Peripherally Inserted Central Catheters

Abstract and Introduction

Abstract

Peripherally inserted central catheters (PICCs) are frequently used to obtain central venous access for patients in acute care, home care and skilled nursing care. PICCs are a reliable alternative to short-term central venous catheters, with a lower risk of complications. Early assessment of hospitalized patients is essential to assure that individuals who will benefit the most from a PICC receive one as soon as possible in their treatment. However, PICCs are not appropriate for every patient. Indications, contraindications, and potential complications must be considered prior to insertion of a PICC. Nurses caring for patients with PICCs must be properly educated in device use, site care, and catheter maintenance, as well as recognition of complications. This article presents a comprehensive review of the core issues related to PICC use by nurses.

Introduction

PICCs have become well recognized as reliable central venous access devices (VADs), with lower potential for complications than short-term central venous catheters.^[1,2,3,4] PICCs first gained popularity in the 1980s, and their use has grown steadily since then. They were initially popular in many parts of the United States due to the need for venous access in home care patients. They have grown in popularity because of their reduction in potential complications and costs compared with short-term central venous catheters, and because PICCs can be inserted by registered nurses who have been trained in the procedure.^[5]

For a VAD to be termed a PICC, it must be inserted into the peripheral vasculature. A vein in the arm is the most common point of insertion. Also, to meet the definition, the distal tip of the catheter must terminate in the superior vena cava, the inferior vena cava, or the proximal right atrium. For infants, the catheter may be inserted in the saphenous vein, with tip termination in the inferior vena cava above the level of the diaphragm. Any tip termination below the level of the diaphragm for lower extremity insertion, or proximal to the superior vena cava for upper extremity insertion, is technically not a PICC but rather a peripheral catheter.^[6,7]

Cite this: An Overview of Peripherally Inserted Central Catheters - Medscape - Aug 17, 2005.

Table 1. Examples of Infusates That Are Irritants or Vesicants
Acyclovir	Nafcillin sodium
Amphotericin B	Norepinephrine
Ampicillin sodium	Oxacillin sodium
Ampicillin sodium/sulbactam sodium	Partial parenteral nutrition (PPN -- high osmolarity)
Ciprofloxacin	Phenytoin sodium
Dextrose 10% or greater	High-concentration potassium chloride
Dopamine	Promethazine hydrochloride
Erythromycin	Sodium bicarbonate
Fluconazole	Sodium nitroprusside
Ganciclovir sodium	Ticarcillin disodium
Iron dextran	Tobramycin sulfate
Mannitol	Total parenteral nutrition (TPN)
Meperidine hydrochloride	Vancomycin
Morphine sulfate	Most chemotherapeutic agents

Table 2. Potential Complications of Peripherally Inserted Central Catheters
Complication	Signs and Symptoms
Air embolus	Hypotension, lightheadedness, confusion, tachycardia, anxiety, chest pain, shortness of breath
Catheter embolus	Shortness of breath, confusion, pallor, lightheadedness, tachypnea, hypotension, anxiety, unresponsiveness, shorter catheter measurement on removal than inserted length
Arterial puncture (during insertion)	Bright red blood, pulsatile bleeding at insertion site, retrograde flow in IV tubing, can be verified by arterial blood gas test on sample aspirated from PICC
Cardiac arrhythmia	Irregular pulse, palpitations, atrial or ventricular arrhythmia on cardiac monitor
Nerve injury or irritation	Shooting "electric shock sensation" of pain down arm during insertion, numbness, tingling, weakness of extremity, paralysis
Inability to advance catheter to desired tip termination	Catheter will not advance
Catheter malposition (can occur during insertion, or after insertion)	Patient hears gurgling sound during flushing of catheter (internal jugular tip malposition), arm or shoulder pain, headache, swelling in neck, dyspnea, discomfort during infusion, absence of blood return, leaking at insertion site, arm swelling, back discomfort, chest pain or tenderness, arrhythmia symptoms
Infection	Fever, chills, tachycardia, fatigue, muscle aches, weakness, hypotension, erythema, swelling at site, induration, purulent drainage at site, elevated white blood cell count
Phlebitis	Erythema, pain at access site, streak formation, palpable venous cord, purulent drainage
Difficult removal of PICC	Resistance met at any point during removal of catheter

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