Central Venous Access & PICC Nursing

◈ Pre-Procedure Assessment

Vein Assessment

• Ultrasound-guided vein mapping: Standard of care — assess diameter (>3mm preferred), compressibility, absence of thrombus
• Basilic vein preferred: average diameter 4–6mm, straight course, lower DVT rate post-insertion
• Assess bilaterally; avoid side of mastectomy, AV fistula, lymphoedema, or prior DVT
• Document vein diameter, depth, and absence of existing thrombus

PICC Length Measurement

• Measure from intended insertion site (mid-upper arm) to the sternal notch, then to the third intercostal space (approximates SVC-RA junction/CAJ)
• Document planned insertion length; compare with post-insertion CXR confirmed length
• Add or trim catheter to measured length before insertion (for trimable PICCs)

Consent & Allergy Screening

• Informed consent: procedure, risks (DVT, infection, malposition, pneumothorax extremely rare for PICC), alternatives
• Allergy screen: Lidocaine/lignocaine (local anaesthetic), latex (gloves/tourniquet), chlorhexidine (skin prep)
• Document allergy status in notes and on procedure form
• For chlorhexidine allergy: use povidone-iodine 10% as skin antiseptic alternative

◈ Insertion Assistance — Nurse Role

Where PICC insertion is performed by a physician or PICC specialist nurse, the assisting nurse plays a critical role:

1. Prepare sterile trolley: PICC kit, ultrasound probe cover, sterile gel, chlorhexidine applicator, transparent dressing, securement device, 10mL NaCl 0.9% flush syringes, 10mL syringe, normal saline for priming
2. Patient positioning: supine, arm abducted 45–90° (T-position), head turned away from insertion side
3. Apply tourniquet: facilitates vein engorgement for initial access; release once wire is placed
4. Maintain sterile field: do not cross or contaminate the sterile drape; hand instruments without breaking sterility
5. Seldinger technique support: wire passage, dilator, peel-away sheath — anticipate each step
6. Catheter advancement: patient asked to turn head toward insertion side (chin to chest) to prevent jugular malposition during advancement
7. Record external catheter length at insertion site once confirmed

◈ Tip Confirmation

Chest X-Ray (CXR) — Primary Method

• Mandatory after every PICC insertion before first use
• Correct tip position: distal SVC / cavoatrial junction (CAJ) — lower third of SVC, just above or at right atrium
• Tip in right atrium: risk of arrhythmia, perforation — withdraw catheter
• Tip in subclavian/innominate: subtherapeutic, risk of vessel irritation — reposition
• Check also for: pneumothorax (rare in PICC but possible), catheter kinking, malposition into jugular vein

ECG-Guided Tip Placement

• Real-time intracavitary ECG monitors P-wave morphology as tip approaches CAJ
• Maximal biphasic P-wave indicates correct tip position at CAJ without CXR needed immediately
• Reduces radiation exposure; widely adopted in GCC hospitals with PICC programs
• CXR still recommended for verification in unclear ECG signals or paediatric patients

◈ Post-Insertion Nursing Care

First Dressing Application

• Apply transparent semipermeable membrane (TSM) dressing (e.g., Tegaderm, IV3000)
• Cover entire insertion site and external catheter; ensure no air pockets or lifting edges
• Apply StatLock or equivalent securement device under the TSM to prevent catheter migration
• Write date of insertion and dressing date on the dressing label
• Consider chlorhexidine-impregnated disc (e.g., Biopatch/Tegaderm CHG) at insertion site per institutional policy for CLABSI reduction

Initial Flush

• Flush each lumen with 10mL 0.9% sodium chloride using a 10mL syringe (minimum) — never use syringes <10mL to avoid excessive pressure
• Use push-pause (pulsatile) technique to create turbulence and clear fibrin
• Confirm blood return before initiating any infusion
• Cap with needleless connector after flushing; scrub the hub before each access

Documentation Checklist Post-Insertion

• Insertion date and time, inserter name, indication
• Insertion site (left/right, vein used), external catheter length (cm)
• Tip confirmation method and documented tip position
• Number of lumens, each lumen colour-coded use documented
• Dressing type and date, securement device used
• Patient tolerance and education provided

◈ CLABSI Definition

A Central Line-Associated Bloodstream Infection (CLABSI) is defined as a laboratory-confirmed bloodstream infection (BSI) in a patient who had a central line in place for >48 hours on the date of the BSI event, with no other identified source of infection.

