|Peripherally inserted central catheter (PICC) insertion using image guidance||1012.00000000000||Peripherally inserted central catheter (PICC) insertion using image guidance||Peripherally inserted central catheter (PICC) insertion using image guidance||P||English||Other||Child (0-12 years);Teen (13-18 years)||NA||Cardiovascular system||Procedures||Caregivers
Adult (19+)||NA||2019-07-25T04:00:00Z||Bairbre Connolly, MB, BCH, BAO; DCH; FRCSI, MCh; FFRRCSI; lmCC, FRCP(C), MD;Barbara Bruinse, RN, BSc, BScN;Lisa Honeyford, RN, MN, CPON;Darlene Murray, BSN, MS(c); Dalia Bozic, MN, RN(EC), NP-PHC||10.2000000000000||55.6000000000000||3256.00000000000||Health (A-Z) - Procedure||Health A-Z||<p>Children's veins may become damaged by frequent, painful needle insertions. A PICC may be the best way for some children to receive medicines and IV fluids or to have blood samples taken. Learn about this procedure and how to care for the PICC.</p>||<h2>What is a PICC?</h2><p>A peripherally inserted central catheter (PICC) is a special intravenous (IV) line. A PICC is a long, soft, thin, flexible tube that is inserted into a vein in the arm and guided through the veins until it is positioned in a large vein just above the heart. For babies, a PICC might be put into a vein in the leg instead.</p>
<figure class="asset-c-80"><span class="asset-image-title">PICC</span><img src="https://assets.aboutkidshealth.ca/akhassets/PICC_Line_MED_ILL_EN.jpg" alt="A catheter inserted into the vein of a child’s arm with a clamp and access cap on the outside" /><figcaption class="asset-image-caption">A peripherally inserted central catheter (PICC line) is used for patients who need long-term frequent IV therapy. It is inserted into a vein in the arm and ends in a large vein above the heart.</figcaption></figure>||<h2>Why is a PICC inserted?</h2><p>A PICC is used in some children who need IV therapy for a long period of time. IV therapy can include IV medications, nutrition and fluids. Having a PICC inserted makes it easier and more comfortable for your child to receive these IV therapies. If your child has a PICC inserted to receive IV therapies then it can also be used to take blood samples and to provide total parental nutrition (TPN).</p><h2>How is a PICC inserted?</h2><p>A PICC is inserted using image guidance by an interventional radiologist. A needle is inserted into a vein in the arm with the assistance of <a href="/Article?contentid=1290&language=English">ultrasound</a> and a special X-ray called fluoroscopy. Using fluoroscopy, the PICC is guided into the vein until the tip is positioned in the large vein just above the heart. This placement allows for better mixing of medicines and IV fluids.</p> PICC lines are usually inserted in the right arm but can be put into any limb. A chest X-ray may be taken after the procedure to make sure the PICC is in the correct position.
<p></p>||<h2>Key points</h2><ul><li>A PICC is a long, soft, thin, flexible tube that is inserted into a vein in the arm and guided to the large vein just above the heart. For babies, a PICC might be inserted into a vein in the leg.</li><li>A PICC may be the best way for some children to receive IV medications, nutrition and fluids.</li><li>Heparin will need to be flushed into the PICC after every use.</li><li>A nurse will teach you how to take care of your child’s PICC, including what to do if it breaks, the cap falls off, the dressing comes loose or it falls out.</li><li>A PICC can stay in for weeks or months.<br></li></ul>||<h2>PICC complications</h2><p>Complications may occur with your child’s PICC. It may break, the cap may fall off, the dressing can come loose or the PICC can fall out. Broken PICCs will need to be removed and replaced. It is important that you are prepared to handle these situations.</p><p>Other possible complications include clotting of the PICC, blood in the catheter or cap, and infection. Remember to wash your hands before handling the PICC.</p><h3>Catheter damage</h3><p>Catheter damage can happen from rough handling, pulling, cutting with scissors, general wear and tear, or puncturing with a sharp object. If this happens, fluid may leak out of the catheter at the damaged point, germs can get inside, and blood may back up into the catheter. You may notice that the catheter is wet if there is a small tear in the line.</p><h3>What to do if the PICC breaks or leaks</h3><p>Before you leave the hospital, you will be given a PICC Emergency Kit. The kit contains the supplies you will need if your child’s PICC breaks. A nurse will give you the kit and review it with you before you leave. You should always make sure the kit is with your child.</p><p>If the PICC breaks, do the following:</p><ol><li>Stay calm.</li><li>Clamp the PICC between the break and your child using the padded clamp that has been provided. If you do not have a clamp, bend the line over and tape it together.</li><li>Stop the infusion if your child has one running.</li><li>Clean the broken area with an alcohol swab.</li><li>Place clean gauze under the broken area and tape the PICC to the gauze.</li><li>Wrap the gauze around the catheter, then tape this gauze roll to your child’s arm.</li><li>If the hole is small, and you have been taught how, you should try to heparinize the PICC to help prevent it from becoming blocked.</li><li>Call the Vascular Access Service as soon as you have secured the PICC for further instructions. You will be asked to bring your child to the hospital for further assessment.</li><li>Bring the broken line with you. This is the fastest way of knowing the correct size.</li></ol><p>Some PICCs can be repaired without having to be replaced. Some broken PICCs will need to be removed and replaced.</p><h3>What to do if the cap falls off<br></h3><p>If the cap falls off:</p><ol><li>Wipe the end of the PICC with an alcohol swab.</li><li>Take a new cap and place it on the end of the line by screwing it onto the hub.</li><li>Wrap clean gauze around the cap and then tape the gauze to your child’s arm.</li><li>Have the cap changed as soon as possible using the sterile technique. You can perform the
