IV Access Team - Aintree University Hospital

PICC Troubleshooting Valid from: Jul 15 to Jul 18

Uncontrolled copy when printed Current version held on intranet

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( Subject: Peripherally Inserted Central Catheter (PICC) / Midline Insertion and

Troubleshooting Guidelines Objective: To enable appropriate staff to manage complications with PICCs &

Midline Catheters Target Level: Trust-wide Guideline Prepared by: Emily Smith, Vascular Access Lead Nurse and Shirley Smith IV

Access Specialist Nurse. Lead author: *Redacted* Smith Contact: *Redacted* Bleep: *Redacted*

Evidence Base: Rank: B Associated Documents: CVC SOP, CVAD Guidelines, ANTT Guidelines, Guidelines for

Flushing Intravenous Lines, Management of central venous catheter obstruction and thrombosis, Medicines Policy.

Information Classification Label: Unclassified Date of Issue: July 2018 Review Date: July 2021

REVIEW HISTORY

Issue No. Page Changes

Date

2 3 9/13 16 17 18-22 27

Update on referral criteria Update on PICC/Midline insertion Troubleshooting guidelines Guidance on Persistent withdrawal occlusion Update on occlusion/partial occlusion algorithms Out of Hours Advice

July 2018

Staff groups applicable to: IV Team Nurses, Advanced Nurse Practitioners, ICU

outreach team, hospital at night team

IV Access Team

Issue number: 2nd Edition



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Contents

Section Section Heading Page No

1 Referral Criteria 3

2 Who should read this document 3

3 Key points 3

4 Roles and Responsibilities 4

5 Key practice points for PICC / Midline insertion 5

6 PICC insertion procedure 9

7 Midline insertion procedure 13

8 Troubleshooting guidelines- infection/thrombosis/removal/fracture

16

9 PICC – Persistant Withdrawal Occlusion (PWO) 17

10 PICC – Partial Occlusion algorithm 18

11 PICC – Total occlusion algorithm 19

12 Midline – Partial occlusion algorithm 20

13 Midline – Total occlusion algorithm – 21

14 Protocol for 3-way tap & Urokinase 22

15 Securacath Instillation 23

16 Securacath removal 25

16 Out of Hours Advice 27

17 Competency Requirements 28

18 References 29



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Refer patients through Sigma to IV Access for assessment by the IV Team for insertion of a vascular access device. Refer patients who meet any of the following criteria;

- Require more than 1 week of IV therapy - Require IV therapy through a central vein - Have poor peripheral venous availability (no visible or palpable veins suitable for

cannulation), or have undergone 3 or more failed attempts of cannulation by an experienced practitioner

Refer to the UK Vessel Health and Preservation Tool for further guidance.

Refer patients who have been admitted with a long term vascular access device to the IV Team for review and monitoring

Who should read this document?

Specialist practitioners with responsibility for insertion and management of a Peripherally Inserted Central Catheter (PICC) & Midline

Clinicians managing partially or fully occluded PICC / Midline

Clinicians who remove securAcath securement devices

Key Points

A PICC is a Central venous device inserted peripherally, into one of the upper limb

veins. With the tip sitting in the lower third of the superior vena cava or junction of

the right atrium

A midline is a peripheral intravenous catheter inserted into an upper limb vein with

the tip situated in the axillary vein. These catheters provide IV access usually for up

to 4 weeks (or as per manufacturers guidance)

PICCs / Midlines are usually inserted by a specialist nurse from the Aintree

Intravenous Team.

PICCs can be single, double, or triple lumen.

Midlines are single lumen.

Strategies within this policy can be used by members of the Aintree IV team (or staff

members deemed competent by the IV Team) to manage midline / PICC

troubleshooting i.e. occlusions.

Referral Criteria



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ROLES & RESPONSIBILITIES

All clinicians / practitioners that insert PICCs / Midlines will:

Inform the IV Steering Group about any issues or concerns relating to this policy.

Complete DATIX form in the event of a near miss or actual event, which could

cause or has caused injury to the patient or practitioner.

Promote good practice and challenge poor compliance.

