1. Peripherally Inserted Central Catheter (PICC) Trouble Shooting
Chantal Miljours, RN BScN
Clinical Nurse Educator
Diagnostic Imaging Department
North Bay Regional Health Centre

2. Objectives How and why PICC lines are inserted
Identify catheter occlusion and trouble shooting methods
Identify potential causes for redness in PICC arm and at insertion site
Air Embolism
Case Studies

3. Purpose of Central Venous Access Device
To infuse fluids (allows for large volume boluses)
No peripheral access
To infuse TPN
To infuse medications
To sample venous blood (when no peripheral access is available)
To provide a method for hemodynamic monitoring i.e.: right atrial and PA pressures(acute care setting)
Best Practice Guidelines

4. Blood Vessels involved in Central Venous Therapy
basilic
cephalic
axillary
jugular
subclavian
innominate
These veins all lead
to superior vena cava

5. Central Venous Access Devices
Port-a-Cath
Port-cath longer dwell inplanted under the skin/ allows swimming more activity bit uses a needle to access each time- good for kids. Easy to see but some with more adipose tissue have to palpate come in both power orregular.
Hickmann Line

6. Central Venous Access Devices
Short term central catheter
Short term central line subclavian/jugular all open ended
Picc line single duel triple some open ended some valved the ones we put in here bioflo are valved however many patients in community have put in elsewhere.
Peripherally Inserted Central Catheter

7. PICC Line Placement
We use both cephalic and basilic veins, the basilic vein is preferable as usually a larger more stable vein, some people do not have cephalic veins or usually quite small. We will some times put in cephalic if using crutches foe example so does not rub.

8. PICC Line Placement
Tip of catheter sits in SVC for PICc as do all other central lines

9. PICC Lines
PICC lines are inserted as a sterile procedure in the diagnostic imaging department
Both Ultrasound and Fluoroscopy are used insert the PICC line and confirm proper placement
Insertion is performed by specially trained nurses and placement is confirmed by the radiologists
-Some hospitals perform procedure at bedside but we do ours right in fluro room so pt doesn’t have to move after for chest x-ray or redress etc.
-Done as a sterile procedure, typically minutes start to finish, most time setting everything up to actually put it in is about 5-10 minutes. Have to lay flat with arm out to side (so needs to be consideration ability to lay flat for that length of time)

10. STATS 2014 356 PICC lines inserted in 2014 12% for TPN 39% Antibiotics
39% Chemotherapy
10 % other
Although meds can be given through an iv in the lower part of the arm, blood flow not that great doesn't dilute the medication therefore any medication with high/low PH we will use a PICC line ,where the tip sits in the svc blood flow is much greater therefore dilutes the medication with less irritation to the vein, with that being said the two biggest risk for a PICC line one being infection and DVT- things to watch for redness, swelling, pain, fever, discharge any of these could be a sign of either infection/dvt.There are alot more cath in community this just ones we have inserted.

11. Troubleshooting
In 2014 we saw 149 patients for PICC line troubleshooting
Only 57% of these patients required thrombolytics
These are various reasons of problems that we see occurring with PICC lines. Not included are skin reactions/infections/dvt which we will touch on later.

12. There are 3 types of occlusions
CVAD Occlusions
There are 3 types of occlusions
Complete
Partial
Withdrawal

13. Signs of a CVAD Occlusion
Resistance when flushing
Sluggish flow
Inability to infuse fluids
Frequent occlusion alarm on infusion pump
Infiltration or extravasion or swelling or leaking at insertion site
Inability to withdraw blood
Sluggish blood return

14. Complete Occlusions
Inability to infuse or withdraw blood or fluid into the CVAD
Can be mechanical, chemical or thrombotic

15. Withdrawal Occlusions
Inability to aspirate blood but ability to infuse without resistance
Lack of free-flowing blood return

16. Partial Occlusions Decreased ability to infuse fluids
Resistance with flushing and aspiration
Sluggish flow through the catheter
Can me mechanical, chemical, or thrombotic