◈ Insertion Bundle (Prevention at Insertion)

1. Hand hygiene: Surgical hand scrub or alcohol-based hand rub before donning sterile gloves; all personnel in the room perform hand hygiene
2. Maximal barrier precautions (MBP): Inserter wears sterile gown, sterile gloves, mask, and cap. Patient covered with large sterile full-body drape. All assistants wear mask and cap minimum.
3. Skin antisepsis: 2% chlorhexidine gluconate in 70% isopropyl alcohol — apply with back-and-forth friction for 30 seconds; allow to dry completely (minimum 30 seconds — do not blot or fan). For chlorhexidine allergy: 10% povidone-iodine (allow 2 minutes contact + drying)
4. Optimal site selection: Subclavian or jugular preferred over femoral. Ultrasound guidance for all insertions where trained operator available.
5. Catheter selection: Use minimum number of lumens clinically necessary. Consider antimicrobial-impregnated CVC if CLABSI rate remains high (see Tab 6).

◈ Maintenance Bundle (Daily Prevention)

Line Necessity Review

• Daily physician-nurse review: Is this line still clinically necessary? Remove if not.
• Document daily line review in the nursing care plan
• JCIA IPSG requirement: active surveillance of line need

Dressing Management

• TSM dressing change every 7 days, or immediately if soiled, loose, or saturated with blood/fluid
• Gauze dressing (if used): change every 48 hours or when soiled
• Chlorhexidine disc replacement at each dressing change
• Never use topical antibiotic ointment on CVC sites (promotes resistance)

Needleless Connector (Cap) Management

• Change caps every 72–96 hours (per manufacturer and institutional policy) or immediately if blood-contaminated or after blood sampling
• Scrub the hub: Vigorously scrub the needleless connector with 70% isopropyl alcohol swab for minimum 15 seconds using friction; allow to dry for 15 seconds before accessing
• Use ANTT (Aseptic Non-Touch Technique) for all line access procedures

Aseptic Non-Touch Technique (ANTT)

• Identify and protect Key Parts (needleless connector, syringe tip, catheter hub) — never allow Key Parts to be touched or contaminated
• Non-sterile gloves acceptable for routine maintenance when Key Parts are protected
• Sterile gloves required for dressing changes and central line access in immunocompromised patients

◈ Flushing & Locking Protocol

◈ Catheter Occlusion

Thrombotic Occlusion

Most common type. Blood components form a thrombus within or around the catheter tip.

• Presentation: Unable to flush or aspirate, or sluggish flow, or one-way valve (can infuse but cannot aspirate)
• Management: Alteplase (tPA) 2mg/2mL — instil into affected lumen, dwell time 30 minutes to 2 hours (up to 4 hours for stubborn occlusions); aspirate and discard; flush with 10mL 0.9% NaCl. Repeat once if needed.
• Document response; if two doses fail, escalate to radiology for fibrin sheath stripping

Precipitate Occlusion

Drug or mineral precipitate forms within the catheter lumen. Identify the cause before treatment.

◈ Fibrin Sheath / Fibrin Tail

• A sleeve of fibrin forms along the external surface of the catheter, potentially covering the tip
• Presentation: Can infuse but cannot aspirate (one-way obstruction); or intermittent occlusion
• Diagnosis: Confirmed by contrast fluoroscopy (linogram)
• Management: Alteplase first; if persistent, fluoroscopic fibrin sheath stripping (radiology procedure); rarely, catheter exchange over wire

◈ CVC-Related Deep Vein Thrombosis (DVT)

Presentation

• Upper extremity: arm/shoulder/neck swelling, pain, prominent collateral veins visible on chest
• Lower extremity (femoral CVC): unilateral leg swelling, pain, warmth

Diagnosis

• Compression ultrasound — first-line imaging
• CT venography or MRI venography for central (subclavian/SVC) thrombus

Management

• Anticoagulation: LMWH (enoxaparin) or DOAC (rivaroxaban/apixaban) for minimum 3 months
• Line removal decision: Remove catheter if no longer needed, or if bacteraemia present. If still needed and thrombus stable, anticoagulate and monitor — line can remain with risk discussion
• Seek vascular/haematology review for SVC thrombosis or recurrent DVT

