The administration of intravenous (IV) therapy by nurses has become common in most clinical settings, with nurses in the USA being at the forefront in the development of advanced nursing practice in this area. Peripherally inserted central catheters (PICCs) were introduced in the UK in the early 1990s, largely in the specialties of oncology, HIV/AIDS and nutrition.
Joanne Todd, RGN, Onc Cert
Lead Cancer Nurse, Mid-Anglia Cancer Network, Colchester
The administration of intravenous (IV) therapy by nurses has become common in most clinical settings, with nurses in the USA being at the forefront in the development of advanced nursing practice in this area. Peripherally inserted central catheters (PICCs) were introduced in the UK in the early 1990s, largely in the specialties of oncology, HIV/AIDS and nutrition.The Scope of Professional Practice (UKCC, 1992, (updated by the Nursing and Midwifery Council (NMC) in 2002) encouraged many nurses working in these specialties to take on the role of patient assessment for IV therapy and insertion of PICCs where appropriate. While nurses have increasing opportunity to broaden their clinical practice to the overall benefit of patient care, they remain professionally accountable for their own clinical practice (NMC, 2002).
The NMC (2002) states: ‘The nurse must ensure that any enlargement or adjustment of the scope of personal professional practice must be achieved without compromising or fragmenting existing aspects of professional practice and care.’This implies that PICC placement by a nurse is acceptable if the nurse is satisfied that a PICC is the most appropriate device for the patient and that he or she has the knowledge, skills and competence to undertake the procedure.It is important that nurses embarking on this practice seek the support of their employers in order to receive the protection of vicarious liability. In most situations, this is achieved by researching and preparing strict policies for PICC placement, care and maintenance and by emphasising the benefits of PICC use.
It is essential that the issue of informed consent is addressed. Consent should be obtained by the individual performing the procedure, but in some cases it is acceptable for consent to be sought by another individual who is capable of performing the procedure or who has been specifically trained to seek consent for the procedure (Department of Health, 2001). However, as Power (1997) says, the law relating to consent is ambiguous and therefore nurses need to be aware of the implications of obtaining consent. This involves judging a person’s competence to consent and deciding what and how much information to give to the recipient of care.It can be argued that the person inserting the device is best placed to obtain patient consent as he or she will be most knowledgeable about the device and the procedure. It has been suggested that nurses obtaining consent should adopt a standard higher than that required by law because the basis of the nurse-patient relationship and of consent is rooted in the principles of honesty and autonomy (Power, 1997).Written and verbal information must be given and understanding checked before informed consent is sought (DH, 2001).
Choosing a suitable administration route
With increased awareness of the complications associated with common intravenous therapy, the administration route of all IV therapies should be considered carefully (Bravery and Todd, 2002). Questions to be asked include:- How long the treatment is likely to last- Whether the treatment is appropriate for peripheral administration- Whether the treatment will be administered in hospital or the community.Many common therapies, including some antibiotics, antivirals, and some total parenteral nutrition (TPN) solutions have a pH or osmolarity outside the safe criteria for peripheral delivery. The peripherally inserted central catheter (PICC) has, in some clinical situations, become the preferred device to other central venous access devices (CVADs), as it is associated with fewer complications, particularly during insertion (Weinstein, 1997).
A number of factors must be considered when assessing a patient for the most appropriate venous access device. Evidence-based clinical guidelines such as the AccessAbility Programme (Bravery and Todd, 2002) and the RCN Standards for IV Therapy (RCN, 2003) will assist the professional to make the most appropriate device selection based on the patient’s clinical need.The decision will depend on the type and duration of therapy required, the patient’s immune status at the time of insertion and that predicted during treatment. The adequacy and integrity of the patient’s peripheral veins should also be assessed, preferably both visually and by Doppler or ultrasound techniques. Likely patient compliance with PICC care should also be considered, and the carer for catheter maintenance must be identified.The patient’s lifestyle is also pertinent.
