Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE

This LOP is developed to guide clinical practice at the Royal Hospital for Women. Individual patient circumstances may mean that practice diverges from this LOP.

PURPOSE & SCOPE:

Principles of Practice:

To insert a PICC line aseptically and safely.

Insertion by competent staff experienced in the procedure Medical Staff wishing to learn must be supervised by an experienced practitioner Inexperienced medical staff inserting lines in infants <27 weeks gestation must be supervised Appropriate vessel is to be identified prior to puncturing the infants skin Only 3 skin punctures should be made in any one occasion Allow time-out for the infant If unsuccessful Effective hand-washing technique using chlorhexidine Adhere to the CENTRAL LINE INSERTI ON BUN DL E Central Line Insertion Bundle Principles. Hand Hygiene Availability of equipment in the vicinity Aseptic Technique Maximal Barrier EQUIPMENT Hat & Mask Sterile gloves x 2 sets Sterile Gown Minor Op Pack Sterile Green Drapes x 3 Sterile Plastic Drape x 2 Sterile cotton balls x 1 pack (Optional) Extra Sterile Gauze packs x 2 Dressing Pack Comfeel Coloplast (wafer thin duoderm) Blue Inco-pad x 1 Appropriate Site Selection Skin Disinfection Surveillance of procedure process and insertion technique

10mL Syringes x 2 5 mL Syringe x 1 18g Blunt drawing-up needle x 1 Needleless drawing-up needle x 1 Steristrip x 1 pack (Surgistrip) Tegederm x 2 (large & small = infants >1kg or x 2 small for infants < 1kg) 5 mL Normal Saline ampoules x 3

In PICC Insertion Pack

Vygon Premicath 28g PLUS 24g Cannula (Yellow) OR 24g Catheter PLUS 21/22g cannula (Pink) Antiseptic Solution: 28 weeks gestation = Chlorhexidine 0.5% in 70% alcohol (Pink solution)

OR
<28 weeks gestation and <7 days old= Chlorhexidine Acetate Aqueaous Solution 0.05% w/v (Blue solution) Sterile glove for tourniquet (Optional) Neutral Detergent Cavilon sachet x 1 (Optional) NSW Health Central Line Insertion Record Form (Surveillance Form)

NOTE:

DO NOT USE less than 10mL syringes for flushing the catheter. The smaller the syringe: the greater the psi and that can rupture the catheter. C 2 - 1/11

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Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011
contd

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE

NOTE: The catheter tip location should be outside the heart. Preference is to withdraw the catheter to re-position rather than advance it. If the long line is withdrawn to re-position, another radiograph must be taken to confirm that it is in an acceptable position. A new infusion set-up and fluid must be used to connect to the new catheter. Picture 1
Preferred Veins for Peripheral Insertion of PICC Lines Basilic Cephalic Long Saphenous Scalp and Axillary Veins Measurement of PICC Lines Arm Veins From the insertion site along the arm to the shoulder joint, then to the sternal notch at the second intercostal space. This is the approximate location of the superior vena cava. The line should be at or below this position and at least 1 cm. proximal to the right atrium. Leg Veins Measure from insertion site to the xiphisternum. Aim is for catheter to be above L4/5 and at least 1cm proximal to the right atrium. Scalp Veins (Only if absolutely necessary) From the insertion site to the clavicular head and then to the second intercostal space (T2) if using the right side OR from the clavicular head diagonally to the second intercostal space (T2) if using the left. Femoral Veins (Not recommended) Not recommended because of increased risk of sepsis and necrosis of femoral head.

Table 1

PROCEDURE PROCESS
1 2 3 Inform parent/s of the procedure (if present). Ensure MO has performed Time Out on the infant. Monitor the infants Vital Signs and ensure supplemental oxygen is available for use during the procedure for infants who are not intubated. Collects all relevant equipment for the procedure. Request a nurse to complete the NSW Health Central Line

RATIONALE
To explain the procedure and the need for the access. Time Out: Correct Patient; Correct Procedure; Correct Site; Correct equipment. Infants who are self-ventilating or on CPAP requires supplemental oxygen. They are covered with the plastic sheet during the procedure.

4 5

Insertion Record Form (Appendix 1).

