Peripherally Inserted Central Catheter (PICC Line)

Feedback We appreciate and encourage feedback. If you need advice or are concerned about any aspect of care or treatment please speak to a member of staff or contact the Patient Advice and Liaison Service (PALS): Freephone (City Hospital Campus): 0800 052 1195 Freephone (QMC Campus): 0800 183 0204 From a mobile or abroad: 0115 924 9924 ext 65412 or 62301 Minicom: 0800 183 0204 E-mail: pals@nuh.nhs.uk Letter: NUH NHS Trust, c/o PALS, Freepost NEA 14614, Nottingham NG7 1BR www.nuh.nhs.uk Peripherally Inserted Central Catheter (PICC Line) Information for patients and carers Interventional Radiology Theatres If you require a full list of references for this leaflet please email patientinformation@nuh.nhs.uk or phone 0115 924 9924 ext. 67754. The Trust endeavours to ensure that the information given here is accurate and impartial. This document can be provided in different languages and formats. For more information please contact: Interventional Radiology Theatres Department City Campus Hucknall Road, Nottingham NG5 1PB Tel: 0115 969 1169 ext 59779 Zafreen Khan, Interventional Radiology Department October 2012. All rights reserved. Nottingham University Hospitals NHS Trust. Review October 2014. Ref: 1400/v1/1012/JH. Order number: NUH02165N

Aim of the leaflet This information booklet is designed for patients who are about to undergo a PICC line procedure in the interventional radiology theatres. It provides detailed information about the procedure, what to expect and aftercare advice. Please note that the best source of information about your PICC line will always be your physician. General Information What is a PICC Line? A PICC line (also known as a Peripherally Inserted Central Catheter) is a long thin flexible tube that is inserted into a large vein in the upper arm. The catheter is slid into the vein until the tip is in the upper portion of the heart and the end of the tube sits outside the body. Notes: (Macmillan, 2012) 2 27

DRESSING CHANGES DIARY Week 12 This is an example of what the PICC line would look like on a real arm: 26 What are they used for? PICC lines are commonly inserted for patients undergoing cancer chemotherapy or for those requiring long term antibiotics. They are also placed in other patients when it is proving difficult to replace peripheral IV tubes (cannulas) in the arms. Blood samples can be taken from a PICC line that is already in place as well. PICC lines are designed to last for up to a year if properly cared for. Is there anything I should do before I come to the radiology department? Continue to eat and drink normally. Keeping up your fluid intake is important as being dehydrated can make it more difficult to access the veins in your arm. Continue to take all of your medications as normal. When you attend for the procedure you should wear clothes which are loose fitting, particularly around the arms. Trying to pull a tight fitting jumper arm over the catheter after the procedure could lead to dislodgement or oozing of blood. It is helpful if ladies wear a bra without any metal parts since they can be kept on during the procedure. It is also better for ladies to wear trousers or skirt rather than a dress. 3

What will happen when I arrive in the Radiology Department? After checking in at X-ray Main Reception, you will be directed to the Interventional Radiology Theatres waiting area. A nurse will come to speak with you and check your details. You will be taken to a private area where you will be asked to remove your shirt and vest and put on a hospital gown. Ladies will have to remove a bra containing metal parts. You can keep your trousers/skirt and shoes on. A doctor or vascular access practitioner will then come to speak to you about the procedure and answer any questions. When you are satisfied that you understand the procedure and are happy to proceed, you will be asked to sign a consent form. Please inform the nurse, doctor, or vascular access practitioner if any of the following apply to you: You are pregnant. You are allergic to injections of x-ray contrast material (dye). This is the injection you may receive when having CT scans or angiograms. You have kidney failure. You are known to have a blockage of the veins of your chest. You are taking any drugs which thin your blood. Which arm is used to put the PICC line in? The PICC line is generally put into the left arm as most people write with their right hand. If you are left handed, the right side is usually more convenient. However, this is not always possible as you may not have a suitable vein in the preferred arm or your medical history may favour placement on a particular side. DRESSING CHANGES DIARY Week 11 4 25

DRESSING CHANGES DIARY Week 10 Will it hurt? The tourniquet strap around the arm is tight but not painful. It is released as soon as the vein is entered. Local anaesthetic is used to numb the area where the PICC line will be inserted. This causes some stinging on injection but then goes numb. There may be some pressure in the arm as the tube through which the PICC line passes is inserted. If any discomfort is encountered further local anaesthetic will be injected. How long does the procedure take? The procedure takes around 30-40 minutes. How are they put in? The procedure takes place in the interventional radiology theatres which is a clean area. You will be brought into the room and asked to lie on your back on the x-ray table. A tourniquet (strap) will be placed around each arm in turn and both will be examined with ultrasound. Once the most suitable vein is selected, the area will be cleaned and covered with drapes to make the area sterile. Local anaesthetic is injected into the area around the vein which may sting. A small needle is inserted into the vein and a soft flexible wire passed along the vessel back to the heart. You will usually not feel the wire passing through the vein. The x-ray camera is used to confirm correct position of the wire. A thin hollow tube is now placed over the wire to facilitate placement of the line. The PICC line is now measured to the appropriate length and inserted into the tube in your arm, again passing into the upper portion of the heart. The tube is now removed and the PICC line secured to the skin with an adherent dressing. 24 5

