PICC insertion using modified Seldinger technique (MST) with ultrasound

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17.7 PICC insertion using modified Seldinger technique (MST) with ultrasound

It is helpful to have an assistant when performing this procedure, if possible.

Essential equipment

Personal protective equipment
One or two pairs of sterile gloves (according to practitioner preference)
Sterile pack containing sterile gown, mask with visor, theatre cap, sterile drapes and scissors
Alcohol‐based skin‐cleaning preparation, e.g. 2% chlorhexidine in 70% alcohol
10 mL syringes × 2–3
Needle‐free connector
MST kit (containing needle, guidewire, 5 mL syringe, dilator/introducer/peel‐away sheath, safety scalpel, and a 22 or 20 G cannula)
PICC
Transparent semi‐permeable IV film dressing
Securing device and sterile tapes
25 G safety needle
Blunt drawing‐up needles
Tape measure
Disposable tourniquet
Sharps container
Ultrasound machine, sterile gel and sterile probe cover
ECG leads, electrodes and monitor
Labels

Medicinal products

Sterile pre‐filled 10 mL syringes of 0.9% sodium chloride × 2–3
1% lidocaine

Pre‐procedure

ActionRationale

1.
Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
2.
Assess the patient's medical and intravenous device history.
To ensure the patient has no underlying medical problems (e.g. taking anticoagulants or previous surgery to arm or chest) and so is suitable to undergo the procedure (Hamilton [198], E; Moureau [329], E).
3.
Draw screens and assist the patient into a (semi)supine position, with the patient's arm at a 90° angle to their torso.
To ensure privacy. To aid insertion of the introducer and then advancement of the catheter (Gabriel [161], E; Moureau [329], E).
4.
Take the ultrasound equipment to the patient. Apply a tourniquet and gel to one of the patient's upper arms and use the ultrasound probe to assess venous access. Repeat for the other arm. Locate the most suitable vein, potentially using the Zone Insertion Method (Dawson [106]) (see Figure 17.25).
To ensure the patient has adequate venous access and to select the vein for catheterization (Gabriel [161], E; Moureau [329], E). To select the best area for PICC insertion (Dawson [106], E).
5.
If necessary (e.g. in very anxious or needle‐phobic patients, or children), apply local anaesthetic cream or gel to the chosen venepuncture site and leave for the allotted time.
To minimize the pain of insertion (BNF [42], C).
6.
Ascertain the length of the catheter by using Lum's ([281]) formula (which is based on the height of the patient; see Box 17.7) or by measurement. Measure from the selected venepuncture site to the sternoclavicular notch, adding 10 cm for right arm insertions or 15 cm for left arm insertions. If using an anchoring stabilization device then additional centimetres will need to be added depending on whether the right or left arm is used.
To enable selection of the most suitable catheter length and to establish how far to advance the catheter in order for its tip to be located in the correct position – that is, the superior veva cava (SVC) (La Greca [256], E; Lum [280], E; Lum [281], E).
7.
Take the equipment required to the patient's bedside. Open the outer pack.
To ensure the appropriate equipment is available for the procedure. E
8.
Attach ECG leads to electrodes and monitor, and apply to the patient: black lead to right shoulder and red lead to left thigh.
To ensure an ECG tracing can be obtained and used as a comparison once PICC inserted (La Greca [256], E; manufacturer's instructions, C; Oliver and Jones [364], E; Oliver and Jones [365], E).
9.
If using a tracking device, attach it to the patient's chest area.
To track the tip of the catheter as it advances into the venous system (La Greca [256], E; manufacturer's instructions, C; Oliver and Jones [364], E; Oliver and Jones [365], E).
10.
Apply a theatre cap and face‐mask with visor.
To minimize the risk of infection during the procedure and to protect the practitioner from blood splash contamination (Loveday et al. [278], E).

