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Approved: June 7, 2017 Page 1 of 35 HEALTH SERVICES CODE P.11 NURSING PROCEDURE TITLE: PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) A. ASSESSMENT B. ESTABLISHING OR CHANGING NEEDLELESS ACCESS ADAPTER C. FLUSHING D. ADMINISTRATION INTRAVENOUS (IV) FLUIDS OR MEDICATIONS E. DRESSING CHANGE WITH STATLOCK® F. DRESSING CHANGE WITH SECURACATH® G. BLOOD SAMPLING H. ACCIDENTAL REMOVAL & DRESSING APPLICATION UPON PHYSICIAN/RN REMOVAL I. OCCLUSION MANAGEMENT J. REMOVAL OF PICC CATEGORY: General RN, RPN Advanced Practice LPN Sections A-H only PURPOSE To provide safe, standardized, evidence based process for PICC care and maintenance. NOTE: This procedure applies to both clamped and clampless catheters unless otherwise indicated. TYPES & PROCEDURAL DIFFERENCES: 1. CLAMPED Rotate clamping site on sleeve. Unused lumens need to be flushed with a minimum of 10 mL normal saline (N/S) q24hrs. Ensure catheter is clamped prior to opening system (i.e. changing needleless access adapter). Clamped catheters can be used for central venous pressure monitoring. NOTE: For pediatrics see Appendix A.

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Page 1: CODE P.11 HEALTH SERVICES NURSING PROCEDURE TITLE

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HEALTH SERVICES

CODE P.11

NURSING PROCEDURE

TITLE: PERIPHERALLY INSERTED CENTRAL

CATHETER (PICC)

A. ASSESSMENT

B. ESTABLISHING OR CHANGING

NEEDLELESS ACCESS ADAPTER

C. FLUSHING

D. ADMINISTRATION INTRAVENOUS (IV)

FLUIDS OR MEDICATIONS

E. DRESSING CHANGE WITH STATLOCK®

F. DRESSING CHANGE WITH

SECURACATH®

G. BLOOD SAMPLING

H. ACCIDENTAL REMOVAL & DRESSING

APPLICATION UPON PHYSICIAN/RN

REMOVAL

I. OCCLUSION MANAGEMENT

J. REMOVAL OF PICC

CATEGORY:

General – RN, RPN

Advanced Practice LPN – Sections A-H only

PURPOSE

To provide safe, standardized, evidence based process for PICC care and maintenance.

NOTE: This procedure applies to both clamped and clampless catheters unless otherwise

indicated.

TYPES & PROCEDURAL DIFFERENCES:

1. CLAMPED

Rotate clamping site on sleeve.

Unused lumens need to be flushed with a minimum of 10 mL normal saline (N/S) q24hrs.

Ensure catheter is clamped prior to opening system (i.e. changing needleless access adapter).

Clamped catheters can be used for central venous pressure monitoring.

NOTE: For pediatrics see Appendix A.

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2. CLAMPLESS

Valve is located in hub of catheter.

NOTE: Due to presence of valve, clampless catheters cannot be used for central venous

pressure monitoring.

Lumen size is equal in dual lumen catheters.

Unused lumens need to be flushed q7 days with a minimum of 10 mL normal saline.

NOTE: For pediatrics see Appendix A.

NURSING ALERT:

Insertion is responsibility of a physician.

Removal of PICC’s is responsibility of a physician, RN or RPN, see Section I.

Ensure aseptic technique when performing PICC care, i.e. accessing lumens, opening

lumen(s) or exposing insertion site.

Ensure needleless access adapter is in place on all PICC lumens.

Use greater than or equal to 10 mL syringe when flushing.

Keep all sharp instruments away from catheter.

Avoid acetone and adhesive remover as they will weaken catheter.

Allow alcohol to dry before applying needleless adapter to lumen hub.

Avoid taking a blood pressure or performing venipuncture on an arm with a PICC. If unavoidable, place BP cuff/tourniquet distal to PICC insertion site.

Apply appropriate personal protective equipment (PPE) before direct contact with patient and

prior to starting procedure.

Infusion pump is required for all PICC’s unless continuously visualized. For pediatrics, an infusion pump is always required.

If there is accidental breakage or damage to catheter, pinch catheter closed with fingers between patient and where catheter is damaged/cracked. Fold catheter over on itself and tape in place. Immediately notify Most Responsible Practitioner (MRP).

For Pediatrics, keep non-traumatic forceps hanging on IV pole in room of patient with CVAD’s and clamp line if there is accidental breakage.

Utilize 2 client identifiers prior to any PICC catheter care and maintenance as per RQHR policy 0612.

Minimize number of times PICC is accessed to prevent complications.

Flush using vigorous push-pause technique creating turbulent flush to maintain patency.

IV tubing to be changed as per Appendix B.

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A. ASSESSMENT

NURSING ALERT:

Proper care and handling of PICC catheters is essential to prevent central line associated blood stream infections (CLA-BSI).

Accessing any part of the PICC for any reason requires; o Hand hygiene o Cleansing connection site vigorously with alcohol swab using a 15 second scrub (let dry).

Assess daily need for existing PICC. Notify MRP/Interventional radiologist (IR) if signs of malposition are present: inability to withdraw

blood, a “gurgling” sound heard when flushing catheter, and/or chest pain experienced by patient.

Notify MRP if patient develops swelling in arm with PICC.

As much as possible, when administering Parenteral Nutrition (PN), use a dedicated lumen and document specified lumen on patient’s plan of care.

PROCEDURE 1. Perform hand hygiene prior to touching any component of PICC, administration set, or fluid

solutions. 2. Assess site minimum once per shift, with each patient assessment and prior to any procedure.

2.1 Palpate area around insertion site (through dressing). 2.2 Assess for tenderness or discomfort. 2.3 Assess surrounding areas for redness, warmth, edema and drainage. 2.4 Assess chest wall for engorged superficial veins.

3. Measure PICC from insertion site to middle of suture wing or StatLock® posts upon initial insertion

and every week with dressing change and prn for adults; once per shift and prn for pediatrics and document. See Appendix C, D and F for picture of where to measure.

4. Document assessment and any unusual findings. Notify MRP of any unusual findings.

B. ESTABLISHING OR CHANGING NEEDLELESS ACCESS ADAPTER

NOTE: Change needleless access adapter at least every 7 days or at any sign of adapter

damage (i.e. cracking, leaking or contamination) and prior to blood culture collection.

