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The Management of

complications in relation
to PICCs
A. MECHANICAL PHLEBITIS

Mechanical phlebitis is where the movement of a foreign object within a vein is the cause of the
inflammation and is the most frequent complication associated with PICCs.

Occurrence is normally evident within 10 days of insertion, therefore it is crucial to observe for
signs and symptoms in the early stages. Symptoms will be present around the bicep region,
above the PICC. As the PICC travels within the vein towards the superior vena cava the veins
become larger therefore accommodating the PICC without damage to the vein wall. The
symptoms include:
o Redness
o Swelling
o Pain
o Skin warm to touch
o Venous Cord (hard, palpable vein tracking up the arm)

The above symptoms can be confused with the development of infection.


Incorrect diagnosis can lead to the premature removal of the catheter or the
unnecessary use of antibiotics.

Management

Follow Flow Chart 1


When symptoms of mechanical phlebitis are present, it is imperative that regular observation
and assessment of the symptoms and of the patient is performed. It is important to assess for
other causes such as thrombosis or infection. Asking the following questions will help to
exclude other complications:

• Is the catheter difficult to flush


• Can blood be withdrawn from the catheter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

If there is no evidence to suggest other complications, treatment for mechanical phlebitis will
commence depending on the severity of the symptoms.

The PICC can still be used when symptoms of mechanical phlebitis are present. However, if
the symptoms become severe and there is no response to treatment, removal of the PICC may
be considered.

M.Hughes/IVAccess/CompPICCs/2006 2
Flow Chart
1
Redness, swelling and pain above PICC.
Tracking up the arm

Has the PICC been in situ No


Yes for less than 12 days

Is the patient pyrexial


Consider or are there symptoms
Mechanical Phlebitis of infection at the exit Yes
site

Symptoms of Thrombosis:
Swelling of the arm, neck or shoulder
Pain in the shoulder No
Are there symptoms Bleeding at the exit site
of thrombosis Discolouration of the skin
Distension of the veins in the

Are there
No Yes symptoms
Treat for
Thrombosis as Yes of
per local policy thrombosis
Is the patient
pyrexial or are
there symptoms of Inform Dr. and consider
infection at the Yes Infection as the cause and
exit site treat with anti-biotics.

No

No. Moderate
to severe
Are the original symptoms of
mechanical phlebitis mild

Inform the Dr. and Consider prescribing


Yes non-steroidal anti- inflammatory
medication (unless contraindicated) and
heat and cold treatment to the upper arm.
Consider treating with hot and cold Evaluate in 3-4 days, or advise pt.to
therapy at the site of redness and report any changes in symptoms.
observe in 3-4 days.

M.Hughes/IVAccess/CompPICCs/2006 3
B. WITHDRAWAL OCCLUSION

Withdrawal Occlusion (WO) can be described as the inability to withdraw blood via the catheter
but it retains a capacity to infuse solutions without difficulty (Mayo 2001).

The main significance of WO is that the practitioner cannot be certain that the catheter is in the
vein when there is no free flowing blood return (Masoorli 2002). A satisfactory blood return is
the verification that the catheter is in a vein and that the catheter is functioning correctly prior to
any intravenous therapy.

The most serious, though rare consequence of WO is the leakage of vesicant or irritant drugs
into the surrounding tissues which can potentially cause extravasation injuries. This event is
extremely rare in PICCs. WO can result from a number of causes and can be classified as
non-thrombotic or thrombotic.
However, it is a thrombotic event that is the major cause of WO.

Non-thrombotic causes: Thrombotic causes:

Catheter malposition (movement) Fibrin sheath


Catheter tip resting close to the vein wall Fibrin tail
Catheter malfunction i.e faulty valve Mural thrombus
Internal catheter fracture Catheter related DVT

When WO is present follow Flow chart 2 overleaf.

Thrombolytic agents.

Thrombolytic agents are a group of drugs which work by breaking down blood clots (clot lysis).
Urokinase is the most commonly used thrombolytic agent in catheter care. A bolus dose of
Urokinase may help to break down the fibrin formation at the tip of the catheter therefore
preventing withdrawal occlusion.

The recommended dose of Urokinase for use as a bolus lock for catheter clearance is 5,000
international units. The Urokinase needs to be prescribed by a Doctor.

Saline challenge

A saline challenge can be used to demonstrate symptoms of extravasation. This is


accomplished by infusing 50 mls of saline into the PICC and observing the patient.
However, this will NOT rule out the presence of a fibrin sheath therefore does have
limitations for use.

