view each film and
review findings with the radiology personnel is
highly recommended and can result in improved
measurements and placement in the SVC. The
only acceptable placement for
Nursing follow-up to review the film and findings with the radiology
personnel is highly recommended.
Vygon Corporation
a Peripherally Inserted Central Catheter is the
Superior Vena Cava or the Inferior Vena Cava.
Catheter tip termination is more difficult to confirm
if located in the right atrium or right ventricle.
Viewing your films following insertion can
be a good educational opportunity; it can also help
with placement and modification of the catheter
measurements to increase accuracy.
Management of
Jugular Placement
Symptoms of jugular placement include
rushing water sounds in the ear, vibration
or movement in that area, facial flushing,
vessel distention or no symptoms. Jugular
tip placements can also be seen
inadvertently on routine chest x-rays.
Re-positioning choices:
Wait 24 hours, and then x-ray again to see if
the tip has dropped. This option is most effective
with 4Fr or smaller catheters.
Perform the jet technique. Have the patient sit
or stand to utilize gravity. Use a continuous 20 cc
NSS steady flush with a 20 cc syringe. Gently
flush the current upward to push the PICC back
into the subclavian vein. Once the line has moved
back blood flow should take the line down. X-ray
again after approximately 1 hour to confirm the
correction.
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 Vygon Corporation

Pull the PICC back and leave it. Radiology Since then hospitals have adopted needle
should be able to tell you how much to pull back. You free devices for the routine access of PICCs. A
no longer have a PICC but a midclavicular line. Once basic understanding of the various types of needle
the initial sterile field has been broken, a catheter free access devices is essential to prevent
must not be re-advanced. complications in the care and maintenance of
PICCs.
Needle free
access devices are
attached to the hub of
the PICC . Most
modern systems
involve a resealable
port to permit safe
access, and ensure a
closed system when Withdraw the applicator
access is not required. to leave the Bionector
It is most important in place.
that nursing personnel
become familiar with
Interventional Radiology may be able to the performance
reposition a malpositioned line if the need is great characteristics of the
(i.e. the patient is requiring a vesicant devices to reduce
chemotherapy). A radiology inserted wire can be complications related Disinfect the Bionector
utilized to assist with repositioning a PICC. to their function and before (and after) use
use.
The devices
Needle-Free can be divided into
three classes by

Accessing Systems performance: Negative

Pressure, Positive
Pressure and Neutral
On April 18, 2001, the Needle Stick Safety Pressure. These Connect the extension
and Prevention Act went into effect. The Act designations describe set or syringe
directs the Occupational Safety and Health what occurs to the fluid
Administration (OSHA) to revise the Blood borne within the device when
The Vygon Bionector:
a needle-free, self sealing,
Pathogen Standard, 29 CFR 1910.1030. The disconnected from a I.V. Access system
purpose of this regulation was to reduce the syringe or I.V. line.
incidence of needle stick injuries.
Disconnection of a syringe from a
Negative Pressure Needle Free Access
device will create negative pressure at the
proximal end of the access device. If connected
to a PICC, the negative pressure will draw blood
into the lumen of the catheter. The smaller the
lumen the greater the negative pressure effect will
be. Negative pressure needle free access
Eliminate the cause, devices are not recommended for use with
PICCs.
eliminate the problem!
54

Positive Pressure Needle Free Access
devices, such as the Vygon Auto-Flush tm, infuse
fluid through the proximal tip of the device. If
connected to a PICC, positive pressure will infuse
a small amount of fluid into the lumen of the
catheter upon disconnection of a syringe. Use of
a positive pressure needle free device such as
the Vygon Auto-Flush can prevent occlusion
of PICCs.
Neutral Pressure Needle Free Access
devices, such as the Vygon Bionector, are also
useful in reducing or eliminating PICC occlusions
due to blood clots. Upon disconnection from a
syringe, there is no pressure change at the
proximal tip, so blood is not drawn into the lumen
and fluid is not infused into the catheter. It is
recommended that slight positive pressure be
maintained on the syringe plunger whenever a
syringe is disconnected from either type of
system.
Other important considerations in the
selection of needle free access devices are:
size, weight, flow rate, internal flow path, aseptic
design, MRI safety, and lipid compatibility.
Care and
Maintenance
Basic care should include daily
assessment and flushing. Other care
concerns that need to be listed in the
patient chart and to all those providing
care are as follows:
Start no radiological procedures through the
line (ie. no power injectors).
Do not infuse with any syringe other than a
5 cc syringe barrel, a 10 cc barrel is preferable.
Do not take blood pressures in the catheter
arm without physician approval.
Make no venipunctures in the arm unless they
are below the catheter hub
Vygon Corporation
Flushing is recommended at least every 8
hours with 2Fr catheters. 3Fr or larger PICCs
require flushing every 12-24 hours depending on
facility policy and procedures. Follow the
manufacturers recommendations for syringe size
usage with PICC Lines. Syringe size is an
important issue for neonates because of their
need for very small volume medication doses,
dilution with saline or sterile water.
Consideration should be given for usage of
larger syringes with PICCs and similar sized
catheters. Flushing volume for routine care is
1-5 cc of saline (preservative free for neonates),
dependent upon age. Flushing with a 1 cc or 3 cc
syringe can generate sufficient pressure to rupture
the catheter and thus should not be used.
Flush catheters daily with a positive turbulent pressure to avoid
occlussion problems that are common with PICCs.
Closed-end (Groshongtm) valved catheters
can be flushed with 10-20 cc of saline; Heparin will
not damage these catheters but it is simply not
necessary in most cases. Rarely are Groshong
catheters used in neonates, the smallest catheter
with the Groshong is 3 Fr. Saline solution needs to
be preservative free for neonates 0-28 days old.
No more than 30cc of Bacteriostatic Saline should
be used per day for any age patient.
The method of flushing is extremely
important. By using a turbulent, push stop, push
stop approach the inner lumen of the catheter is
cleaned and blood build-up is not as likely to
occur.
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 Vygon Corporation