◈ CLABSI — Recognition & Action

Clinical Presentation

• Fever >38°C or hypothermia <36°C, rigors, hypotension (signs of systemic sepsis)
• Local signs: erythema, warmth, purulent discharge, tenderness at insertion site
• No other identified source of infection

Nursing Action Algorithm

1. Inform medical team immediately. Do not remove line without physician assessment.
2. Obtain two sets of blood cultures: one peripheral (venepuncture) + one through the central line (using ANTT). Document time and site of each culture.
3. Assess line site: photograph if purulent discharge present; document findings.
4. Do not delay empiric antibiotics for culture collection. Administer per medical order promptly.
5. Physician decision: remove vs. exchange over wire — in most cases of confirmed CLABSI, removal is preferred. Exchange over wire is controversial and generally not recommended for S. aureus or Candida.
6. If line removed, tip culture: cut 5cm of distal tip using sterile scissors into culture container (semi-quantitative roll-plate method).

◈ Pneumothorax Post-CVC Insertion

• Risk highest with subclavian approach (1–3%); less with ultrasound-guided jugular
• Mandatory CXR after every subclavian and jugular CVC insertion before line use
• Presentation: ipsilateral chest pain, dyspnoea, reduced breath sounds, hypoxia
• Small pneumothorax (<20%): observation, supplemental O2
• Large or tension pneumothorax: emergency needle decompression (2nd ICS MCL) → chest drain insertion

◈ Air Embolism

Causes

• Open catheter hub during connection/disconnection; tubing disconnection; negative intrathoracic pressure

Emergency Management

1. Immediately clamp the catheter and occlude any open port
2. Position: Trendelenburg (head down) + left lateral decubitus — traps air in right ventricle apex, prevents pulmonary embolism
3. Administer 100% oxygen via non-rebreather mask — accelerates nitrogen absorption
4. Call for emergency assistance; prepare for CPR if cardiovascular collapse
5. Aspirate air via CVC if tip positioned correctly near right heart
6. Consider hyperbaric oxygen if available and patient stable

◈ Catheter Fracture & Embolism

• Causes: Repeated kinking, pinch-off syndrome (subclavian between clavicle and first rib), mechanical damage, over-pressure flushing with small syringe
• Pinch-off syndrome: Positional flow changes; intermittent occlusion worsened by arm adduction — radiological findings on CXR/fluoroscopy
• Catheter embolism: Fragment migrates to pulmonary artery or right heart — presents with chest pain, palpitations, hypotension
• Emergency: Call interventional radiology for percutaneous snare retrieval; limit patient movement
• Prevention: Never use syringes <10mL; avoid sharp kinks at insertion site; secure catheter properly; monitor for PICC migration (check external length daily)

◈ Blood Sampling from CVC

Discard Method (Standard)

1. Stop all infusions through the sampling lumen for minimum 1 minute
2. Scrub the hub: 70% isopropyl alcohol, 15 seconds friction, 15 seconds dry
3. Attach 10mL syringe; aspirate and discard 5–10mL blood (waste volume clears catheter dead space and infusate dilution)
4. Attach fresh syringe; aspirate required sample volume
5. Flush lumen with 20mL 0.9% NaCl push-pause technique after sampling
6. Reconnect infusion or lock lumen

Coagulation Samples (Specific Requirement)

• Discard minimum 10mL before coagulation sample to eliminate heparin contamination
• If patient has continuous heparin infusion through that lumen: use peripheral venepuncture for coagulation studies where possible

Blood Cultures from CVC (ANTT Protocol)

• Don non-sterile gloves; perform hand hygiene
• Scrub the hub ≥15 seconds; allow to dry
• Discard 5–10mL (do not inject discard into blood culture bottles)
• Collect 8–10mL per bottle (aerobic + anaerobic); inoculate bottles immediately
• Label: lumen used, time, collector — essential for differential time-to-positivity interpretation
• Take peripheral blood culture simultaneously (different site)