M.Hughes/IVAccess/CompPICCs/2006 4
Flow Chart
2 Unable to obtain a blood
sample from a PICC

Check for any signs of


mechanical kinking, ensure
that the arm is straight

Flush the PICC with aprox 3-4


mls of N. Saline 0.9% using a
positive pressure technique

If blood return is still not possible


use a 20 ml syringe containing
15mls of N. Saline 0.9% and use
a ‘push pull’ method to obtain a
blood return

Is there a blood return

Yes No

Discard the original 20 ml Assess for symptoms of malposition.


syringe. Use another 10ml Consider a chest X-ray to verify tip
syringe to waste the first placement and if correct placement
3 mls of blood from the Instill Urokinase 5,000 units into the
PICC. Obtain the blood PICC - follow the guide on page *
sample and flush with 15-
20 mls of N. Saline 0.9%

If there is still no blood


return attempt to instill a
further dose of Urokinase

M.Hughes/IVAccess/CompPICCs/2006 5
C. COMPLETE CATHETER OCCLUSION

Complete catheter occlusion is when there is an inability to infuse any solution into the catheter
together with the inability to aspirate any blood from it. Complete occlusion can result from a
thrombotic or a non-thrombotic cause. In order to be able to diagnose and manage the
occlusion effectively, it is important to verify the source of the problem.

The most common non-thrombotic causes of catheter occlusions are:


• Mechanical obstruction
• Drug or mineral precipitates
• Lipid residue

A thrombotic complete occlusion develops as a result of a build up of blood within the catheter

Management – follow the Flow Chart 3. overleaf:

M.Hughes/IVAccess/CompPICCs/2006 6
Flow Chart
3 Unable to flush a PICC

Check for any external kinks


or any damage to the PICC.
Ensure the arm is straight and
well supported

Attempt to flush but do


not use excessive force

Can you flush the PICC


Yes

Determine the cause of


the occlusion. If TPN or
No precipitation of drugs is
the cause inform IV
Access nurse and or
pharmacy department
Attempt to infuse Urokinase (Dr.
to prescribe) into the PICC using
the 3 way tap method. See If the probable
instructions overleaf. cause is blood
within the lumen of
the PICC
Are you able to
withdraw blood and
flush the PICC No

Repeat the infusion of


Urokinase using the 3
Yes way tap.

Can you flush


Yes the PICC No

Inform a PICC placer or relevant


M.Hughes/IVAccess/CompPICCs/2006 7 specialist. Catheter removal may be
indicated if occlusion cannot be cleared
ADMINISTRATION OF BOLUS UROKINASE INTO A BLOCKED PICC USING A 3 WAY TAP

Equipment required

Small dressing pack


Sterile gloves (powder free)
2 x 10ml syringes
Green needle
Sharps bin
3 way tap
Urokinase 5,000units (currently the only unlicensed prescription available is supplied in 10,000
unit vials)
2mls Water for injection
Sterile alcohol wipe
New injectionable bung/bionector

Procedure:

1 Explain the procedure to patient.


2 Wash hands effectively and prepare equipment. Check Urokinase details in usual
way, e.g., Name; Dose; Expiry Date; Route of administration.
3 Open the dressing pack, tip syringes, needle, sterile alcohol wipe and 3 way tap
ontothe sterile field. Place vial of Urokinase and water for injection on the edge of the
sterile field
4 Wash hands again or use hand rub, put on gloves and using sterile swab to hold vial,
draw up 2mls of water for injection into the syringe. Again using a piece of sterile
gauze, pick up the urokinase vial, use sterile alcohol wipe to clean the rubber bung of
Urokinase vial and allow to dry.
5 Reconstitute the Urokinase vial of 10,000 units with 2mls water for injection. Draw up
1.5mls of Urokinase solution into syringe. 1ml is the dose required for the lock and the
extra .5 is used to prime the 3 way tap.
6 Prime the 3-way tap with the Urokinase solution. With a sterile swab, remove the
bionector from end of the PICC and attach 3-way tap to the end of the PICC. Close
the 3 way tap to the patient.
7 Attach the syringe containing the Urokinase to one access point of 3-way tap and one
empty syringe to other access point. i.e urokinase at 3 oclock and the empty syringe at
6 oclock.
8 Turn off tap to Urokinase (3 o’clock), pull gently back on empty syringe (6 o’clock) to
create vacuum in catheter to approximately 8-9mls and hold the plunger at 8 mls
whilst turning the closed position onto the empty syringe. A small amount of
Urokinase will then be drawn into vacuum. Remove empty syringe and expel air from
empty syringe.
9 Repeat every 5 minutes until all Urokinase solution is inserted into line. This can take
up to 20 minutes to complete.
10 Apply the new bionector or bung to the end of Catheter and leave the Urokinase insitu
for 60-120 minutes, then withdraw the Urokinase lock. Attempt to withdraw blood. If

M.Hughes/IVAccess/CompPICCs/2006 8
blood withdrawal is possible flush with 15-20 mls saline as per normal protocol. If
blood return is not possible repeat the injection of bolus urokinase.
11 Dispose of equipment according to hospital procedure, and document clearly in
patient’s notes.