Procedure

11.
Wash hands with soap and water, or an alcohol‐based handrub. Dry using sterile paper towels from the sterile pack.
To minimize the risk of infection (Fraise and Bradley [156], E; NHS England and NHSI [348], C).
12.
Put on sterile gown and sterile gloves. Open the inner pack, arranging the contents as required.
To prevent contamination (Elliott [139], E; Loveday et al. [278], C). To have medications prepared for use. E
13.
If not using pre‐filled syringes then draw up 0.9% sodium chloride into a 10 mL syringe (provided by assistant if possible). Label the syringe.
To prevent contamination (Elliott [139], E; Loveday et al. [278], C). To have medications prepared for use. E
14.
Draw up 1% lidocaine into a 5 mL syringe and attach a 25 G safety needle. Label the syringe.
To have medications prepared for use and avoid confusion or medication errors. E
15.
Remove the cap from the extension set and attach a syringe of 0.9% sodium chloride; gently flush to the end of each lumen and leave the syringe attached.
To check that the catheter is patent and to enable easy removal of the guidewire (manufacturer's guidelines, C).
16.
Place a sterile towel under the patient's arm.
To provide a sterile field to work on. E
17.
Clean the skin at the selected site with 2% chlorhexidine in 70% alcohol, with friction, for 30 seconds, and prepare an area of 15–25 cm².
To ensure the removal of skin flora and to minimize the risk of infection (Fraise and Bradley [156], E; Loveday et al. [278], C).
18.
Allow the solution to dry thoroughly.
To ensure coagulation of bacteria and disinfection (Loveday et al. [278], C).
19.
Drape the patient with a full‐body sterile fenestrated drape.
To provide a sterile field (Loveday et al. [278], C).
20.
Add sterile gel to the ultrasound probe cover. Then apply the sterile ultrasound probe cover over the probe head and pull down along the cable.
To ensure all equipment that is in contact with the patient is sterile (Loveday et al. [278], C).
21.
Re‐tighten the disposable tourniquet through the sterile drapes or ask an assistant to do this.
To aid venous distension (Dougherty [124], E).
22.
Apply gel to the skin and scan for the chosen vein.
To visualise the chosen vein. E
23.
Keeping the probe in position, inject local anaesthetic intradermally using a 25 G needle and wait for it to take effect.
To provide adequate anaesthesia (BNF [42], C).
24.
While visualizing the vein under ultrasound, perform venepuncture with a needle or cannula. (If using a cannula, when flashback is seen, advance the cannula into the vein.)
To gain venous access (Gabriel [161], E; Moureau [329], E). To prevent blood loss and through‐puncture and enable advancement of the catheter (Gabriel [161], E).
25.
Remove the stylet and advance the guidewire through the needle (or cannula) until there is 10–15 cm of wire in the vein (Action figure 25).
To maintain venous access. E
26.
Release the tourniquet and remove the probe.
To contain flashback, prevent contamination of the area with blood and minimize the amount of blood loss from the patient (Gabriel [161], E).
27.
Advance the introducer over the wire up to the puncture site. (If using a cannula, remove it first applying digital pressure.)
To prepare for insertion. E
28.
Reinfiltrate over the puncture site with 1% lidocaine (intrademally) if necessary, until a small bleb is observed (Action figure 28).
To achieve anaesthesia and minimize patient discomfort. E
29.
Check the patient has no sharp sensations at the puncture site and then make a small incision by sliding the tip of the scalpel blade along the top of the wire (Action figure 29).
To ensure the area is anaesthetized before proceeding. E
30.
Activate the safety function on the scalpel and place it back onto the sterile field.
To minimize the risk of sharp stick injury. E
31.
Grip the introducer firmly and advance through the puncture site (Action figure 31).
To enable advancement of the dilator. E
32.
Measure using the desired method to ascertain the final length of the catheter.
To ensure the correct length of catheter is used. E
33.
If the catheter tip can be trimmed, using the graduated markings along the catheter, select the marking required and pull back the stylet (if required) 1 cm from the desired new tip. Using sterile scissors, trim the catheter. Be careful not to trim the stylet.
To ensure the catheter will be the correct length for SVC tip placement and to prevent damage to the vein if the guidewire is damaged (manufacturer's guidelines, C).
34.
Remove the guidewire and the dilator from the introducer/peel‐away sheath. Grip the catheter a few centimetres from the tip and thread through the introducer/peel‐away sheath.
To enable catheter insertion. E
35.
Continue slow advancement of the catheter and aspirate (if possible) and flush to check for blood return or resistance.

To minimize damage to the tunica intima of the vein (Gabriel [161], E).

