CODE P.

11
HEALTH SERVICES

NURSING PROCEDURE TITLE: PERIPHERALLY INSERTED CENTRAL

CATHETER (PICC)
A. ASSESSMENT
B. ESTABLISHING OR CHANGING
NEEDLELESS ACCESS ADAPTER
C. FLUSHING
D. ADMINISTRATION INTRAVENOUS (IV)
FLUIDS OR MEDICATIONS
E. DRESSING CHANGE WITH STATLOCK®
F. DRESSING CHANGE WITH
SECURACATH®
G. BLOOD SAMPLING
H. ACCIDENTAL REMOVAL & DRESSING
APPLICATION UPON PHYSICIAN/RN
REMOVAL
I. OCCLUSION MANAGEMENT
J. REMOVAL OF PICC

CATEGORY:
General – RN, RPN
Advanced Practice LPN – Sections A-H only

PURPOSE

 To provide safe, standardized, evidence based process for PICC care and maintenance.

NOTE: This procedure applies to both clamped and clampless catheters unless otherwise
indicated.

TYPES & PROCEDURAL DIFFERENCES:

1. CLAMPED
 Rotate clamping site on sleeve.
 Unused lumens need to be flushed with a minimum of 10 mL normal saline (N/S) q24hrs.
 Ensure catheter is clamped prior to opening system (i.e. changing needleless access adapter).
 Clamped catheters can be used for central venous pressure monitoring.

NOTE: For pediatrics see Appendix A.

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2. CLAMPLESS
 Valve is located in hub of catheter.

NOTE: Due to presence of valve, clampless catheters cannot be used for central venous
pressure monitoring.

 Lumen size is equal in dual lumen catheters.

 Unused lumens need to be flushed q7 days with a minimum of 10 mL normal saline.

NOTE: For pediatrics see Appendix A.

NURSING ALERT:
 Insertion is responsibility of a physician.
 Removal of PICC’s is responsibility of a physician, RN or RPN, see Section I.
 Ensure aseptic technique when performing PICC care, i.e. accessing lumens, opening
lumen(s) or exposing insertion site.
 Ensure needleless access adapter is in place on all PICC lumens.
 Use greater than or equal to 10 mL syringe when flushing.
 Keep all sharp instruments away from catheter.
 Avoid acetone and adhesive remover as they will weaken catheter.
 Allow alcohol to dry before applying needleless adapter to lumen hub.
 Avoid taking a blood pressure or performing venipuncture on an arm with a PICC. If unavoidable,
place BP cuff/tourniquet distal to PICC insertion site.
 Apply appropriate personal protective equipment (PPE) before direct contact with patient and
prior to starting procedure.
 Infusion pump is required for all PICC’s unless continuously visualized. For pediatrics, an infusion
pump is always required.
 If there is accidental breakage or damage to catheter, pinch catheter closed with fingers between
patient and where catheter is damaged/cracked. Fold catheter over on itself and tape in place.
Immediately notify Most Responsible Practitioner (MRP).
 For Pediatrics, keep non-traumatic forceps hanging on IV pole in room of patient with CVAD’s and
clamp line if there is accidental breakage.
 Utilize 2 client identifiers prior to any PICC catheter care and maintenance as per RQHR policy 0612.
 Minimize number of times PICC is accessed to prevent complications.
 Flush using vigorous push-pause technique creating turbulent flush to maintain patency.
 IV tubing to be changed as per Appendix B.

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A. ASSESSMENT

NURSING ALERT:
 Proper care and handling of PICC catheters is essential to prevent central line associated blood
stream infections (CLA-BSI).
 Accessing any part of the PICC for any reason requires;
o Hand hygiene
o Cleansing connection site vigorously with alcohol swab using a 15 second scrub (let dry).
 Assess daily need for existing PICC.
 Notify MRP/Interventional radiologist (IR) if signs of malposition are present: inability to withdraw
blood, a “gurgling” sound heard when flushing catheter, and/or chest pain experienced by patient.
 Notify MRP if patient develops swelling in arm with PICC.
 As much as possible, when administering Parenteral Nutrition (PN), use a dedicated lumen and
document specified lumen on patient’s plan of care.