(If procedure unsuccessful on first attempt, procedure may be repeated once after 1
hour)

(If the procedure is unsuccessful after two attempts, try again in 24hrs and leave the
urokinase lock insitu for 12 -24hrs)

(If the procedure is still not successful – remove the line.)

M.Hughes/IVAccess/CompPICCs/2006 9
D. TORN/SPLIT PICC.

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

Signs and symptoms:

1) Leakage from the PICC when flushing


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

Management – follow the Flow Chart 4. overleaf

If there has been leakage of chemotherapy around the split, the arm must be washed with
copious amounts of saline (maintaining sterility around exit site

M.Hughes/IVAccess/CompPICCs/2006 10
Flow Chart
4 Leaking at the site of the
PICC

Remove the dressing and


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

The PICC leaks from The PICC leaks from a


the exit site portion on the external
part of the PICC

The PICC will require The PICC will need to


withdrawal prior to repair. be repaired. See
Taking care to withdraw the guidelines for repair:
minimum amount of line. Overleaf.

Dr. to request a chest X-


ray to verify tip
placement of the PICC

Use the PICC Yes Is the tip of the PICC correctly


as normal placed in the SVC

No

Contact a PICC placer or relevant


specialist practitioner to assess the
possibility of performing an exchange
over a wire or alternatively remove the
PICC depending on location of the PICC
and therapy needs of the patient
M.Hughes/IVAccess/CompPICCs/2006 11
PROCEDURE FOR REPAIRING A TORN//DAMAGED SINGLE LUMEN PICC

This procedure should not be performed unless the practitioner has received specific
training in PICC repair.

Equipment needed

• Small dressing pack (containing powder free sterile gloves)


• 1 sterile stitch cutter
• PICC repair kit
• 10ml syringe
• Green needle
• bionnector
• 10ml 0.9% Sodium Chloride
• Steri strips
• Occlusive dressing
• Sterile alcohol wipe

Procedure

(N.B. If connected to chemotherapy pump, this should first be disconnected and capped
off in the appropriate chemotherapy area where cytotoxic safe handling equipment is
easily available)

1 Explain procedure to patient

2 Support patients arm on a pillow ensuring arm is horizontal at 90 degrees to the body.

3 Wash hands effectively and prepare equipment

4 Open dressing pack, tip PICC repair kit, syringe, needle/s, stitch cutter, steri strips,
occlusive dressing and bionnector onto sterile field

5 Open 10ml 0.9% Sodium Chloride and place on trolley outside sterile field

6 Carefully remove old dressing and steri strips except the steri strip closest to where
the PICC exits the patients skin.

7 Wash hands effectively and put on sterile gloves

8 Using the green needle and 10ml syringe, draw up 10ml 0.9% Sodium Chloride using
swab from pack to hold ampule

9 Prime PICC repair kit sections. Place sterile dressing towel or bag from pack onto
patients arm under PICC line

M.Hughes/IVAccess/CompPICCs/2006 12
10 Clean needle-free connector with sterile alcohol wipe and allow to dry. Flush 2mls

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

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

a Inserting blue cuffed repair piece over PICC line (blue to blue)

b Hold PICC catheter push steel pin on grey piece of repair kit into blue catheter
up to hilt.

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

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

13 Remove old steri strip and apply new steri strips and dressing

14 Dispose of equipment as per policy. Wash hands

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

M.Hughes/IVAccess/CompPICCs/2006 13
E. DEEP VENOUS THROMBOSIS

Deep venous thrombosis (DVT) is a condition which may present in the deep veins of the upper
or lower extremities. Catheter-related DVT involves the veins of the upper extremity, usually
the subclavian vein, the axillary vein and the Superior Vena Cava. This condition is referred to
as Upper Extremity Deep Vein Thrombosis (UEDVT).

Management – follow Flow Chart 5. overleaf

It is important that if the PICC remains in situ, careful and frequent assessment of the patient
and the PICC should take place to detect any deterioration in symptoms or function.

When a clinical decision is made to remove the PICC, care must be taken when removing the
device due to the risk of a pulmonary embolus. The catheter should be removed in a suitable
area with access to oxygen and suction and the nurse should be aware of the correct
management of a patient in respiratory distress (Hadaway 2002).

M.Hughes/IVAccess/CompPICCs/2006 14
The patient has a swollen arm, hand
Flow Chart or neck
5

Consider Thrombosis

Observe for the following symptoms:


• Bleeding at exit site
• Discolouration of the arm
(cyanosis)
• Pain in shoulder
• Protruding veins in the chest or
neck

Attempt to aspirate blood and


flush the PICC with 20mls
N.Saline 0.9%

Does the patient experience


Yes any pain during the flushing No
procedure

Explore the possibility of internal Follow Flow Trust Policy for the
catheter fracture. Dr. to request management of a suspected Thrombosis
linogram. Inform PICC placer or • Chest X-ray to verify tip
relevant specialist practitioner placement
• Doppler Ultrasound
• Review catheter function
• Ensure line is giving blood
Do not use line

Positive result: Complete a thrombosis


Ensure that the SPR nursing assessment sheet and review on
or Consultant is a regular basis. Remove if line not
aware of the functioning or if tip out of position (post
diagnosis and anticoagulant therapy).
treatment.

