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December 30, 2009
Providing scrupulous PICC maintenance
It takes more than new devices, of course, to limit the risk of infection. As you would with a patient with any invasive device, you’ll need to follow evidence-based infection control guidelines: Hand hygiene, sterile dressing changes, cleaning catheter hubs and caps daily, changing IV fluids and tubing as recommended, and preventing (or eliminating) occlusions all help prevent infections that could lead to septicemia and death.4
In recent years, both the CDC and the Infusion Nurses Society (INS) have updated their PICC care guidelines to reflect the latest devices and techniques.6,12 Sterile dressing changes and flushing the line are particularly important.
The CDC and INS recommend that the first dressing change be done 24 – 48 hours after the PICC is inserted.6,12 By then, the gauze dressing placed on the insertion site may be blood-soaked and a breeding ground for bacteria, and must be removed.
When changing the dressing, always use sterile technique, which includes wearing a mask and using sterile gloves when touching the PICC insertion area. Clean the site with chlorhexidine gluconate 2% using a scrubbing motion for 30 seconds. Allow the site to dry and then apply a new transparent, semi-permeable membrane dressing (TSM). A TSM dressing is recommended for PICCs because it allows you to continuously inspect the site. It also requires less frequent dressing changes and helps to secure the catheter.
The TSM dressing should be changed once every seven days, or sooner if it’s coming apart, the line is not properly secured, or the site is soiled or draining.6 If continued bleeding or drainage requires the use of a gauze dressing, change the gauze every 48 hours.6,12 You should change the sutureless securement device and the caps every seven days with the dressing change, or sooner if indicated.6
To prevent occlusion and infection, a PICC must be flushed before all medication administration to check for patency, and after medication administration to prevent medication precipitates from forming. It’s necessary to flush before and after all blood draws and the administration of blood products as well, to prevent occlusion by a clot or fibrin.
To avoid rupturing the catheter, it’s important to use a 10 cc or larger syringe to flush the line, typically with 5 cc – 10 cc of normal saline (NS). Turbulent flushing—an intermittent push-stop-push technique in which you quickly inject a small amount of flush solution, pause, then inject again and repeat until all the flush solution has been injected—is recommended.13
Turbulent flushing helps remove built-up residue, medication, and fibrin from the walls of the catheter.13 It must be done even if IV fluids are running because the IV pump (or gravity flow) doesn’t generate enough force to clean the line.
Even when they’re not in use, PICCs must be flushed regularly to maintain patency. The recommended schedules and amounts of NS flush for line maintenance depend on the type of device and the manufacturer.
Because of their closed-valve system, Groshong PICCs require flushing only once a week with 5 cc – 10 cc NS. Open-ended PICCs, on the other hand, require daily or twice-daily flushes with 5 cc – 10 cc NS, followed by 3 cc – 5 cc of heparinized saline. Be sure to check your facility’s protocol, though, to determine whether its requirements are more stringent than those of the manufacturer.
If not flushed properly, PICCs can become sluggish or completely occluded. Occluded lines attract and trap bacteria that cause dangerous systemic infections.14 (The box explains how to recognize and troubleshoot PICC occlusions.)