Long Line (PICC), Insertion and Care of (for Infants)

Long Line (PICC), Insertion and Care of (for Infants) - Policy and Procedure Manual

Purpose
To provide hydration, nutrition and medication requirements when these cannot be met orally and/or when
peripheral intravenous access is not ideal/possible.
To minimise risk of nosocomial infection.
To reduce handling, stress and skin trauma due to multiple peripheral intravenous insertions, attempted insertions
and infusion of irritating, hyperosmolar fluids peripherally.
Indications:
 parenteral access required for more than 7 days
 administration of solutions which are hyperosmolar, have nonphysiologic pH or irritating properties
Contra-indications:
 infection at potential insertion sites
 uncontrolled bacteraemia or fungaemia (allow 48 hours of antibiotic therapy before attempted long line
insertion). Note: For some infants a long line may be the only means of administering therapy.
 thrombocytopenia, disseminated intravascular coagulation
 limb fracture, malformation of extremity
 decreased venous return from limb (e.g. due to nerve palsy)
Definition of terms
Long Line (peripherally inserted central venous catheter (PICC): catheter inserted into a large peripheral vein (e.g.
great saphenous or cephalic vein), with tip located in superior or inferior vena cava.
Midline catheter: catheter tip placement out of thorax or abdomen in large vein/proximal portion of extremity.
Asepsis: is the prevention of microbial contamination of living tissues or sterile materials by removal, exclusion or
destruction of micro-organisms.
Sterile technique: implies the use of sterile equipment and gloves, avoidance of direct contact with the susceptible
site and other measures to reduce the probability of introducing potential pathogens into a susceptible site. These
procedures require:
 Mask
 Sterile gown
 Sterile gloves
 Sterile equipment
Aseptic technique
- implies the use of sterile equipment and avoidance of direct contact with the susceptible site to reduce the
probability of introducing potential pathogens. These procedures require:
 Sterile gloves
 Sterile equipment
No touch technique
- implies the use of sterile equipment, decontaminated hands and avoidance of surfaces or hands contacting exposed
sterile equipment or sites. (This refers to the surfaces of sterile equipment that will come into contact with surfaces
or sites that must remain uncontaminated to maintain asepsis). These procedures require:
 Non sterile gloves if contact with blood or body fluids is likely
 Sterile equipment
Responsibility

Insertion by medical officer experienced in the placement of long lines, with assistance from second staff member.
If a cut down is needed, this should be done in consultation with a Paediatric surgeon.
All staff caring for the infant are responsible for care of the long line.
Medical officer to order removal of long line.
Long line to be removed by medical officer (experienced in care of long lines) or nurse accredited for removal of
long lines.
Equipment
Insertion

 Goggles (Standard Precautions)