If symptoms persist or become worse,


remove the PICC after 3-4 days of
M.Hughes/IVAccess/CompPICCs/2006 15 therapy.
anticoagulant
F. CATHETER TIP MALPOSITION

The optimal position for the tip of a Central Venous Catheter (CVC) is the lower third of the
Superior Vena Cava (SVC) (Vesley 2002).

When the tip of the catheter moves from the desired position, the movement is referred to as
catheter tip malposition (Wise, Richardson and Lum 2001).

Signs and Symptoms

It important to remember that malposition of a CVC can be symptom free. There are however
some symptoms to observe which may require investigating:
o Sensation in the neck during flushing ‘ear gurgling’
o Chest pain
o Difficulty aspirating blood
o Inability or difficulty infusing fluids via the catheter
o Visible reflux into the catheter (blood within the catheter)
o Visible movement of the external portion of the PICC

If there is a suspicion that the external measurement of the PICC is longer than at the time of
placement, follow the guidelines below:
• Observe for any damage to the catheter
• Review the post insertion measurement if available and compare

Management – follow Flow chart 6. overleaf

Under what circumstances should the line be removed?

• When the tip of the PICC is in the jugular vein


• When the tip of the PICC is not in the SVC (i.e in the Subclavian vein or Brachial vein)
and vesicant treatment is given via the PICC
• When the tip of the PICC is in a small tributary vein

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

M.Hughes/IVAccess/CompPICCs/2006 16
Flow Chart
6 Symptoms of Catheter
Malpositioning are present

Measure the external part


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

Compare the external measurement with the


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

Has there been


movement in the PICC
since placement
No Continue to
Yes use the PICC

Withdraw the PICC the desired


The tip of the line is in length. Trim the PICC if
Dr. to request the right atrium necessary
a chest Xray.
Review the
position of the The tip of the line is in Use the PICC as normal. Observe
tip of the the mid or lower SVC for any symptoms of thrombosis
PICC
The tip of the PICC is
in the upper SVC or out
of the SVC Refer to PICC placer or relevant
specialist practitioner.

M.Hughes/IVAccess/CompPICCs/2006 17
G. EXIT SITE INFECTION

Management – follow Flow Chart 7 below

Flow Chart Redness at the exit site of the PICC


7

Is the redness associated with


swelling and pain at the site

Yes No

Is there exudate at the site


Consider early
signs of infection

Yes No

Cleanse the exit site


with chlorhexidine in
Collect swab from site alcohol and leave to dry

Consider exit site infection

Advise patient to report


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

Cleanse the site with


chlorhexidine in alcohol

Assess for symptoms of systemic


infection:
Rigors and pyrexia. If present, inform Dr.,
take blood cultures from the PICC and
from a peripheral vein and consider
M.Hughes/IVAccess/CompPICCs/2006 18
treatment with intravenous antibiotics.
H. ALLERGY TO DRESSING
Management - Follow Flow Chart 8 below:

Flow Chart Redness and soreness beneath the


8 PICC dressing

Is there any discoloured


Yes exudate at the exit site No

Consider Granuloma or
infection Consider - allergy to
the dressing

Is there swelling Are the symptoms moderate


at the PICC site Yes to severe
and a larger
opening of the
skin at the exit site
Yes No
Take a swab
No

Consider Apply cavilon


Granuloma and re- Apply a Duoderm barrier to the skin
dress twice weekly dressing beneath beneath the IV
Consider Infection to prevent exudates 3000 dressing
as the cause. the PICC. Refer to
from excoriating the guidelines overleaf:
skin

Review the
Review the Patient patient within 5
within 4 days days. Consider
changing the
dressing to an
alternative if
symptoms
persist

M.Hughes/IVAccess/CompPICCs/2006 19
I. PAIN

Management – Follow Flow Chart 9 below:

Flow Chart
9
Pain in the shoulder, neck
or chest

Consider

Thrombosis
Migration of the tip Extravasation Damaged PICC
of the catheter into a
location other than
the SVC

Review patient
Flush the PICC for other
with Saline and symptoms of
observe for any thrombosis
Dr. to order a chest X-ray to symptoms flow chart 5
determine tip position

If in doubt Dr.
to order a
lineogram

M.Hughes/IVAccess/CompPICCs/2006 20
M.Hughes/IVAccess/CompPICCs/2006 21