Positive pressure within the lumen of the Everything under the dressing needs to be
catheter must be maintained during and following changed at least weekly, but neonatal
the administration of flush departments frequently opt to
solution to prevent reflux of blood change dressings only as needed
into the cannula lumen. This citing CDC guidelines.
involves a push, clamp, push Integrity of the skin is an important
method which will maintain issue with neonates and the
pressure on the line while the dressing should not be covered by a
clamp engages and prevents roller bandage or any type of wrap
blood from refluxing into the tip that is tight. The wrap must be
of the catheter, decreasing the removed prior to infusing through
chance of clotting and fibrin A push-clamp, push- clamp method
the PICC. When the patients are
formation. will maintain pressure on the line active, it is important to observe the
while the clamp engages and
Turbulent positive prevents blood from refluxing into
site and the child frequently.
pressure flushing is an effective the catheter. Consider the use of
technique to use with all special securement devices to
intravenous access devices. It is accepted that secure the catheter and prevent catheter
the volume of flush be equal to the volume migration. Special tape may be needed for
capacity of the cannula and add-on devices times neonatal skin and some sensitive pediatric skin.
two (INS). There are many different types of caps; There are multiple securement devices available
valved, non-valved and positive displacement on the market. Stat-locks by Venetec, special
caps. Caps do play a role in decreasing Velcrotm anchors, and non adhesive tapes can be
occlusions, especially with the smaller gauge used to secure the hub of the PICC or Midline.
catheters. Adequate taping or securement will reduce
complications. Refer to the manufacturers
Dressings: The dressing for a PICC or Midline in recommended taping techniques.
the first 24 hours should be a pressure dressing.
When the insertion is complete the dressing Blood Draws may be done through PICC lines
should be replaced with a sterile transparent or but INS Standards discourage blood draws from
gauze and tape covering. A transparent dressing Midline Catheters. Each time blood is drawn into
with gauze over the site is considered a gauze the catheter your risk is occlusion, rupture and
dressing (INS). Use semi infection are increased.
permeable dressings to Policies vary regarding
anchor silicone catheters or reinfusion of blood into the
peripheral intravascular neonate. Refer to the most
catheters which allow for recent references on blood
visualization of the insertion draws. Some institutions
site and allows the skin to have continuous infusion with
breathe. (AWHONN Neonatal heparin added to the solution
Skin Care 2001) for the smaller gauge
Gauze dressings are catheters (2 Fr or below) to
routinely changed every 24-48 Semi-permeable dressings should be used to maintain patency.
anchor silicone catheters and peripheral
hours. Transparent dressings intravascular catheters allowing the skin It is important to flush
may be left on for up to 3-7 to breathe and visualization of the insertion site. adequate amounts of saline
days, or changed when damp, after blood is obtained. When
loose or dirty per CDC guidelines, optimal aspirating blood from a catheter, pressure from
recommended dressing change is unknown. the syringe

56
 Vygon Corporation

works in reverse. You These injection/access ports should be changed

should use a smaller immediately if suspected of having been
syringe for aspiration compromised or if residual blood remains in the
and a larger syringe injection/access port. If at anytime the injection
when flushing. A cap/port is removed, it should be discarded and a
smaller syringe new sterile cap attached (INS).
creates less pressure
when aspirating. Catheter Repair equipment is provided by some
Consider using a 3 cc manufacturers. Follow the appropriate procedure
or 5 cc syringe for using the right size and brand for each catheter.
blood aspiration and a Decide whether to repair or replace the line.
Blood draws may be done through
10 cc syringe for Consider the circumstances and the time the hole
PICC lines. flushing. or break remained open when making your
determination. Keep a repair kit near the patient if
Extension and Cap changes should be possible.
performed weekly. An extension set can be Consider a catheter exchange if there is no
applied during the initial sterile insertion procedure. other site available and the catheter is not
When the extension set is considered permanent, repairable. You may also want to do a catheter
the connection with the catheter remains under exchange if a repair is necessary and the patient
the sterile dressing and the set is not changed. requires intermediate to long term access.