NOTE: Ensure alcohol is dry before applying needleless access adapter to hub.

EQUIPMENT 1. PPE, including mask 2. Needleless access adapter (#313420) 3. Alcohol swabs 4. 10 mL N/S in a greater than or equal to 10 mL syringe 5. Sterile normal saline (as required) 6. 2x2 sterile gauze (as required)

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NOTE: For pediatrics, see Appendix A.

PROCEDURE 1. Perform hand hygiene.

2. Prepare new sterile needleless access adapter for each lumen.

2.1 Open package. 2.2 Prime adapter with N/S while keeping it inside package.

3. Don PPE. 4. Stop IV infusion, if in place. 5. Disconnect IV tubing from adapter, if infusing. 6. Ensure lumen is clamped, if clamp present. 7. Cleanse adapter connection site vigorously with alcohol swab using a 15 second scrub (let dry).

NURSING ALERT:

Ensure asepsis is maintained during needleless access adapter change.

8. Remove existing adapter and discard.

NOTE: Avoid using forceps on catheter lumen hub. This may damage hub.

NOTE: Clean catheter lumen hub with alcohol only if visibly soiled; ensure alcohol is dry

before attaching adapter. If visible encrustations will not come off with alcohol, soak

threads with normal saline soaked gauze prior to cleaning infusion tubing threads

with alcohol. 9. Attach pre-flushed needleless access adapter with N/S filled syringe in place. 10. Release clamp (if applicable). 11. Aspirate slowly for blood, only until flashback appears.

NURSING ALERT:

If unable to aspirate blood, try the following techniques in this order:

Have patient position their neck to look over opposite shoulder of PICC insertion, cough, move arm away from body at a 90 degree angle and slightly back or take a deep breath and hold.

Instill 1 – 2 mL of N/S using push pause technique and attempt to aspirate.

May repeat above steps. (For pediatrics may repeat x2). If still unable to aspirate for blood, document and refer to section I – Occlusion Management. Attempt accessing another lumen if available.

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12. Flush with N/S using vigorous push-pause technique. 13. Remove syringe.

14. Initiate infusion (refer to section D) or heparinize only if ordered by MRP.

NOTE: If heparin flush is ordered, follow steps 12 and 13 using Heparin following N/S. 15. Document.

C. FLUSHING

NURSING ALERT:

Avoid previously accessed multi-use vials and bag spikes when flushing PICCs.

Flush with 10 mL N/S (5-10 mL for pediatrics) between incompatible solutions and 20 mL (10-20 mL for pediatrics) after administration of blood products, PN, contrast medium or blood sampling.

Each lumen of a clampless catheter should be flushed at minimum every 7 days and after each access.

Clamped catheters should be flushed every 24 hrs (every 48 hours for pediatrics) to each unused lumen and after each access.

Heparin to be used only with MRP orders. (Heparin may be required for pediatrics, or adult patients with blood dyscrasias.)

EQUIPMENT

1. PPE 2. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen) 3. If ordered, 2 mL heparin (100 u/mL) per lumen, in a greater than or equal to 10 mL syringe 4. Alcohol swabs

NOTE: For pediatrics, see Appendix A.

NURSING ALERT (Continued)

Refer to Section I – Occlusion Management if order for fibrinolytic agent (Cathflo®) is obtained.

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PROCEDURE:

1. Perform hand hygiene. 2. Don PPE. 3. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry). 4. Access needleless access adapter with N/S filled syringe. 5. Release clamp (if applicable) and aspirate slowly for blood, only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B. 6. Flush lumen with N/S and follow with heparin if ordered using vigorous push-pause technique. 7. Remove syringe. 8. Clamp lumen (if applicable). 9. Document.

D. ADMINISTRATION OF IV FLUIDS AND MEDICATIONS

NURSING ALERT:

When administering PN through a multi-lumen catheter, use a dedicated lumen as much as possible for PN.

NOTE: Refer to Appendix B for routine IV tubing changes.

EQUIPMENT

1. PPE 2. Alcohol swabs 3. Infusion pump 4. Primed IV set with solution (as ordered) 5. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen)

PROCEDURE: 1. Perform hand hygiene. 2. Don PPE. 3. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry). 4. Access needleless access adapter with N/S filled syringe.

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5. Release clamp (if applicable) and aspirate slowly for blood, only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B.

6. Flush lumen with N/S utilizing vigorous push-pause technique. 7. Remove syringe. 8. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry). 9. Connect primed IV tubing to adapter.

NOTE: Ensure connection and tubing is secure. 10. Start infusion of IV fluid or medication.

11. Document.

NOTE: When infusion is complete, refer to Section C - Flushing.

E. DRESSING CHANGE WITH STATLOCK®

NOTE: Assess dressing daily; replace dressing and StatLock® when it becomes damp,

loosened or soiled. Transparent semi permeable dressing is recommended for site

visualization; change every 7 days and PRN. Sterile gauze dressing changed every

2 days and PRN.

NOTE: Gauze underneath a transparent semi permeable dressing is considered a gauze

dressing.

NURSING ALERT:

Care must be taken when removing existing dressing to avoid dislodging PICC which may be anchored with securement device.

Measure and document external length of catheter once a week for adults and once a shift for pediatrics. Refer to Appendix C, D and F for pictures of how to measure a PICC.

If PICC is found to have migrated 5 cm or more from its originally placed position, contact Interventional Radiology (IR) for PICC check.

If PICC is displaced 1-4 cm from its original position and is working well upon assessment, continue to use as required and notify MRP. The MRP may obtain a chest x-ray to verify PICC position and need for interventional radiology assessment.

If PICC is displaced and found not to be working well, regardless of amount of displacement, contact Interventional Radiology for PICC check.

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EQUIPMENT 1. PPE including mask 2. Clean gloves 3. Sterile gloves 4. Sterile dressing set 5. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410) (Orange tint available if

needed, usually used on insertion #310411) 6. Alcohol swabs

NOTE: Chlorhexidine (ChloraPrep®) use on pediatric patients less than 2 months of age is

not recommended. Use 70% alcohol.

NOTE: For patients with sensitivities:

First, ensure you are applying dressing correctly (see Appendix E for tips on

application of dressing) and also making sure Chlorhexidine is completely dry

before applying dressing.

Second, rule out if sensitivity is to Chlorhexidine or dressing:

o Swab area on inner arm with Chlorhexidine 2% with 70% alcohol. Observe

for skin reaction.