<a href="/Article?contentid=3391&language=English">aseptic non-touch technique (ANTT)</a>, if you have been taught, or the home-care nurse can do it.</li></ol><h3>What to do if the dressing comes loose</h3><ol><li>If the dressing comes loose, reinforce it with tape.</li><li>If the dressing comes off, cover the site with sterile gauze and tape it to your child’s skin.</li><li>As soon as possible, a new dressing needs to be applied using the sterile technique. You can perform the ANTT, if you have been taught, or the home-care nurse can do it.</li></ol><h3>What to do if the PICC falls out</h3><p>If the catheter falls out or gets pulled out:</p><ol><li>To stop the bleeding, apply pressure for 10 minutes to the site where the catheter enters the vein in the child’s arm.</li><li>Clean the exit site with the usual cleaning solution, and apply a bandage over the area.</li><li>Observe the entry site for any swelling or bruising.</li><li>Contact a member of your health-care team for further instructions. The procedure to re-insert the PICC may not be possible right away.</li></ol><h3>What to do if there is blood visible in the catheter or cap</h3><p>There may be blood visible in the catheter or cap if there is an increase in pressure in the chest veins from crying, laughing, exercising or leaving the clamp open while the pump is turned off. It will also happen if there is an opening anywhere along the system, such as a loose connection or defective cap.</p><p>If blood appears in the catheter, you should flush it and then heparinize it, if you have been taught how to do so. If you see blood, always check the system for leaks, cracks and loose connections. Replace any parts that are replaceable, and re-check for blood back-up. Let the health-care team know if you cannot fix the problem.</p><h3>What to do if you cannot flush the PICC</h3><p>Most PICCs have clots or sludge build-up. If you notice gradually increasing pressure when flushing the PICC, there may be particles sticking to the inside walls of the PICC, making the pathway for fluids narrower. If you are suddenly not able to flush the PICC, check that the clamp is open and that the PICC is not bent or twisted. If it is not one of these things, the PICC may have a clot stopping the flow of fluids. You must call a member of your health-care team if this happens.</p><p>Never try to flush a clot out of the PICC. You may burst the PICC or push a clot into your child’s heart and lungs. If you find a complete blockage while trying to flush the PICC, report this to your health-care team. You will need to come to the hospital or clinic for help.</p><h3>Infection</h3><p>Having a PICC gives bacteria an easy route into the blood system. Therefore, there is a risk of infection every time you handle the line. The ANTT during PICC care is the most important way to prevent an infection. The catheter exit site must be cleaned and dressed properly to prevent the growth of germs. Getting the supplies dirty or wet, or not following the methods of ANTT could allow germs to enter and grow in the body, which could cause a serious infection.</p><p>If your child develops a fever of <strong>one degree above their normal temperature</strong> or has <strong>chills</strong> or <strong>sweats</strong>, call a member of your health-care team right away. Not all fevers mean that there is an infection in the PICC; but infection is always suspected, and the PICC needs to be looked at.</p><p>Before you call:</p><ul><li>Check to see if your child has any other signs of infection, such as a sore throat, cough, runny nose, sleepiness or any change in behaviour.</li><li>Look at the PICC exit site to see if there is any redness, swelling or discharge.</li></ul><table class="akh-table"><thead><tr><th>Signs and symptoms to watch for</th><th>What to do</th></tr></thead><tbody><tr><td>Fever, chills</td><td>Check your child’s temperature.</td></tr><tr><td>Redness, swelling or discharge at the exit site</td><td>Change dressing, and check for red streaking following the tunnel part of the PICC.</td></tr><tr><td>General feeling of tiredness</td><td>Look for other signs of infection.</td></tr><tr><td>Pain</td><td>Ask if your child is experiencing pain, for the location of their pain and for the intensity of their pain.</td></tr><tr><td>Fever over:<br> 38°C by mouth (or 1°C above normal)<br> 37.5°C under arm<br>38.5°C rectally</td><td>Call your health-care team to report the fever and any other symptoms.</td></tr></tbody></table>||<h2>Caring for your child at home with a PICC</h2><p>There must always be a bandage over the PICC exit site on the arm. This bandage keeps the PICC clean and secure. The end of the catheter, called the hub, will be closed with a cap.