PROCEDURE

1. Perform hand hygiene prior to touching any component of PICC, administration set, or fluid
solutions.

2. Assess site minimum once per shift, with each patient assessment and prior to any procedure.
2.1 Palpate area around insertion site (through dressing).
2.2 Assess for tenderness or discomfort.
2.3 Assess surrounding areas for redness, warmth, edema and drainage.
2.4 Assess chest wall for engorged superficial veins.

3. Measure PICC from insertion site to middle of suture wing or StatLock® posts upon initial insertion
and every week with dressing change and prn for adults; once per shift and prn for pediatrics and
document. See Appendix C, D and F for picture of where to measure.

4. Document assessment and any unusual findings. Notify MRP of any unusual findings.

B. ESTABLISHING OR CHANGING NEEDLELESS ACCESS ADAPTER

NOTE: Change needleless access adapter at least every 7 days or at any sign of adapter
damage (i.e. cracking, leaking or contamination) and prior to blood culture collection.

NOTE: Ensure alcohol is dry before applying needleless access adapter to hub.

EQUIPMENT

1. PPE, including mask

2. Needleless access adapter (#313420)
3. Alcohol swabs
4. 10 mL N/S in a greater than or equal to 10 mL syringe
5. Sterile normal saline (as required)
6. 2x2 sterile gauze (as required)

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NOTE: For pediatrics, see Appendix A.

PROCEDURE

1. Perform hand hygiene.

2. Prepare new sterile needleless access adapter for each lumen.

2.1 Open package.
2.2 Prime adapter with N/S while keeping it inside package.

3. Don PPE.

4. Stop IV infusion, if in place.

5. Disconnect IV tubing from adapter, if infusing.

6. Ensure lumen is clamped, if clamp present.

7. Cleanse adapter connection site vigorously with alcohol swab using a 15 second scrub (let dry).

NURSING ALERT:
 Ensure asepsis is maintained during needleless access adapter change.

8. Remove existing adapter and discard.

NOTE: Avoid using forceps on catheter lumen hub. This may damage hub.

NOTE: Clean catheter lumen hub with alcohol only if visibly soiled; ensure alcohol is dry
before attaching adapter. If visible encrustations will not come off with alcohol, soak
threads with normal saline soaked gauze prior to cleaning infusion tubing threads
with alcohol.

9. Attach pre-flushed needleless access adapter with N/S filled syringe in place.

10. Release clamp (if applicable).

11. Aspirate slowly for blood, only until flashback appears.

NURSING ALERT:
If unable to aspirate blood, try the following techniques in this order:
 Have patient position their neck to look over opposite shoulder of PICC insertion, cough, move arm
away from body at a 90 degree angle and slightly back or take a deep breath and hold.
 Instill 1 – 2 mL of N/S using push pause technique and attempt to aspirate.
 May repeat above steps. (For pediatrics may repeat x2).

If still unable to aspirate for blood, document and refer to section I – Occlusion Management. Attempt
accessing another lumen if available.

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NURSING ALERT (Continued)

 Refer to Section I – Occlusion Management if order for fibrinolytic agent (Cathflo®) is

obtained.

12. Flush with N/S using vigorous push-pause technique.

13. Remove syringe.

14. Initiate infusion (refer to section D) or heparinize only if ordered by MRP.

NOTE: If heparin flush is ordered, follow steps 12 and 13 using Heparin following N/S.

15. Document.

C. FLUSHING

NURSING ALERT:

 Avoid previously accessed multi-use vials and bag spikes when flushing PICCs.
 Flush with 10 mL N/S (5-10 mL for pediatrics) between incompatible solutions and 20 mL (10-20
mL for pediatrics) after administration of blood products, PN, contrast medium or blood sampling.
 Each lumen of a clampless catheter should be flushed at minimum every 7 days and after each
access.
 Clamped catheters should be flushed every 24 hrs (every 48 hours for pediatrics) to each unused
lumen and after each access.
 Heparin to be used only with MRP orders. (Heparin may be required for pediatrics, or adult
patients with blood dyscrasias.)