If patient is sensitive to Chlorhexidine, use 70% alcohol first followed

by povidone iodine as an acceptable alternative.

o Place a dressing or small section of dressing on opposite inner arm.

Observe for skin reaction.

If patient is sensitive to dressing, then an alternative dressing will have

to be explored. 7. Transparent semi permeable dressing (#319299) 8. Catheter securement device (StatLock®) (#313508) (Pediatrics #313510) 9. Sterile normal saline (as required) 10. 2 x 2 sterile gauze (as required) 11. Mesh netting in appropriate size for limb 12. Measuring tape

PROCEDURE 1. Explain procedure to patient. 2. Perform hand hygiene. 3. Don PPE including mask and clean gloves. 4. Position patient.

5. Assemble supplies on sterile field.

5.1 Open sterile dressing set. 5.2 Add StatLock® and package contents to sterile field. 5.3 Add transparent dressing to sterile field. 5.4 Add ChloraPrep® to sterile field.

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6. Inspect insertion site for redness, inflammation, tenderness or drainage.

7. Remove existing dressing. 7.1 Roll transparent dressing to expose StatLock® only (keep insertion site covered).

NURSING ALERT:

If PICC insertion site is against the wings, you will need to remove entire dressing. Use tape provided in StatLock® package to secure PICC at insertion site in order to prevent line migration.

7.2 Remove StatLock® (use alcohol swabs):

7.2.1 Unlock wings of StatLock® (this may take some force). 7.2.2 Lift PICC suture wings off of StatLock® posts. 7.2.3 Position PICC to side. 7.2.4 Use alcohol swabs to loosen StatLock® and remove.

NOTE: For blood or exudate on PICC catheter or wings, apply saline soaked gauze and

cleanse with sterile saline prior to cleaning with Chlorhexidine.

8. Remove gloves.

9. Perform hand hygiene.

10. Don sterile gloves.

11. Cleanse skin beneath StatLock® site: 11.1 Cleanse entire area where dressing is placed using Chloraprep® in a crosshatch motion

(back and forth) with light friction in two different directions for a total of 30 seconds.

NOTE: Never Fan Dry 11.2 Place ChloraPrep® swab with sponge end pointing upward on sterile field to be reused later.

12. Apply skin protectant using pad from StatLock® package. Let dry.

13. Apply new StatLock® device:

13.1 Secure PICC suture wings on StatLock® posts and close wings. 13.2 Apply StatLock® to skin.

14. Grasp remaining dressing with a sterile 2x2 (to remain sterile) while removing remainder of old

dressing.

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15. Cleanse skin at insertion site with previously used ChloraPrep® swab:

15.1 Cleanse area to be re-covered with dressing in a crosshatch motion (back and forth) with light friction in two different directions for a total of 30 seconds.

15.2 Cleanse length of exposed catheter from insertion site down with same ChloraPrep® swab.

Let dry 2-3 minutes.

NOTE: Never fan dry. 16. Apply new dressing.

16.1 Apply transparent semi permeable dressing over insertion site, including StatLock® (ensure insertion site is visible). See Appendix E for tips on application of dressing.

16.2 Avoid stretching, smooth from centre out to edge and mold around catheter lumens. 16.3 Place one tape from dressing package over PICC lumen(s) leg(s). 16.4 Write date on second tape and position just below first tape.

17. Measure length of PICC from insertion site to StatLock® posts (or to suture wings). See Appendix C

and D for how to measure a PICC. 18. Ensure PICC lumen(s) are anchored securely (i.e. mesh netting).

19. Document.

F. DRESSING CHANGE WITH SecurAcath® (See Appendix F for Pictures)

NOTE: SecurAcath® is intended to stay in situ for the life of PICC.

NOTE: Assess dressing daily; replace dressing when it becomes damp, loosened or

soiled. Transparent semi permeable dressing is recommended for site

visualization; change every 7 days and PRN. Change sterile gauze every 2 days and

PRN.

NOTE: Gauze underneath a transparent semi permeable dressing is considered a gauze

dressing.

EQUIPMENT 1. PPE including mask 2. Clean gloves 3. Sterile gloves 4. Sterile dressing set 5. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410) (Orange tint available if

needed, usually used on insertion (#310411) 6. Sterile normal saline (as required) 7. 2 x 2 sterile gauze (as required) 8. Transparent semi permeable dressing (#319299) 9. Mesh netting in appropriate size for limb 10. Measuring tape

NOTE: Chlorhexidine (ChloraPrep®) use on pediatric patients less than 2 months of age is

not recommended. Use 70% alcohol.

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NOTE: For patients with sensitivities:

First, ensure you are applying dressing correctly (see Appendix E for tips of

application of dressing) and also making sure Chlorhexidine is completely dry

before applying dressing.

Second, rule out if sensitivity is to Chlorhexidine or dressing:

o Swab area on inner arm with Chlorhexidine 2% with 70% alcohol. Observe

for skin reaction.

If patient is sensitive to Chlorhexidine, use 70% alcohol first followed

by povidone iodine as an acceptable alternative.

o Place a dressing or small section of dressing on opposite inner arm.

Observe for skin reaction.

If patient is sensitive to dressing, then an alternative dressing will have

to be explored.

PROCEDURE 1. Explain procedure to patient. 2. Perform hand hygiene. 3. Don PPE including mask and clean gloves. 4. Position patient. 5. Assemble supplies on sterile field.

5.1 Open sterile dressing set. 5.2 Add ChloraPrep® to sterile field. 5.3 Add transparent dressing to sterile field.

6. Remove dressing. 7. Inspect insertion site for redness, inflammation, tenderness or drainage. 8. Perform hand hygiene. 9. Don sterile gloves. 10. Cleanse insertion site with ChloraPrep® in a crosshatch motion (back and forth) with light friction

in two different directions. 10.1 Cleanse both sides of SecurAcath® with the same ChloraPrep® swab. To cleanse the

underside of SecurAcath® you can lift device less than 30-45 degrees. Do not twist it. 10.2 Cleanse entire area of skin that will be under new dressing with the same ChloraPrep®

swab in a crosshatch motion (back and forth) with light friction in two different directions for a total of 30 seconds.

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10.3 This entire cleansing process should take a total of 30 seconds

NOTE: For blood or exudate on PICC catheter or SecurAcath®, apply saline soaked gauze

and cleanse with sterile saline prior to cleaning with Chlorhexidine. 11. Cleanse entire length of PICC catheter up to and including body of PICC with the same

ChloraPrep® swab. Let dry 2-3 minutes.