The practitioner will have the knowledge and skills required to insert PICCs /

Midlines, will be able to demonstrate this by way of recognised training

mechanisms. These mechanisms will differ according to the practitioner’s specific

training and experience but for many doctors in training, will include satisfactory

completion of Direct Observation of a Procedural Skill (DOPS). Acquisition of core

knowledge and skills for CVC insertion may need to be supplemented with

additional training for specific circumstances such as the use of ultrasound.

Only personnel suitably trained and assessed by the Intravenous Nurse Specialists

within the trust can place PICCs and Midlines using Ultrasound guidance.

Practitioners will complete consent training in line with Aintree’s Policy.

The use of an ultrasound Locating Devices is required, this is to improve outcomes

when inserting Central Venous Catheters (Stokowski 2009, Simcock 2008, Krstenic

et al 2008).

Ultrasound guided PICC/Midline insertion;

- Increases the success rate of first attempt placement by locating the precise location of the vein (Parkinson et al 1998)

- Decreases the incidence of complications such as mechanical phlebitis and

thrombosis (Simcock 2008) - Reduction in the trauma for the patient caused by failed attempts

- Provides assessment of the integrity of the vein – assess vessel size and

detects thrombosis within the vessel - Reduced complications associated with insertion

- Avoids the needs to place PICC/Midlines in the Antecubital Fossa



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The practitioner, if non-medically qualified, can administer 1% lidocaine if named on

the ‘Patient Group Direction’ within its dosage guidelines during the insertion of a

PICC or Midline’.

The practitioner, if non-medically qualified referrer can request chest x-rays

provided the referrer complies with ‘The Ionising Radiation (Medical Exposure)

Regulations’ and is named on the Patient Imaging Direction ‘Plain Film Radiography

of the Chest after insertion of Peripherally Inserted Central Catheters (PICC) and

Ultrasound guided PICC placement requests by Specialist Nurses’

Key practice points for PICC / Midline insertion

Vessel identification and selection Identification

A vein is a non-pulsatile vessel and easily compresses with the ultrasound probe; ie the vein will collapse easily when pressure is applied by the probe.

An artery is a pulsatile structure that is difficult to compress with the ultrasound probe

Once the vessel has been accessed, the practitioner must observe the flow of blood from the needle to ascertain if the vessel is a vein or an artery. Blood flow from an artery will pulsate, be excessive and may be bright red in colour. Vein Selection The veins of choice for the placement of a PICC when using ultrasound guidance are the basilic and the brachial veins in the upper arm. The cephalic vein should only be used if the fore mentioned veins are unsuitable providing the cephalic vein is above 0.5mm in diameter. PICCs should not be placed in a small cephalic vein. Care must be taken when cannulating the brachial vein due to its proximity to the brachial artery and the median nerve. Patient preparation and consent An explanation of the following must be provided prior to obtaining informed consent:

reason for PICC / Midline and available alternatives

explanation of procedure

time frame of the procedure



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after care

potential complications and associated symptoms

contact numbers for patient concerns and reporting complications.

pre-assessment questions A PICC Passport should be provided for the patient in addition to verbal explanation All patients must verbally consent for Midline/PICC insertion. For PICC insertion, a written consent form must also be completed. If a patient lacks capacity to consent a consent form 4 should be completed in their best interests. (refer to trust Consent to Examination or Treatment Policy) Patients on warfarin should have an INR of below 3.0 prior to placement. Haematology patients need to have platelets of >20. If Patient parameters fall below these criteria, discuss plan with patient’s medical team. Infection control A dedicated procedure room should always be adopted (unless patient is acutely unwell) All lines must be placed using strict maximal barrier precautions following epic3 guidelines (Pratt et al 2014) This includes:

Cleansing the site with chlorhexidine 2% in 70% alcohol using a friction scrub with a single use applicator for 3mls for at least 30 seconds in an area of approximately 6cm squared around the proposed exit site and allowed to dry for at least 30 seconds.

In the event of chlorhexidine allergy, use 70% alcoholic povidone iodine for skin cleansing.

Full body draping

Thorough hand-washing using a surgical scrub technique and drying with sterile towels

Wearing hat, mask and eye protection

The use of sterile equipment placed onto a sterile field Observe for any pooling of the chlorhexidine. Spread out any pooling of the drug to avoid ignition where electrical equipment is used. If any electrical equipment is used during placement or PICC cleansing, the chlorhexidine must be allowed to dry for 3 minutes. Lidocaine Injection

Lldocaine 1% is a local anaesthetic solution that is used prior to placement. The maximum dose of lidocaine, alone as a single agent is 3mg per kg, i.e. 21mls of 1% solution for an adult of 70kgs. This dose must not be exceeded.