EQUIPMENT

1. PPE
2. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen)
3. If ordered, 2 mL heparin (100 u/mL) per lumen, in a greater than or equal to 10 mL syringe
4. Alcohol swabs

NOTE: For pediatrics, see Appendix A.

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PROCEDURE:

1. Perform hand hygiene.

2. Don PPE.

3. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry).

4. Access needleless access adapter with N/S filled syringe.

5. Release clamp (if applicable) and aspirate slowly for blood, only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B.

6. Flush lumen with N/S and follow with heparin if ordered using vigorous push-pause technique.

7. Remove syringe.

8. Clamp lumen (if applicable).

9. Document.

D. ADMINISTRATION OF IV FLUIDS AND MEDICATIONS

NURSING ALERT:
 When administering PN through a multi-lumen catheter, use a dedicated lumen as much as
possible for PN.

NOTE: Refer to Appendix B for routine IV tubing changes.

EQUIPMENT

1. PPE
2. Alcohol swabs
3. Infusion pump
4. Primed IV set with solution (as ordered)
5. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen)

PROCEDURE:

1. Perform hand hygiene.

2. Don PPE.

3. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry).

4. Access needleless access adapter with N/S filled syringe.

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5. Release clamp (if applicable) and aspirate slowly for blood, only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B.

6. Flush lumen with N/S utilizing vigorous push-pause technique.

7. Remove syringe.

8. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry).

9. Connect primed IV tubing to adapter.

NOTE: Ensure connection and tubing is secure.

10. Start infusion of IV fluid or medication.

11. Document.

NOTE: When infusion is complete, refer to Section C - Flushing.

E. DRESSING CHANGE WITH STATLOCK®

NOTE: Assess dressing daily; replace dressing and StatLock® when it becomes damp,
loosened or soiled. Transparent semi permeable dressing is recommended for site
visualization; change every 7 days and PRN. Sterile gauze dressing changed every
2 days and PRN.

NOTE: Gauze underneath a transparent semi permeable dressing is considered a gauze

dressing.

NURSING ALERT:

 Care must be taken when removing existing dressing to avoid dislodging PICC which may be
anchored with securement device.
 Measure and document external length of catheter once a week for adults and once a shift for
pediatrics. Refer to Appendix C, D and F for pictures of how to measure a PICC.
 If PICC is found to have migrated 5 cm or more from its originally placed position, contact
Interventional Radiology (IR) for PICC check.
 If PICC is displaced 1-4 cm from its original position and is working well upon assessment,
continue to use as required and notify MRP. The MRP may obtain a chest x-ray to verify PICC
position and need for interventional radiology assessment.
 If PICC is displaced and found not to be working well, regardless of amount of displacement,
contact Interventional Radiology for PICC check.

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EQUIPMENT

1. PPE including mask

2. Clean gloves
3. Sterile gloves
4. Sterile dressing set
5. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410) (Orange tint available if
needed, usually used on insertion #310411)
6. Alcohol swabs

NOTE: Chlorhexidine (ChloraPrep®) use on pediatric patients less than 2 months of age is
not recommended. Use 70% alcohol.

NOTE: For patients with sensitivities:

 First, ensure you are applying dressing correctly (see Appendix E for tips on
application of dressing) and also making sure Chlorhexidine is completely dry
before applying dressing.
 Second, rule out if sensitivity is to Chlorhexidine or dressing:
o Swab area on inner arm with Chlorhexidine 2% with 70% alcohol. Observe
for skin reaction.
 If patient is sensitive to Chlorhexidine, use 70% alcohol first followed
by povidone iodine as an acceptable alternative.
o Place a dressing or small section of dressing on opposite inner arm.
Observe for skin reaction.
 If patient is sensitive to dressing, then an alternative dressing will have
to be explored.