NOTE: Never fan dry. 12. Apply new dressing.

12.1 Apply transparent semi permeable dressing over insertion site, including SecurAcath® (ensure insertion site is visible).

12.2 Avoid stretching and smooth around edges of dressing only, do not press down on SecurAcath®.

12.3 Place one tape from dressing package over PICC lumen(s) leg(s). 12.4 Write date on second tape and position just below first tape.

13. Measure length of PICC from insertion site to suture wings. See Appendix F for how to measure a

PICC. 14. Ensure PICC lumen(s) are anchored securely (i.e. mesh netting). 15. Document.

G. BLOOD SAMPLING

EQUIPMENT 1. PPE 2. Blood specimen tubes and labels (plus discard tube 3-5 mL)

NOTE: Refer to test compendium in laboratory services manual on RQHR Intranet for

appropriate blood tubes.

http://rhdintranet/lab/public/Manuals/Laboratory%20Services%20Manual.htm

3. Vacutainer® Luer-Lok™ access device (#952058) 4. 3 x 10 mL N/S in a greater than or equal to 10 mL syringe

NURSING ALERT:

PICC access should be minimized to conserve blood and decrease manipulation of adapter.

Assess patient to determine best method for blood sampling.

Venipuncture may be an option.

Vacutainer® Luer-Lok™ access device has rubber sheathed needle in center (ensure caution is taken to avoid skin puncture).

If patient has PN infusing through any lumen, avoid blood draws from this lumen as much as possible.

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5. Alcohol swabs 6. Blood transfer device (#952056) (if required to transfer blood from syringe draw to blood sample tube) 7. Blood collection set – with male adapter (Angel Wing®) – from lab for blood culture collection 8. Needleless access adapter if blood culture collection

NOTE: For pediatrics, see Appendix A.

PROCEDURE

NURSING ALERT:

In a triple-lumen catheter use red/larger lumen for blood sampling when possible.

If continuous infusion in place, stop infusion through all lumens, flush and wait 1 minute before drawing discard.

1. Perform hand hygiene.

2. Don PPE.

3. Disconnect infusion if in place, maintaining asepsis.

4. Cleanse needleless access adapter vigorously with an alcohol swab using 15 second scrub (let dry).

5. Change needleless access adapter (if drawing blood cultures).

6. Attach greater than or equal to 10 mL syringe with 10 mL N/S.

7. Aspirate slowly for blood only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B. If still unable to

aspirate sample, attempt blood sampling from another lumen if possible or notify lab

to obtain samples via venipuncture. Notify MRP and document.

8. Flush lumen with attached N/S syringe using vigorous push-pause technique and wait 1 minute.

9. Attach Vacutainer® Luer-Lok™ access device.

10. Insert blood specimen tube (3-5 mL) for discard and remove when filled.

NOTE: Blood cultures should be collected via venipuncture unless ruling out PICC as

source of infection. Change needleless access adapter prior to blood culture

sampling from PICC and use discard as part of first sample. Draw one set from PICC

and have lab draw one set via venipuncture. 11. Insert appropriate blood specimen tubes in appropriate order and obtain samples, filling each sample

to fill line.

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NOTE: Order of blood collection should be as below:

Blood culture (SPS) aerobic then anaerobic

Blue (Citrate)

Orange, Red or Yellow (Serum Tube)

Green (Heparin)

Mauve (EDTA)

Grey (Fluoride/Glucose)

NOTE: If unable to aspirate blood through Vacutainer® Luer-Lok™ access device, remove

device and aspirate blood using greater than or equal to 10 mL syringe. Obtain discard

in separate syringe prior to obtaining blood samples. Transfer blood samples to tube

by attaching blood transfer device to blood filled syringe. Insert blood specimen tubes.

DO NOT use a needle to transfer blood. 12. Invert tubes gently 5 times immediately following obtaining each sample.

13. Remove Vacutainer® Luer-Lok™ access device and discard in sharps container.

NOTE: Discard blood transfer device and blood discard in sharps container.

14. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry).

15. Attach greater than or equal to 10 mL pre-filled N/S syringe and flush with total of 20 mL N/S, using vigorous push-pause technique (10-20 mL for pediatrics).

16. Remove syringe. 17. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry).

18. Reconnect continuous infusion to lumen, if applicable, and restart. 19. Label specimen tubes in presence of patient at time of collection and send to lab immediately.

NOTE: Label according to laboratory services manual on RQHR intranet

http://rhdintranet/lab/public/Manuals/Laboratory%20Services%20Manual.htm

Cross match samples also require birth date. Requisition should indicate where

sample obtained from (i.e. PICC).

NOTE: If coagulation studies are collected, indicate on requisition if PICC was heparinized. 19. Document.

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H. ACCIDENTAL REMOVAL & DRESSING APPLICATION UPON PHYSICIAN/RN REMOVAL

NURSING ALERT:

Intentional removal of PICC is the responsibility of a physician or RN/RPN. See Section E.

EQUIPMENT 1. PPE 2. 4x4 gauze (sterile) 3. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410)(Orange tint available if

needed, usually used on insertion #310411) 4. Occlusive dressing with sterile Petroleum Jelly (single use packet), 2x2 sterile gauze and transparent

semi permeable dressing

PROCEDURE 1. Don PPE.

2. Apply pressure to site using 4x4 gauze until bleeding has stopped.

3. Cleanse site with ChloraPrep® as needed, while keeping puncture site covered with gauze.

4. Apply sterile gauze with sterile petroleum jelly to site. Cover with transparent dressing.

5. Compare length of catheter using catheter markings with catheter length recorded at time of insertion (see physician progress note, x-ray report, or interagency referral form for initial length).

6. Notify MRP that PICC has been accidentally removed.

7. Complete occurrence report.

8. Document.

NURSING ALERT:

If you suspect PICC has broken because length is shorter than documented, immediately contact Interventional Radiologist (IR) and monitor patient condition.

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I. OCCLUSION MANAGEMENT

NURSING ALERT:

An Order is required for instillation of a fibrinolytic agent into a PICC.

Fibrinolytic Agents are contraindicated: o in patients who have internal bleeding o if any of the following occurred within 48 hours:

coronary artery bypass graft surgery, obstetrical delivery, organ biopsy, puncture of non-compressible vessels (i.e. subclavian vein) or recent trauma.

o in presence of known or suspected infection in CVAD. o allergy to fibrinolytic agent to be used.