17. Types of Thrombotic Occlusions
Mural
Occurs when fibrin from a vessel wall injury binds to fibrin covering the catheter surface
Caused by the catheter rubbing in the vessel, traumatic insertion, or poor blood flow
Intraluminal
Often cause complete catheter occlusions
Develops from blood build up as a result of insufficient flushing, inadequate infusion rate, or frequent blood withdrawals
Fibrin Tail
Fibrin adheres to the end of the catheter and causes more cells to be deposited on the tail
Acts as a one-way valve: fluids can be pushed out but with aspiration the tail is sucked back over the opening
Fibrin Sheath
Fibrin adheres to the external surface of the catheter, creating a “sock” over the catheter
Occasionally the sheath covers the end of the catheter and causes occlusion

18. Dual-Lumen PICC (Navalist)

19. Fibrin Sheath Occlusions
Fluid can usually be injected, but blood cannot be aspirated
Infiltration/extravasation can occur when medications are infused up the fibrin sheath and back to the insertion site
May cause mixing of incompatible solutions
Short term cath in ccu setting swelling , cath tip holes not all in vein chest xray post. at inserttion site break in catheter, all Never had a PICC line

20. Subclavian central line left in for two months, pulled out with fibrin sheath/tail on the end,usually do not leave hospital with these devices, nurse told MD that had a PICC line in , when home care nurse went to access wanted tip placement confirmation and discovered not a PICC line but short term catheter. KNOW your devices.

21. CASE STUDIES

22. Case Study #1: The Repeat Offender
69 year old patient receiving antibiotics through the PICC line is sent to DI by homecare for a withdrawal occlusion. This patient has been seen multiple times in the past 2 weeks.
Vancomycin is one of the ones that is the worst for doing this.

23. Chemical Occlusions
Many PICC line occlusions are caused by a build-up of precipitate from antibiotic or other medications
Feeding tube blocked by sediment build up Cipro/ these type of occlusions are what we mostly see in community people on pumps.

24. Precipitate
Blocked PICC line related to antibiotics, cathflo instilled left to dwell ½ hour to hour1/2 when done instillation we then draw back till we get blood returns, pulling off any datk clot till runs brighter red. Can actually see the precipitate in the line

25. Troubleshooting tips
First determine there is no mechanical cause for the occlusion
Assess for kinks, closed clamps, or change in external length
Assess for clogged cap or if the cap is on too tight (finger tip tight)
Assess for positional catheter:
Reposition arm, have patient cough, put patient in Trendelenberg position
Take the time to assess PICC line even if have to take dressing off, is the length correct any kinks. Pt came in by ambulance end of the day put cathflo did not work , went to reinstill still did not work took dressing off kink in line nothing wrong. Don’t take short cuts.

26. The Art of Flushing
Knowing how PICC feels with flushing can tell you what is happening with PICC
Flush with 20ml Normal saline turbulent flush to each port after each use
May require daily flushes depending on medication i.e. Vancomycin

27. Pause push but not as aggressive

29. Troubleshooting tips
Remove any add on devices such as cap or y-connector and attempt to aspirate and flush the catheter directly at the hub with normal saline
Consider changing the dressing to ensure there is no twisting/kinking of the catheter

30. Troubleshooting tips Once mechanical obstructions have been ruled out:
If no blood return on aspiration, may alternate gently drawing back and then gently flushing
Try using a dry 3cc syringe to aspirate blood returns as it exerts less negative pressure when withdrawing
If still unable to get returns will require Cathflo instillation.
Consider radiography to determine malposition of the catheter tip
3cc syrine not to push forward but can draw back acts like a plunger.

31. Case #2: What Do You See?
Single lumen, power PICC (Purple) , BARD CAth, STAT lock in place, Dressing on, Blood backed up in line ??? Missing clamp

32. Case #2
Patient sent to ED with a blocked PICC line, home care nurse unable to flush or get venous returns
Upon assessment in ED blood noted backed up in catheter hub. Cathflo instilled overnight in ED for complete occlusion.
Patient to return in am for follow up assessment in am with DI Nurse.

33. Case# 2
What is missing?
What is wrong with this PICC?

34. Solution
When questioned about the missing clamp, the patient states “ the nurse cut it off because it was digging into his skin”
Do Not Remove any clamps that is attached a CVAD
RISK OF AIR EMBOLISIM
Patient required new PICC line insertion
If unsure about type of CVAD device look it up or consult with DI nurse.
Unable to reinsert through old cath could have caused an embolus pt takes a deep breath getting pt to cough changing the prn adaptor, air could easily have gone into right atrium, also took off important device info BARD/. Faulty valve could also cause blood back up. Never should be getting blood back.