7. Transparent semi permeable dressing (#319299)

8. Catheter securement device (StatLock®) (#313508) (Pediatrics #313510)
9. Sterile normal saline (as required)
10. 2 x 2 sterile gauze (as required)
11. Mesh netting in appropriate size for limb
12. Measuring tape

PROCEDURE

1. Explain procedure to patient.

2. Perform hand hygiene.

3. Don PPE including mask and clean gloves.

4. Position patient.

5. Assemble supplies on sterile field.

5.1 Open sterile dressing set.
5.2 Add StatLock® and package contents to sterile field.
5.3 Add transparent dressing to sterile field.
5.4 Add ChloraPrep® to sterile field.

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6. Inspect insertion site for redness, inflammation, tenderness or drainage.

7. Remove existing dressing.

7.1 Roll transparent dressing to expose StatLock® only (keep insertion site covered).

NURSING ALERT:

 If PICC insertion site is against the wings, you will need to remove entire dressing. Use tape
provided in StatLock® package to secure PICC at insertion site in order to prevent line migration.

7.2 Remove StatLock® (use alcohol swabs):

7.2.1 Unlock wings of StatLock® (this may take some force).
7.2.2 Lift PICC suture wings off of StatLock® posts.
7.2.3 Position PICC to side.
7.2.4 Use alcohol swabs to loosen StatLock® and remove.

NOTE: For blood or exudate on PICC catheter or wings, apply saline soaked gauze and
cleanse with sterile saline prior to cleaning with Chlorhexidine.

8. Remove gloves.

9. Perform hand hygiene.

10. Don sterile gloves.

11. Cleanse skin beneath StatLock® site:

11.1 Cleanse entire area where dressing is placed using Chloraprep® in a crosshatch motion
(back and forth) with light friction in two different directions for a total of 30 seconds.

NOTE: Never Fan Dry

11.2 Place ChloraPrep® swab with sponge end pointing upward on sterile field to be reused later.

12. Apply skin protectant using pad from StatLock® package. Let dry.

13. Apply new StatLock® device:

13.1 Secure PICC suture wings on StatLock® posts and close wings.
13.2 Apply StatLock® to skin.

14. Grasp remaining dressing with a sterile 2x2 (to remain sterile) while removing remainder of old
dressing.
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15. Cleanse skin at insertion site with previously used ChloraPrep® swab:
15.1 Cleanse area to be re-covered with dressing in a crosshatch motion (back and forth) with
light friction in two different directions for a total of 30 seconds.
15.2 Cleanse length of exposed catheter from insertion site down with same ChloraPrep® swab.
Let dry 2-3 minutes.

NOTE: Never fan dry.

16. Apply new dressing.

16.1 Apply transparent semi permeable dressing over insertion site, including StatLock® (ensure
insertion site is visible). See Appendix E for tips on application of dressing.
16.2 Avoid stretching, smooth from centre out to edge and mold around catheter lumens.
16.3 Place one tape from dressing package over PICC lumen(s) leg(s).
16.4 Write date on second tape and position just below first tape.

17. Measure length of PICC from insertion site to StatLock® posts (or to suture wings). See Appendix C
and D for how to measure a PICC.

18. Ensure PICC lumen(s) are anchored securely (i.e. mesh netting).

19. Document.

F. DRESSING CHANGE WITH SecurAcath® (See Appendix F for Pictures)

NOTE: SecurAcath® is intended to stay in situ for the life of PICC.

NOTE: Assess dressing daily; replace dressing when it becomes damp, loosened or
soiled. Transparent semi permeable dressing is recommended for site
visualization; change every 7 days and PRN. Change sterile gauze every 2 days and
PRN.

NOTE: Gauze underneath a transparent semi permeable dressing is considered a gauze

dressing.

