Safety Tip - Preventing PICC Fractures
MedSun: Newsletter #1, February 2006

By Roberta Sullivan, Nurse Consultant, CDRH, FDA

Device Description:
Peripherally-inserted central catheters provide access to the central venous system via a percutaneous access site, usually in the upper arm. PICC placement combines the benefits that a central line offers for complex medication and fluid administration along with the advantages of peripheral insertion.

Reported Incident:
A PICC catheter became clotted and was unable to be used for fluid administration or to draw blood. The catheter was sluggish to flush and one of the ports was totally occluded. The catheter was discontinued for use and a peripheral intravenous catheter was inserted.

In addition to adverse events involving catheter occlusion, the FDA receives reports involving PICCs associated with catheter tears, leaks, ruptures, and fractures. Potential patient complications from PICC fractures include migration, perforation, arrhythmia and embolization of catheter fragments. Health care practitioner awareness of PICC care guidelines to maintain catheter integrity will promote patient safety.

Recommended Actions:
•Follow the manufacturer’s device-specific instructions for catheter placement and insertion site maintenance. Certain chemicals, solutions, or antibiotic ointments should be avoided near catheters made of materials susceptible to damage.

•Position in-line clamps near the center of the distal connector hubs. If the clamps are placed too close to the connector ends, excessive or repeated clamping may lead to tubing fatigue and stress fractures. However, failure to use the clamps may increase the risk of air embolism or blood loss.

•Secure the catheter to prevent occlusion, stress or kinking. Observe and monitor the length of the catheter from the placement site. Catheter migration from the intended placement in the superior vena cava can lead to serious complications such as perforation, erosion, and cardiac tamponade. Pediatric patients with PICCs pose special challenges for securing the catheter. Tubular elastic netting applied over the child’s arm may help prevent dislodgement and the need to repeat line placements in this high risk population.

•Always use at least a 10 cc syringe for flushes and medication administration. Flush the catheter with a brisk push/pause technique. To prevent damage to blood vessels or catheters, infusion pressure should not exceed 25 psi (pressure per square inch). The same force applied to a 3 cc syringe can result in a psi up to 55, compared to only 15 psi if using a 10 cc syringe. When using small gauge (< 4Fr) catheters in pediatric patients, a 10 cc syringe should still be used for medication and flushes, with the appropriate volume.

•Do not flush against resistance. Partial or complete catheter occlusions may be caused by thrombosis, drug precipitates or mechanical factors. Prevention of occlusion includes the use of heparin, positive pressure, and adequate flushing techniques between medications, blood draws, and TPN (total parenteral nutrition). Follow your institution’s protocol for appropriate interventions.

Gorski L. and Czaplewski L. (June 2005). Managing complications of midlines and PICCs. Nursing 2005. 35(6):68-9.

Infusion Nurses Society. (November/December 2000). Infusion nursing standards of practice. Journal of Intravenous Nursing. 23(65).

Ray C. (2001). Central Venous Access. Lippincott, Williams & Wilkins: Philadelphia, PA.

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