Problem Solving for Health Care Providers
Definition: Impairment of catheter function by the inability to withdraw blood or resistance with flushing the line.
The four common types of clots associated with PICC lines are depicted below (Genetech, 2007)
- Intraluminal thrombus. Forms within the catheter lumen and causes either a partial or complete occlusion.
- Fibrin Tail. The most common type of catheter occlusion forms when fibrin adheres to the catheter tip. It can act as a one-way valve, permitting infusion but not withdrawal of fluid or blood from the catheter.
- Mural Thrombus. Forms when the fibrin from a vessel-wall injury binds to the fibrin covering the catheter surface. A mural thrombus may lead to the formation of a venous thrombus.
- Fibrin Sheath. Forms when fibrin adheres to the external surface of the catheter, covering it like a sock
Solution:
- An order for t-PA is provided upon PICC line placement and should be in the chart. The pharmacy order must be renewed after 30 days. If you are unable to locate the order, please contact either the UCLA PICC Service to obtain an order for an inpatient or the patient's physician if an order is needed for an outpatient.
- Gather supplies
- Chloraprep applicator
- t-PA (alteplase) 0.5mg/1ml-This will come from the pharmacy in a pre-filled syringe or in powder form which will need to be reconstituted with sterile water (follow packet instructions)
- 10ml Normal Saline flushes (2)
- 10 ml syringe
- Scrub the junction between the catheter and the cap with Chloraprep prior to removing the cap. Remove the cap and scrub the injection port with Chloraprep using friction for 30 seconds before attaching the syringe to the catheter. T-PA should always be administered without the cap present. Administer 05mg/1ml t-PA into clotted port. Re-attach positive pressure cap and allow t-PA to dwell in catheter for 120 minutes.
- After 120 minutes, use 10ml syringe to withdraw t-PA. Continue withdrawing until you have aspirated 4 to 5ml of blood.
- Flush with at least 20ml of normal saline.
- If you are unable to withdraw the t-PA and get blood return, this process can be repeated one time.
**For UCLA staff, please refer to Westwood Policy # 104 or Santa Monica Policy # 1396 for hospital-specific recommendations.
Definition: Unilateral arm swelling on the same side as the PICC. This could be indicative of a thrombus formation. A thrombus is a blood clot also known as a Deep Vein Thrombosis (DVT). Swollen extremities are not uncommon for individuals who remain inactive and in bed for prolonged periods of time.
Solution:
- Observe for arm swelling in the extremity which the PICC was placed and note pre-insertion extremity measurements for comparison. An increase in circumference may reflect DVT formation.
- Contact the PICC Service.
- Stop all infusions.
- Start a peripheral IV on opposite extremity if possible.
- Do not take blood pressure on swollen extremity.
- Raise the affected area to reduce swelling.
- Apply moist heat to reduce related inflammation and pain.
- Notify MD and recommend a Doppler ultrasound. If the Doppler ultrasound is positive for a DVT, the medical team may outline a treatment plan which may include medications such as analgesics, thrombolytics, anti-coagulants, or NSAIDS.
- Initiate an order for a new PICC if access is still required.
Definition: Vessel wall irritation with damage to endothelial cells in tunica intima. Symptoms may include edema, heat, erythema along vein pathway, and pain upon palpation.
Types of Phlebitis:
- Mechanical - The catheter is a source of irritation from frequent movement of the catheter back and forth in the vein. This usually occurs at the insertion site.
- Chemical - Infusions can be a source of irritation. This process is usually associated with irritating medications being delivered via a peripheral IV.
- Bacterial - Due to contamination of components within the infusion system. This is uncommon but can cause inflammation along the vessel wall.
**Palpable venous cord may indicate progression from phlebitis to the development of a thrombosis. If this is evident line removal may be warranted.
Pain / Discomfort in the Extremity
Definition: Pain can be experienced after PICC insertion. This could be associated with a difficult line placement causing an inflammatory response. In some cases, this could reflect nerve stimulation, specifically the median cubital nerve. Symptoms include pain, specifically a dull ache or throbbing, numbness of the fingers and/or digits, tingling sensations, and weakness of the extremity.
Solution:
- Apply warm compresses TID and PRN for 48 hours post placement. If discomfort continues after 48 hours, please contact our service for evaluation.
*If electric-like sensations, numbness, or tingling is felt by the patient, please contact the PICC service. These symptoms could be more suggestive of nerve stimulation requiring prompt removal of the catheter.