EQUIPMENT

1. PPE including mask

2. Clean gloves
3. Sterile gloves
4. Sterile dressing set
5. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410) (Orange tint available if
needed, usually used on insertion (#310411)
6. Sterile normal saline (as required)
7. 2 x 2 sterile gauze (as required)
8. Transparent semi permeable dressing (#319299)
9. Mesh netting in appropriate size for limb
10. Measuring tape

NOTE: Chlorhexidine (ChloraPrep®) use on pediatric patients less than 2 months of age is
not recommended. Use 70% alcohol.
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NOTE: For patients with sensitivities:

 First, ensure you are applying dressing correctly (see Appendix E for tips of
application of dressing) and also making sure Chlorhexidine is completely dry
before applying dressing.
 Second, rule out if sensitivity is to Chlorhexidine or dressing:
o Swab area on inner arm with Chlorhexidine 2% with 70% alcohol. Observe
for skin reaction.
 If patient is sensitive to Chlorhexidine, use 70% alcohol first followed
by povidone iodine as an acceptable alternative.
o Place a dressing or small section of dressing on opposite inner arm.
Observe for skin reaction.
 If patient is sensitive to dressing, then an alternative dressing will have
to be explored.

PROCEDURE

1. Explain procedure to patient.

2. Perform hand hygiene.

3. Don PPE including mask and clean gloves.

4. Position patient.

5. Assemble supplies on sterile field.

5.1 Open sterile dressing set.
5.2 Add ChloraPrep® to sterile field.
5.3 Add transparent dressing to sterile field.

6. Remove dressing.

7. Inspect insertion site for redness, inflammation, tenderness or drainage.

8. Perform hand hygiene.

9. Don sterile gloves.

10. Cleanse insertion site with ChloraPrep® in a crosshatch motion (back and forth) with light friction
in two different directions.
10.1 Cleanse both sides of SecurAcath® with the same ChloraPrep® swab. To cleanse the
underside of SecurAcath® you can lift device less than 30-45 degrees. Do not twist it.
10.2 Cleanse entire area of skin that will be under new dressing with the same ChloraPrep®
swab in a crosshatch motion (back and forth) with light friction in two different directions for
a total of 30 seconds.

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10.3 This entire cleansing process should take a total of 30 seconds

NOTE: For blood or exudate on PICC catheter or SecurAcath®, apply saline soaked gauze
and cleanse with sterile saline prior to cleaning with Chlorhexidine.

11. Cleanse entire length of PICC catheter up to and including body of PICC with the same
ChloraPrep® swab. Let dry 2-3 minutes.

NOTE: Never fan dry.

12. Apply new dressing.

12.1 Apply transparent semi permeable dressing over insertion site, including SecurAcath®
(ensure insertion site is visible).
12.2 Avoid stretching and smooth around edges of dressing only, do not press down on
SecurAcath®.
12.3 Place one tape from dressing package over PICC lumen(s) leg(s).
12.4 Write date on second tape and position just below first tape.

13. Measure length of PICC from insertion site to suture wings. See Appendix F for how to measure a
PICC.

14. Ensure PICC lumen(s) are anchored securely (i.e. mesh netting).

15. Document.

G. BLOOD SAMPLING

NURSING ALERT:

 PICC access should be minimized to conserve blood and decrease manipulation of adapter.
 Assess patient to determine best method for blood sampling.
 Venipuncture may be an option.
 Vacutainer® Luer-Lok™ access device has rubber sheathed needle in center (ensure caution is
taken to avoid skin puncture).
 If patient has PN infusing through any lumen, avoid blood draws from this lumen as much as
possible.

EQUIPMENT

1. PPE
2. Blood specimen tubes and labels (plus discard tube 3-5 mL)

NOTE: Refer to test compendium in laboratory services manual on RQHR Intranet for
appropriate blood tubes.
http://rhdintranet/lab/public/Manuals/Laboratory%20Services%20Manual.htm

3. Vacutainer® Luer-Lok™ access device (#952058)

4. 3 x 10 mL N/S in a greater than or equal to 10 mL syringe

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5. Alcohol swabs
6. Blood transfer device (#952056) (if required to transfer blood from syringe draw to blood sample tube)
7. Blood collection set – with male adapter (Angel Wing®) – from lab for blood culture collection
8. Needleless access adapter if blood culture collection

NOTE: For pediatrics, see Appendix A.