Use with caution in presence of a known or suspected infection in PICC. Caution should be exercised in patients who have hemostatic defects (including those secondary to

severe hepatic or renal disease) or any condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location, or who are at high risk for embolic complications (e.g. recent pulmonary embolism, deep vein thrombosis, endarterectomy).

Consider contacting nursing educator for troubleshooting occlusion. Refer to occlusion management algorithm in Appendix I.

EQUIPMENT 1. PPE as required (gloves, etc.) 2. Sterile water for injection to reconstitute fibrinolytic agent 3. 3 mL syringe 4. Blunt fill needle 5. 3 greater than or equal to 10 mL syringes 6. Fibrinolytic Agent (Cathflo® 2 mg vial) from Pharmacy 7. Normal Saline for injection Pre-filled normal saline (N/S) syringes 8. Alcohol swabs 9. Medication label 10. Heparin 100 units/mL (as required) 11. Needleless access adapter (as required)

PROCEDURE 1. Notify MRP and obtain an order for a fibrinolytic agent (Cathflo®).

NOTE: Ensure no contraindications as noted in previous Nursing Alert. 2. Perform hand hygiene. 3. Reconstitute fibrinolytic agent according to product guidelines immediately before use as per

Appendix J. 4. Draw up 2 mL of reconstituted fibrinolytic agent (Cathflo® 1mg/mL) into a greater than or equal to

10 mL syringe.

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NOTE: See Appendix H for pediatric dosage chart. 5. Inspect fibrinolytic agent for foreign matter and discoloration.

NOTE: Do not administer if particulate matter is noted. 6. Don PPE. 7. Explain procedure to patient. 8. Stop infusions through all lumens for duration of dwelling.

NOTE: If multiple lumens are occluded, instil fibrinolytic agent into only one (1) lumen. 9. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub; (let dry). 10. Remove blunt needle from syringe. 11. Access occluded lumen with reconstituted fibrinolytic agent in greater than or equal to 10 mL syringe. 12. Instil fibrinolytic agent slowly into occluded lumen.

NOTE: If difficult to infuse through needleless access adapter, clamp catheter (if applicable),

remove needleless access adapter, and attach syringe with fibrinolytic agent directly

to hub of PICC catheter. Instil fibrinolytic agent, clamp catheter (if applicable), remove

syringe and attach new needleless access adapter. 13. Remove syringe and clamp (if applicable). 14. Label lumen hub with name of drug, dosage, and time of instillation. 15. Document on Patient’s Record and sign for drug instillation on patient’s Medication Administration

Record (MAR).

NOTE: If multiple lumen PICC, indicate which lumen instilled with fibrinolytic agent. 16. Allow fibrinolytic agent to dwell for 30 minutes. 17. Cleanse needleless adapter vigorously with alcohol swab using 15 second scrub (let dry). 18. Attach greater than or equal to 10 mL syringe and attempt to aspirate drug and blood.

NOTE: If PICC is functional, go to step 19.

If PICC remains occluded go to step 22. 19. Aspirate 4-5 mL of blood in patient greater than 10 kg and discard or 3 mL in patients less than 10 kg

and discard. 20. Flush with 20 mL NS in greater than or equal to 10 mL syringe using vigorous push pause technique.

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NOTE: For pediatrics, flush with 10–20 mL of NS depending on age of patient. 21. Attach to infusion or Saline lock. 22. Allow fibrinolytic agent to dwell another 90 minutes (total of 120 minutes), if no blood return after 30

minutes. 23. Follow steps 17– 21 after an additional 90 minutes of dwell time if occlusion was not resolved after 30

minutes. 24. Follow previous steps in procedure if a repeat dose is required. 25. Document results of procedure. 26. Notify MRP if unsuccessful after second attempt.

J. REMOVAL OF PICC

EQUIPMENT

1. Stitch cutter for pediatrics only 2. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®) (Clear #310410)(Orange tint available if

needed, usually used on insertion #310411) 3. Dressing bundle 4. PPE 5. 2x2 sterile gauze x2

NURSING ALERT:

• If no blood return after 120 minutes, a second dose of fibrinolytic agent may be attempted in same lumen.

• An order must be obtained to attempt another dose. • If still unable to aspirate blood after second instillation, notify MRP.

NURSING ALERT:

This procedure may be performed by RN’s or RPN’s educated in this skill.

PICC’s in pediatric patients will be removed by MRP or RN specializing in pediatrics and educated in this skill.

An occlusive dressing is required to provide a complete seal to prevent air embolism and infection.

Routine tip cultures are not performed unless removal for suspected infection or sepsis and require an MRP order.

If catheter tip is to be sent for C&S, corresponding blood cultures must be collected prior to

removal (1 set drawn venipuncture and 1 set from catheter).

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6. Sterile petroleum jelly (occlusive dressing) 7. Transparent semi permeable dressing 8. Sterile gloves

PROCEDURE

J.1 REMOVAL 1. Verify order to remove PICC. 2. Note catheter length recorded at time of insertion. (See progress note, x-ray report, or interagency

referral form. 3. Perform hand hygiene. 4. Explain procedure to patient. 5. Don PPE.

6. Discontinue administration of all infusions. 7. Position patient supine or sitting with PICC arm at 45-90º angle to body where possible.

NOTE: Insertion site should be placed below level of heart.

8. Set up sterile field adding occlusive dressing and ChloraPrep® swab.

9. Remove dressing.

10. Remove Statlock® (if applicable).

11. Remove clean gloves, perform hand hygiene and apply sterile gloves.

12. Cleanse insertion site with ChloraPrep® in a crosshatch motion (back and forth) with light friction in two different directions for a total of 30 seconds.

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13. Remove PICC catheter from SecurAcath® (if applicable) see appendix G for pictures: 12.1 Remove cover of SecurAcath® by placing finger under device to stabilize (on side of

SecurAcath® that says HOLD), grasp tab on SecurAcath® that says LIFT with other hand. 12.2 Lift tab to completely detach cover from anchor base and discard cover. 12.3 Lift PICC line out of SecurAcath® device leaving SecurAcath® base in place until PICC is

removed.

14. Instruct patient to take a deep breath and hold, bear down (if not contraindicated) or exhale during PICC removal.

NOTE: Removal should take approximately 1-2 minutes to prevent vasospasm; nurse may

need to pause several times during removal and allow patient to take another deep

breath and hold or bear down as removal occurs.