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The administration of lidocaine must be preceded by a withdrawal technique to verify that a vessel had not been inadvertently punctured. Adverse symptoms relating to the use of lidocaine may be delayed post administration, therefore each patient must be observed for 20 minutes post injection. The lidocaine will be prescribed prior to the procedure or issued as part of a Patient Group Directive (appendix 1). Administration: Lidocaine anaesthetic injection can be given prior to inserting the needle.

Place the orange needle into the subcutaneous tissue and withdraw on the plunger to verify that the needle is not in a vein

First raise a fine shallow bleb and inject slowly into the subcutaneous space. If lidocaine anaesthetic is given prior to needle insertion, another injection will be required in order to anaesthetise deeper within the subcutaneous tissue using ultrasound guidance to identify the location of the needle tip in relation to the vein. Care must be taken not to inject the lidocaine too close to the surface of the vein as this will cause the vein to collapse.

Leave the lidocaine to become effective.

Test the effectiveness with the tip of the needle prior to needle insertion. When preparing the equipment on the sterile field, the lidocaine injection must be drawn into a smaller syringe than the saline in order to clearly distinguish between the two. Ideally syringes should be labelled.

Venepuncture When inserting the needle into the vein, the probe can be held perpendicular (across) or longitudinal (along) the vein. The needle should be placed slowly into the skin. When the needle approaches the vessel target, the anterior wall will indent. A swift insertion into the vein at this time will prevent excessive collapse of the vein wall. Once venepuncture has taken place, the vessel returns to normal shape. Always observe for a blood return from the needle or cannula.

Inadvertent arterial puncture The inadvertent puncture of an artery can be avoided by:

Recognising the position and location of all main and aberrant arteries.

If the vein accessed is close to an artery, visualize and identify brachial artery with ultrasound.

During insertion, if the artery is punctured (pulsatile and excessive flow). Remove needle immediately and apply pressure.

Please note: If line has been placed and brachial vein used and excessive bleeding is noted, blood gas analysis or doppler ultrasound should be considered.



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In the event of inadvertent introducer or line placement in an artery, leave device in place, secure device and seek advice from Interventional Radiology.

Inadvertent nerve damage The inadvertent damage of a nerve can be avoided by:

Possessing the knowledge of anatomic location of the nerve.

If brachial vein to be accessed for PICC insertion, visualize and identify median nerve with ultrasound.

During insertion, if the patient reports sudden “electric shock” like pain shooting down the arm. Has involuntary and rapid movement of the arm, when nerve is touched. Remove the needle immediately.



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PICC insertion procedure – guidance notes for practitioners The PICC placement procedure is a two person procedure to ensure compliance to VAD insertion document

1. Collect the equipment required: Portable Ultrasound machine Ultrasound conduction gel Disposable tourniquet CVC pack PICC kit Sterile gloves x 2 Filter needle x 1 SecurAcath Saline adaptor (If using ECG guidance) ChloraPrep 3ml x 3 Biopatch Semipermeable IV transparent dressing Sterile 0.9% Nacl for injection Lidocaine 1% 5mls 2. Non-sterile vessel assessment with ultrasound.

Instruct the patient on the purpose of the ultrasound procedure.

Position the patient with the arm supported.

Ensure that the Ultrasound machine is in a suitable location for optimum visualisation by the placer.

Scan the patient with a non-sterile technique to determine the location, depth and patency of the vein and arteries

Identify insertion site. 3. Preparation Prepare the sterile field:

a) Put on hat, mask and eye protection b) Wash hands and arms using a surgical scrub technique c) Ensure assistant, after appropriate hand hygiene, has opened outer PICC pack d) Dry hands with sterile towels within the pack e) Put on sterile gown & sterile gloves f) Prepare the PICC insertion trolley. Your assistant should open remaining sterile

items onto the trolley in a manner that maintains strict asepsis. g) Draw up lidocaine injection and place an orange needle onto the filled syringe –

only a 5ml syringe and a 10ml syringe are permitted onto the sterile field in order to clearly distinguish between the lidocaine and the saline.

h) Draw up sterile 0.9% sodium Chloride for injection in 20ml syringe.