 Surgical face mask x 2
 Gown pack
 Sterile gloves
 Paediatric tray
 Sterile gauze
 Sterile cotton balls
 Catheter - Medical Officer requests length of catheter desired (includes sterile insertion device). A 27
gauge is used only when it has not been possible to insert a 24 gauge catheter. (Due to the very narrow
lumen of a 27 gauge catheter it is very difficult to infuse large volumes of fluid, particularly lipid solution.)
 Sterile paper tape measure
 Sterile plastic drape
 Large sterile cloth drape
 Skin preparation solution
 Sterile Water x 1 ampoule (if required)
 10ml syringe
 2ml syringe
 Drawing-up needles x 2
 Sodium Chloride 0.9% ampoule
 Heparin Sodium 50 units/5ml ampoule
 Skin closures (Surgistrips)
 Sterile Comfeel
 Sterile transparent dressing (OpSite)
 Splint and adhesive tapes to immobilise limb if necessary
 Parenteral administration set (tubing, filter/s)
 Parenteral solution (heparinised) requirements as ordered (notify Pharmacy - Heparin can only be added to
PG by Pharmacy (laminar flow)).
 Imed and syringe pumps as required
 If cutdown required (performed by surgical registrar only): 5/0 suture with atraumatic needle, ampoule of
1% Lignocaine, 25 gauge needle, 2ml syringe, No. 15 scalpel blade
Removal of Long Line
 Sterile gloves
 Dressing pack
 Skin preparation solution
 Sterile Water x 1 ampoule (if required)
 Stitch cutter only if required
Process
Inform parents of planned procedure and explain.
Refer to procedure: Central VenousCatheters (CVC) Management Guidelines.
Insertion ("Sterile" technique)
Provide draught free area.
Ensure resuscitation equipment is readily available.
Ensure adequate lighting.
Check and assemble equipment onto a clean trolley.
Monitor infant continuously via cardiorespiratory monitor and oximeter.
Maintain infant warmth and ventilation.
Medical officer to measure the estimated length of insertion.
Place limb on blue underpaid. Remove later if pooling of solution occurs.
Immobilise infant/limb.
For insertion via arm, place arm at 90 degree angle from side and turn infant's head toward the arm of insertion.
Insertion Procedure (Medical Officer)
 Prime catheter and connections with Heparinised Saline solution (add 1ml of Heparin Sodium (10 units) to
9ml of 0.9% Sodium Chloride to obtain 1 unit/ml solution).
 Prepare chosen site with antiseptic solution as per skin preparation procedure ().
 Drape infant with sterile clear plastic drape to allow observation. Use large sterile paper drape (included
with Paediatric tray) or cloth drape to provide a sterile working area around the infant as equipment will
slip off the plastic drape.
 Insert catheter gently via needle/introducer measured distance into selected vein.
 Ensure catheter flushes easily.
 Ensure catheter remains connected to syringe of solution during procedure, i.e. closed to atmosphere.
 Wait for any bleeding from insertion site to stop. Apply gentle pressure (while elevating limb) for at least 5
minutes or longer if required.
 If required (as per skin preparation procedure) - clean antiseptic solution from skin with Sterile Water and
allow to dry.
 Place the catheter with a slight curve as it exits from the skin.
 Place a short piece of Surgistrip over the long line approximately 1 cm from the insertion site. The
Surgistrip must not encircle the limb.
 Coil remaining length of line without kinking.
 Place a piece of Surgistrip over the hub to secure it in place.
 Apply OpSite to completely cover insertion site, all of catheter and hub.
 Do not apply tension to OpSite during application. If possible, avoid encircling limb completely with
OpSite. Usually this is unavoidable, so ensure tension is not applied (to ensure maintenance of perfusion
and venous return from extremity).
 Ensure OpSite adheres completely to the skin.
Document size and length of catheter used and length at insertion site on infant's observation chart. Medical officer
to document procedure including these details in the medical history, plus insertion site and vein used.
Check position of catheter radiologically before commencing maintenance infusions (hypertonic). (If Xray to be
performed prior to application of Op-site, use great care to maintain long line position and sterility of the procedure
area.) The tip should be located outside the heart, in the superior vena cava (level of T3 - T5) or inferior vena cava
between right atrium and diaphragm (level of T8 - T10). The catheter should lie parallel to the vein wall.
Flush line with heparinized solution, at least intermittently after insertion, until position is checked by Xray.
Only if necessary - immobilise limb with splint (to prevent kinking of long line due to limb flexion) - back adhesive
side of tape with cotton wool to prevent adhesion of tape to infant's skin or OpSite).
Do not advance the catheter after insertion.
Note: If tip is located out of thorax or abdomen in a large vein (Midline catheter), it may be decided to leave the line
in situ. Only infuse solutions suitable for infusion via a peripheral intravenous cannula. (There is an increased risk
of thrombosis. Place tip away from areas of flexion.) In all other aspects treat midline as a central line.
Commence parenteral solution administration. Refer to procedure: Intravascular Lines: Changing of all, Intensive &
Special Care Nurseries.
Precautions