15. Grasp PICC near insertion site below anchor wings and pull gently.

16. Remove PICC slowly over 1 to 2 minutes to prevent venospasm.

17. Stop removal if you meet resistance and have patient change position by lifting arm at a 90 degree

angle away from body and slightly backwards, turning neck to look over opposite shoulder than side of PICC insertion.

18. Continue to remove PICC slowly, if you continue to meet resistance proceed to Section J.2 - Resistance to Removal.

19. Hold sterile gauze gently over insertion site when there is approximately 5 cm of PICC left to remove.

20. Continue until completely removed then apply direct pressure to insertion site with sterile gauze until

bleeding is controlled, usually 2-5 minutes.

21. Compare length of catheter using catheter markings with catheter length recorded at time of insertion. (See progress note, x-ray report, or interagency referral form for initial length.)

22. Remove SecurAcath® (if applicable).

22.1 Fold edges of SecurAcath® anchor base downward. Place a finger under back edge of device to help begin folding motion.

22.2 Place one hand near insertion site to stabilize the tissue. Hold folded anchor base horizontal to skin and lift anchor out of insertion site.

NOTE: If skin appears to be growing over SecurAcath® legs skip folding steps and move

directly to cutting the SecurAcath®.

NURSING ALERT:

Do not grasp Luer hub to remove as catheter damage could occur.

Do not apply excessive pressure to PICC as it may break.

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22.3 Resistance to removing SecurAcath® while folding requires cutting base with blunt tip scissors

in half lengthwise along blue groove. 22.4 Place one hand near insertion site to stabilize tissue. Use a swift, deliberate tug to remove

each half of anchor base separately. Flexible anchor will straighten as it is pulled out and will not cause tearing or trauma to the tissue.

23. Ensure bleeding has stopped. 24. Apply 2x2 gauze with sterile petroleum jelly and transparent dressing over insertion site and leave

on for minimum of 24 hours. 25. Instruct patient to remain in supine or sitting position for 30 minutes after removal.

NOTE: If culture and sensitivity of PICC line is ordered: After completion of step #21 place

PICC tip on sterile field and after completion of step #25 use sterile scissor and cut 2-

3 cm from distal PICC end and drop directly into sterile container. Send to lab for

culture and sensitivity.

26. Discard PICC in appropriate waster container. 27. Document:

condition of exit site

length of catheter

patient response

if PICC tip was sent for culture

J.2 RESISTANCE TO REMOVAL

PROCEDURE

NOTE: Resistance to PICC removal may be caused by venospasm, phlebitis, thrombus, or

presence of a fibrin sheath.

NOTE: Before initiating following steps try trouble shooting by having patient change

position by lifting their arm at a 90 degree angle away from their body and slightly

backwards and turning their neck to look over their opposite shoulder than side of

PICC insertion.

NURSING ALERT:

If you suspect PICC has broken because it pops or length is shorter than documented, immediately apply an occlusive dressing over insertion site.

Immediately contact interventional radiologist and monitor patient condition.

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1. Apply a sterile dressing to insertion site.

2. Apply a warm compress to upper arm for 20 minutes to relax vein.

3. Remove dressing and attempt removal again starting from steps 16 in section J.1.

4. Stop procedure if resistance continues.

5. Apply a sterile dressing over insertion site.

6. Secure catheter to skin below dressing.

7. Notify MRP/Interventional Radiologist.

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REFERENCES:

Adler, A. (2016). Peripherally Inserted Central Catheter (PICC) Removing. Retrieved from CINAHL. Broadhurst, D., & Ulman, A. (2017). Management of Central Venous Access Device Associated Skin Impairment. Wound Ostomy Continence Nursing. Lippincott, Williams & Wilkins. Caple, C., & Schub, T. (2016). Peripherally Inserted Central Catheter (PICC) Care: Performing-an Overview. Retrieved from CINAHL. Centers for Disease Control, (2011). Guidelines for the prevention of intravascular catheter-related

infections, 2011. Atlanta, GA: CDC. Davis, M.B. (2013). Pediatric Central Venous Catheter Management: A review of Current Practice.

JAVA Vol 18 No 2 p.93 -98. Infusion Nurses Society. (2016). Infusion nursing standards of practice. Norwood, MA: Lippincott,

Williams & Wilkins. Infusion Nurses Society. (2016). Policies and procedures for infusion nursing. Norwood, MA: Infusion

Nurses Society. Lynn-McHall Wiegand, D., & Carlson, K. (Eds.). (2011). AACN procedure manual of critical care (6th

ed.). St. Louis, MO: Elsevier Saunders. McGee, W., Headley, J., & Frazier, J. (Eds.). (2010). Quick guide to cardiopulmonary care (2nd ed.).

Irvine, CA: Edwards Lifesciences LLC. Mosby’s Skills (2012) Peripherally Inserted Central Catheter (PICC): Blood sampling and Catheter

Removal. Elsevier Inc. Regina Qu'Appelle Health Region Laboratory Services. (2017). Lab services manual Safer Healthcare Now (2012). Getting started kit: Prevent central line infections. Revised by: Teresa Vall, Lisa Roland, Jana Lowey, CNE’s, RQHR Date: September, 2013 Revised by: Kim Hunt, Lisa Roland, Jana Lowey, Kim Rapchalk, Dana Lamers, Tara Griffiths, Sarah

Harder, CNEs Date: May 2017 Approved by: Date:

Regina Qu’Appelle Health Region

Health Services

Nursing Procedure Committee

June 7, 2017 Keyword(s): Central Line, PICC, Power PICC

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PEDIATRIC AND ADOLESCENT CENTRAL VENOUS ACCESS

DEVICE PROTOCOL RN must obtain order stating “follow pediatric CVAD protocol”

Short term

Central

Venous Line

(CVL)*

Tunnelled

Intravascular

Catheter (TIC)

Implanted

Venous Access

Device (IVAD)

Peripherally

Inserted

Central

Catheter (PICC)

< 1 year Pre flush with

0.9% saline

5mL 5mL 10mL 5mL

< 1 year Agent used to

maintain

patency

50u/mL heparin

*Mix 0.5ml of

100u /ml

heparin +0.5

mL N/S

50u/mL heparin

*Mix 1ml of

100u/ml

heparin + 1ml

N/S

50u/mL heparin

*Mix 1.5ml of

100u/ml

heparin + 1.5

ml N/S

0.9% saline

< 1 year Final Volume 1mL 2mL 3mL 5mL

< 1 year Flushing

frequency of

unused lumens

EOD EOD Q Monthly EOD (clamped) OR Q 7 days PASV (clampless)

> 1 year – 18 years of age

Pre flush with

0.9% saline

5-10mL 5-10mL 10mL 5-10mL

> 1 year – 18 years of age

Agent used to

maintain

patency

100u/mL heparin

100u/mL heparin

100u/mL heparin

0.9% saline

> 1 year – 18 years of age

Final Volume 1mL 2mL 3mL 5mL

> 1 year – 18 years of age

Flushing

frequency of

unused lumens

EOD EOD Q Monthly EOD (clamped) OR Q 7 days PASV (clampless)

*Includes midlines, cut downs and femoral lines.

