·                 Obtain and review physician’s order

·                 Obtain and review physician’s order

·                 Provide patient with educational material/information regarding the procedure

H             Provide clear information about the procedure

H             Benefits of the procedure

H             Necessity for the procedure

H             Risks of the procedure

H             Any alternatives

H             Risks associated with refusing the procedure

·                 Provide patient with educational material/information regarding the procedure

H             Provide clear information about the procedure

H             Benefits of the procedure

H             Necessity for the procedure

H             Risks of the procedure

H             Any alternatives

H             Risks associated with refusing the procedure

·                 Obtain patient’s consent

·                 Obtain patient’s consent

·                 Assess patient

H             Check for patient allergies

·                 Assess patient

H             Check for patient allergies

·                 Examine both arms with Site~RiteÃ’ Ultrasound System, and select the best vein for cannulation[i]

H             Hold the probe perpendicular to the vessel so that the front and back wall of the vessel will be seen clearly

H             Avoid veins that are sclerotic

H             Select patient’s non-dominate arm, if possible

H             Avoid extremities that may have compromised circulation, such as the presence of lymphedema or venous congestion secondary to superior vena cava syndrome

H             Access vessels above the antecubital fossa, to help eliminate antecubital tension and complications.

H             Place the Site~RiteÃ’ Ultrasound System probe in the side arm probe holder on the roll stand.

H             Apply a layer of non-sterile ultrasonic coupling gel on the acoustic window of the probe head

·                 Examine both arms with Site~RiteÃ’ Ultrasound System, and select the best vein for cannulation[ii]

H             Hold the probe perpendicular to the vessel so that the front and back wall of the vessel will be seen clearly

H             Avoid veins that are sclerotic

H             Select patient’s non-dominate arm, if possible

H             Avoid extremities that may have compromised circulation, such as the presence of lymphedema or venous congestion secondary to superior vena cava syndrome

H             Place the Site~RiteÃ’ Ultrasound System probe in the side arm probe holder on the roll stand.

·                 Place patient in comfortable position

·                 Place patient in comfortable position

·                 Wash hands

·                 Wash hands

·                 Assemble equipment

·                 Assemble equipment

·                 Apply a tourniquet above the anticipated insertion site

·                 Apply a tourniquet above the anticipated insertion site

·                 Select a vein based on ultrasound   assessment.  

·                 Position the arm at a 90 degree angle

·                 Position the arm at a 90 degree angle

·                 For SVC placement, measure from the planned insertion site over to the right sternal notch, then down to the third intercostal space (use this method for both right and left sided placements)

·                 Position the patient with the arm to be accessed extended at 90 degrees from the trunk of the body.

Note:   Place patient in comfortable position.

·                 Position the patient with the arm to be accessed extended at 90 degrees from the trunk of the body.

Note:   Place patient in comfortable position.

·                 Wash hands with an antimicrobial agent

·                 Wash hands with an antimicrobial agent

·                 Set up a convenient work area and open the kit following sterile procedure.

·                 Set up a convenient work area and open the kit following sterile procedure.

·                 Remove the absorbent underdrape from the kit and place it under the patient’s arm and shoulder area.

·                 Remove the absorbent underdrape from the kit and place it under the patient’s arm and shoulder area.

·                 Place the tourniquet under the area high on the upper arm close to the axilla or between the axilla and the acromion process of the humerus.   Determine the appropriate vessel and cannulation site.

·                 Place the tourniquet under the area high on the upper arm close to the axilla or between the axilla and the acromion process of the humerus.   Determine the appropriate vessel and cannulation site.

·                 Open any additional supplies and drop them onto the sterile field. (Site Rite probe cover and/or needle guides)

·                 Open any additional supplies and drop them onto the sterile field. (Site Rite probe cover and/or needle guides)

·                 Place a mask on the patient, if indicated by policy.

·                 Place a mask on the patient, if indicated by policy.

·                 Minimize the risk of occupational exposure to bloodborne pathogens and utilize maximum sterile barrier precautions by donning hair cover, goggles/face shield, mask and sterile gown.