Are there any complications associated with PICC lines? As with any procedure, there are risks involved. The most common difficulties and complications are highlighted below and the rest will be discussed on the day during the consent process. Occasionally it is not possible to place a PICC line in one of your arms due to either a lack of suitable arm veins or blockage of the vessels centrally in the chest. In this situation, either a catheter will be placed in an alternative location or arrangements will be made for a different venous access device, possibly at another appointment. Sometimes a little blood can ooze around the insertion site of the PICC line at the end of the procedure. This is unlikely to be of significance in itself but can act as a source of infection. In this case, an absorbent dressing will be placed over the wound and arrangements will be made for an early change of dressing and cleaning of the area. This problem almost always resolves quickly. Displacement: If the line is pulled on sharply or the fixing dressing comes off then all or some of the PICC may be pulled out of the body. If displacement has been minimal it may be possible to continue with the treatment after the line has been rescued and a satisfactory position confirmed with a chest-x-ray. Otherwise, the catheter will have to be replaced for a new one. Infection Every effort is made to reduce the risk of infection by performing the procedure in a sterile environment and always handling you PICC line in an aseptic fashion afterwards. However, infection does occur. This is usually recognised as pain, tenderness, redness of the skin or discharge of fluid or pus from the insertion site. Infection may also cause fever and/or make you feel generally unwell. If DRESSING CHANGES DIARY Week 9 6 23

DRESSING CHANGES DIARY Week 8 22 the line becomes infected it is usually removed and antibiotics administered. Blood clots The body can react to the presence of the catheter in the blood vessel by forming clot on its surface. If the blood vessel becomes blocked swelling of the arm and face on the same side can occur. Very rarely, a blood clot can separate from the catheter and pass into the lung. You might suspect you were developing a blood clot in the arm if your arm or face began to swell or become tight. Swelling which can be indented with a finger to form a visible depression is particularly suspicious for a clot. Sudden onset of breathlessness could mean a clot has passed to your lung (this is, however, very rare). What will happen after the PICC line has been inserted? The PICC line is secured to your arm with an adherent dressing which connects to the catheter to keep the line secure and a round circular antimicrobial impregnated disc will be placed around the entry site to help prevent infection. The insertion site is protected by an additional adherent transparent dressing which will allow you to inspect the insertion site and this circular disc. If there has been some oozing of blood at the end of the procedure an additional gauze dressing will be present under the transparent film. Finally a bandage will be wound around the catheter. After you leave the interventional radiology theatre your nurse will: Check you have a follow-up appointment to receive your treatment. Give you written information on catheter care and how to detect any problems. Your PICC requires regular maintenance to keep it functioning properly and prevent complications. Usually the PICC requires a dressing change and injection of 7

sterile water every week, sooner if a gauze dressing has been used to absorb some bleeding. This can be carried out by yourself, the district nurse or in the clinic, depending on what is most convenient. Arrangements for this will take place before you leave the department. Answer any further questions you may have. DRESSING CHANGES DIARY Week 7 Can I Exercise with the PICC line in place? Avoid strenuous exercise or heavy lifting for the remainder of the day after insertion or until any oozing of blood around the catheter has resolved. After that you may exercise or carry out most activities as normal. However, swimming is not permitted as it leads to a higher risk of infection because it is almost impossible to prevent the line and dressing from becoming wet. Take care that the PICC is secured before exercise or it may become displaced. Sweating may lead to loosening of the dressing or moisture formation around the catheter. If this occurs the dressing will need to be changed. NO SWIMMING Can I drive after the procedure and with a PICC line in? Yes, you can drive with a PICC line in and straight after the procedure as well. 8 21

DRESSING CHANGES DIARY Week 6 Can I shower/bathe with a PICC line? Yes, you may shower and bathe with a PICC line but it is important to keep it dry. You must not immerse the line in water. There are PICC line covers available that you can buy online or from a Boots pharmacy. One which is very popular is the ACU-Life shower sleeve and is priced around 5. (Boots, 2012) 20 9