The PICC has a number of advantages over other peripheral or central IV access devices. The insertion involves one cannulation only for the duration of treatment, thus reducing the patient’s exposure to multiple, repeated venepunctures and associated trauma.The method of placement involves minimal risk, whereas with centrally place CVADs there is a potential for complications such as pneumothorax, ‘pinch-off’ (where the catheter becomes compressed between the clavical and first rib) and artery, vein or cardiac perforation.If recommended guidelines are followed for care and maintenance, one PICC should provide reliable vascular access throughout the patient’s course of therapy. This preserves the patient’s peripheral veins for future vascular access, which is particularly important where further treatment is likely to be required.The device can be inserted in the ward, outpatient clinic or during a home visit (Brown, 1989), with obvious financial benefits because theatre space and time is not required and the device is cheaper.There are fewer colony-forming units (CFUs) of skin flora on the arm than the chest. This may partly explain the reported low rate of infection in PICC catheters, less than 1% in the immuno-competent patient (Goodwin and Carlson, 1993).The central delivery of medication allows for rapid haemodilution of thrombophlebogenic agents. This reduces the risk of venous intimal damage, and thus decreases the potential for thrombosis formation and thrombophlebitis (Lawson et al, 1979).
PICCs are inserted via the peripheral veins, usually the basilic or cephalic, and threaded through the axillary vein into the lower third of the superior vena cava.In order to ensure that the tip resides in the superior vena cava, the patient is carefully measured before placement to assess the required PICC length. The patient is measured from the antecubital fossa to the clavicle and sternum to gain an estimate of required line length.The PICC should ideally be inserted just above or just below the antecubital fossa for patient comfort and to help prevent catheter kinking, particularly for continuous infusions.
PICC insertion must be a sterile procedure if infection-related complications are to be minimised (EPIC, 2001). Within the author’s clinical setting, PICCs are inserted in the treatment area or in an available single-patient room. A placement pack (containing gowns, drapes, syringes, needles, gauze, a gallipot, scissors and sterile tape measure) is useful and can usually be provided by local sterile supplies departments.Local anaesthesia is achieved by using a topical anaesthetic cream over the skin near the vein in the antecubital fossa. The cream must be left in place for the length of time recommended by the manufacturer. Immediate anaesthesia can be achieved using subcutaneous lignocaine, but this can cause swelling locally, which can obscure the insertion site. The patient is helped into the supine position with the arm supported at a right angle to the trunk.The skin is prepared with chlorhexidine 0.5% in 70% alcohol (NICE, 2003). Maki et al (1991) have reported chlorhexidine as being the most effective skin preparation for use before central venous catheterisation (EPIC, 2001). The area is draped in sterile towels and the practitioner should maintain strict aseptic technique at all times. A sterile gown is recommended and non-powdered gloves to prevent particulate-induced phlebitis (EPIC, 2001). When the prepared area is dry, venous access is obtained using an introducer needle. Once the vein is cannulated and good blood flow obtained, the catheter is advanced through the cannula to the desired point using depth markings on the catheter as a guide. Aspirating blood and irrigating with normal saline will help confirm catheter placement within a vein. The PICC is secured using steri-strips, sutures or a Statlock device (Venetech), an anchoring device attached to the skin that reduces movement of the PICC (Gabriel, 2001), and a transparent dressing. A gauze pad may be applied for the first 24 hours as a minor amount of bleeding may be present post-insertion. Anchoring the PICC securely helps to minimise any catheter movement that may initiate mechanical phlebitis. A chest X-ray is then performed to confirm the position of the catheter within the lower third of the superior vena cava. Manipulation of the PICC may be required if the catheter tip is not within the superior vena cava.Insertion-related complications can be minimised through the development of a skilled PICC placement technique and thorough patient assessment. The most likely complications include: bleeding, tendon damage, nerve damage, catheter tip malposition and cardiac arrhythmias.The early recognition and management of potential complications promotes successful resolution and maximises the durability of the catheter.
Care and maintenance
The frequency for irrigating and changing the dressings of CVADs, including PICCs, has been much debated (Maki and Ringer, 1987; Maki et al, 1991; Fitchie, 1992; Cunningham and Bonham Crawford, 1993; Aston, 2000).Manufacturers of these devices produce guidelines that should be followed implicitly in the absence of audited alternatives, particularly regarding irrigation. Each trust should produce evidence-based policies regarding the care and maintenance of CVADs.