</p><p>When you go home, a home-care nurse will care for your child’s PICC. As you become more comfortable caring for the PICC, the nurse can teach you how to provide some of this care yourself.</p><p>To prevent the PICC from becoming blocked, it will always have one of the following:</p><ul><li>An infusion, where fluids are being pushed into the PICC through a pump.</li><li>A <a href="/Article?contentid=3404&language=English">heparin lock</a>. Heparin is a medication that helps prevent the PICC from becoming blocked when there is no fluid infusing into it. New heparin will be flushed into the PICC after each use. If the PICC is not being used each day, the heparin flush will be done every 24 hours.</li></ul><p>It is important to always keep the PICC dry. If the PICC gets wet, it is more likely to become infected. Your nurse will teach you how to cover the PICC to keep it dry when your child bathes. If the bandage gets wet, it should be changed right away.</p><h3>Protecting the PICC</h3><p>Although the PICC is quite secure, it is not attached to anything inside your child’s body; so if it is pulled, it can come out. It is very important to make sure the PICC is always secured to your child’s arm. This helps to prevent it from being accidentally pulled out. Keeping the PICC taped to your child’s arm will also prevent it from twisting or kinking. This is important to prevent it from becoming damaged or broken.</p><h3>Activities after the PICC insertion</h3><p>After the PICC is inserted, your child will be able to go back to most activities. This includes going to daycare or school. Tell your child’s caregivers or teachers about the PICC.</p><p>Your child may also be able to play some sports and games, such as bike riding. It is important for your child to maintain as many usual activities as possible. There are a few things that should be avoided:</p><ul><li>Your child should not play water sports or swim. If the bandage gets wet, the risk of infection increases. Change the bandage right away if it gets wet.</li><li>Your child should not play sports that might result in a hit to the PICC or cause the catheter to be pulled out, such as hockey, football, gymnastics or basketball.</li><li>Do not use scissors anywhere near the PICC. No one, including you, your child, a nurse or a doctor should be allowed to use scissors near the PICC. This will prevent it from being cut.</li><li>Do not let other children touch or play with the PICC.</li></ul>||<h2>When to seek medical assistance</h2><p>Contact your doctor or go to the nearest Emergency Department right away if your child has any of the following:</p><ul><li>A fever higher than 38°C (100.4°F), or over the normal range provided by your doctors or nurses</li><li>Pain requiring <a href="/Article?contentid=62&language=English">acetaminophen</a> after 48 hours</li><li>Bleeding that does not stop with pressure</li><li>Leakage or drainage at the PICC site</li><li>Difficulty breathing</li><li>A funny feeling in their heart</li><li>Noticeable swelling in the face, chest, neck or arm on the side where the PICC line is located</li><li>The PICC gets pulled out a little or all the way</li></ul><p>Each child’s situation is different, so you should ask your doctor if there are any specific instructions for your child.</p>||<h2>How long can the PICC stay in?</h2><p>A PICC can stay in for weeks or months, as long as it remains problem-free and working well.</p><h2>Removing the PICC</h2><p>Once your child's health-care team is confident that the PICC is no longer needed, they will make arrangements for the PICC to be removed. This procedure is simple and takes about five to 10 minutes. Sometimes, a cream will be used to numb the skin around the PICC, or a local anaesthetic will be injected into the skin before the PICC is removed. Depending on the type of PICC your child has, or how long it has been in, there is sometimes no need to use any local anaesthetic. Your child will not need any type of sedation.</p>||<h2>On the day of the PICC insertion</h2><h3>Your child will have medicine for pain<br></h3><p>It is important that your child is as comfortable as possible for the procedure. Depending on your child’s age and medical condition, they might be awake during the procedure, slightly sedated (relaxed) or receive general anaesthesia.</p><p>Many children only receive a <a href="/Article?contentid=3001&language=English">local anaesthetic</a> when the PICC is inserted. Local anaesthetic is medication that numbs the area of the arm where the PICC will be inserted. This medication is usually given by a needle into the skin. Once the medication has had time to work, your child should not feel any pain.</p><p>Sometimes, children are given <a href="/Article?contentid=1260&language=English">sedation</a> or a <a href="/Article?contentid=1261&language=English">general anaesthetic</a>.</p><ul><li>If your child receives sedation, they may fall asleep or be sleepy during the procedure. Often, your child will not remember everything that happened during the procedure. Your child will be given a local anaesthetic as well.</li><li>If your child receives general anesthetic, they will not hear or feel anything during the procedure.</li></ul><p>During the procedure, you will be asked to wait in the waiting area.