Catheter Repair Procedure

Obtain supplies for the repair kit specific to
the size of the catheter, a central dressing
change kit, sterile scissors, a soft clamp and
extra gloves as needed.
Establish a sterile field, dropping the repair kit,
scissors and clamp into the field.
Remove the dressing and bend or soft clamp
the catheter above the rupture.
Prep the site.
Follow the manufacturers recommended
procedure for repair.
Cut the catheter to provide clean edges or
remove the ruptured portion.
Apply the repair sleeve as indicated in the IFU.
Insert the blunt connector into the catheter.
Slide the sleeve piece back over the blunt
connector or as indicated by the manufacturer.
Snap or completely overlap the areas, and
secure per the manufacturers directions.
The device pictured above is a universal repair
hub for PICCs and can be used on any brand
catheter.
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 Vygon Corporation
Catheter Removal
Peripherally inserted central catheters
should be removed immediately upon
suspected contamination, complication or
when therapy is discontinued.
Precautions against air embolism should
be taken. If resistance is encountered when
attempting to remove the catheter, the nurse
should not remove it and the physician should be
consulted regarding further intervention. Because
of the risk of complications, these catheters
should be removed when they are no longer
indicated (INS).
Position the patient in a supine position.
Apply sterile gloves.
Remove the dressing.
Grasp the catheter and have sterile gauze
ready in your other hand.
Pull with gentle, steady pressure but stop the
removal if there is resistance. Contact the
physician, apply heat, reposition the limb and
consider trying removal again later or the next day.
Do not pull against resistance.
If breakage is suspected, immediately apply a
tourniquet to the proximal portion of the
58
extremity, and check the Radial artery for a pulse,
Only occlude venous flow and transport to the ER.
Otherwise, remove the entire catheter, applying
slight pressure as it is pulled out of the skin.
After removal, apply pressure, antiseptic
ointment and sterile gauze dressing to the site.
The application of ointment may occlude the skin
tract and prevent air embolism. The dressing
should be changed and the site assessed every
24 hours until the site has epithelialized (INS).
Inspect the catheter tip to ensure it is
intact, and measure the catheter and compare it
to recorded documentation. If there is no
appropriate documentation call the individual who
performed the insertion, prior to removal. If the
catheter is difficult to remove, contact the
physician.
Recommendations for management:
reposition the limb, apply heat, wait 24 hours, and
give an anti-anxiety agent with a physicians order,
or refer to interventional radiology. Consider
thrombosis or a knot in the line if there is
continued difficulty with removal.
PICC Complications
There are potential complications related to
PICCs but most are very manageable.
Complications are divided into two
categories: insertion related complications
and post insertion complications
INSERTION RELATED
COMPLICATIONS
Arterial puncture. This can occur if you are
attempting to access a vein and inadvertently an
artery is accessed. Both the Basilic vein and
Temporal vein are close in proximity to arteries.
Never do a blind stick in the Antecubital Fossa
region. Palpate the area and check the vein for a
pulse before you access it. The blood return from
the introducer should be a steady flow, not bright
red and pulsatile. It is not always easy to
determine arterial access. Factors that may