◈ Administering Blood Products via CVC

Lumen Selection

• Dedicate one lumen for blood products where possible
• Never administer calcium-containing solutions (including Hartmann's/LR) through the same lumen or simultaneously with blood products — calcium chelates citrate anticoagulant, causing clot formation in the line
• If only one lumen available: flush thoroughly with 0.9% NaCl between calcium-containing and blood infusions

Blood Administration Considerations

• Blood components (pRBC): can infuse via 16G or larger lumen; large-bore CVC preferred for rapid transfusion
• Standard blood giving set with 170–200μm integral filter; change set after each unit or per policy (usually every 12 hours)
• FFP, platelets, cryoprecipitate: can be administered via any central lumen
• Monitor for transfusion reactions: vital signs at 15 minutes after commencement, then per protocol

◈ TPN Administration via CVC

Setup Requirements

• Dedicated lumen: One lumen exclusively for TPN — do not co-infuse other medications or take blood samples from the TPN lumen
• Filter requirements:
  • Standard TPN (2-in-1: no lipid): 0.2μm filter (removes bacteria, particulate, air)
  • 3-in-1 (lipid-containing TPN/TNA): 1.2μm filter (allows lipid particles to pass; 0.2μm would block lipid)
• Administration sets: change every 24 hours
• Light protection: wrap bag and tubing in dark sleeve for formulas containing vitamins A, D, K (photodegradation)

Line Care During TPN

• Strict ANTT for all connections and disconnections
• Inspect bag for particulate, cloudiness, phase separation (lipid emulsions) before administration
• Never add medications to a TPN bag — stability is pharmacy-calculated
• Blood glucose monitoring: TPN lumen blood sampling is unreliable (glucose in bag); use peripheral finger-stick for glucose monitoring during TPN

◈ Implanted Port Access (PORT-a-Cath)

Equipment Required

• Non-coring Huber needle (19G–22G, length appropriate for port depth — usually 20mm or 25mm)
• Sterile gloves, antiseptic swabs, 10mL 0.9% NaCl flush syringes, extension set, sterile drape
• EMLA cream or topical anaesthetic (apply 60 minutes before access, if time allows)

Accessing the Port — Step-by-Step

1. Apply topical anaesthetic cream (EMLA/LMX) 45–60 minutes before procedure; cover with occlusive dressing
2. Perform hand hygiene; don sterile gloves
3. Clean port skin with 2% chlorhexidine/70% IPA — allow to dry fully
4. Palpate the port: identify the boundaries of the septum with thumb and index finger of non-dominant hand; stabilise the port
5. Insert Huber needle at 90° angle to the port septum; advance firmly through skin until needle contacts the back wall of the port reservoir (you will feel a stop)
6. Confirm placement: aspirate for blood return (brisk blood return confirms correct needle position)
7. Flush with 10mL 0.9% NaCl push-pause; observe for swelling (extravasation)
8. Secure Huber needle with sterile TSM dressing; change dressing every 7 days during continuous access

Port Deaccess Procedure

1. Flush with 20mL 0.9% NaCl push-pause to clear the port
2. Draw up heparinised saline: 5mL at 100 units/mL (or 4% sodium citrate for Muslim patients)
3. Administer heparin lock using positive pressure technique: maintain plunger pressure while withdrawing the Huber needle — prevents blood reflux into the port reservoir
4. Withdraw Huber needle smoothly at 90°; apply gentle pressure with gauze
5. No dressing required after deaccess — site should heal closed
6. Document: deaccess date, locking solution used, patient tolerance

◈ CLABSI in GCC Hospitals — Context

GCC hospitals have historically reported higher CLABSI rates than many Western benchmarks, though significant improvement has occurred over the past decade through quality improvement (QI) initiatives.

◈ JCIA IPSG Standards for Line Care

Joint Commission International Accreditation requires hospitals to address central line care as part of the International Patient Safety Goals (IPSG).