Following PICC insertion, it is advisable that the dressing is changed within 24 hours, as there is likely to be some bleeding at the exit site. A transparent semipermeable membrane dressing such as the IV3000 (Smith & Nephew) is advised as it provides anchorage for the catheter, thus preventing catheter migration, and allows frequent visual inspection of the exit site (Fitchie, 1992). The dressing technique should be performed aseptically, using chlorhexidine 0.5% in 70% alcohol as a cleansing agent (Maki et al, 1991). Unless the dressing becomes soiled or wet, it can be changed on a weekly basis thereafter (Gabriel, 1994). To prevent kinking or tugging of the PICC, the dressing should be applied up to the hub of the device.
Open-ended catheters should be flushed with heparinised saline after each use and when not in use, according to catheter size and manufacturers’ guidelines. Those with a valve on the distal end (such as the Groshong), prevent blood entering the catheter when the valve is closed, therefore heparin is not routinely required to maintain catheter patency. The required frequency of flushing, and therefore handling, is thus reduced.A pulsated, push-pause and positive pressure technique should be adopted (Goodwin and Carlson, 1993). The pulsated flush creates turbulence in the catheter lumen, clearing debris from the catheter wall. The maintenance of positive pressure helps to prevent a vacuum forming after catheter flushing (this can lead to a small amount of blood being sucked back into the catheter), thus helping to prevent catheter occlusion (Goodwin and Carlson, 1993).
It is important that patients and carers as well as nurses are aware of the possible complications that may arise as a result of a PICC insertion. Complications are discussed below:
Phlebitis is defined as injury to the endothelial layer of the vessel, exposing the cells of the sub-endothelial layer and may be caused by trauma, infection or thromboli/blood clots.Mechanical phlebitis is caused by particulate matter and damage to the venous intima during forceful insertion or excessive movement of the PICC (Goodwin and Carlson, 1993). The incidence of mechanical phlebitis in PICC catheters has been reported as being 1.2-23% (Goodwin and Carlson, 1993). The risk of developing mechanical phlebitis is higher in women as their veins are smaller (Goodwin and Carlson, 1993). It is therefore advisable to use a smaller size PICC if available. Any occurrence of mechanical phlebitis is usually evident within seven days of PICC insertion (Goodwin and Carlson, 1993). Signs include pain, redness, warmth, venous cord (a hard, palpable, thrombosed vein), induration and swelling. It can be managed by observation, application of heat, elevation of the arm, gentle exercise and non-steroidal anti-inflammatory drugs. As a last resort, the PICC should be removed.
The literature reports an incidence of infective phlebitis of less than 1% in the non-immunosuppressed patient (EPIC, 2001). It is suggested that this is likely to be because of the presence of fewer colony-forming units of bacteria on the skin of the arm than on the chest (Maki et al, 1991). The skin of the arm generally has less perspiration than the chest and is less exposed to expired air and secretions from the mouth or nose.Infective phlebitis may be caused by poor aseptic technique during PICC placement or when accessing the device. Signs include inflammation, swelling and exudate at the catheter exit site.The site should be cleaned with 0.5% chlorhexidine in 70% spirit (Maki et al, 1991). A swab should be taken for culture from the catheter site and the phlebitis should be treated with an appropriate, usually systemic, antibiotic (EPIC, 2001). The PICC should be removed only if the patient is acutely unwell with bacteraemia or the infection fails to respond to anti-bacterial therapy (EPIC, 2001).
This is caused by injury to the venous intima by traumatic insertion of the access device, an abnormal coagulation profile, or if the PICC tip is malpositioned in smaller veins, exposing the intima to damage by irritants such as vesicant drugs (James et al, 1993). Signs include pain, redness, venous cord, induration and swelling. The device should then be replaced (EPIC, 2001).
The development of venous thrombosis associated with CVADs can be minimised with the use of daily low-dose warfarin, starting three days before insertion (Bern et al, 1990). Signs include oedema of the arm, shoulder, neck or face, distended veins and collateral circulation. It can be caused by catheter tip malposition as with thrombophlebitis (James et al, 1993). Management is by fibrinolytic therapy and device replacement.
Catheter occlusion is indicated by either total occlusion or withdrawal occlusion.