35. CVAD 911 Emergency!
Damaged PICC line, hickmann line or any central line
RISK FOR AIR EMBOLUS
DVT
Dvt potential for air embolis and contamination dvt start on anticoagulant

36. Air Embolism
Venous air embolism can occur during time CVC insertion, while catheter in place or at time of removal
Air can easily get into vascular system when needle or catheter open to atmosphere
As little as 200ml of air can be fatal

37. Signs and Symptoms Air Embolism
Sudden complaints of dyspnea
Respiratory distress
Coughing
Chest pain
Tachyarrhythmia's
Cardiovascular collapse

38. Treatment for Air Embolus
Lay patient on left side
Trendelenberg position
100% oxygen
Call 911
Supportive measures ( i.e. fluid resuscitation)
Traps air in the right ventricular apex

39. Case #3 :What Do You See?

40. CASE: 3
65 year old woman with breast cancer is receiving chemo through a PICC line in the right basilic vein
CT tech unable to get blood returns from PICC
Pt had states had a recent fall on the ice injuring her right shoulder
Upon further exam noted distended veins
Cathflo drawn up then upon further exam noted distended vein always talk to patient and get hx of what has been happening.

41. Case #3: Deep Vein Thrombosis
The patient had an obstrutive DVT in her right arm from the basilic vein to the subclavian vein
Sent to ER for treatment of DVT
PICC line pulled and reinserted after DVT resolved
“70-80% of thrombotic events occurring in superficial and deep veins of upper extremity are due to the presence of intravenous catheters”
If patient has a DVT we do not always pull the PICC line out , but this one was so large.Tube of chocolate pudding put a string through it doesnt make dvt go away dvt doesnt go away until started treatment and IN this case was related to mechanical compression.

42. DVT
An extraluminal thrombus can progress to a deep vein thrombosis (DVT)
Fibrin build-up from the vein wall to the catheter may cause blockage of blood flow in the vein
This can lead to SVC syndrome - when the SVC is completely occluded and venous return cannot empty into the right heart to be oxygenated
This is an emergency!
Unable to get another PICC in past clot, also risk for PE

43. DVT Pt may experience redness to arm localized or can extend up arm
Swelling to arm or hand(compare to non PICC line arm.
May experience pain to arm chest neck
No fever noted

44. Vein Measurement
Use brachial and cephalic veins , measure with ultrasound machine size of vein if too small we don’t put them in for increased risk of developing DVT. (0.26cm 4Fr or 0.34Cm for 5fr. We have had pretty low rates of DVT plus using Bioflo catheter. We do not usually remove the PICC line usually treated for DVT and keep in place as tip past the clot/would not be able to put PICC back in same arm if pulled.

45. Thrombus to Vein
If has previous PICC line we can see thrombosed vein not able to compress together/scarring unable to likely put PICC back in this vein

46. Case Study # 4: The Quick Draw
60 year old female with hx of breast cancer, presented to ED with a fever .
Urine culture came back positive and admitted to hospital for urosepsis and was started on antibiotics
No blood culture drawn from PICC
PICC line pulled and tip sent for culture, came back negative

47. Case # 4 Patient starting to improve on antibiotics A febrile now
Limited peripheral veins due to lymph node involvement
Important to establish if patient has a true Catheter Related Blood Stream Infection (CRBSI) in order to decide whether to salvage, exchange, or remove the catheter.
Be sure especially in implanted devices.. May not get another acess

48. Systemic Antibiotic Therapy is NOT required for the following:
Positive catheter tip in absence of clinical signs of infection
Positive blood cultures obtained through a catheter with negative cultures through a peripheral vein
Phlebitis in the absence of infection, the risk of CRBSI usually low

49. CRBSI –catheter removal
Severe sepsis
Hemodynamic instability
Endocarditis or evidence of metastatic infection
Erythema or exudate due to suppurative thrombophlebitis
Persistant bacteremia after 72hrs of antimicrobial therapy to which the organism is suseptible
Pathogen also important for guiding decision n to remove, Staph aoreous fungus gram negative bacilli . Fungal infection seen in a few pICCs removed treated first with antifungal for 48hrs prior to reinsertion, all patients had growth elsewhere IE ostomy.