·                 Minimize the risk of occupational exposure to bloodborne pathogens and utilize maximum sterile barrier precautions by donning hair cover, goggles/face shield, mask and sterile gown.

·                 Don the first pair of sterile gloves

Note:   powderfree gloves are recommended.

·                 Don the first pair of sterile gloves

Note:   powderfree gloves are recommended.

·                 Set up all supplies on the sterile field

·                 Set up all supplies on the sterile field

·                 Open glass vials (multidose vials), using a gauze to cover the area to be broken open.   Use filter needles, as appropriate, to draw up the NS and lidocaine (if it is to be used).   Prepare at least three 10ml syringes filled with NS.   Attach a tuberculin needle to the syringe containing the local anesthetic.

·                 Open glass vials (multidose vials), using a gauze to cover the area to be broken open.   Use filter needles, as appropriate, to draw up the NS and lidocaine (if it is to be used).   Prepare at least three 10ml syringes filled with NS.   Attach a tuberculin needle to the syringe containing the local anesthetic.

·                 Remove the catheter from the tray and examine it along the entire length.   Be sure the internal stylet is straight (any bends or kinks make stylet removal difficult once the catheter is inserted into the vein).

·                 Remove the catheter from the tray and examine it along the entire length.   Be sure the internal stylet is straight (any bends or kinks make stylet removal difficult once the catheter is inserted into the vein).

·                 Prepare the catheter by priming it with normal saline and checking it for patency.   Position the sterile measuring tape alongside the catheter.

H             Single/Dual Lumen GroshongÃ’ Catheters:  

H             Measure the distance (written down during pre-measurement) from the tip of the catheter and note the marking point where it will exit the body.

H             Never cut the tip of a Groshong catheter.

H             The marking will be the point to where the catheter will be advanced.

H             A Groshong single lumen catheter is cut when insertion is completed, prior to attaching the connector.

Per-Q-CathÃ’ Plus and Poly Per-Q-CathÃ’ Catheter Trimming Instructions:

H             Measure the distance from the exit site end of the catheter to where the tip will lie in the vessel.   Note this marking, then allow for the distance of the catheter segment that will extend out of the arm.

H             Retract the internal stylet, proximal to the place where the catheter will be cut at the tip.

H             Cut the tip with sterile scissors, straight across, not at an angle, so the tip will be positioned freely within the lumen of the vessel and not lay flush against the side of the vein.

H             Once the catheter tip is cut, advance the guidewire to within 1/8 to ¼   inch of the tip, covering it completely with the catheter.

H             Bend the guidewire at a 90-degree angle at the external tip of the catheter hub so it cannot advance beyond the catheter tip.

·                 Prepare the catheter by priming it with normal saline and checking it for patency.   Position the sterile measuring tape alongside the catheter.

·                 Prime the catheter connector.

·                 Prime the catheter connector.

PICC

·                 Prep the insertion site using three 70% alcohol and three povidone-iodine swabsticks.  

·                 Prep the insertion site using three 70% alcohol and three povidone-iodine swabsticks.  

·                 Prep the area (diameter of the arm), scrubbing from the intended cannula insertion site outward in a concentric circle.   Do not back track over an already cleansed area.

·                 Prep the area (diameter of the arm), scrubbing from the intended cannula insertion site outward in a concentric circle.   Do not back track over an already cleansed area.

·                 Use the alcohol swabs first.   The alcohol scrub should last for two minutes and must be completely dry before the povidone-iodine is applied.

·                 Use the alcohol swabs first.   The alcohol scrub should last for two minutes and must be completely dry before the povidone-iodine is applied.

·                 Apply the povidone-iodine, scrubbing for two minutes.   Allow it to dry completely.

·                 Apply the povidone-iodine, scrubbing for two minutes.   Allow it to dry completely.

·                 Remove the prep gloves.

·                 Remove the prep gloves.

·                 Apply tourniquet

·                 Apply tourniquet

PICC

·                 Don second pair of sterile gloves.

·                 Don second pair of sterile gloves.

PICC

·                 Palpate and locate the distended vessel.

·                 Palpate and locate the distended vessel.