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Prep the patient:

a) Clean the skin around the chosen area for PICC insertion using Chloraprep 2% using a friction scrub technique for at least 30 seconds, allowing to air dry for at least 30 seconds.

b) Place sterile full body drape underneath the arm and across the body. c) Repeat step a). d) Change sterile gloves. e) Drape the insertion area with fenestrated sterile drape.

Drape the probe for sterile use:

a) Allow the assistant to place the probe in the side arm holder on the stand. b) Apply a layer sterile ultrasonic gel on the acoustic window of the probe. c) Place the sheath over the probe head, being careful not to wipe off the gel d) Cover the probe and cable with the sheath without contamination. e) Smooth the sheath over the acoustic window of the probe head and remove any air

bubbles f) Use a sterile elastic band to hold the sheath in place. g) Place the probe safely onto the sterile drapes. h) Ask assistant to apply tourniquet.

4. Insertion of the PICC

Apply sterile gel onto the skin at the intended site of cannulation

Locate the site of a suitable vein for venepuncture using the ultrasound machine

Administer intradermal lidocaine at the proposed venepuncture site using the guide described above in key points.

Place the probe on the skin at the intended access site and hold the probe perpendicular to the vein.

If the vein is superficial, a longitudinal method can be used to place the needle into the vein

When the vein is successfully accessed blood return will be observed in the needle. (release tourniquet). If cannulation is unsuccessful after 2 attempts, consider seeking assistance from another equally competent practitioner.

Introduce the guidewire into the needle

The guidewire should never be forced.

Take extreme care not to lose the wire into the bloodstream, allow at least 15cm of wire outside the sheath and dilator.

The wire should never be removed through the needle, due to the risk of severing the wire on the tip of the needle.

Remove the needle over the guide wire.

To determine the length to be inserted: Measure from the puncture site to shoulder. Measure from the shoulder point to the sternal notch.



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Measure down from sternal notch to third intercostal space. Add 4cm for a left sided placement. Be mindful of depth from puncture site to vein and 3cm length required for securAcath.

Trim PICC to appropriate length for insertion, flush and check integrity of device.

Thread the introducer over the guide wire, through the subcutaneous tissues and into the vein

If the introducer is damaged prior or during placement – replace.

Remove the guidewire and inner portion of the introducer, hold thumb over the end of the introducer to prevent blood loss and reduce the risk of air embolus.

Thread the PICC through introducer so the tip of line is approximately located in the axillary vein. (Connect saline adaptor if using ECG technology).

Ask patient to turn their head towards the arm of insertion, place their chin on their clavicle if possible to aid correct advancement of catheter towards the SVC and minimise the risk of advancement into the internal jugular vein.

Optional: Place the probe transverse onto the jugular vein in order to locate malposition into the jugular vein.

Slowly advance the PICC to the desired length.

Aspirate blood from the lumen to confirm intravascular placement and flush with 10mls of sterile sodium chloride 0.9% for injection. Identify initial ECG trace to indicate correct placement.

Peel away the introducer and advance the PICC the remaining desired length if required.

Confirm correct PICC tip positon using ECG technology as per manufacturer’s guidance. If ECG placement is contraindicated place PICC to measurement.

Once the PICC is in position aspirated and flush lumen with 0.9% sodium chloride for injection to ensure.

Remove the stiffening wire and attach needle free connector to all lumens.

Insert Securacath to secure PICC (recommended method of fixation). If patient has a nickel allergy, use skin fixation dressing. Check patency of al lumens post securacath insertion.

Clean the skin around the PICC using Chloraprep 2% using a friction scrub technique for at least 30 seconds, allowing to air dry for at least 30 seconds.

The PICC exit site should be dressed with Biopatch, Steristrips (optional) and a transparent semi permeable IV dressing.

Apply medical grade wound adhesive or gauze to exit site for exit site bleeding. Confirming satisfactory placement of the CVAD

Confirm placement using ECG PICC tip placement technology (Specialist training is required for the use of this equipment) Or

Confirm placement using radiological confirmation of tip position prior to use and document. Optimal tip position will be located in the lower third of the superior vena cava/junction of the right atrium.