PROCEDURE

NURSING ALERT:

 In a triple-lumen catheter use red/larger lumen for blood sampling when possible.
 If continuous infusion in place, stop infusion through all lumens, flush and wait 1 minute before
drawing discard.

1. Perform hand hygiene.

2. Don PPE.

3. Disconnect infusion if in place, maintaining asepsis.

4. Cleanse needleless access adapter vigorously with an alcohol swab using 15 second scrub (let dry).

5. Change needleless access adapter (if drawing blood cultures).

6. Attach greater than or equal to 10 mL syringe with 10 mL N/S.

7. Aspirate slowly for blood only until flashback appears.

NOTE: If unable to aspirate blood, see related nursing alert in section B. If still unable to
aspirate sample, attempt blood sampling from another lumen if possible or notify lab
to obtain samples via venipuncture. Notify MRP and document.

8. Flush lumen with attached N/S syringe using vigorous push-pause technique and wait 1 minute.

9. Attach Vacutainer® Luer-Lok™ access device.

10. Insert blood specimen tube (3-5 mL) for discard and remove when filled.

NOTE: Blood cultures should be collected via venipuncture unless ruling out PICC as
source of infection. Change needleless access adapter prior to blood culture
sampling from PICC and use discard as part of first sample. Draw one set from PICC
and have lab draw one set via venipuncture.

11. Insert appropriate blood specimen tubes in appropriate order and obtain samples, filling each sample
to fill line.

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NOTE: Order of blood collection should be as below:

 Blood culture (SPS) aerobic then anaerobic
 Blue (Citrate)
 Orange, Red or Yellow (Serum Tube)
 Green (Heparin)
 Mauve (EDTA)
 Grey (Fluoride/Glucose)

NOTE: If unable to aspirate blood through Vacutainer® Luer-Lok™ access device, remove
device and aspirate blood using greater than or equal to 10 mL syringe. Obtain discard
in separate syringe prior to obtaining blood samples. Transfer blood samples to tube
by attaching blood transfer device to blood filled syringe. Insert blood specimen tubes.
DO NOT use a needle to transfer blood.

12. Invert tubes gently 5 times immediately following obtaining each sample.

13. Remove Vacutainer® Luer-Lok™ access device and discard in sharps container.

NOTE: Discard blood transfer device and blood discard in sharps container.

14. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry).

15. Attach greater than or equal to 10 mL pre-filled N/S syringe and flush with total of 20 mL N/S, using
vigorous push-pause technique (10-20 mL for pediatrics).

16. Remove syringe.

17. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry).

18. Reconnect continuous infusion to lumen, if applicable, and restart.

19. Label specimen tubes in presence of patient at time of collection and send to lab immediately.

NOTE: Label according to laboratory services manual on RQHR intranet

http://rhdintranet/lab/public/Manuals/Laboratory%20Services%20Manual.htm
Cross match samples also require birth date. Requisition should indicate where
sample obtained from (i.e. PICC).

NOTE: If coagulation studies are collected, indicate on requisition if PICC was heparinized.

19. Document.

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H. ACCIDENTAL REMOVAL & DRESSING APPLICATION UPON PHYSICIAN/RN REMOVAL

NURSING ALERT:
 Intentional removal of PICC is the responsibility of a physician or RN/RPN. See Section E.

EQUIPMENT

1. PPE
2. 4x4 gauze (sterile)
3. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410)(Orange tint available if
needed, usually used on insertion #310411)
4. Occlusive dressing with sterile Petroleum Jelly (single use packet), 2x2 sterile gauze and transparent
semi permeable dressing

PROCEDURE

1. Don PPE.

2. Apply pressure to site using 4x4 gauze until bleeding has stopped.

3. Cleanse site with ChloraPrep® as needed, while keeping puncture site covered with gauze.

4. Apply sterile gauze with sterile petroleum jelly to site. Cover with transparent dressing.

5. Compare length of catheter using catheter markings with catheter length recorded at time of insertion
(see physician progress note, x-ray report, or interagency referral form for initial length).