The Surveillance Form should be used at the commencement of the procedure i.e. when the MO begins scrubbing. C 2 - 2/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011
contd

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE PROCEDURE PROCESS

5 MO to use Hand Scrub or washes hands before assessing the infant for a vein. Locate the vein for catheter insertion and measure the insertion length (See Table 1). Discuss/consult the catheter length and site with a Senior Medical Staff. Position the infant comfortably and drape the part of the body for the insertion with a blue inco-pad. Ensures the infant is administered oral sucrose. Wash hands.

RATIONALE
Adhering to the 5-Moments of Hand Hygiene. Ascertain the most appropriate entry site and the desired catheter length for insertion. To verify the information with a senior colleague. To ensure the infant is comfortable during the procedure. To minimise solution pooling on bed and potential for body-heat loss. To provide pain-relief. Adhering to the 5-Moments of Hand Hygiene.

8 9

10 MO clean the work-surface of procedure trolley (Picture 1). 11 Put hat, mask and goggles on. 12 MO scrub hands and lower arms for 2 minutes. 13 Use the green towel to dry hands and put sterile gown on. 14 Using Closed-gloving technique, put on sterile gloves (2 pairs) (Page C6). 15 MO requests assistant to open plastic sheet packet. 16 MO drapes the work-surface with the plastic sheet without contaminating the field (Picture 2). 17 MO requests assistant to open remaining packets of equipment. (Picture 2). 18 MO arranges sterile equipment methodically on the procedure trolley for easy access during the procedure.
(Picture 3)

Picture 1 Adhering to the 5-Moments of Hand Hygiene.

Picture 2 C 2 - 3/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011
contd

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE

Picture 3

Picture 4

Picture 5

PROCEDURE PROCESS
19 MO prepares the equipment: 19.1 Open the green cloth for the following equipment: 5mL syringe of Normal Saline (18g needle attached) (Picture 4). 5mL of Normal Saline in 10mL syringe, attach to catheter and prime the catheter (Picture 4). 24g cannula Sterile gauze x 2
NOTE:

RATIONALE

To flush cannula hub.

The catheter must NOT be picked up by the gloved hands. Use an un-toothed pair of forceps to manouvre the catheter.

Picture 6 To avoid contaminating the catheter. To protect the catheter from contamination.

19.2

Close the green cloth to contain equipment.

20 Cut the following equipment (Picture 5):

xxxx

A rectangular piece of Comfeel (about 1.5 x 2.5cm). Steristrips into sections as Diagram 1. A piece of sterile rubber glove for tourniquet(Optional). A hole in the centre of the 2nd plastic sheet. Shape the small piece of plastic (from the hole of the plastic sheet) into a small square (approx. 2.5 x 2.5 cm). Put the square plastic to stick on the large tagederm (Picture 6).

To provide a platform for the cannula and white catheter connection (See Picture 5). For use as a tourniquet. To insert the infants limb for the catheter insertion.

To position the plastic that is adhered to the tagederm on the insertion site: to avoid accidental dislodgement during dressing change. C 2- 4/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE contd

CUTTING THE STERISTRIPS INTO SECTIONS

X2 Secure catheter cm away from Insertion site.

Secure Yellow Cannula hub To Comfeel Secure White wings Of catheter To Comfeel

Attach alongYellow cannula hub to white wings of catheter Use to secure circled catheter to skin

Criss-cross to secure yellow hub To white wings of catheter

Diagram 1

PROCEDURE PROCESS
22 Requests assistant (assistant must scrub and put sterile gloves on) to hold the infants limb with one of his/her gloved hand (keep the other gloved hand sterile). 23 MO cleans the insertion site with antiseptic solution - twice starting with the extremities. Leave to air-dry. 24 MO applies sterile gauze over the cleaned extremities for the assistant to hold with his/her clean gloved hand (Picture 7).

RATIONALE
For cleaning with antiseptic solution.

To ensure the insertion site is cleaned for the sterile procedure. To clean the lower part of the limb.