 Maintain secure luer locks on all tubing connections. Eliminate 3-way taps from infusion lines when
possible.
 Maintain continuous infusion of heparinized solution (1 unit/ml). Prevent kinking of line. Apply/reapply
 splint if necessary.
 Administer medications via long line only when alternative access is not available/appropriate. Do not
administer blood transfusions via a long line, unless ordered by Neonatal Fellow or Consultant (when no
other intravenous access is possible).
 Do not attempt to withdraw blood from a long line.
 Avoid rapid infusions via a long line. Flush line or administer drugs slowly in a pulsatile (start-stop)
fashion or via an infusion pump, according to Pharmacy Manual. Use largest possible syringe - smaller
syringe = greater pressure exerted. Do not flush line forcefully if resistance is felt. (Applying too much
pressure can lead to holes in the catheter and catheter embolisation). Notify medical officer experienced in
care of long lines.
 Note: Re 27 gauge catheter - Do not alter infusion pump pressures (set at "L3" = 300mmHg). Inform
medical officer if infusion pump alarms indicate fluid volumes are not infusing. (It may be helpful to raise
the pump higher (increased gravity).
Continuing Care

 Maintain "asepsis" at all times. Refer to procedure: Central Venous Catheters (CVC) Management
Guidelines.
 Ensure integrity of catheter dressing is maintained (no part of catheter including the hub should protrude
from the dressing) and prevent pulling on tubing. The catheter must be held securely in the correct position
to prevent migration or dislodgement.
 At least once per shift:
 Observe insertion site for erythema, oedema or fluid leakage. (Leakage of fluid may indicate blockage
or hole in long line.)
 Check path of catheter from insertion site to tip location.
 Check long line dressing is intact and catheter is held securely in place. If possible, check correct
measurement of catheter at insertion site.
 Palpate course of catheter in limb vein for venous cord or symptom of pain.
 Check limb distal to insertion site for discolouration or oedema.

 Verify catheter tip location on an ongoing basis when Xrays have been taken.
 Do not take BP on limb with long line (increased risk of damage to vein and catheter).
Heparin Locks

In this unit we do not practice heparin locking of long lines. (Continuous infusion of heparinized solution is to be
maintained.)

Dressing Change (only if required)

 Do not change OpSite unless seal around insertion site is no longer intact or line is no longer held securely
in position under OpSite.
 OpSite may require changing if bleeding from insertion site occurs.
 Discuss need for dressing change with nurse in charge and medical officer.
 Maintain strict "aseptic" technique for dressing change.
 Use extreme caution when removing OpSite dressing (aseptic technique and catheter position must be
maintained).
Removal of Long Line
Long line removal is ordered by medical staff. Long line removal is performed by a medical officer experienced in
the care of long lines for infants or nurse accredited for removal of long lines, with assistance from second staff
member.

Procedure ("aseptic" technique):

  Assistant carefully removes OpSite by pulling it towards the insertion site (to avoid dislodging catheter).
 Prepare insertion site with antiseptic solution and allow to dry (as per procedure: Skin preparation prior to
invasive procedures).
 Hold catheter near insertion site. Do not pull catheter using hub.
 Remove catheter using slow and steady motion. Remove catheter on expiration if the catheter is in the
external jugular vein.
 Stop if resistance is met during removal. (Force on catheter has potential to cause line breakage.) If
resistance is met - discuss with Consultant.
 Measure to check entire long line has been removed.
 Apply gentle pressure to insertion site if bleeding occurs.
 If required - remove skin preparation solution using sterile water.
 Document removal including length of catheter removed.
Complications

 Infection, septicaemia
 Thrombus formation
 Phlebitis (mechanical, infectious, chemical)
 Haemorrhage (vascular perforation, extravasation)
 Embolism (thrombus, air, catheter)
 Cardiac arrhythmias
 Cardiac perforation, effusion, tamponade
 Pleural effusion
 Chest wall abscess
 Pain

 Catheter - occlusion, leakage, dislodged, malposition, migration, knotting, looping

Signs and Symptoms of catheter migration
 Erythema, oedema (of shoulder, neck or arm for arm insertion site)
 Sluggish flushing
 Unexplained IV pump occlusion alarms
 Cardiac arrhythmias
 Longer length of catheter visible
Reference documents

 Peripherally Inserted Central Catheters, Guidelines for Practice, Pettit J, Mason Wyckoff M, national
association of Neonatal Nurses, 2001.
 Central Venous Access Device Management, Policy and Procedure Manual RCH
 Central Venous Catheters (CVC) Management Guidelines.
 Intravascular Lines: Changing of all, Intensive & Special Care Nurseries.
 Skin preparation prior to invasive procedures