·                 Anesthetize the venipuncture site.

H             Check for patient allergy

H             Insert the needle at a 15-to 25-degree angle, inject the lidocaine intradermally into the side of the vein next to the desired insertion site.   Do not nick vein.

H             Withdraw the needle—allow 5 to 10 seconds for anesthetic to take effect.

·                 Anesthetize the venipuncture site.

H             Check for patient allergy

H             Insert the needle at a 15-to 25-degree angle, inject the lidocaine intradermally into the side of the vein next to the desired insertion site.   Do not nick vein.

H             Withdraw the needle—allow 5 to 10 seconds for anesthetic to take effect.

PICC

·                 Release the tourniquet through the sterile drape without compromising the sterile field.

·                 Release the tourniquet through the sterile drape without compromising the sterile field.

·                 Observe the pattern of blood flow from the vessel.   It is very important to observe the pattern of blood flow from the vessel to ascertain that a vein, not an artery, has been cannulated.   The color of the blood is not always a reliable indicator.   The pulsating flow of blood is the true indicator or arterial access, even in patients with low blood pressure.

·                 Observe the pattern of blood flow from the vessel.   It is very important to observe the pattern of blood flow from the vessel to ascertain that a vein, not an artery, has been cannulated.   The color of the blood is not always a reliable indicator.   The pulsating flow of blood is the true indicator or arterial access, even in patients with low blood pressure.

PICC

·                 Insert the flexible end of the guidewire into the introducer.   Advance the guidewire 5 to 10 cm into the vein.

Caution:   If the guidewire must be withdrawn while the needle is inserted, remove both the needle and the guidewire as a unit to prevent the needle from damaging or shearing the guidewire.

·                 Insert the flexible end of the guidewire into the introducer.   Advance the guidewire 5 to 10 cm into the vein.

Caution:   If the guidewire must be withdrawn while the needle is inserted, remove both the needle and the guidewire as a unit to prevent the needle from damaging or shearing the guidewire.

·                 If necessary, a small skin nick may be made adjacent to the guidewire to facilitate insertion of the sheath and dilator.

·                 If necessary, a small skin nick may be made adjacent to the guidewire to facilitate insertion of the sheath and dilator.

·                 Advance the small sheath and dilator together as a unit over the guidewire using a slight rotational motion.

·                 Advance the small sheath and dilator together as a unit over the guidewire using a slight rotational motion.

·                 Withdraw the dilator and guidewire, leaving the small sheath in place.

·                 Withdraw the dilator and guidewire, leaving the small sheath in place.

·                 Place a finger over the orifice of the sheath to minimize blood loss and risk of air embolism.   The risk of air embolism is reduced by performing this part of the procedure with the patient performing the valsalva maneuver.

·                 Place a finger over the orifice of the sheath to minimize blood loss and risk of air embolism.   The risk of air embolism is reduced by performing this part of the procedure with the patient performing the valsalva maneuver.

·                 Thread the PICC into the vein through the dilator to the depth determined by previous measurements, advancing the catheter slowly.

·                 Note:   Rapid entry may cause venospasam.

·                 Thread the PICC into the vein through the dilator to the depth determined by previous measurements, advancing the catheter slowly.

·                 Note:   Rapid entry may cause venospasam.

PICC

·                 Continue to advance the catheter, for central placement, when the tip has advanced to the shoulder, have the patient turn head (chin on shoulder) toward the insertion site to prevent possible cannulation into the jugular vein.

·                 Continue to advance the catheter, for peripheral placement.

·                 Complete catheter advancement to the desired location.

·                 Complete catheter advancement to the desired location.

·                 Stabilize the catheter position by apply pressure to the vein distal to the introducer sheath.

·                 Stabilize the catheter position by apply pressure to the vein distal to the introducer sheath.

·                 Withdraw the introducer sheath from the vein and away from the site.   For peel-apart cannulas, split the introducer sheath and peel it away from the catheter.   Slide the intact cannula off the end of the PICC.

·                 Withdraw the introducer sheath from the vein and away from the site.   For peel-apart cannulas, split the introducer sheath and peel it away from the catheter.   Slide the intact cannula off the end of the PICC.