Picture 7 25 Using his/her dirty gloved hand, assistant pushes the blue inco-pad down from the limb for the MO clean twice. 26 After cleaning, MO inserts the cleaned limb through the hole of the sterile plastic. Maintain sterility. To provide maximal barrier. C 2- 5/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE

contd

Picture 8

Picture 9

PROCEDURE PROCESS
25 Assistant continues to hold the cleansed limb with the sterile gauze for the MO to drape with green cloth (Pictures 8 & 9) and secures with towel clips. 26 MO transfers the folded green drape (that contains the catheter and other instruments) on the sterile field of the bed. 27 MO removes the first set of sterile gloves (without contaminating the second set of gloves) and discard. 28 Applies tourniquet above insertion site (Picture 10). For easy access to equipment and catheter for the procedure without risk of accidental contamination. The first set of gloves is for preparation and cleaning the site with antiseptic solution. The second set of sterile gloves is for the insertion procedure. To pool blood in the vein for cannulation.

RATIONALE

Picture 10 29 MO commences cannulation: When flashback occurs in the yellow cannula, remove the introducer. Using a non-toothed forceps, inserts and advances the catheter in 0.5-1cm increments through the cannula to the premeasured length (Picture 11). Flush the catheter with saline while threading if obstruction is realised. Confirms that the cannula is in the vein. To avoid contamination of the catheter with contaminants from the gloves. To avoid venous irritation and the development of phlebitis (Hadaway, 1998) use slow and controlled insertion manoeuvres. It also allows the catheter to float into the central circulation with the flow of blood. To minimize trauma to the vessel, threading the catheter should take at least 3060 seconds. To facilitate insertion. C 2- 6/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE

contd

Picture 11

Picture 12

PROCEDURE PROCESS
29 When catheter is advanced, apply gentle pressure on the insertion site and simultaneously ease the yellow cannula out without removing the catheter. PREFERABLE: Do NOT remove the cannula from insertion site until feeding the catheter to designated length is complete to avoid contamination. 30 Apply continual pressure to insertion site if bleeding continues. Secure the catheter with a short piece of steristrip on the skin - about 0.5cm away from the insertion site (Picture 12). Apply the 2nd small piece of steristrip to overlap onto the 1st steristrip. Flush the hub of the yellow cannula with a18g needle attached to the 5mL syringe of normal saline. Secure the yellow cannula onto the white wingedconnection of the catheter (Picture 13) with a steristrip. To arrest bleeding. Securing the catheter is a priority to avoid accidental dislodgement. To re-enforce the 1st steristrip. To remove access blood in the yellow cannula. To anchor the yellow cannula to the white wingedconnection of catheter.

RATIONALE
To remove the cannula from the vein to be secured to the white winged connection of the catheter.

31

32

34

35

Picture 13 C 2-7/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE contd

PROCEDURE PROCESS
36 Use a long piece of steristrip and put onto the yellow hub of cannula, crosses-over the strip to catch on the white wings of the catheter (Picture 15).

RATIONALE

Picture 15 37 Stick the rectangular Comfeel on the infants skin and secure the yellow cannula on it. (Picture 16 application on a mannequin).

Picture 17 To provide a platform to prevent pressure area for the cannula and white winged-connector.

Picture 16 38 If bleeding, place Cavilon sponge onto the insertion site and surrounding steristrips and apply gentle pressure for 30 seconds. Remove when bleeding stops. 39 Coil excess catheter around the entry site without crossing the long line (Picture 17). 40 Secure the coiled line with a steristrip (Picture 17). DO NOT apply excessive steristrips. 41 Stick the large tegederm that has a plastic attached (Picture 18) on the catheter site. Ensure the plastic is placed on the insertion site and steristrips are completely covered by the tagederm (Picture 18). Stick the small tegederm to cover the yellow cannula and remainder of the catheter. 42 MO request assistant/SMO to organise x-ray. Request the xray technician to bring Omnipaque (x-ray contrast).

Picture 18 To arrest excessive bleeding. To contain excess catheter length.

Using excessive steristrips creates difficulty in removing the dressing during dressing change and a potential for catheter dislodgement when the old dressing is being removed. The plastic minimises the catheter sticking to the tegederm and the potential of removal. The dressing is applied before xray to avoid contamination. Attendance of Xray technicians can inadvertently be delayed. Constrast is required to be administered prior to the xray. C 2-8/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE contd