NB for all CVAD limit heparinization to no more than 3 times/24 hours If greater than 3 times/24hr required:

For single lumen run IV fluid continuously in between meds

For dual lumen divide fluid amount between lumens and run continuously

Explore with attending physician changing the strength of heparin solution. For example

50u/mL versus 100u/mL. Physicians’ order required.

Attending physicians may override this protocol if they feel the amount of heparin will not jeopardize the child’s coagulation status. Physicians order required.

CVAD’s inserted for purpose of hemodialysis are used exclusively for that purpose, therefore without the

express written consent of the nephrologist those lines may not be used. Hemodialysis lines generally

contain a much stronger heparin concentration. Heparin in the CVAD used for hemodialysis should be

withdrawn and discarded, not flushed through catheter and into patient’s cardiovascular system.

APPENDIX A

Code: P.11 Date: May 2002, reviewed July 2007, February 2008, February 2011 Author: Pediatric CDE

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APPENDIX B

IV Tubing Changes

IV Bag change Tubing Change Time

Plain IV solution (no additives) this includes pressure tubing

Every 96 hours Every 96 hours

IV solution with additives: manufacturer or pharmacy mixed

Every 96 hours Every 96 hours

IV solution with additives: nurse mixed

Every 24 hours Every 96 hours

IV solution with Lipids

Every 24 hours Every 24 hours

Propofol Every 12 hours Every 12 hours

Blood products Per orders Every 4 units or 24 hrs, whichever occurs first.

Intermittent medications

___ Every 24 hours

Code: P.11 Date: May 2002, reviewed July 2007, February 2008, February 2011, January 2012 Author: Pediatric CDE

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APPENDIX C

HOW TO MEASURE A PICC

1. Assess catheter, insertion site and affected arm prior to any catheter management or procedure. (pg 2 PICC

procedure.) 2. Measure and document length of PICC from insertion site to proximal end of suture wing or StatLock® posts.

(See picture below)

3. Measure and document upon initial insertion and then once per shift and prn for pediatrics and once a week following dressing changes and prn for adults.

4. If there are concerns that exterior length of the PICC line has changed, compare to the baseline

measurement and notify radiologist or physician.

**For pediatrics, always print off and include PICC procedure in the care plan so everyone can refer to it. Include baseline measurement in the care plan and nurse’s notes. All other measurements should be in the nurse’s notes.**

Code: P.11 Date: May 2002, reviewed July 2007, February 2008, February 2011, January 2012, August 2013 Author: Pediatric CDE

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PICC line dressing using Statlock PICC Plus securement device

and PICC line with no suture

1. Open sterile dressing set at bedside table and assemble

supplies on sterile field.

Add stat lock and transparent dressing

2. Add ChloraPrep® swab to field

3. Apply non-sterile gloves and roll the transparent dressing

back to expose the stat lock only .

keep the insertion site covered with the transparent

dressing

SEE NOTE AT END FOR DIFFERENCES IN TECHNIQUE

WHEN PICC LINE SUTURE WING IS BUTTED UP TO THE

INSERTION SITE.

4. Remove the PICC from the Stat Lock securement device.

Position the PICC to the side to enable proper cleansing

5. Remove the Stat Lock using alcohol swabs as needed.

6. Remove gloves, perform hand hygiene and don sterile

gloves.

7. Cleanse the exposed area, including the PICC line itself with

chlorhexidine swab using gentle friction and let dry 2-3

minutes.

APPENDIX D

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8. Apply skin protectant to the area where the new stat lock will

be applied

9. Attach the PICC line to the Statlock device.

secure the PICC suture wings to the statlock posts and close the doors

Arrows point towards the insertion site

10. Apply Statlock to the skin.

11. Using a sterile 2x2 from sterile field, remove the remainder of

the transparent dressing.

12. Cleanse exposed area with chlorhexidine swab.

13. Apply the new Transparent dressing

Apply dressing over insertion site including statlock, ensuring the insertion site is within in the clear window.

Avoid stretching the dressing

Smooth from the center to the edge

Mold with your hands around the statlock

14. Apply one of the tape strips supplied with transparent

dressing over the PICC lumen(s).

15. Write date on the 2nd

tape and position distal to the first tape.

16. Measure from insertion site to Statlock posts and record in

the care plan.

17. Apply mesh netting to secure the PICC lumens securely

Code: P.11 Date: August, 2013 Author: Teresa Vall, Lisa Roland, Jana Lowey, CNE’s

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Tegaderm™ Appendix E

Application Hints 1. Select a dressing size that will adequately cover the catheter and insertion site or wound. Ensure at least a one

inch margin of dressing adheres to healthy, dry skin.

2. Prepare the catheter insertion site or wound according to your institution’s approved protocol.

3. To ensure good adhesion, clip excess hair where the dressing will be placed. Do not shave the skin because of the potential for microabrasions.

4. Make sure skin is free of soaps, detergents, and lotions. Allow all preps and protectants to dry thoroughly

before applying the dressing. Wet preps and soap residues can cause irritation if trapped under the dressing. Additionally, adhesive products do not adhere well to wet or oily surfaces.

5. Do not stretch the Tegaderm™ dressing during application. Applying an adhesive product with tension can

produce mechanical trauma to the skin. Stretching can also cause adhesion failure. 6. The adhesive of Tegaderm™ dressing is pressure-sensitive. To ensure best adhesion, always apply firm

pressure to the dressing from the center out to the edges. 7. To tailor a dressing for a special application, use sterile scissors to cut the dressing into desired shapes or sizes

before removing the printed liner. For best results and ease of application, cut the pieces so that a portion of the frame remains on at least two sides.