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Midline Insertion Procedure – Guidance Notes for Practitioners The Midline placement procedure is a two person procedure to ensure compliance with VAD insertion document.



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1. Collect the equipment required: Portable Ultrasound machine Ultrasound conduction gel Disposable tourniquet CVC Pack Midline kit Sterile gloves x 2 Filter needle x 1 ChloraPrep x3 Biopatch Semipermeable IV Transparent Dressing Sterile 0.9% Nacl for injection Lidocaine 1% 5mls 2. Non-sterile vessel assessment with ultrasound.

Instruct the patient on the purpose of the ultrasound procedure.

Position the patient with the arm supported.

Ensure that the Ultrasound machine is in a suitable location for optimum visualisation by the placer.

Scan the patient with a non-sterile technique to determine the size, location, depth and patency of the veins and location of nerves and arteries.

Identify insertion site.

Choose appropriate size and length of Midline 3. Preparation Prepare the sterile field:

Put on hat and mask.

Wash hands and arms using a surgical scrub technique.

Ensure assistant, after appropriate hand hygiene, has opened outer CVC pack

Dry hands with sterile towels within the pack

Put on sterile gown & sterile gloves

Prepare the Midline insertion trolley. Your assistant should open remaining sterile items onto the trolley in a manner that maintains strict asepsis.

Draw up lidocaine injection and place an orange needle onto the filled syringe – only a 5ml syringe and a 10ml syringe are permitted onto the sterile field in order to clearly distinguish between the lidocaine and the saline.

Draw up sterile 0.9% sodium chloride for injection in 20ml syringe. Prep the patient:

Cleanse the skin thoroughly using Chloraprep 2% using a friction scrub technique for at least 30 seconds, allowing to air dry for at least 30 seconds.

Place sterile full body drape underneath the arm and across the body.



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Cleanse the skin thoroughly using Chloraprep 2% using a friction scrub technique for at least 30 seconds, allowing to air dry for at least 30 seconds.

Change sterile gloves.

Drape the insertion site with fenestrated sterile drape. Drape the probe for sterile use:

Allow the assistant to place the probe in the side arm holder on the stand

Apply a layer of sterile ultrasonic gel on the acoustic window of the probe

Place the sheath over the probe head, being careful not to wipe off the gel

Cover the probe and cable with the sheath without contamination

Smooth the sheath over the acoustic window of the probe head and remove any air bubbles

Use a sterile elastic band to hold the sheath in place.

Place the probe safely onto the sterile drapes.

Ask assistant to apply tourniquet. 4. Insertion of the Midline

Apply sterile gel onto the skin at the intended site of cannulation

Locate the site of a suitable vein for venepuncture using the ultrasound machine

Administer intradermal lidocaine at the proposed venepuncture site using the guide described above in key points.

Place the probe on the skin at the intended access site and hold the probe perpendicular to the vein. Realign the vein on the centre dot marker (if using, on the ultrasound screen).

If the vein is superficial, a longitudinal method can be used to place the needle into the vein

When the vein is successfully accessed blood return will be observed in the needle. (release tourniquet). If cannulation is unsuccessful after 2 attempts, consider seeking assistance from another equally competent practitioner.

Introduce the wire into the needle o The wire should never be forced. o Take extreme care not to lose the wire into the bloodstream, allow at least

10cm of wire outside the sheath and dilator (if using). o The wire should never be removed through the needle, due to the risk of

severing the wire on the tip of the needle.

Remove the needle over the guide wire.

If using 4fr midline thread the introducer over the guide wire, through the subcutaneous tissues and into the vein and remove introducer.

Thread midline over guidewire holding midline close to insertion site to prevent kinking of guidewire. Thread midline to position tip in the axillary vein.

If using 2fr or 3fr midline, thread midline over guidewire directly into the vein, omitting the introducer step. Thread midline to position tip in the axillary vein.



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Aspirate blood from the lumen to confirm intravascular placement and flush with 10mls of sterile 0.9% sodium chloride for injection.

The Midline must be secured using a skin fixation dressing (recommended method of fixation). A securacath can be used as fixation if there is an increased risk of migration.

The Midline exit site should be dressed with a Biopatch and a transparent semipermeable IV dressing.