Maintaining your PICC line How do I look after my PICC line? changes and flushing of your catheter are an essential part of maintaining catheter patency and to prevent infections. The nursing staff in the areas that you will be having your treatment will take care of this. changes Your dressing will be changed every 7 days unless any of the following occur and then it must be changed immediately: Blood or moisture under the dressing. The dressing becomes loose. An air bubble forms underneath the dressing at the exit site. The dressing changes are normally carried out in the hospital at a clinic or on the ward where the nursing staff will change them. For outpatients, this can be done through making an appointment or by dropping in to the appropriate clinic, depending on what treatment you are having. The needleless injection cap (the bung at the end of your catheter) and the fixator device (stat lock) will be changed every 7 days. If the cap becomes damaged or loose then it needs to be changed immediately. Flushing the PICC line Your PICC line will be flushed by your caregiver with hepsal flushing solution every 7 days in addition to normal flushing with saline after routine drug injections or blood sampling. This is important as it helps to prevent blood clot formation in the line and reduces the chances of your line becoming blocked. NOTE: If you are a patient who will be discharged home for your DRESSING CHANGES DIARY Week 5 10 19

DRESSING CHANGES DIARY Week 4 18 treatment, you will be provided with additional instructions and teaching sessions on taking care of your PICC including dressing changes, flushing the PICC, recognising problems and changing the needleless injection cap. What do I do if my arm hurts after the procedure? It is normal to have a bit of pain and tenderness around the area where your PICC line is placed initially after the procedure. It will take a few days for your body to adjust to the line being in place. Things that you can do to help ease the pain are: Applying a cold pack to the PICC line area for 30 minutes regularly during the first 24 hours can help ease discomfort. Taking over the counter pills for pain relief such as ibuprofen or paracetamol can help to ease the pain and reduce inflammation. Please consult a pharmacist or your GP for advice if you are unsure what medication is safe for you to take. If, after a couple of days, your PICC line is still causing you lots of pain, it is best to contact the hospital and the department where you are having your treatment for advice. NOTE: Try to avoid wearing tight clothing on the arm that your PICC line is in and, if you are having your blood pressure taken, make sure it is done on the opposite side that your PICC line is in as this will cause pain in your arm. What do I do if my PICC line falls out or gets dislodged? If the catheter has come out completely then press on it with a paper towel or tissue and elevate for 5 minutes to minimise bruising. You will need to contact the clinic as it may be necessary to arrange for replacement depending on how much more treatment you need. Bring the catheter with you when you come to the clinic so we can be certain it is all out. It is most unlikely there will be any significant bleeding. If the catheter has 11

only become partially dislodged then it may be possible to rescue it. Cover the catheter with a transparent dressing and contact the hospital department where you are having your treatment. What if my PICC line gets damaged? If your PICC line gets damaged then you will need to contact your nurse or physician at the hospital. If there is blood leaking from the line then use the clamp to close it. DRESSING CHANGES DIARY Week 3 Are there any signs I should watch out for? Some of the signs to look out for are listed below: Excessive pain in the arm the PICC line is in. Fever or chills (as this could be a sign of an infection) Swelling of the hands, arm and / or neck on the same side as the PICC line (possible sign of a blood clot in the vein) If you get any of the symptoms above it is always best to contact your nurse or physician as soon as you can. However, if you get shortness of breath, coughing or chest pain please notify the emergency medical services immediately as this could be a sign that air has entered the blood stream. 12 17

DRESSING CHANGES DIARY Week 2 CATHETER INFORMATION The following form should be filled in as soon as possible with your nurse or physician. This information will be useful for your caregiver to help with the maintenance of your line. PATIENT NAME DATE OF PLACEMENT INSERTED BY CATHETER MAKE / TYPE SINGLE LUMEN DOUBLE LUMEN TRIPLE LUMEN CATHETER USE: ANTIBIOTICS CHEMOTHERAPY BLOOD SAMPLING POWER INJECTABLE VENOUS ACCESS TPN OTHER: EMERGENCY NUMBERS: CITY HOSPITAL NUMBER FOLLOWED BY THE EXTEN- SION NUMBER YOU REQUIRE: 01159691169 THEN (EXT No) INTERVENTIONAL RADIOLOGY: EXT 59779 OPAT CLINIC: EXT 54672 or EXT 54620 CHEMOTHERAPY CLINIC: EXT 57275 or 57060 16 13

GLOSSARY OF TERMS DRESSING CHANGES DIARY PHLEBITIS THROMBOSIS SALINE SALINE FLUSH HEPSAL EXIT SITE ENTRY SITE NEEDLELESS INJECTION CAP CATHETER Inflammation of the walls in a vein Clotting of blood within a vein A salt and water solution Sterile saline used to clear the catheter after routine use A flushing solution used to flush Catheters to help prevent the formation of blood clots inside the PICC line Where the PICC line comes out of the arm Where the PICC line goes into the arm This is the cap that prevents blood from backing up into the Catheter. It also allows the delivery of medication into your bloodstream A soft tube inserted into the body (in this case a PICC line inserted into a vein in the arm) Week 1 14 15