Complications


PICC lines have demonstrated fewer anatomical complication than other types of central venous catheters. However, insertion of any indwelling catheter entails some risk. Many facilities will have a Central Line Management Team who will respond to PICC issues. Your facility's policies are your best guide to safe catheter care and maintenance. Nurses should remain vigilant for the following complications.

COMPLICATIONS
MANAGEMENT OF COMPLICATIONS
Bleeding or leaking at insertion site
Absorbent sterile gauze dressing changed PRN or at least q 24 hours. Cleanse PRN with chlorhexidine skin prep.

Thrombophlebitis is a common complication of PICCs. The Paauw, Borders study found that 37.5% of PICC patients formed thrombus. Three factors known as Virchow's Triad are related to thrombus formation: a) disruption of the endothelium, b) venous stasis and c) hypercoagulability. Endothelial disruption can occur due to pressure or movement of the catheter against the endothelium. Stasis occurs due to the blockage or slowing of blood flow through the vein caused by the presence of the catheter. Hypercoagulability is influenced by inherited and acquired factors. Increased risk of PICC related deep vein thrombosis (DVT) has been associated with previous history of DVT, recent surgery lasting more than 1 hour, larger catheter diameter. Mural thrombus forms on the wall of the vein at the site of injury and can extend to occlude the vessel. Venous occlusion can manifest as local swelling and discomfort progressing to peripheral venous distention. DVT increases the risk of pulmonary embolism.

Grading Phlebitis 0- no symptoms;
1- erythema at insertion site;
2- erythema & pain at insertions site;
3- Pain, erythema, edema, streak formation and venous cord;
4- Pain, erythema, edema, streak formation and venous cord >1 inch in length, purulent discharge

Symptoms:

  • Pain: Arm, shoulder, neck
  • Distention arm and neck veins
  • Edema: arm, shoulder, neck/face
Document Notify per policy
Diagnosis Ultrasonography/venogram
Treatment
  • warm compresses
  • thrombolysis
  • anticoagulant
  • catheter removal

Catheter malfunction - sluggish aspiration/infusion or leaking at the insertion site

  • Mechanical kinking, malposition and catheter migration
Measure/check external catheter and clamps. Reposition arm/head, cough; retry aspiration.
Migration- obtain order for chest x-ray
  • intraluminal substance accretion such as blood and fibrin build-up or medication precipitation.
Blood reflux is most common cause. Flushing and capping per facility policy is the best prevention. Treatment may require an order to instill alteplase (t-PA) or catheter removal
Use of positive/neutral displacement connectors to reduce reflux
  • Leaking at insertion site may require removal or replacement to continue treatment
External tubing leak - close tubing clamp clamp, stop infusion and notify per policy, avoid use of sharp instruments around tubing
Site leakage - stop infusion, notify, replace transparent drsg. with sterile absorbent drsg.

Catheter related blood stream infections (CRBSI) associated with PICC devices vary by setting.

  • The rate of CRBSI in high-risk hospitalized patients with PICCs is about 2-5 per 1000 patient days. CRBSI in outpatient PICCs occur about 0.4 per 1000 patient days. (Safdar, N.; Maki, G. 2005) Improvements in PICC management may further reduce the incidence of CRBSI.
  • Zero CRBSI rate over 15 months in a community based medical center for nurse inserted PICCs (n=2083) (Harnage, S.)

 

Preventing CRBSI
Education and credentialing of staff providing PICC palcement and care.
Hand hygiene with alcohol based or antiseptic soap for allcentral line care including before and after donning gloves
Maximal sterile barrier precautions for central line insertion include: surgical gown, sterile gloves, mask, cap, and a large sterile sheet drape.
>0.5% chlorhexidine with alcohol skin prep for central venous catheter and peripheral arterial catheter insertion and during dressing change - CDC 2011
Avoid femoral central catheters have a higher rate of CLABSI than other insertions site and should therefore be .

Standardize the central venous catheter insertion procedure, utilizing dedicated insertion kit or cart, a catheter insertion checklist and a trained professional health care observer empowered to suspend the procedure until breaches in policy or sterile technique are corrected.

Chlorhexidine impregnated sponge and semipermeable dressing are changed not earlier than 7 days unless soiled or moisture is visible. Chlorhexidine antiseptic skin prep applied and dried at dressing change.

Change IV set no sooner than 96 hours. If blood/products, fat, amino acids or irritants are infused change within 24 hours. Change every 6-12 hours per manufacturer if propofol is infused.

Change needleless connectors with IV sets. Cleanse connectors chlorhexidine or alcohol when accessed
Prompt removal of PICC if alternative treatment delivery is acceptable.



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