indicate arterial access may include: bright red
blood, excessive blood return, pulsation of blood,
pain after insertion, pulsation in the end cap,
questionable x-ray, or a positive arterial blood gas
study.
If an artery is inadvertantly accessed,
remove the introducer and apply direct pressure
for 10 minutes. Observe the site for hemostasis.
You may want to attempt the procedure in the
other extremity once an artery has been accessed
to prevent compromise of the hemostasis
achieved. If your catheter tip threads to the left
side of the heart, measures should be taken to
reassess that the catheter is actually in a vein.
The appropriate track of the catheter is in
the SVC on the right side of the heart. There is
however, a small percentage of the population that
has a left-sided SVC. A blood gas study can be
obtained to verify appropriate placement whenever
there is a question. Always be conscious of the
color of the patients blood, flow of the blood and
the catheter tip termination.
Cardiac Arrhythmia. If the catheter has
threaded too deeply into the heart, the catheter
can stimulate the SA or AV nodes and irritate the
heart, resulting in an arrhythmia. Older patients
may also complain of feeling lightheaded. This can
be prevented by accurately measuring and
trimming the catheter. Make it a practice to never
overshoot or measure to deep; this can
compromise patient safety, especially with
neonates.
Nerve injury. There are many nerve bundles
surrounding the veins in the arms. The largest of
these is found around the Brachial veins in the
middle of the arm. If a patient complains of severe
pain, tingling or involuntary abduction of the arm
during cannulation of the vein, suspect nerve injury.
Remove the cannula and document the event, then
attempt to introduce the PICC in an alternate vein.
Difficulty with advancing catheter. Tortuous
veins, valves and venospasms can be responsible
for difficulty when threading catheters. Flush the
catheter and assess whether the catheter flushes
with ease or leaks out of the introducer. If the fluid
leaks out of the introducer, you may not be in the
Vygon Corporation
vessel. If the catheter flushes with ease, it is
sometimes helpful to withdraw the catheter 1-
2cm. Flush again and attempt to advance it again.
It may also be helpful to withdraw the
guidewire 1-2 cm to make the catheter tip floppy
allowing easier advancement through the valves.
Repositioning the extremity or anecdotally milking
or massaging the vein can also assist in
threading the catheter to the SVC or IVC.
POST INSERTION COMPLICATIONS
Phlebitis: An inflammation
of the vein which may be
accompanied by pain,
redness, arrhythmia,
swelling and/or a palpable
cord.
The inflammatory response is
delayed in children, but
inflammation due to phlebitis
Phlebitis: may occur in the first 7-10 days
Inflamation of the vein
post insertion. Close
observation is necessary to detect problems
before they become severe.
Phlebitis can be caused by talc from
gloves, irritating medications or solutions,
inappropriate terminal tip location, threading too
rapidly, rigid or stiff catheters, a catheter gauge
that is too large for the vein, restricted blood flow,
or from bacterial contamination.
Sterile phlebitis may occur within the first
24-48 hours after insertion as a direct response to
foreign material in the body. Mechanical and
chemical phlebitis can occur any time during the
dwell life of the catheter. Larger gauge catheters
and catheters with sharp or stiff materials may
promote the onset of phlebitis.
Treatment for phlebitis is based on an MD
order for warm compresses, used aggressively
and continuously at the first sign of pain or
swelling. If there is no improvement or worsening
within 24-48 hours the line will need to be removed
based on an MD order. Because phlebitis may be
a precursor to infection, the catheter will need to
be removed if there is no response to treatment.
Thread slowly to prevent irritation.
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 Vygon Corporation
Occlusion and Clotting: an Inability to flush
a line related to blood or precipitate in the
catheter. Pediatric PICCs and Midlines have very
small diameters. Some institutions have policies
stating that neonatal lines require continuous
heparin added to all solutions to reduce occlusions.
When blood is aspirated into the line, the risk
of occlusion and infection is increased. Pediatric
lines 2 Fr or smaller are not designed for blood
draws. Blood should only be drawn from a smaller
PICC (less than 3 Fr) when the risk is deemed
necessary for laboratory testing (i.e. a blood culture).
Methods to avoid occlusion include flushing
the catheter at least once daily with a turbulent,
positive pressure flush (hospital or agency policy
should determine the amounts and solutions).
Nurses should be trained concerning the hazards of
routine blood return checks; using anticoagulants
such as heparin, and initiating TPA (Tissue
Plasminogen Activation) when a catheter has
persistent withdrawal occlusion.
Treatment for an occluded catheter is a
thrombolytic (i.e. TPA , Alteplasetm, and CathFlotm by
Genentech) for declotting PICCs. The negative
pressure approach to declotting is recommended to
avoid accidental rupture. Other occlusions will be
cleared based on the precipitating agent. For
additional information refer to The Advanced PICC
Curriculum.
Thrombosis and Deep Vein Thrombosis: If
you flush the line and the saline backs out, you may
be looking at a possible thrombus formation or a
blockage above the catheter. The extremity may
also be swollen, discolored, and the hand may be
cool. When
irritating, hypertonic
or hyperosmolar
solutions are
infused into the
Subclavian, Axillary, Fibrin Sheath / Sleeve
Basilic or Cephalic
vein, the Tunica
Intima begins to react immediately.
Neonates and children take longer to react and their
immune response is not as well developed.
Phlebitis, thrombosis or a cascade leading to deep
vein thrombosis (DVT) can develop. The safest
60
placement for our patients requiring medications or
solutions with an osmolarity greater than 500mOsm
is the Superior or Inferior Vena Cava.
Partial Parenteral Solutions (PPN) should
not be administered through Midclavicular
placements or Midline Catheters. Treatment for
thrombosis should be based on identification of the
clot and then either treat with a thrombolytic, remove
the line, or surgically extract the thrombus. If
symptoms continue to worsen after the removal of a
catheter, DVT may have begun. Treatment for DVT
involves aggressive hospital intervention with
thrombolytics, anticoagulants or surgery.
To avoid these types of problems, place
PICCs for irritating medications and all types of
parenteral nutrition. Pediatric patients with cancer,
sickle cell anemia and other conditions that change
the cell may be at increased risk for thrombosis.
Hemorrhage: Excessive bleeding at the site.
When excessive bleeding at the site occurs apply a
pressure dressing for the first 24 hours, and a heavy
pressure dressing for insertions using the Seldinger
technique or skin cuts. Identify patients at risk for
bleeding problems ahead of time. Assess carefully
for possible arterial access.
Infection: Infection can occur with the site or
in the bloodstream. Common symptoms of a site
infection include redness greater than 1-2 cm, shiny
skin, pain, and drainage. Neonates may have other
symptoms such as bradycardia, greater need for
oxygen, or poor temperature regulation. Contact the
MD and get an order to culture the site and/or obtain
a blood culture through the PICC. The MD will
decide whether to remove the line or treat the
infection. Purulent drainage at the skin cannula
junction should be cultured prior to cleansing the
skin (INS). MD Anderson Cancer Center in Houston
Texas has had success in treating PICC local site
infections with Bactroban. It is difficult to maintain
the dressing with ointment so a gauze and tape
dressing is necessary. Pink, swollen tissue around
the catheter insertion site is common and similar to
that of a gastrostomy tube insertion site. In some
cases the PICC or Midline will piston in and out of
the insertion site causing tissue overgrowth and
granulation.