• IPSG.6: Reduce the risk of healthcare-associated infections — includes HAI prevention program, surveillance, CLABSI bundle compliance monitoring
• Hospitals must demonstrate measurable CLABSI rate data and improvement trends
• Bundle compliance audits (insertion and maintenance) are required at minimum monthly
• Nursing staff must demonstrate competency in central line care; documented education required
• Hand hygiene compliance monitoring is tied to CLABSI prevention program

◈ DHA & Regional Infection Control Mandates

• Dubai Health Authority (DHA): Mandates CLABSI prevention bundles in all licensed facilities; annual IC competency for nursing staff; electronic surveillance reporting
• Ministry of Health UAE / HAAD / DOH: Circular mandates for HAI surveillance including CLABSI, CAUTI, SSI; facilities must report rates to authority dashboards
• Saudi MOH / CBAHI: CBAHI (Central Board for Accreditation of Healthcare Institutions) includes CLABSI prevention in accreditation standards; mandatory online surveillance (NHSN-adapted)
• Qatar MOH / JCI Qatar: Similar surveillance requirements; Hamad Medical Corporation has published CLABSI improvement data

◈ ICU Nurse Ratios & Line Care Workload

• Most GCC ICUs target 1:1 or 1:2 nurse-to-patient ratios in closed ICUs
• High CLABSI rates in some facilities correlate with: understaffing, high patient acuity, rapid turnover, high proportion of agency/travel nurses unfamiliar with local protocols
• Line care workload includes: daily dressing inspections, cap changes, flushing, documentation, blood sampling — significant time investment per patient
• Role of infection control link nurses at ward level is expanding in GCC hospitals for real-time bundle compliance support

◈ Antimicrobial-Impregnated CVCs in GCC

Antimicrobial CVCs are indicated when CLABSI rate remains above target despite full bundle compliance. Two types:

◈ PICC Nurse Specialist Role in GCC

• The PICC Nurse Specialist role is increasingly recognised in GCC hospitals, particularly in oncology centres, teaching hospitals, and institutions with active PICC programs (Hamad, SKMC, KKH, Cleveland Clinic Abu Dhabi, etc.)
• Responsibilities: PICC insertion, tip confirmation, care plan initiation, nursing staff education, troubleshooting, CLABSI surveillance data for PICC patients
• Competency: formal PICC insertion training program + supervised insertions (typically 50+ for certification); ultrasound competency; ECG-guided tip placement certification
• Benefit: PICC nurse specialist programs have demonstrated reduced PICC malposition rates, lower CLABSI from PICC, and reduced physician workload

◈ Patient & Family Education for Home PICC Care

• Increasing number of GCC patients discharged home with PICC for IV antibiotics, chemotherapy, TPN, or parenteral nutrition
• Education must be provided in the patient's primary language — Arabic language materials essential for most GCC patients
• Key education topics:
  • Dressing integrity monitoring: when to call/go to emergency (lifting, wet, dirty dressing)
  • Signs of infection: redness, swelling, discharge, fever — action plan
  • Signs of arm DVT: swelling, pain, prominent veins — call immediately
  • Catheter migration: check external length at each dressing change; if changes, notify PICC nurse
  • Activity restrictions: avoid immersion (bath, swimming pool); shower with waterproof cover; no heavy lifting with PICC arm
  • Emergency: if catheter disconnects or breaks — clamp immediately, attend emergency
• Provide written discharge instructions in Arabic + English; ensure verbal teach-back completed and documented

◈ Heparin Lock & Halal Considerations

Heparin used for catheter locking is predominantly derived from porcine (pig) intestinal mucosa, which is not permissible (haram) under Islamic law. This is a relevant clinical and cultural consideration in GCC practice.

Clinical Context

• Many GCC patients and families will raise concern about porcine heparin when informed
• Islamic scholars' positions vary: some permit porcine heparin under medical necessity (darura); others do not
• Best practice: inform patients, document discussion, and offer a halal alternative where clinically equivalent

4% Sodium Citrate — Halal Alternative

• Citrate 4% (e.g., Citra-Lock, Dirinco) is a synthetic chelating agent — locks calcium in blood, preventing thrombus formation in the catheter lumen
• Evidence: equivalent to heparin for catheter patency in multiple RCTs; may also have anti-biofilm properties
• Suitable for: PICC locks, tunnelled CVC locks, port locks, dialysis catheter locks
• Dose: 1–1.5mL per lumen (volume must fill dead space only; confirm with catheter specifications)
• Warning: Do not use citrate concentrations >4% in ward/ICU settings (high-concentration citrate [30%] used in dialysis is nephrotoxic if inadvertently infused — restricted to specialist use only)