Confirming satisfactory placement of the Midline

Check that blood can be aspirated freely and flushed from the lumen of the midline.

Midline is a peripheral device and so X-ray confirmation is NOT required.

Trouble Shooting Algorithms:

Infection



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For guidance on management of suspected or confirmed catheter related blood stream infection, please see: *Redacted* Thrombosis For guidance on how to assess for thrombosis and how to manage thrombosis of midlines & central lines, please see: *Redacted* Catheter Removal For guidance on removal of PICCs and Midlines, please see: *Redacted* Catheter Fracture

Catheter fracture of a PICC/Midline can occur when a device had accidently been cut or severed, from overuse of a clamp or when excessive pressure had been exerted on an occluded device.

Fracture is evident from an obvious hole, crack or breach on inspection the device and/or obvious leakage (fluid spurting out) when the device is flushed. This is complication requires urgent attention.

If fracture occurs do not use the device. Clamp device above fracture, seal the fracture with an occlusive dressing and ensure device is secure. Contact the IV Team for an urgent review. The device will require removal.

Be vigilant for symptoms of air embolism entering the bloodstream, symptoms include shortness of breath, coughing or chest pain. Air embolus is a medical emergency.

The following algorithms should only be undertaken by the IV team of staff deemed

competent by the IV Team.

Go to ‘Out of Hours Advice’ (page 27) in the IV Teams absence

Algorithms to resolve PICC PWO, occlusion and partial occlusion can also be used to resolve patency issues for other CVADs (Port-a-caths, Tunnelled CVCs and non-tunnelled

CVCs)

PICC- Persistant Withdrawal Occlusion (PWO) Algorithm



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This occurs when blood return is persistently absent from a PICC, but device flushes without resistance. This is most commonly caused by fibrin sheath/tail, but can also be the

result of malposition.

In absence of blood return, ask patient to deep breath, cough and alter head and arm position. Flush and aspirate device with 0.9% sodium chloride for injection

10-20mls.

If Blood return remains absent, satisfactory PICC tip position should be

confirmed by chest x-ray to exclude malposition.

Once satisfactory PICC tip position is verified, the IV Team will instil urokinase

5000 units in 1ml of 0.9% sodium chloride for injection to each lumen of

PICC. Leave urokinase in device for minimum

1 hour.

If urokinase is effective and blood return is present, document in notes

and use PICC.

If urokinase is ineffective, repeat

urokinase line lock.

If blood return remains absent after two instillations of urokinase, PICC should be removed.

Ward contact IV Team to report PWO.



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PICC - Partial Occlusion Algorithm

If blood return is absent, or line remains sluggish attempt to restore patency by flushing the device with 10ml syringe containing 5-10mls NaCl 0.9% for injection

using a flush and withdraw method



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Check for external kinks, ensure arm is

straight and well supported

Instill urokinase 5000 units in 1ml of NaCl 0.9% (to each lumen) for minimum 1

hour then withdraw

Able to instil

urokinase?

Yes No

Attempt ‘3-way tap & urokinase’ technique (Refer to IV Team or

this intervention).

Stop algorithm and document in notes.

Continue using PICC as per protocol. Flush with 10mls

sodium chloride 0.9% - followed by - 5mls

heparinised saline 10 units per ml using push pause

technique.


Continue using PICC as per protocol. Flush with 10mls sodium chloride

0.9% - followed by - 5mls heparinised saline 10

units per ml using push pause technique.

Yes No

Remove line if unsuccessful

Are you able to aspirate

blood and flush PICC?

Able to instil

urokinase Attempt to infuse

5000units of urokinase in 1ml

of sodium chloride 0.9% for

2-4 hrs then

withdraw

Yes No

Is PICC now flushing an

aspirating blood?

Yes No

Has venous returned been

obtained?

Yes No

Stop algorithm and document in notes. Continue using PICC

as per protocol. Flush with 10mls sodium chloride 0.9% - followed by - 5mls heparinised

saline 10 units per ml using

push pause technique.


Attempt to infuse 5000units of

urokinase in 1ml of sodium

chloride 0.9% for 2-4 hrs then

withdraw

Has venous returned been

obtained?