More common with children than
neonates, this is normal and not an infection.
Frequent bathing and the use of lotions with the
neonate may reduce skin flora and thus set up a
greater risk of infection.
Emboli, Air: The relative length of a PICC or
Midline catheter, when the location of the insertion
site is below the heart, contributes to the low risk
of air emboli. As with any intravenous device the
risk remains, however remote.
Whenever an intravenous hub is open to
air or the line is removed, care should be taken to
have the patient perform a Valsalva Maneuver, a
forceful expiration or humming to increase
thoracic pressure, reducing the potential for air to
be drawn into the vessel. With pediatric patients,
a clamp will prevent blood backing up into the
catheter if the cap is removed.
Some catheters have clamps; others
need extension sets added for clamp usage. If a
patient suddenly becomes short of breath, pale,
experiences HR increases, and/or BP drops,
immediately place them on their left side to trap
the air in the lung long enough for the air emboli to
dissipate.
Emboli, Catheter: Breakage of the catheter
by the patient (chewing on the line, excess
stretching), by too much pressure, flushing against
resistance, or pulling back through a needle
introducer (a breakaway needle) can all result in a
catheter emboli. To treat this condition, hold the
catheter, if possible, by quickly applying a tourniquet
to the upper arm, impeding venous flow but not
arterial flow. If unable to catch and remove the end at
the insertion site, contact the MD for immediate
referral to radiology and surgery for removal.
Catheter Malpositioning and Migration:
An initial placement check may reveal jugular
placement. Only a few options are available. The
PICC line can be pulled back into the subclavian
vein, but not re-advanced once the initial sterile field
has been broken. It is possible to wait 8-24 hours,
and then recheck by X-ray to see if gravity has
displaced the line into the SVC, this often works.
Interventional radiology can successfully move
some PICCs into the SVC under fluoroscopy.
Vygon Corporation
Occasionally PICCs will displace into the
jugular after placement, due to vomiting, crying or
coughing as with Cystic Fibrosis or other
illnesses with chronic coughing.
Catheters can migrate in or out of the
insertion site. Close monitoring of the catheters
external length is vital. Be sure to have
appropriate documentation to accompany the
patient to any care setting. Once a line has
migrated out of place, secure the catheter well, it
should not be readvanced due to the risk of
infection. A migrated catheter has an increased
risk of breakage because of the excess catheter
protruding from the insertion site.
Accurate catheter measurements are
important and it is important not have an excessive
length of the catheter protruding from the skin at the
insertion site. Trim catheters prior to insertion, as
needed, to reduce the bulk of external catheter. This
will eliminate the risk of infection under the dressing.
Also, reinforce any activity restrictions with the
parent when a child has a PICC, to decrease the
chance that the PICC may be pulled out.
Complications may occur with PICCs in up
to 25% of total lines. Most complications are mild
and can be managed easily. The two most serious
complications are infection and thrombosis.
Infection rates with PICCs continue to be low (in one
study as low as .4/1000 catheter days) but varies
with differing age groups. Prevention is the key to
maintaining a low complication rate. Refer to the
charts on the following pages for prevention
strategies.
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Complications with PICCs:

PROBLEM PROBABLE TREATMENT AVOIDANCE

CAUSE
Cant flush Clamped line, Determine cause of obstruction, Flush at least once daily and before and after
Clotted or obstructed remove, declot or clear precipitate. If infusions. Do not excessively check for blood
unsuccessful remove line. Catheter return. Understand risk verses benefit of drawing
exchange can be performed. blood into catheters. Know your incompatible
solutions. Flush by using the SASH method,
Saline - Medication - Saline - Heparin
Hole in Flushing with small Repair based on manufacturers Flush with 5-10cc syringes only, no excessive
Catheter, syringe, or against recommendations. Consider repair pressure. Clear clotted or sluggish lines by using
resistance. Heat verses replacement. Catheter Urokinase for Catheter Clearance. Dont carry
Hub breaks
from storage, exchange may also be performed if no PICCs or Midlines in the trunk of cars, excessive
off degradation of the other sites available. heat or cold can damage the material.
material. Accidental
stretching, or caught
on something.
Purulent Bacterial infection Culture external site, draw culture Sterile dressing changes. Use chlorhexidine or
drainage at from catheter/port. MD orders for 70% alcohol, Iodophor for dressing changes.
meds, can the catheter be salvaged? Limit access to line.
the site

Swelling to Obstruction and Venogram, cathetergram or ultrasound Best tip positioning into Superior Vena Cava,
arm, neck pressure caused by to diagnose problem before treatment. upper portion of the distal third. Avoiding
thrombosis, pinch off If thrombosis then maintain catheter midclavicular/subclavian positioning. Provide
or chest
syndrome, etc. for urokinase for injection to infuse education for staff to
into clot. Pinch off needs replaced
catheter.
Pain in arm Phlebitis, Aggressive use of heat. Warm moist Do not use solutions above
from PICCs inflammation, heat to upper arm. Anti-inflammatory 500 mOsm or irritants with
irritating solutions, agents. midline or midclavicular lines or terminal tip
crutches. placements other than Superior Vena Cava.