6. Notify MRP that PICC has been accidentally removed.

7. Complete occurrence report.

8. Document.

NURSING ALERT:
 If you suspect PICC has broken because length is shorter than documented, immediately contact
Interventional Radiologist (IR) and monitor patient condition.

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I. OCCLUSION MANAGEMENT

NURSING ALERT:

 An Order is required for instillation of a fibrinolytic agent into a PICC.

 Fibrinolytic Agents are contraindicated:
o in patients who have internal bleeding
o if any of the following occurred within 48 hours:
 coronary artery bypass graft surgery, obstetrical delivery, organ biopsy, puncture of non-
compressible vessels (i.e. subclavian vein) or recent trauma.
o in presence of known or suspected infection in CVAD.
o allergy to fibrinolytic agent to be used.
 Use with caution in presence of a known or suspected infection in PICC.
 Caution should be exercised in patients who have hemostatic defects (including those secondary to
severe hepatic or renal disease) or any condition in which bleeding constitutes a significant hazard or
would be particularly difficult to manage because of its location, or who are at high risk for embolic
complications (e.g. recent pulmonary embolism, deep vein thrombosis, endarterectomy).
 Consider contacting nursing educator for troubleshooting occlusion.
 Refer to occlusion management algorithm in Appendix I.

EQUIPMENT

1. PPE as required (gloves, etc.)

2. Sterile water for injection to reconstitute fibrinolytic agent
3. 3 mL syringe
4. Blunt fill needle
5. 3 greater than or equal to 10 mL syringes
6. Fibrinolytic Agent (Cathflo® 2 mg vial) from Pharmacy
7. Normal Saline for injection Pre-filled normal saline (N/S) syringes
8. Alcohol swabs
9. Medication label
10. Heparin 100 units/mL (as required)
11. Needleless access adapter (as required)

PROCEDURE

1. Notify MRP and obtain an order for a fibrinolytic agent (Cathflo®).

NOTE: Ensure no contraindications as noted in previous Nursing Alert.

2. Perform hand hygiene.

3. Reconstitute fibrinolytic agent according to product guidelines immediately before use as per
Appendix J.

4. Draw up 2 mL of reconstituted fibrinolytic agent (Cathflo® 1mg/mL) into a greater than or equal to
10 mL syringe.

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NOTE: See Appendix H for pediatric dosage chart.

5. Inspect fibrinolytic agent for foreign matter and discoloration.

NOTE: Do not administer if particulate matter is noted.

6. Don PPE.

7. Explain procedure to patient.

8. Stop infusions through all lumens for duration of dwelling.

NOTE: If multiple lumens are occluded, instil fibrinolytic agent into only one (1) lumen.

9. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub; (let dry).

10. Remove blunt needle from syringe.

11. Access occluded lumen with reconstituted fibrinolytic agent in greater than or equal to 10 mL syringe.

12. Instil fibrinolytic agent slowly into occluded lumen.

NOTE: If difficult to infuse through needleless access adapter, clamp catheter (if applicable),
remove needleless access adapter, and attach syringe with fibrinolytic agent directly
to hub of PICC catheter. Instil fibrinolytic agent, clamp catheter (if applicable), remove
syringe and attach new needleless access adapter.

13. Remove syringe and clamp (if applicable).

14. Label lumen hub with name of drug, dosage, and time of instillation.

15. Document on Patient’s Record and sign for drug instillation on patient’s Medication Administration
Record (MAR).

NOTE: If multiple lumen PICC, indicate which lumen instilled with fibrinolytic agent.

16. Allow fibrinolytic agent to dwell for 30 minutes.

17. Cleanse needleless adapter vigorously with alcohol swab using 15 second scrub (let dry).

18. Attach greater than or equal to 10 mL syringe and attempt to aspirate drug and blood.

NOTE: If PICC is functional, go to step 19.

If PICC remains occluded go to step 22.