Yes No


*Please follow 3-way tap guidance on page 22

PICC - Total Occlusion Algorithm: Urokinase

Attempt to re-establish patency using a 10ml syringe containing 5-10mls sodium chloride 0.9% using a flush and withdraw method.

Is PICC flushing without resistance and blood return

present?

No

Yes Stop algorithm and document

in notes. Continue to use

PICC as per protocol.



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Midline - Partial Occlusion Algorithm

Ward reports to the IV Team the midline is sluggish and causing

occlusion problems

Check for any external kink in line, Ensure arm is straight and well

supported.

Flush midline with 10mls sodium chloride 0.9% using a push-

pause technique


Continue using midline as per protocol. Flush with

10mls sodium chloride 0.9% - followed by -

5mls heparinised saline 10 units per ml using push

pause technique.

Instill Urokinase 2,500 units in 0.5mls 0.9% NaCl for minimum 1 hour then

withdraw. If unable to Instill, go to three way tap method

using the reduced dose

Yes No

Does the midline flush easily with no occlusion

problems?

If line is still sluggish use a 10ml syringe containing 5-10mls sodium chloride 0.9% attempt to restore patency using a flush and

withdraw method

*Please follow 3-way tap guidance on page 22

Does Midline flush without

resistance?

Yes?

No? Remove Midline

and document.



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Midline Total Occlusion Algorithm

Ward Contact IV Team to report occluded Midline

Check for any external kink in line, ensure arm is straight and well support

Flush Midline with 10mls 0.9%sodium Chloride for injection using a push

pause technique

If line is still sluggish use a 10ml syringe containing 5-10mls sodium chloride 0.9% and attempt to restore patency using a flush and withdraw method

Does the midline flush without resistance?

No Yes


Continue using midline as per protocol. Flush

with 10mls sodium chloride 0.9%, then

5mls heparinised saline 10 units per ml using

push pause technique.

Instill Urokinase 2,500 units in 0.5mls 0.9% NaCl for minimum 1 hour then withdraw. If unable to Instill, go to three way tap method using the reduced dose

Does Midline flush without resistance?

Yes? No? Remove Midline and document.



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Using a 3-way tap & urokinase in a completely occluded catheter

Attach 3-way-tap & syringes see below.

(NB 3-way taps are now contraindicated for routing IV use but are still available for this procedure)

Open clamp (if there is one).

Open stopcock to the empty 2ml syringe and the blocked catheter.

Pull back on the plunger of the empty 2ml syringe to create a vacuum in the catheter. You will need to pull quite forcibly.

Maintain suction with one hand and with the other hand turn stopcock so it is closed to the empty syringe and open to the 10ml syringe containing urokinase (5000 units in 1ml 0.9% sodium chloride for injection), which will be drawn into the catheter. Don’t worry if it seems that very little urokinase is sucked in: even a tiny volume will reach several cm into the catheter. Repeat this process several times (Up to 20 Minutes).

Leave instillation of urokinase for at least 1 hour. After this time, assess the catheter by attempting to flush the catheter using 0.9% sodium chloride injection in a 10ml syringe. Do not use excessive force. (It is best NOT to try aspirating before flushing at this stage as you may block the catheter again). “Test“ the patency of the lumen, if patent then draw back the urokinase and flush with 10ml of 0.9% sodium chloride injection. . Once the catheter can be flushed, check for flashback. If flashback is absent, administer urokinase as described in page 19 (Total occlusion algorithm). If the catheter is still completely blocked, repeat the procedure s described above.

If the procedure fails despite 2 attempts consult the insertion team or medical team with a view to removing the catheter.

If the urokinase used correctly (see above) fails to restore function, further imaging may be required which may reveal a fibrin sheath



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SecurAcath securement device installation



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PICC / Midline removal with a SecurAcath securement device



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If Securacath is resistant/painful on removal, soak exit site with gauze and saline and re attempt removal. If resistance/pain is still felt, refer patient to IV Team for removal which may require local anaesthetic.



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Out of hours Advice

The following advice applies to management of PICC and Midlines out of normal working hours when the IV Team are not available.

In the event of an occluded device PICC or Midline –

Check device for external kinking and attempt to flush as per policy, if device is functioning normally, continue to use.

