Peripherally inserted central catheters

A peripherally inserted central catheter is also referred to as a PICC line. This type of catheter is placed in the antecubital vein (a large vein in the inner elbow area) and is threaded into a large vein above the right atrium of the heart (see Figure 8-4). Unlike other catheters, a PICC line can be inserted by an IV nurse, rather than by a surgeon.

Figure 8-4. PICC (peripherally inserted central catheter) line

The PICC line can remain in place for many weeks or months, avoiding the need for a new IV every few days. PICC lines can be used to deliver chemotherapy, antibiotics, blood products, other medications, and intravenous nutrition. When the PICC line needs to be accessed, an intravenous (IV) line is connected to the end of the catheter. When it is not in use, the IV is disconnected and the catheter is flushed and capped.

How it's put in

The peripherally inserted central catheter can be inserted in your child's hospital room by a nurse or physician. Your child will be positioned on a flat surface, and she will need to keep her arm straight and motionless during the procedure. An injection to numb the area is given to decrease discomfort during insertion. A special needle is used to place the PICC line into the arm vein. The catheter is then threaded through the needle. Once the line is in place, a chest x-ray is taken to ensure that it is positioned properly.

Brian had his Hickman pulled when he started maintenance in February 1997, but two weeks later he developed pancreatitis and needed total parenteral nutrition. Since he was still on active treatment, he was given the choice of another Hickman or a PICC, which he decided to try. It was inserted right in our room with no anesthetic other than the morphine pump he was already on for the pancreatitis pain. He pushed his PCA button (the control that allows patients to administer their own doses of pain medication) moments before it was inserted, because he was not sure what to expect. The procedure was uncomfortable, but not terribly painful. They did an x-ray to make sure that it was in the right place. It wasn't, but after some aerobics (moving him into different positions) and lots of flushing, they checked again, and it was.

Care of the peripherally inserted central catheter

The PICC line, like the external catheter, requires care to prevent problems. The nurses will teach you to change the dressing, flush the line, change the injection cap, and inspect the site for possible signs of infection. The dressing covering the exit site is changed on a weekly basis, and is changed if it becomes wet or is exposed to the air. The line must be flushed after every use, or every day. You should get plenty of practice under the supervision of a nurse until both you and your child are comfortable with caring for the line. The care required for your childs PICC line may be slightly different from what has been described in this section since institutional preferences vary.

Kelsey had a PICC line in her right arm, and she would not straighten it out, but kept it a little bent. I definitely think she was protecting it, and also I think when she tried to straighten it, it pulled on the suture and on the dressing in an uncomfortable way that could have been painful, so she just wouldn't try. I had to do a heparin flush every day and change the dressing twice a week. She could not tolerate Tegaderm, so we used another kind of porous adhesive bandage, and doused it with Detachol, which dissolved the adhesive within a few minutes, allowing us to get the bandage off quite easily. The Detachol was a godsend for her, as removing the adhesive was like pulling teeth and a source of unnecessary pain.

Risks

The problems associated with a PICC line are similar to those with any external catheter. Veins may become irritated, infection can occur, or the line can be accidentally torn or moved.

Irritated veins

The vein where the catheter is located may become irritated. This is most likely to occur during the first few days after it has been inserted. Signs of irritation include swelling or pain in the area or the development of small veins near the site. Often, a warm moist cloth or a carefully monitored heating pad placed on the vein will help alleviate discomfort. Elevating the arm on a pillow is also sometimes helpful.

Infection

Meticulous care using sterile techniques is very important to reduce the risk of infection. The dressing exit site should be changed every week, or if it becomes wet or exposed to the air. Injection caps must also be regularly changed using sterile techniques when the line is not in use, and the line must be flushed on a regular basis. Signs of infection include redness, swelling, pain, drainage, or warmth around the exit site. Fever, chills, tiredness, and dizziness may also indicate that the line has become infected. You should notify the doctor if any of these signs are present or if your child has a fever above 101° F (38.5° C).

Torn catheter

Accidents sometimes happen, and a hole or tear in the line can occur. Careful handling of the catheter can help prevent these accidents. You should suspect a torn catheter if fluid leaks out of the line, especially during an injection. If a tear is found, you should find the hole, fold the line above the tear, tape it together and cover it with sterile gauze. You should immediately notify your child's doctor of the problem.

Displacement of the catheter

As with the external catheters discussed earlier in this chapter, it is important that the PICC line be securely taped to the exit site to prevent movement. Signs of a displaced catheter include chest pain, burning or swelling in the arm above the exit site or in the chest, fluid leaking around the catheter, or pain when fluid is injected into the line. If you suspect that the line has moved, you should tape the catheter in place and immediately notify your childs doctor.

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