Signs include fluid leaking from the catheter or exit site on infusion, which may be caused by accidental puncture of the catheter, excessive syringe pressure or poor catheter care. Where possible, the catheter should be repaired, using the correct repair kit, by an experienced practitioner. Future IV drug therapy may need to be modified, dependent on the catheter tip position. An X-ray will determine tip placement if the catheter has been withdrawn from the vein before any drugs or fluids are administered.
This is indicated by excess catheter visible at the exit site. It can occur if the dressing is not adequately secured or because of patient movement. The catheter tip position should be verified by X-ray. Any contaminated excess catheter should be trimmed, the end secured and the site dressed. Future IV therapy may need to be modified according to the tip position.
The PICC is a device that minimises insertion and catheter-related complications, permits the patient to be cared for at home as well as in hospital and has financial savings associated with its use (Bravery and Todd, 2002). However, it is the positive effect on the quality of holistic care that has motivated nurses to advance their practice in this area.This development in practice has increased professional responsibility and accountability, but also liability. It is therefore vital that nurses prepare themselves for this advance in practice and that they provide convincing data to justify their practice through audit. The challenge is then to develop this concept of care further through nursing research.
- This is an updated version of a paper that appeared in the February 1998 issue of Professional Nurse: Todd, J. (1998) Peripherally inserted central catheters. Professional Nurse 13: 5, 297-302.
Aston, V. (2000) Community management of PICCs. British Journal of Community Nursing 5: 7, 315-318.
Bern, M.M., Lokich, J.J., Wallach, S.R. et al. (1990)Prophylaxis against central vein thrombosis with low-dose warfarin. Surgery 90: 2, 216-220.
Bravery, K., Todd, J. (2002)The AccessAbility(R) Programme. Available at: www. accessabilitybybard.co.uk
Brown, J. (1989)Peripherally inserted central catheter use in home care. Journal of Intravenous Therapy 12: 3, 144-150.
Cunningham, R.S., Bonham-Crawford, D. (1993)The role of fibrinolytic agents in the management of thrombotic complications associated with vascular access devices. Nursing Clinics of North America 8: 3, 899-907.
Department of Health. (2001)12 Points on Consent: The law in England. London: DH.
EPIC. (2001)Guidelines for preventing infections associated with insertion and maintenance of central venous catheters. Journal of Hospital Infection 47: 47-67.
Faubio, W.C., Bollish, S.J., Wesley, J.R. (1983)Central venous catheter occlusion treated by thrombolytic agents. Nutritional Support Services 3: 2, 24-26.
Fitchie, C. (1992)Central venous catheter-related infection and dressing type. Intensive and Critical Care Nursing 8: 199-202.
Gabriel, J. (1994)An intravenous alternative. Nursing Times 90: 31, 39-41.
Gabriel, J. (2001)PICC securement. Nursing Standard 15: 43, 42-44.
Goodwin, M.L., Carlson, I. (1993)The peripherally inserted central catheter. Journal of Intravenous Nursing 16: 2, 22-26.
James, L., Bledshoe, L., Hadaway, L.C. (1993)A retrospective look at tip location and complications of PICCs. Journal of Intravenous Nursing 16: 2, 104-109.
Lawson, M., Bottino, J., McCrediek, P. (1979)Long-term IV therapy: a new approach. American Journal of Nursing 6: 1100-1103.
Maki, D.G., Ringer, M. (1987)Evaluation of dressing regimens for prevention of infection with intravenous catheters. Journal of the American Medical Association 285: 2396-2403.
Maki, D.G., Ringer, M., Alvarado, C.J. (1991)Prospective randomised trial of povidone-iodine alcohol and chlorhexidine for the prevention of infection associated with central venous and arterial catheters. Lancet 338: 339-343.
Mayo, D., Pearson, D. (1995)Chemotherapy extravasation. Oncology Nursing Forum 22: 4, 675-679.
NICE. (2003)Prevention of Healthcare-associated Infections in Primary and Community Care. Available at: www.nice.org.uk
Nursing and Midwifery Council. (2002)The Scope of Professional Practice. London: NMC.
Power, K. (1997)The legal and ethical implications of consent to nursing procedures. British Journal of Nursing 6: 15, 885-888.
Royal College of Nursing. (2003)Standards for IV Therapy. London: RCN.
Weinstein, S.M. (1997)Plumer’s Principles and Practice of Intravenous Therapy. Philadelphia, Pa: Lippincott.