·                 Groshong only:   Remove the suture wing from the delivery card.   Squeeze the suture wing together so that it splits open.   Place the suture wing around the catheter near the venipuncture site.   IF the “Y” adapter of the dual lumen catheter is at the insertion site, the suture wing will not be needed.

Caution:   To minimize the risk of catheter breakage and embolization the suture wing and “Y” adapter must be secured in place.

·                 Groshong only:   Remove the suture wing from the delivery card.   Squeeze the suture wing together so that it splits open.   Place the suture wing around the catheter near the venipuncture site.   IF the “Y” adapter of the dual lumen catheter is at the insertion site, the suture wing will not be needed.

Caution:   To minimize the risk of catheter breakage and embolization the suture wing and “Y” adapter must be secured in place.

PICC

·                 Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.

Caution:   Never use force to remove the stylet.   Resistance can damage the catheter.   If resistance or bunching of the catheter is observed,   stop stylet withdrawal and allow the catheter to return to normal shape. Withdraw both the catheter and stylet together approximately 2cm and re-attempt stylet removal.   Repeat this procedure until the stylet is easily removed.

·                 Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.

Caution:   Never use force to remove the stylet.   Resistance can damage the catheter.   If resistance or bunching of the catheter is observed,   stop stylet withdrawal and allow the catheter to return to normal shape. Withdraw both the catheter and stylet together approximately 2cm and re-attempt stylet removal.   Repeat this procedure until the stylet is easily removed.

Single Lumen GroshongÃ’ PICC

Single Lumen GroshongÃ’ PICC

·                 Using sterile scissors, carefully cut the catheter leaving at least 4-7 cm of the catheter for connector attachment.   Inspect cut surface to ensure there is no loose material.

·                 Using sterile scissors, carefully cut the catheter leaving at least 4-7 cm of the catheter for connector attachment.   Inspect cut surface to ensure there is no loose material.

·                 Retrieve the oversleeve portion of the connector.   Advance it over the end of the catheter.   If you feel some resistance while advancing the oversleeve, gently twist back and forth or spin to ease, its passage over the catheter.

·                 Retrieve the oversleeve portion of the connector.   Advance it over the end of the catheter.   If you feel some resistance while advancing the oversleeve, gently twist back and forth or spin to ease, its passage over the catheter.

·                 Gently advance the catheter onto the connector blunt until it butts up against the colored plastic body.     The catheter should lie flat on the blunt without any kinks.

·                 Gently advance the catheter onto the connector blunt until it butts up against the colored plastic body.     The catheter should lie flat on the blunt without any kinks.

·                 Advance completely until the connector barbs are fully attached.   A tactile, locking sensation will confirm that the two pieces are properly engaged.   (there may be a small gap between the oversleeve and the winged portion of the connector)

·                 Advance completely until the connector barbs are fully attached.   A tactile, locking sensation will confirm that the two pieces are properly engaged.   (there may be a small gap between the oversleeve and the winged portion of the connector)

All PICCS

All PICCS

·                 Using the 10ml syringe of normal saline, aspirate for adequate blood return (each lumen).

·                 Using the 10ml syringe of normal saline, aspirate for adequate blood return (each lumen).

·                 Flush each lumen of the catheter with 10ml normal saline to ensure patency.   Flush vigorously using the push-pause method.    To reduce for blood backflow into the catheter tip, always remove needles or needleless caps slowly while injecting the last .5ml of normal saline.

Note:   When infusing volume is a concern in small and pediatric patients, flush with 3cc normal saline per lumen.  

Note:   Groshong single lumen catheter:   If the catheter will not aspirate and infuse immediately after insertion and connector assembly, the catheter may be kinked within the connector assembly.   If this is the case, trim the catheter just distal to the connector oversleeve (blue) and attach a new connector.   If this situation persists, verify radiographically that the catheter is not kinked inside the vessel.

·                 Flush each lumen of the catheter with 10ml normal saline to ensure patency.   Flush vigorously using the push-pause method.     To reduce for blood backflow into the catheter tip, always remove needles or needleless caps slowly while injecting the last .5ml of normal saline.