If device remains occluded obtain alternative IV access and refer to the IV Team for review as soon as possible

In the event of Persistent withdrawal (PWO) occlusion of a PICC –

Flush device using 10-20mls of 0.9% sodium chloride for injection. If ineffective, ask patient to deep breath, cough, and alter head and arm position to resolve PWO and repeat flushing step.

If still ineffective confirm satisfactory PICC tip position with chest x-ray

and PICC can be used. Refer to IV Team for review as soon as possible.

Fracture PICC or Midline -

External fracture of a PICC/Midline is evident from an obvious hole, crack or breach on inspection the device and obvious leakage when the device is flushed (fluid spurting). This is complication requires urgent attention.

If this occurs, clamp device above fracture, seal the fracture with an

occlusive dressing and ensure device is secure. Seek advice from a practitioner competent in PICC/Midline management for review and removal. Refer patient to the IV team for an urgent review as soon as possible.

Be vigilant for symptoms of air embolism entering the bloodstream, symptoms include shortness of breath, coughing or chest pain. Air embolus is a medical emergency.



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Minimum requirement

to be monitored

Process for monitoring e.g. audit/ review of incidents/

performance managemen

t

Job title of individual(s)

responsible for monitoring and

developing action plan

Minimum frequency

of monitorin

g

Name of committee

responsible for review of results and action plan

Job title of individual/ committee

responsible for monitoring

implementation of action plan

PICC / Midline insertion competence

Assessment IV Team Annually IV Team

Vascular Access Lead Nurse/ IV

Access Specialist nurses

6.0 EQUALITY, DIVERSITY AND HUMAN RIGHT STATEMENT

The Trust is committed to an environment that promotes equality and embraces diversity in its performance both as a service provider and employer. It will adhere to legal and performance requirements and will mainstream Equality, Diversity and Human Rights principles through its policies, procedures, service development and engagement processes. This policy should be implemented with due regard to this commitment.



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7.0 REFERENCES

Aintree University Hospital NHS Foundation Trust Medicines Policy *Redacted*

Aintree University Hospital Foundation Trust CVC obstruction and thrombosis guidelines *Redacted*

Centres for Disease Control and Prevention (2011) Guidelines for the Prevention of Intravascular Catheter-Related Infections www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf (last accessed 31/07/2018). Department of Health (2003) - Winning Ways: Working Together to Reduce Healthcare Associated Infection in England. London: HMSO. Department of Health (2008) – Saving Lives: reducing infection, delivering clean and safe care. London: HMSO. Dougherty L, Lister S (Eds) (2008) - The Royal Marsden Hospital Manual of clinical nursing procedures. 7th Edition. Chichester: Wiley Blackwell Publishing. Dougherty L, Lamb J (Eds) (2008) - Intravenous Therapy in Nursing Practice. 2nd Edition. London: Blackwell Publishing. Finlay T (2004) Intravenous Therapy Oxford: Blackwell Publishing. Hallam, C., Weston, V., Denton, A., Hill, S., Bodenham, A., Dunn, H., Jackson, T. (2015) UK Vessel Health and Preservation Infection Prevention Society, National Infusion and Vascular Access Society, Royal College of Nursing 2015. Inwood S (2007) Skin antisepis: using 2% chlorhexidine gluconate in 70% isopropyl alcohol British Journal of control of healthcare-associated infections in primary and community care. Nursing and Midwifery Council (2015) - The Code: professional standards of practice and behavior for Nurses and Midwives. London: NMC.

Nursing and Midwifery Council (2010) - Standards for Medicines Management. London: NMC. Nursing, Vol 16, No 22. p.1390-1394. Loveday HP, Wilson JA, Pratt RJ et al. (2014) epic 3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 86 (Suppl. 1): S1–70 National Institute for Clinical Excellence (2016) – Infection: prevention and control of healthcare-associated infections in primary and community care. Clinical Guideline 113 https://www.nice.org.uk/guidance/qs113 (last accessed 01/08/2018)

Aintree%20University%20Hospital%20NHS%20Foundation%20Trust%20Medicines%20Policy%20http:/intranet.aintree.nhs.uk/sites/dms/Documents/Medicines%20Policy.pdf




http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

https://www.nice.org.uk/guidance/qs113



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Royal College of Nursing (2016) - Standards for Infusion Therapy. 4th Edition. London: RCN.