Clear Hole in catheter. Obtain order to discontinue. Remove Clearly, identify drugs and solutions that should
leakage at Thrombosis blocking line looking for hole, if no hole, not go through midline or midclavicular lines.
flow and adding thrombus, phlebitis, or both are This is common with Midlines, not PICCs
the
pressure at the present!
insertion terminal tip. Phlebitis
site with swelling adding
pressure.
Pulsing in Arterial access. Remove the catheter slowly, apply Signs of arterial access include bright red blood,
the hub of pressure for 10-15 minutes. excess blood loss, continued pulsing, difficulty
threading, and blood flow pushes catheter back.
the catheter
Be aware of normal threading feel.
Child Touched or hit a Stop and pull out. Do not continue to Difficult to anticipate nerve locations. Reliance
complains of nerve stick or probe after patient response on the patient for involuntary response when
indicating nerve pain. nearing a nerve. Difficulty in differentiating small
an electrical
or large nerves. Don't try to differentiate, just
type pain stop and pull out. Document that you hit a nerve
with and your action. You will save yourself litigation
insertion of problems.
the
introducer
Guidewire Guidewire stuck to Remove the entire line and insert Use catheters that have hydrophilic coatings on
won't come catheter or bent. using a new line and a new insertion the guidewire. Flow through guidewires are
site. commonly coated. Newer products have more
out
problems. Flushing the catheter prior to insertion
sometimes helps.
No Blood Catheter up against When administering Chemo, blood Confirm positional status of catheter by moving
Return wall of vein. Fibrin return is vital and must be treated. In patient, arm, cough, etc. Use Urokinase when
sheath or flap over other situations treatment is optional any problem develops with blood return or
(Do not check
end of catheter. and could help to prevent additional sluggish flow. Consider locking catheter with
for blood complications. Urokinase for catheter clearance, then aspirating
return with prior to next dose. Flushing regularly with
catheters 2 turbulent positive pressure flushing can reduce
french and intralumenal build-up. Injection caps or
smaller) needleless systems with positive pressure ending
push will reduce blood build-up.