Note:   When infusing volume is a concern in small and pediatric patients, flush with 3cc normal saline per lumen.  

Note:   Groshong single lumen catheter:   If the catheter will not aspirate and infuse immediately after insertion and connector assembly, the catheter may be kinked within the connector assembly.   If this is the case, trim the catheter just distal to the connector oversleeve (blue) and attach a new connector.   If this situation persists, verify radiographically that the catheter is not kinked inside the vessel.

·                 Apply injection cap.

·                 Apply injection cap.

·                 Heparinize (Per-Q-CathÃ’Plus and Poly Per-Q-CathÃ’ catheters only).

·                 Heparinize (Per-Q-CathÃ’ Plus and Poly Per-Q-CathÃ’ catheters only).

·                 As previously noted, the suture wing has been placed near the venipuncture.   Place two anchor tapes over suture wing or bifurcation.     Form “S” curve in the catheter.

·                 Form “S” curve with the PICC or midline

·                 Place a folded two by two gauze over the insertion site.   (during first 24 hours after placement)[vi]

·                 Place a folded two by two gauze over the insertion site.   (during first 24 hours after placement)

·                 Place a third anchor tape, sticky side up, under catheter just above the suture wing or bifurcation.

·                 Place first anchor tape over wings or bifurcation

·                 Chevron third anchor tape on top of first two anchor tapes.

·                 Cover site and first anchor tape with transparent dressing, up to hub, but not over hub.

·                 Place transparent dressing over suture wing or bifurcation and catheter hub.

·                 Place second anchor tape, sticky side up, under hub and close to transparent dressing.   Wedge tape between hub and wings.   Anchor only one hub of dual lumen catheter.

·                 Chevron second anchor tape on top of transparent dressing and place third anchor tape over hub.

·                 Intermittent warm moist packs may be applied to the upper arm to prevent the occurrence of phlebitis.

·                 Intermittent warm moist packs may be applied to the upper arm to prevent the occurrence of phlebitis.

Midlines

·                 Verify radiographically prior to use.   Tip must be located in the superior vena cava.

·                 The following technique has been found extremely effective in visualizing the PICC line when verifying placement:

H             Adult:   A 14 x 14 shoulder view is used with a Bucky tray and grid.   A MR-400 screen is used and the KV is increased by 5-10KV over the normal shoulder technique.   Visualization is further enhanced by the use of a 10-15 degree oblique angle rather than the anterior-posterior view.  

H             Pediatric and Neonate:   A rib visualization technique is used with a medium to fast screen (a fast screen will give less patient exposure but also less detail)   A KodakÃ’ O.G. PMG high-contrast, or TMG film is used.   A KV of 50-60 and a setting of 1.0 to 1.5 with a distance of 36-40 inches (the distance may need to be reduced to 30 inches due to the use of overhead warmers).

H             The use of contrast medium may expose the patient to the risk of an adverse reaction to the contrast medium.   The use of a water soluble radiographic contrast medium containing iohexol may be indicated.   This type of contrast solution has shown a lower incidence of adverse reaction when compared to iodized contrast media

H             If it is necessary to use contrast fluid to verify catheter placement, care must be used to prevent subjecting the catheter to extreme pressures.   The use of techniques requiring high pressures may weaken the catheter wall and cause the catheter to rupture.   Also, note the small fluid volumes required to fill the catheter.

·                 Radiographic position confirmation is recommended when:

H             Difficult catheter advancement

H             Pain of discomfort after catheter advancement

H             Inability to obtain free flowing blood return

H             Catheter does not flush easily

H             Guidewire is difficult to remove or is bent after removal

·                 Document in medical record (refer to legal chapter for documentation details)

·                 Document in medical record (refer to legal chapter for documentation details)

Skill

1.

Educate patient on the purpose of the ultrasound.

2.

Wash hands

3.

Position the patient’s arm.   To access above the antecubital fossa, the patient’s arm should be at a 90-degree angle from the body with the palm facing up.

4.

Apply tourniquet if indicated.

Skill