50. Difficult PICC line Removal
This usually due to venous spasm
Sometimes PICC lines can be difficult to remove especially if catheter too big for size of vein
Ask patient to relax arm
Apply warm compress
After these measures the PICC line usually comes out easily
Not every institution has strict guidelines as we do for insertion size of veins, PICC should come out smooth no resistance met. Apply pressure for a couple of minutes dressing applied for 24hrs post .

51. Case #5:What do you see?
See redness,irritation, may note blistering. In picture clear outline where tegaderm was no streaking.

52. Contact Dermatitis Dermatitis
Dermatitis presents as reddened irritated skin at the site
Always allow antiseptic (ie. Chlorhexidine) to dry completely before applying dressing
Consider changing dressing to IV3000
Consider changing antiseptic solution to povidone-iodine solution
Scrub time 30 seconds allow to air dry completely prior to application of product such as tegaderm if blisters we have been applying aquacel dressing with good results

53. Case #6 : What Do You See?

54. PICC Line Site problems
Infection vs Dermatitis
Dermatitis presents as reddened irritated skin at the site
Infection presents as redness, swelling, warmth, and possible purulent drainage at site?
Does patient have a fever?
Does patient have any swelling to arm?

55. What do you See?

56. PICC Line Infection
Send to ER with signs of sepsis (ie. Fever, chills, tachycardia, hypotension)
Rule out other sources of infection
Obtain cultures – draw blood culture from PICC line (do not discard a waste sample) and consider swab for C&S if site infection noted
Administer antimicrobials
Do not necessarily pull the PICC!
If running antibiotics and have a duel lumen ensure to infuse though both lumens (split dose) also draw blood from vein not just PICC line

57. Prevention Good hand hygiene
Ensure to “Scrub the hub” with Chlorehexidine for minimum 30sec prior to accessing devices
Wear sterile gloves and mask (pt should wear mask as well) anytime opening dressing.
Removal of unnecessary CVC should be regularly assessed.

58. Leaking at PICC site
If leaking at site is present when flushing or infusing through CVAD
Send to DI for catheter-o-gram (to rule out a hole in the catheter)
Doppler studies (to rule out thrombosis
Lymphatic drainage? ? PUSS leakage of lymphatic pale gold colour fluid not a sign of infection sometimes when inserting nick lymphatic vessel or node and can take a long time to heal leak out insertion site, not bloody like old no redness no pain no fever leaky boggy dressing, put on absorbent dressing aquacel dressing / foam dressing don't have to change we cannot see lymphatic tissue when doing ultrasound.

59. Case 4: Pain in the neck
A 59 year old man with a PICC line in the right basilic vein presents with a withdrawal occlusion.
Has also been complaining lately of a constant “wooshing” sound in his right ear
The patient has been vomiting lately due to chemo treatment
Chest xray done to confirm proper placement…
Gurgling sound, pain in neck bending over with head below waist increased intra abdominal pressure

61. PICC line malposition PICC line must be removed and reinserted
If PICC pulled out more than 2cm from original position, tape it in current position do not pull it out completely
Do Not attempt to push catheter back into position
Do not use PICC until tip placement confirmed by chest X-ray

62. Cracked PICC If there is a crack or a hole present, determine location
Fold catheter over on itself and cover with tegaderm or other film dressing
Close catheter clamp if there is one
Send to hospital right away

63. Cap on TOO Tight Crack more visible with cap on
Crack faintly visible with cap off
Patient presented with PICC line leaking , two finger tip tight also when flushing stabalize cap then turn

64. Prevent Damage to PICC
Never put steri-strips over picc line, always make sure they are underneath the line or on top of white wing
Do not force fluid into PICC if resistance is met
Ensure clamps are open before attempting to flush
Do not over tighten cap

65. Broken PICC
If the end of the catheter breaks off grab CVAD (to prevent it from migrating internally)
Fold catheter over, cleanse catheter, tape securely to arm, and send patient to hospital right away with the external portion of the catheter
Monitor for air embolism
North bay unable to perform as we do not have a vascular surgeon closet place would be Sudbury. Did have a patietn who had PICC line in for three years and PICC actually adhered to the vessel wall had to be surgically removed.

66. Broken PICC If catheter disappears inside vein:
Apply tourniquet to upper arm close to axilla
Place patient in Trendelenburg position
Call 911
Monitor for air or obstructive embolism

67. QUESTIONS ???