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Fluids & Electrolytes
FOR MANY PATIENTS, a peripherally inserted central catheter (PICC) is the vascular access device of choice. Placing the PICC early in therapy also can improve patient outcomes. Made of a soft material such as silicone or polyurethane, the catheter can have one to three lumens. A PICC is inserted in a large peripheral vein close to the antecubital fossa and advanced until its distal tip rests in the superior vena cava (SVC). Although these are central catheters, in many facilities, nurses with proper training can insert them.
In this article, we'll describe when PICCs are used and how to initiate therapy. In a future article, we'll look at managing PICCs and dealing with potential complications.
If your patient will need I.V. therapy for more than 7 days, a PICC may be appropriate. You can use a PICC in a patient of any age, but they're especially suited to patients with poor or limited venous access because they have a longer dwell time than a short peripheral I.V. catheter. A PICC also is suitable for patients who need infusions of parenteral nutrition or vesicants (infusates with a pH less than 5 or greater than 9 or an osmolality greater than 600 mOsm/L).1 These infusions should be administered into a central vein for better hemodilution.
A PICC is cost-effective, reduces the risk of complications, and increases patient satisfaction.2 The insertion procedure is minimally invasive and can often be done at the bedside.
Before PICC insertion, tell your patient about the procedure. If you're the practitioner performing the insertion, tell your patient about the risks and benefits of a PICC as related to his diagnosis and prescribed I.V. therapies. Also explain any alternatives that are available. Depending on your facility's policy, the patient may need to give informed consent.
A sterile field is required for PICC insertion. Ultrasound may help you find a vein in the upper arm. Administer premedication as ordered for pain or anxiety, so the patient can remain still and cooperative during the procedure.
After insertion, secure the catheter and cover it with a sterile transparent semipermeable dressing. (The Infusion Nurses Society recommends using a catheter securement device to prevent catheter dislodgment.) Anchor the lumens as shown in the photo. Before using the catheter, obtain an X-ray to confirm that the tip is in the correct location.
If the catheter tip is in the right atrium or ventricle, patients may describe pressure or pain in the mid to lower sternum. They also may experience dysrhythmias. Follow your facility's policy for repositioning the PICC and reconfirming proper tip placement before beginning infusions.
Here are some tips for starting therapy with a PICC:
* If your patient is receiving parenteral nutrition, dedicate and label one lumen for that purpose.
* Use strict aseptic technique to minimize the risk of line contamination and infection. Vigorously scrub injection ports with alcohol before connecting anything to the PICC.
* Positive or neutral pressure caps may be placed on each PICC lumen to minimize blood backflow and prevent catheter occlusion.
* Keep the PICC dressing dry, intact, and air occlusive. Tell the patient not to get it wet when bathing or showering.
* Don't take the patient's blood pressure on the arm with the PICC. Cuff pressure can cause bleeding at the insertion site, increase the risk of thrombus formation, and cause retrograde blood flow, raising the risk of catheter occlusion.
* Use an infusion pump to provide consistent flow rates.
1. Infusion Nurses Society. Infusion nursing standards of practice. Journal of Infusion Nursing. 29(1, Suppl.):S1-S92, January/February 2006. [Context Link]
2. Bard Access Systems. Vascular access device selection, insertion and management online course. http://www.bardaccess.com/picc-online.php. Accessed February 25, 2007. [Context Link]
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