62

Complications with PICCs:
Prevention Centered
Complications Causes
Infection Bacterial growth and access into or onto the
central line through hands, skin, infusate or
contaminated syringe/needle. Open lines,
no end cap, cap falls off, cap on floor placed
back on line, dirty hands touching
everything. Hub contamination the most
common. Poor site prep. Contaminated field
on insertion, failure to use maximum
drapes for central line insertion. Bright red,
shiny, greater than 2cm of redness,
possible drainage, an infection is a good
guess. Contact the MD, get an order to
culture the site. The MD will decide whether
to remove the line or treat the infection.
Pink, swollen tissue around the catheter
insertion site is common and similar to that
of a gastrostomy tube. In some cases the
PICC/Midline will piston in and out of the
insertion site causing this tissue overgrowth
and granulation. This is normal and not an
infection. Purulent drainage at the skin
cannula junction shall be cultured prior to
cleansing the skin.(INS)
Breakage/rupture Use of small syringes, ie 1cc, 3cc, over-
stretching of catheters, failure to secure the
line, loosening of tape with heat and
perspiration,
Malpositioning Excessive movement by the patient,
coughing, vomiting, accidental pull on
catheter. Initial placement check may
reveal jugular placement. Occasionally
PICCs will displace into the jugular after
placement, due to high positioning in the
SVC. Catheters can migrate in or out of the
insertion site. Close monitoring of catheter
external length is vital, with appropriate
documentation to accompany the patient to
any care setting. Once a line has migrated
out, secure the catheter well, it may not be
readvanced, due to the risk of infection.
Vygon Corporation
Prevention
One of the most important measures for
preventing catheter-related infections is
initial site preparation. Approved
antimicrobial solutions include 70% alcohol,
10% povidone iodine, tincture of iodine 2%,
or chlorhexidine. Application of alcohol after
an iodine solution has a negative effect as it
removes the residual action of iodine.
Chlorhexidine has demonstrated action
superior to any of the other prepping
solutions. While used at some beta testing
sites, the sterile 2% chlorhexidine solution is
not approved by the FDA for use in the
United States. Hand washing, meticulous site
prep on insertion and with dressing changes
using approved prepping agents, in the order
specified by INS (ie alcohol then povidone
iodine). Catheters placed in less than sterile
fashion should be replaced as soon as
medically feasible. Only sterile caps placed
on lines, no reuse. Completed infusions
require end caps. Prep all rubber vial tops,
injection caps or needleless caps before
entry.
Use of small size syringes should be avoided
due to their ability to produce psi levels in
excess of 100, with little force. 5-10cc
syringes are to be considered with all central
lines, PICCs and Midlines. Smaller syringes
may be used when absolutely necessary,
after line patency has been confirmed. A
policy should exist for approval of small
syringe usage. Leakage at the insertion site
may indicate a break/fracture in the line,
confirm by cathetergram to avoid other
complications
All central lines require x-ray placement
check to confirm SVC placement. Patients
should receive periodic x-ray confirmation if
they experience tinnitis, rushing sounds in
the ear, dizziness, feeling of fullness in the
head, pain, and numbness or tingling.
Cathetergram or venogram may be
considered if problem can not be pinpointed.
The malpositioned or mal-placed PICC line
can be pulled back into the subclavian, but
not readvanced, once the initial sterile field
has been broken. It is possible to wait 8-24
hours, and then recheck by x-ray to see if
gravity has displaced the line into the SVC.
Interventional radiology can successfully
move some PICCs into the SVC under
Fluoroscopy.
63
 Vygon Corporation
Complications with PICCs:
Prevention Centered
Phlebitis Number one complication with PICCs/Mids
occurring in approximately 5% of cases
post insertion. Phlebitis can be caused by
talc from the gloves, irritating medications
or solutions, threading too fast, rigid
catheters, gauge too large restricting blood
flow or bacterial contamination. Sterile
phlebitis may occur within the first 24-48
hours of insertion, as a direct response to
the foreign material in the body.
Mechanical and chemical phlebitis can
occur any time during the dwell life of the
catheter. Larger gauge catheters and
catheters with sharp or stiff materials may
promote the onset of phlebitis.
Hemorrhage Bleeding at the site. Large holes, small
catheters. Excess exertion soon after
insertion. Traumatic Seldinger insertions
may bleed.
Arrhythmias Irregular heart activity caused by
advancement of the PICC line into the
right atrial or ventricular areas. The patient
may complain of a feeling of fullness in the
head, difficulty breathing and a weight on
the chest. Many patients will be
asymptomatic.
Cardiac rupture, Catheter malpositioned against the wall of
the SVC or Innominate. Catheter is
tamponade
inserted with the terminal tip in the right
atrium, erosion through the heart wall can
occur if the tip is against the heart wall.
Arterial Access Threading into an artery instead of a vein.
Failure to differentiate between palpable
pulsatile artery and vein. Symptoms
include:
Difficulty threading due to strong
blood flow
Pulsation within an extension set or
injection cap
Strong blood movement out when the
end cap is removed
Blood gases indicating arterial blood
(may be skewed with ventilator
patients)
64
Treatment for phlebitis is based on an MD
order for warm compresses, used
aggressively and continuously at the first
sign of pain or swelling. If no improvement
or worsening within 24-48 hours, the line
needs to be removed based on an MD
order. Because phlebitis may be a
precursor to infection, the catheter needs
to be removed, if there is no response to
treatment. Standing orders can be
established for phlebitis treatment as well
as declotting and removal procedures.
Apply a pressure dressing for the first 24
hours, a heavy pressure dressing for
insertions with gauge sizes greater than
16g. Consider the use of hemostatic gels
(ie Actigoam or Avitene by Davol/Bard)
Avoid arrhythmias by practicing
measurements, measure for accuracy,
never intentionally over shoot, view x-
rays, and learn anatomy. Get a baseline
HR, before the procedure, compare after
line is inserted. Treatment is to pull back
on the catheter whenever the patient is
experiencing symptoms. If an x-ray shows
placement too deep, reposition in the SVC
and take another x-ray.
The FDA working group established that
central catheters must be confirmed by x-
ray, and the tip position should not be
allowed to migrate or reside in the heart.
Differentiation can be made with
ultrasound prior to access, identifying
artery pulsation and compressible vein. X-
ray for placement check will not clearly
indicate artery over a vein. Arterial
placement the tip is likely to visualize to
the left of the mediastinum. Fluoroscopy
will show more movement of the tip
related to aortal flow and left heart action.

