Mary Larson, Senior Nursing Student SCSU Leadership Project

1. Central and PICC Lines
Care and Best Practices
Mary Larson, SN
St. Cloud State University

2. Mary Larson
 Hometown: Atwater, MN
 St. Cloud State University Nursing Program: December 21st
 Capstone Semester
 Preceptor: Jamie Daniel
 180 Direct Patient Care Hours, 90 Leadership Hours (40 at Meeker Memorial)
 Leadership Project- Teaching

3. Pre-Quiz

4. Central Venous Access
 Catheters inserted into large veins in central circulation
 Tip of catheter threaded to reside in lower third of the vena cava
 Chest X-ray to confirm correct placement

5. Central Venous Access
Indications:
 Patients requiring multiple sites for IV access
 Patients lacking useable peripheral IV sites
 Patients requiring central venous pressure monitoring
 Patients requiring total parenteral nutrition
 Patients receiving incompatible medications
 Patients requiring multiple infusions of fluids, medications, or chemotherapy
 Patients requiring long term antibiotic therapy
 Patients subject to frequent blood sampling or receiving blood transfusions
 Patients requiring a temporary access site for hemodialysis
 Patients receiving infusions that are hypertonic, hyperosmolar or infusions that
have divergent pH value

6. Non-Tunneled Percutaneous Central
Venous Catheter
 AKA Central Line
 Inserted by physician
 Subclavian vein of upper chest or internal jugular veins in the neck
 Occasionally femoral – higher rates of infection
 Measure 7-10 inches (18-25 cm)
 1 to 5 Lumens
 Used most common: Trauma, critical care, surgery
 No recommended dwell time: used for short term, not the catheter of choice
for home care or ambulatory clinic settings

7. Peripherally Inserted Central Venous
Catheters (PICC)
 Long catheter, inserted in vein of antecubital fossa or middle of upper arm
 Basilic vein preferred, cephalic used if necessary
 Inserted by physicians or specially trained nurses
 Length 18-29 inches (45-72 cm), 1-3 Lumens
 Optimal dwell time unknown: reported to dwell successfully for months or
even years
 Lower rate of Central Line Assoc. Bloodstream Infections (CLABSI) than
Central Lines
 Patients requiring lengthy antibiotics, chemotherapy, parenteral nutrition, or
vasopressor agents – benefit from PICC line.

8. Lumens
 Central Line: 1-5
 PICC Line: 1-3
 Port Designation: (with 3 Lumens)
 Proximal
 Blood Sampling
 Medications
 Blood Administration
 Medial
 TPN
 Medications (Only if TPN use in not anticipated)
 Distal
 CVP monitoring
 Blood Admin
 High Volume or Viscous Fluids
 Colloids
 Medications

9. Catheter Dressings
 Centers for Disease Control and Prevention (CDC)
 Recommendations:
 Use either sterile gauze or sterile transparent semipermeable dressing
 If pt is diaphoretic or site is bleeding or oozing, use gauze until
resolved
 Replace dressing if damp, loosened, or visibly soiled
 Do not use antibiotic ointments or creams
 Dressing changes:
 Short-term CVC sites q 2 days for gauze and at least q 7 days for
transparent
 PICC-24 hours post insertion, then transparent dressings q 5-7 days unless
soiled or loose, gauze q 2 days unless wet, soiled, or non-occlusive
 >5% Chlorhexidine to cleanse skin during dressing changes

10. Dressing Changes
 Dressing Removal:
 Stabilize catheter and Luerlock hub to prevent dislodgement
 Separate dressing away from Luerlock hub and toward insertion site
 Chlorhexidine should be used to swab in a back and forth pattern for 30
seconds to ensure the skin is clean and disinfected
 If patient is diaphoretic with a great deal of fluid present on skin, area should
be scrubbed for 2 minutes to ensure bactericidal activity
 During dressing change- assess external catheter length to determine if
migration had displaced catheter tip
 Sterile occlusive dressing should cover entire insertion site, suture wing and
at least 2.5 cm of the extension tubing is recommended