Definition: A catheter tip which does not terminate in the superior vena cava. Several factors can cause a malpositioned PICC. The most common cause of a malposition is accidental dislodgement by patient or staff, especially during bed transfers. Other factors that may result in internal catheter displacement include vigorous arm movement, excessive coughing, mechanical ventilation, and vomiting.
External Signs of Catheter Malpositioning
- Increase external length of the catheter outside the body.
**Please refer to the PICC placement documentation to determine the length of catheter external to the body at the time of placement.
- Inability to aspirate blood
Internal Signs of Catheter Malpositioning
- Migration of catheter tip to another anatomical site confirmed by chest x-ray
- Cardiac arrhythmias
- Pain or discomfort in the chest, neck, and back
- Gurgling or swishing sounds in the ear
Solution:
- Review the most recent chest x-ray to see if the PICC is terminating anywhere other than the SVC.
- Contact the PICC Service if chest x-ray shows that PICC tip does terminate in the SVC.
- If there is no new chest x-ray, prompt a new P-CXR to be done to verify tip placement.
- Utilize proper securement devices such as Stat-locks and steri-strips.
- If the patient is confused, place mittens on both hands to prevent the pulling and accidental removal of these lines.
- Provide patient and/or caregiver(s) education on activity limitations.
Definition: When a PICC line removal is met with resistance. If a PICC is not retracting with ease during removal it could be related to a venous spasm, fibrin build up, an infectious process, or possible thrombus.
Solution:
- Please do not "pull" against resistance.
- Apply heat for 20 minutes and attempt again. Provide a slow steady continual retraction with removal.
- If unable to remove catheter, contact PICC Services for removal, possible venogram and fluoroscopy.
Significant Bleeding at the Insertion Site
Definition: Post insertion bleeding from a PICC placement is common. However, excessive bleeding can prompt continued PICC inspection and assessment. Clinical observation is crucial to distinguish normal bleeding from excessive.
Symptoms
- Continuous bleeding at PICC insertion site
- Detachment of the occlusive transparent dressing secondary to excessive bleeding
- Hematoma expanding from entry site outward
Solution:
- Investigate the patient's coagulation studies. If they are outside normal parameters, prompt this to the medical teams attention for correction.
- Verify that excessive bleeding is not from inadvertent brachial artery cannulation by performing a blood gas directly from the PICC line.
- Apply pressure dressing (Teloplast) to insertion site.
- Minimize dressing changes because any external clot will be dislodged at entry site and prevent hemostasis.
- Minimize any excessive body movements and use of crutches if possible
Catheter Related Blood Stream Infection (CRBSI)
Definition: Colonization of a pathogenic bacteria or fungus causing an immune response. Catheter Related Blood Stream Infection can manifest by either a local or systemic infections which originate from the catheter itself.
Signs and symptoms of local PICC infection
- Limited infection at site of insertion
- Tenderness, erythema, and purulence at catheter-skin junction
Signs and symptoms of systemic PICC infection
- Positive blood cultures from PICC
- Persistent fevers
- Multi-organ involvement and failure
Solution:
- Sterile dressing change should be performed 24 hours after PICC placement if sterile gauze is present.
- Sterile dressing change Q-7 days thereafter.
- Change caps every 7 days per hospital protocol.
- Use alcohol at the hub prior to infusions, blood sampling, or flushing. Provide a friction rub to site for at least 30 seconds.
- 30 second chloraprep scrub to hub prior to cap changes.
- If signs and symptoms of local or systemic PICC infection are noted, contact the primary medical team immediately.
**For UCLA staff, please refer to Westwood Policy # 104 or Santa Monica Policy # 1396 for hospital-specific recommendations.
Definition: Leakage of fluids from the PICC insertion site, external pigtail, or hub. This may be due to a thrombus or rupture or fracture of the catheter.
Solution:
- Stop all infusions.
- Identify the catheter. Is it a Midline or a PICC line?
- Observe for arm swelling in the extremity which the PICC/Midline is placed. If the extremity is swollen, note pre-insertion extremity measurements for comparison.
- Observe the catheter "pigtails" or "lumens" for a possible micro-puncture.
- If leakage is occurring at insertion site, apply a sterile pressure dressing. Contact the primary medical team to order a Doppler Ultrasound to evaluate for a DVT.
- If leakage or ballooning of the catheter occurs with flushing, clamp the catheter.
- Contact PICC Services for possible repair or exchange of the catheter.