Occlusion Blood, drug precipitate or lipids build up in
a catheter completely occluding flow. Each
time blood is drawn into a catheter the risk
of occlusion increases. Occlusion can also
be due to tight suture, kinked catheter,
clamps or other mechanical obstruction.
Inability to flush a line related to blood in
the catheter or precipitate. PICC/Mids have
very small diameters. Frequent blood
return checks may be normal for
peripheral lines, but can be detrimental to
PICCs and Mids. Blood should only be
drawn into a PICC/Mid when the risk is
deemed necessary to establish lack of
complications or laboratory testing.
Emboli, Catheter lumen left open to air, air flushed
into a catheter in large enough quantity to
Air/Catheter
cause venous flow change or collecting in
the heart chamber. The relative length of a
PICC or Midline catheter, along with the
location of insertion site being below the
heart, contributes to the low risk of air
emboli. Catheter breakage resulting in an
emboli. Inappropriate insertion resulting in
shearing of catheter and embolization.
Breakage of the catheter by the patient,
by too much pressure, flushing against
resistance, or pulling back through a
needle introducer (breakaway needle) can
all result in catheter emboli. As with any
intravenous device the risk remains,
however remote.
Persistent Inability to aspirate a blood return
Withdrawal
Occlusion
(PWO)
Thrombosis Pain, swelling, numbness, tingling, leakage
at the site all caused by increased
pressure in the vessel as a clot builds. You
flush the line and the saline comes back
out, you are looking at a possible
thrombus formation. When irritating,
hypertonic or hyperosmolar solutions are
infused into the subclavian, axillary, basilic
or cephalic vein, immediately the tunica
intima begins to react. Phlebitis,
thrombosis or a cascade leading to deep
vein thrombosis (DVT) will develop; the
only question is how long. Some patients
are predisposed to thrombosis due to
changes in their cellular structure.
Predisposing conditions include:
Pregnancy, Cancer, Sickle Cell Anemia,
Obesity, Cigarette Smoking, COPD, Multi-
trauma, surgery, joint replacement, HIV,
Diabetes and many more.
Vygon Corporation
Methods to avoid occlusion include flushing
at least once daily with turbulent, positive
pressure flushes, following your policy for
amount and solutions and training nurses
on the hazards of routine blood return
checks. Turbulent positive pressure
flushing is performed on at least daily with
a push, pause, push, pause on the
syringe, then continue flushing and
disconnect or clamp catheter. Treatment
for a clotted catheter is urokinase for
blood. Refer to the reference by Bonstell
and Brown, Declotting with the Stopcock
Method. Treatment for Lipid build-up is
ethyl alcohol, for acid precipitates
Hydrochloric acid and for basic precipitates
Sodium Bicarbonate. Refer to Herbst,
Kaplan and McKinnon Managing Catheter
Occlusions.
Use clamps for catheter connect and
disconnect. Never leave catheter
uncapped. Whenever an intravenous hub
is open to air or the line is removed, care
should be taken to have the patient
perform a Valsalvas Maneuver, forceful
expiration or humming to increase the
thoracic pressure and reduce the potential
for air to be draw into the vessel. Some
catheters have clamps; others need
extension sets added for clamp usage.
Treatment when a patient suddenly
becomes short of breath, pale, HR jumps,
BP drops, immediately place them on their
left side to trap the air in the lung long
enough to dissipate. No small syringes to
flush or administer meds. Secure catheter
well. For catheter emboli treatment is to
catch the catheter, if possible, quickly
apply a tourniquet to the arm if unable to
catch the end at the insertion site, and
then contact the MD for immediate referral
to radiology/surgery for removal.
Early treatment can prevent occlusion.
Confirmation of blood return is one
necessary step in ensuring patency of a
device prior to the infusion of a
chemotherapeutic agent.
Persistent withdrawal occlusion or inability
to aspirate blood is the first sign of clot
formation with a catheter. Use of
thrombolytics such as Urokinase early will
prevent occlusion and thrombosis
development. Correct terminal tip
placement is also vital for preventing
thrombus formation. Any placement in the
upper portion of the SVC, innominate or
subclavian vein has a much higher
incidence of thrombus formation (up to
68%). The safest placement for our
patients requiring medications or solutions
with an osmolarity greater than 500mOsm
is Superior Vena Cava. Avoid these
problems, place catheters centrally
(PICCs) for irritating medications, and all
types of parenteral nutrition. Be aware of
the symptoms of thrombosis as they can
occur in relation to any venous catheter,
even those placed in the SVC or IVC.
65
 Vygon Corporation
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 Vygon Corporation
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Other Sources

www.vygonusa.com

www.INS1.org; www.nann.org; www.awhonn.org; www.neonatalnetwork.com;

www.bizjet.com/jnn; www.avainfo.org; www.sir.org;
http://www.academyonline.org
http://www.parentbooks.ca/premature_babies.html;
http://www.aplacetoremember.com/frames/bibnicu.html

NANN Guidelines are available at www.nann.org ($49.95).

INS Position Papers and 2000 Revised Standards are available on www.INS1.org ($40.00).
NAVAN (AVA) Tip Position is available with reprints of Summer 1998 JVAD ($9.95), 1-888-57-navan,
www.avainfo.org
LITE home care guidelines for practice are available at 1-412-678-5025, www.lite.org
ONS Access Device Guidelines can be obtained at 1-412-921-7373
or www.ons.org ($49.95).

Internet Listserv: send email to majordomo@ohsu.edu, no subject, message should say subscribe venous
Other internet list groups for vascular access include vascular smartgroup. The groups home page is:
http://www.smartgroups.com/groups/vascular

NANN has established multiple email listservs for the exclusive use of its members as neonatal issues forums.
Members can post and discuss news and information of interest to neonatal nursing professionals specific to
several distinct areas via specific issue listservs: Membership (NANNnet), Chapters (CHAPTERnet), Advance
Practice (ASIGnet), Developmental Care/Pain (DSIGnet), Education (ESIGnet), Home Healthcare (HSIGnet),
International (ISIGnet), Management (MSIGnet), Research (RSIGnet), Transport (TSIGnet). See the website for
more details www.nann.org

Competencies:
Practice competencies are available if desired by contacting PICC Excellence, Inc.
at info@piccexcellence.com or calling 1-888-714-1951.

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