11. Dressing Change Procedure
 Gather supplies
 Hand hygiene
 Don clean gloves and mask (patient)
 Remove old dressing (toward insertion site) and discard
 Remove gloves, perform hand hygiene, and don sterile gloves
 Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck
 Cleanse site (chlorhexidine) back and forth motion
 Allow to air dry
 Secure catheter in place
 Apply sterile dressing to site
 Document date, time, and initials on new dressing
 Document the procedure, any complications, and external catheter length to
patient’s chart

12. Caps: Needleless Access Devices
 CDC recommends changing caps at least as frequently as administration sets
 No benefit to changing these more frequently than every 72 hours
 TPN/Lipids (enhance microbial growth)
 Accessing: “Scrub the Hub” for 15 seconds
 Types:
 Negative Displacement Device
 Neutral Displacement Device
 Positive Displacement Device
 At Meeker Memorial: Baxter Clearlink System (Negative Displacement)

13. Flushing Lines
 A single use syringe should never be used more than once
 10 mL syringes should not be divided into several doses and used for multiple
lumens
 Never use a syringe smaller than 10 mL
 The pressure created by smaller syringes could damage the catheter
 Volume: Minimum of twice the volume of the catheter should be used to flush
 In general for adults 10 ml is sufficient
 0.9% NaCl solution should be used
 Frequency: If being used a minimum of q 8 hours, flush with 10 mL NS before
and after every use and for lines in maintenance mode flush with 10 mL NS
every 24 hours.
 Flush using a pulsative or “stop-start” technique
 Creates turbulence within the catheter to adequately flush medications from the
line

14. Preventing:
Blood Reflux
 Major problem
 Catheters are deep in the body, reflux cannot be seen when it occurs
 Caused by inadequate flushing, also b/t flushes caused by increased
intravascular pressure (ex: coughing, vomiting) leading to biofilm formation and
buildup, occlusion, and even infection
 Prevention Strategy: Know which type of needleless connector is being used.
 Negative Displacement (Meeker Memorial – Baxter Clearlink System)
 Catheter must be clamped BEFORE syringe is removed
 Neutral Displacement
 Fluid should remain neutral, therefore clamping can be done before or after syringe removal
 Positive Displacement
 Important to clamp the catheter AFTER the syringe is removed in order to get displacement
https://www.youtube.com/watch?v=X5wIhmR0SIE

15. Assessment
 Visually examine insertion site daily for erythema, drainage, tenderness,
suture integrity, and catheter position
 Routine IV site assessments
 Routinely assess dressings (change if necessary)
 Daily assessment of need for Central Line and promptly discontinue lines
which are no longer indicated
 Nursing staff should be encouraged to notify physicians of Central Lines which
are unnecessary

16. Documentation
 The following should be included in the patient’s chart:
 Product Name
 Date of insertion, inserter
 Anatomical location
 Catheter depth according to catheter reference markings
 X-ray confirmation of catheter tip location
 Port designation for infusions/measurements, e.g. TPN, CVP, Medications
 Ensures uniform use of lumens
 Amount, type, and frequency of flush solution
 Dressing and tubing changes
 Document exposed catheter length with dressing changes
 Site assessments
 Every shift
 Complications
 Catheter removal and application of air-impermeable dressing

17. References
 Angiodynamics (2014). Bioflo picc with endexo technology: Directions for use. Marlborough, MA:
Navilyst Medical, Inc.
 Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow International,
Inc.
 Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan for
outpatient oncology settings. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/basic-infection-
control-prevention-plan-2011/central-venous-catheters.html
 Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular
catheter-related infections. Retrieved from http://www.cdc.gov/hicpac/bsi/bsi-guidelines-
2011.html
 Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered
collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.
 Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive care unit
(non-icu) settings toolkit. Atlanta, GA: Centers for Disease Control and Prevention.
 Stacey, K.M. (2014). Peripherally inserted central catheter (picc): Maintenance and dressing
change quicksheet. Mosby’s Skills. St. Louis, MO: Elsevier, Inc.
 Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based practice and
technologies: A continuing educational activity for pharmacists and nurses. Irving, TX: VHA, Inc.
 The Nebraska Medical Center (2012). Standardizing central venous catheter care: Hospital to home
(2nd ed.). Omaha, NE: The Nebraska Medical Center.

18. Questions?

19. Post-Quiz