PROCEDURE PROCESS
43 MO draw up 1mL of Omnipaque in a 10mL syringe. 44 MO inject (pulsatile action push-pause x 6) the x-ray contrast into the catheter for the x-ray. 45 After x-ray, flush (pulsatile push-pause action x 6) the catheter with normal saline in a 10mL syringe. 46 The MO remains scrubbed to maintain asepsis whilst waiting for the x-ray result. 47 When catheter position is confirmed, MO removes all equipment and drapes from the infant. 48 Ensure the infants surrounding skin is cleaned with water and dried. 49 MO removes all sharps and discards appropriately before transferring the tray of equipment to the CSD bin in Utility Room. 50 MO removes green gown and gloves correctly (Page xx ) 51 MO checks the surveillance form and completes the relevant sections (Appendix 1). 52 Documents relevant information in the infants notes: infants tolerance to the procedure additional support required during the procedure eg. supplemental oxygen, insertion site catheter size and length position. To minimise contamination. To be able to re-adjust catheter if required. To avoid potential accidents with equipment. To avoid potential chemical burns on infants skin. Residual cleaning solutions on the infants skin can be a potential for chemical skin burns. To avoid Sharps Injuries. Do not use sustained pressure during injection of xray contrast. It can result in a fractured catheter or a pin-hole catheter rupture.

RATIONALE

To provide data for reference.

C 2- 9/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE contd

Appendix 1:

C 2- 10/11

Royal Hospital for Women LOCAL OPERATING PROCEDURES

NEWBORN CARE CENTRE

APPROVED BY CLINICAL CO-DIRECTORS

Date: 18th May 2011

INSERTION OF A PERCUTANEOUS INTRAVASCULAR CENTRAL CATHETER (PICC) LINE contd

References Ainsworth, SB, Clerihew, L & McGuire, W. (2007) Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates. Cochrane Database Syst. Rev., 3:CD004219. Bredemeyer, S. & Carman, E (2005). Nosocomial infection and the use of topical antiseptics in the extremely preterm infant. Neonatal Paediatric & Child Health Nursing, 8:1, 25-29. Byrnes, MC & Coopersmith, CM (2007). Prevention of catheter-related blood stream infection (The surgical patient). Current Opinion in Critical Care, 13:4, 411-415. Cartwright, D. (Nov. 2004). Central venous lines in neonates: a study of 2186 catheters. Archives of Disease in Childhoood: Fetal & Neonatal v89(6): F504-508 Donnelly, LF, Dickerson, J. & Racadio, JM. ( 2007). Is hand injection of central venous catheters for constrast-enhanced CT safe in Children. AJR, 189:1530-1532. 5 Million Lives Campaign, Getting Started Kit : How-to Guide: Prevent Central Line infections. Institute for Healthcare Improvement (2007). www.ihi.org/IHI/Programs/Campaign (Last assessed on 09/11/2007) Fioravanti, J; Buzzard, CJ; Harris, JP (August, 1998). Pericardial effusion and tamponade as a result of percutaneous silastic catheter use. Neonatal Netw; 17(5):39-42
Hadaway, L. C. (1998). Major thrombotic and nonthrombotic complications . Journal of Intravenous Nursing, 21, S143S160.

Kaler, W. & Chinn, r. (2007). Successful disinfection of needleless access ports: a matter of time and friction. JAVA 12(3): 140-142 Leipala, JA; Petaja, J, Fellman, V. (April 2001). Perforation complications of percutaneous central venous catheters in very low birthweight infants. J Paediatr Child Health; 37 (2): 168-171 Mermel, LA (2000). Prevention of intravascular catheter-related infections. Ann Intern Med; 132: 391-402. NeoReviews, 2004. American Academy of Pediatrics, (5).2, e60 c2004. NSW Health Policy Directive,(30th October 2007). Correct Patient, Correct Procedure and Correct Site. Department of Health, NSW. Document No. PD2007_07, File No. 06/280 Odd, DE, Page, B, Battin, MR & Harding, JE. ( January 2004). Does radio-opaque contrast improve radiographic localisation of pertcutaneous central venous lines? Arch. Dis. Child Fetal neonatal Ed., 89(1): F41-3. Ruess L, Bulas DI, Rivera O, Markle BM (1997). In-line pressures generated in small-bore central venous catheters during power injection of CT contrast media. Radiology 203(3): 625-629.

Date 4th Nov. 2005 Jan. 2011

Revised No. Primary 3 CNC K.B. Lindrea

Author; Revised by

CNC K.B. Lindrea & NCC Policy/ Procedure Working Group

C 2- 11/11