</p>||<h2>After the PICC insertion</h2><p>Once the PICC is inserted, the doctor, nurse or technologist will come and speak with you about the details of the procedure.</p><p>The area where the PICC comes out of the skin will be covered with a clear bandage. This bandage is put on in a special way to keep the site as clean as possible.</p><p>The PICC can be used right away for your child’s medication or fluids. Your child should not feel any pain when the PICC is being used.</p><h3>Pain relief after the procedure</h3><p>After the procedure, some children may feel pain in the small area where the PICC comes out of the skin. Usually this pain is mild and will go away within a few hours. If your child complains of a lot of pain, ask your nurse or doctor if they can have something to relieve the pain.</p><p>Children often try to protect the arm that has the PICC. Encourage your child to use their arm normally. It is good and safe for your child to move the arm in all directions.</p>||<h2>Preparing for a PICC insertion</h2><p>If your child is already in the hospital, you will meet a nurse from the Vascular Access Service who will explain the procedure and answer your questions. If your child is an outpatient, the health-care team looking after your child will explain the procedure to you.</p><p>If your child requires a general anaesthetic for the PICC insertion, you will meet the anaesthetist before the procedure. This is the doctor who will give your child the medicine to sleep during the procedure.</p><h3>Giving consent before the procedure</h3><p>Before the procedure, a member of the interventional radiology team will go over how and why the procedure is done, as well as the potential benefits and risks. They will also discuss what will be done to reduce these risks and will help you weigh the benefits against them. It is important that you understand all of these potential risks and benefits of the PICC insertion and that all of your questions are answered. If you agree to the procedure, you can give consent for treatment by signing the consent form. A parent or legal guardian must sign the consent form for young children. The procedure will not be done unless you give your consent.</p><h3>How to prepare your child for the procedure</h3><p>Before any treatment, it is important to talk to your child about what will happen. When talking to your child, use words they can understand. Let your child know that medicines will be given to them to make them feel comfortable during the procedure.</p><p>Children feel less anxious and scared when they know what to expect. Children also feel less worried when they see their parents are calm and supportive.</p><h3>Food, drink, and medicines before the procedure</h3><ul><li>Your child’s stomach must be empty prior and during sedation or anaesthetic.</li><li>If your child has special needs during fasting, talk to your doctor to make a plan.</li><li>Your child can take their regular morning medicine with a sip of water two hours before the procedure.<br></li><ul></ul></ul><p>Medicines such as <a href="/Article?contentid=77&language=English">acetylsalicylic acid (ASA)</a>, <a href="/Article?contentid=198&language=English">naproxen</a> or <a href="/Article?contentid=153&language=English">ibuprofen</a>, <a href="/Article?contentid=265&language=English">warfarin</a>, or <a href="/Article?contentid=129&language=English">enoxaparin</a> may increase the risk of bleeding. Do not give these to your child before the procedure unless they have been cleared first by your child’s doctor and the interventional radiologist.</p>||<h2>Risks of a PICC insertion for your child</h2><p>A PICC insertion is usually considered a low-risk procedure. The risks of the procedure will vary depending on your child’s condition, age and health.</p><p>The risks of any central catheter insertion, including a PICC, can include:</p><ul><li>failure to find an open vein that will accept the PICC </li><li>bleeding or bruising </li><li>pain or discomfort</li><li>infection</li><li>clotting</li><li>air in the lungs or veins </li><li>irregular heart rhythm </li><li>breakage of the catheter</li><li>movement of the catheter</li><li>X-ray exposure</li><li>vein perforation</li><li>nerve or artery damage</li></ul>||<h2>At SickKids</h2><p>At SickKids, the interventional radiologists work in the <a href="http://www.sickkids.ca/IGT/index.html">Department of Diagnostic Imaging – Division of Image Guided Therapy (IGT)</a>. You can call and speak to the Vascular Access Service resource nurse at (416) 813-6986 during working hours, or leave a message with the Vascular Access Team. If you have concerns and it is after working hours, please call The Hospital for Sick Children switchboard at 416-813-7500 and ask them to page your child’s doctor on call, or go to the nearest Emergency Department.</p><p>For more information on fasting, see “<a href="http://www.sickkids.ca/VisitingSickKids/Coming-for-surgery/Eating-guidelines/index.html">Eating and drinking before surgery</a>.”</p><p>For more information on preparing your child for their procedure, see “<a href="http://www.sickkids.ca/VisitingSickKids/Coming-for-surgery/index.html">Coming for surgery</a>.”</p>||https://assets.aboutkidshealth.ca/akhassets/PICC_Line_MED_ILL_EN.jpg||Peripherally inserted central catheter (PICC) insertion using image guidance||False|