To check there is no obstruction and that the catheter advances into the correct location. E
36.
Ask the patient to turn their head towards the arm of insertion and place their chin on their shoulder if possible.
To prevent the catheter entering the jugular vein and to ensure correct advancement of the catheter downwards to the SVC (Gabriel [161], E).
37.
Ask the patient if they have any aural (behind the ear) sensations on the side of the catheter insertion. If using a tracking device, observe the direction of the catheter on the screen.
Aural sensations could indicate that the catheter has advanced along the internal jugular vein and needs to be withdrawn and readvanced (Dougherty [123], E; manufacturer's instructions, C).
38.
Continue slow advancement of the catheter until unable to advance any further. If using a tracking device, check the catheter is in the expected position.

To minimize damage to the intima of the vein (Gabriel [161], E).

To make sure the catheter has entered the SVC (manufacturer's instructions, C; Mussa [341], E).
39.
Apply pressure above the introducer. Carefully withdraw the introducer and peel apart.
To ensure there is no movement of the catheter. To remove the peel‐away introducer (Gabriel [161], E).
40.
Advance the catheter to the hub and do a final check for any aural sensations. If using ECG technology, gently manipulate the catheter, observing the ECG trace for changes in the P wave. When the highest P wave without deflection is observed, the catheter tip is in the correct position (cavo‐atrial junction).

To check for malposition. E

To ascertain tip position (La Greca [256], E; manufacturer's instructions, C; Moureau et al. [331], E; Oliver and Jones [364], E; Pittiruti et al. [375], E).
41.
Apply gentle pressure on the catheter and slowly withdraw the stylet.
To ensure there is no withdrawal of the catheter (Gabriel [161], E).
42.
Aspirate for blood return and flush the catheter with 0.9% sodium chloride.
To check the patency of the device and ensure continued patency (Gabriel [161], E; Loveday et al. [278], C).
43.
Attach a needle‐free connector and flush as per local policy.
To ensure the patency of the device (Gabriel [161], E; Loveday et al. [278], C).
44.
Secure the catheter with a securing adhesive device (e.g. StatLock) or anchoring device (e.g. SecurAcath). Fold the device and then slide the prongs down the side of the venotomy and release (Action figure 44).
To ensure stability of the device (Gabriel [161], E; Hughes [219], E; Moureau and Iannucci [334], E; NICE [353], C; RCN [381], C).
45.
Apply a small pad of sterile low‐linting gauze or an absorbent pad (impregnated with chlorhexidine gluconate or ionic silver alginate) directly over the insertion site and secure with sterile tape if required. If an absorbent pad is used, there is no need to change the dressing after 24 hours.
To minimize blood leakage at the site, which occurs following insertion (Gabriel [161], E; Loveday et al. [278], C; RCN [381], C).
46.
Apply a semi‐permeable transparent IV film dressing. Date the dressing.

To ensure protection of the site while enabling observation of the exit site at all times (Loveday et al. [278], C; RCN [381], C).

To know when the dressing is due to be changed. E
47.
Apply low‐linting gauze over the lumens (optional), then bandage or apply a tubular bandage.
To prevent the tubing pressing into the patient's skin (Gabriel [161], E; RCN [381], C).

Post‐procedure

48.
Dispose of sharps and clinical waste. Remove gloves, gown, mask and theatre cap and dispose of equipment appropriately.
To prevent sharps injury. To ensure safe disposal in the correct containers and avoid laceration or injury to other staff. To prevent reuse of equipment (HSE [217], C; NHS Employers [346], [347], C).
49.
Send the patient for a chest X‐ray if necessary. Ensure the position of the catheter is assessed and documented by the appropriate healthcare professional (see Figure 17.5).
To ensure that the catheter tip is in the correct position (Wise et al. [474], E).
50.
If ECG tip positioning technology was used during catheter insertion (recommended), a chest X‐ray is not required provided that a good ECG tracing is obtained showing maximal P wave elevation. This must be verified by the operator, who should be proficient in the use of this type of technology.
To ensure correct tip position and minimize unnecessary patient exposure to radiation (La Greca [256], E; NICE [353], C; Oliver and Jones [365], E; Pittiruti et al. [375], E; RCN [381], C).
51.
Document the procedure in the patient's notes:
- type, length and gauge (Fr) of catheter
- where it was inserted
- tip confirmation by ECG and/or chest X‐ray
- batch number of catheter and lot number of sterile packs
- ECG trace
- any problems
- how it was secured
- patient education given.
To ensure adequate records are maintained and enable continued care of the patient and device (NMC [356], C; RCN [381], C). To enable any faulty equipment to be traced back to the manufacturer (MHRA [312], C).