8. For subclavian and jugular sites, apply the dressing with the patient’s head turned away and neck extended as

expected in normal movement. This helps prevent contamination of the site from respiratory secretions and stress on the dressing when the patient moves.

Removal Hints Support the skin when removing Tegaderm™ dressing. For removal from I.V. sites, also stabilize the catheter to prevent dislodgment. Use one of the following removal techniques based on your patient’s skin condition and your own personal preference:

Gently grasp one edge and slowly peel the dressing from the skin in the direction of hair growth. Try to peel the dressing back over itself, rather than pulling it up from the skin.

or Grasp one edge of the dressing and gently pull it straight out to stretch and release adhesion.

or Apply an adhesive remover suitable for use on skin to the adhesive edge while gently peeling from the skin.

*To aid in lifting a dressing edge, secure a piece of surgical tape to one corner and rub firmly. Use the tape as a tab to help you slowly peel back the dressing.

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PICC Dressing change with SecurAcath This document is intended to provide guidance for PICC dressing change with SecurAcath

NOTE: SecurAcath is intended to stay insitu the entire life of the PICC line APPENDIX F

1. Measure and record external length: From insertion site to PICC suture wings. NOTE: IF PICC LINE HAS DISPLACED 5CM OR MORE FROM ITS ORIGINAL POSITION PLEASE CONTACT INTERVENTIONAL RADIOLOGY FOR A PICC LINE CHECK.

Measurement

2. Perform hand hygiene and set up sterile field.

3. Don non-sterile gloves

4. Remove dressing

5. Perform hand hygiene and apply sterile gloves

6. Cleanse insertion site with chlorhexidine swab using a cross hatch technique

(only one swab is needed). Note: For blood or exudate on the catheter or SecurAcath, apply saline soaked gauze and cleanse with sterile saline prior to cleansing with chlorhexidine.

7. Cleanse both sides of the SecurAcath with a chlorhexidine swab.

8. To clean the underside of the SecurAcath, You can lift the SecurAcath less than 30-45 degrees, but don’t twist it.

9. Cleanse the entire area of skin that will be under the new dressing with chlorhexidine swab, using a cross hatch

technique.

10. Cleanse the entire length of PICC catheter up to including the body of the PICC,

with a chlorhexidine swab.

11. Let chlorhexidine dry (approx 2-3 minutes) and apply new dressing.

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PICC Removal with SecurAcath This document is intended to provide guidance for PICC removal with SecurAcath

NOTE: SecurAcath is intended to stay in situ until the PICC line is discontinued.

APPENDIX G

1. Clean work surface with appropriate disinfectant. Allow to dry.

2. Position the patient supine or sitting with the arm at 45 to 90 degree angle with the

insertion site below the level of the heart.

3. Set up sterile field, adding occlusive dressing.

4. Wash hands and apply clean gloves.

5. Remove dressing, remove gloves and cleanse hands.

Apply sterile gloves.

6. Cleanse insertion site with Chlorhexidine swab and let dry. If PICC has been in situ for

longer than one week, it may be helpful to apply saline soaked 2x2 gauze at insertion

site to help ease removal of SecurAcath.

7. Remove cover of securAcath by placing finger under the

device to stabilize (on side of SecurAcath that says HOLD).

Grasp tab on cover (on side that says LIFT) with other hand.

8. Lift tab to completely detach cover from anchor base.

9. Lift PICC line out of the SecurAcath® device.

10. Remove PICC line as per Nursing Procedure. Apply Pressure for at least 2 minutes or until hemostasis is achieved. Cover insertion site with occlusive dressing before removing SecurAcath®.

11. Hold edges of SecurAcath® anchor base downward.

Place a finger under back edge of device to help begin

folding motion.

12. Place one hand near the insertion site to stabalize the

tissue. Hold folded anchor base horizontal to the skin

and lift the anchor out of the insertion site.

NOTE: If skin appears to be growing over SecurAcath® legs skip folding steps And move directly to cutting the SecurAcath®.

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13. If unable to remove securAcath by folding, cutting the base

may aid removal. Use blunt tip scissors to cut the anchor base In half lengthwise along the groove.

14. Place one hand near the insertion site to stabilize the tissue. Use a swift, deliberate tug to remove each half of the anchor base separately. The flexible anchor will straighten as it is pulled out and will not cause tearing or trauma to the tissue

15. Ensure occlusive dressing is covering insertion site, secure with transparent dressing.

Dressing to remain intact for at least 24 hours or until epithelization occurs.

16. Inspect catheter for integrity and length. Note any damage or irregularities. Compare

with documented length at insertion, if required.

17. Remove gloves and perform hand hygiene.

18. Document in the patient’s health record date and time of removal, reason for removal,

condition of site and catheter (including length), patient’s tolerance of procedure and

patient teaching.

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APPENDIX H

Pediatric Dosage:

For Patients >30 kg Use adult dosing of 2mg/2mL

For Patients <30 kg >10kg Reconstitute fibrinolytic agent according to preparation guidelines. Use 110% of intralumenal volume, not exceeding 2mLs.

For Patients <10 kg The suggested dose is 0.5 mg for any type of catheter, diluted with normal saline to an appropriate volume to fill the catheter. There is no literature for this dosage; dose used at the Hospital Sick Children (Toronto) under a hematology consult. Nursing staff must draw up 0.5 mg/0.5 mL and further dilute for lumen volume.

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CathFlo Algorithm APPENDIX I

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APPENDIX J

CathFlo Reconstitution

PREPARATION OF SOLUTION Reconstitute Cathflo® to a final concentration of 1 mg/mL: 1. Aseptically withdraw 2.2 mL of Sterile Water for Injection, USP (diluent is not provided). Do not

use Bacteriostatic Water for Injection, USP, for reconstitution as it has not been studied clinically.

2. Inject 2.2 mL of Sterile Water for Injection, USP, into the Cathflo® vial, directing the diluent stream into the powder. Slight foaming is not unusual; let the vial stand undisturbed to allow large bubbles to dissipate.

3. Mix by gently swirling until the contents are completely dissolved. DO NOT SHAKE. The reconstituted preparation results in a colourless to pale yellow transparent solution containing 1 mg/mL Cathflo® at a pH of approximately 7.3.

4. Cathflo® contains no antibacterial preservatives and should be reconstituted immediately before

use. The solution may be used within 8 hours following reconstitution when stored at 2C-30C.

5. Withdraw 2.0 mL (2.0 mg) of solution from the reconstituted vial.

No other medication should be added to solutions containing Cathflo®.