19. Aspirate 4-5 mL of blood in patient greater than 10 kg and discard or 3 mL in patients less than 10 kg
and discard.

20. Flush with 20 mL NS in greater than or equal to 10 mL syringe using vigorous push pause technique.

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NOTE: For pediatrics, flush with 10–20 mL of NS depending on age of patient.

21. Attach to infusion or Saline lock.

22. Allow fibrinolytic agent to dwell another 90 minutes (total of 120 minutes), if no blood return after 30
minutes.

23. Follow steps 17– 21 after an additional 90 minutes of dwell time if occlusion was not resolved after 30
minutes.

NURSING ALERT:

• If no blood return after 120 minutes, a second dose of fibrinolytic agent may be
attempted in same lumen.
• An order must be obtained to attempt another dose.
• If still unable to aspirate blood after second instillation, notify MRP.

24. Follow previous steps in procedure if a repeat dose is required.

25. Document results of procedure.

26. Notify MRP if unsuccessful after second attempt.

J. REMOVAL OF PICC

NURSING ALERT:

 This procedure may be performed by RN’s or RPN’s educated in this skill.

 PICC’s in pediatric patients will be removed by MRP or RN specializing in pediatrics and educated
in this skill.
 An occlusive dressing is required to provide a complete seal to prevent air embolism and infection.
 Routine tip cultures are not performed unless removal for suspected infection or sepsis and require
an MRP order.
 If catheter tip is to be sent for C&S, corresponding blood cultures must be collected prior to
removal (1 set drawn venipuncture and 1 set from catheter).

EQUIPMENT

1. Stitch cutter for pediatrics only

2. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®) (Clear #310410)(Orange tint available if
needed, usually used on insertion #310411)
3. Dressing bundle
4. PPE
5. 2x2 sterile gauze x2

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6. Sterile petroleum jelly (occlusive dressing)

7. Transparent semi permeable dressing
8. Sterile gloves

PROCEDURE

J.1 REMOVAL

1. Verify order to remove PICC.

2. Note catheter length recorded at time of insertion. (See progress note, x-ray report, or interagency
referral form.

3. Perform hand hygiene.

4. Explain procedure to patient.

5. Don PPE.

6. Discontinue administration of all infusions.

7. Position patient supine or sitting with PICC arm at 45-90º angle to body where possible.

NOTE: Insertion site should be placed below level of heart.

8. Set up sterile field adding occlusive dressing and ChloraPrep® swab.

9. Remove dressing.

10. Remove Statlock® (if applicable).

11. Remove clean gloves, perform hand hygiene and apply sterile gloves.

12. Cleanse insertion site with ChloraPrep® in a crosshatch motion (back and forth) with light friction in
two different directions for a total of 30 seconds.

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13. Remove PICC catheter from SecurAcath® (if applicable) see appendix G for pictures:
12.1 Remove cover of SecurAcath® by placing finger under device to stabilize (on side of
SecurAcath® that says HOLD), grasp tab on SecurAcath® that says LIFT with other hand.
12.2 Lift tab to completely detach cover from anchor base and discard cover.
12.3 Lift PICC line out of SecurAcath® device leaving SecurAcath® base in place until PICC is
removed.

14. Instruct patient to take a deep breath and hold, bear down (if not contraindicated) or exhale during
PICC removal.

NOTE: Removal should take approximately 1-2 minutes to prevent vasospasm; nurse may
need to pause several times during removal and allow patient to take another deep
breath and hold or bear down as removal occurs.

15. Grasp PICC near insertion site below anchor wings and pull gently.

NURSING ALERT:

 Do not grasp Luer hub to remove as catheter damage could occur.

 Do not apply excessive pressure to PICC as it may break.

16. Remove PICC slowly over 1 to 2 minutes to prevent venospasm.

17. Stop removal if you meet resistance and have patient change position by lifting arm at a 90 degree
angle away from body and slightly backwards, turning neck to look over opposite shoulder than side
of PICC insertion.

18. Continue to remove PICC slowly, if you continue to meet resistance proceed to Section J.2 -
Resistance to Removal.

19. Hold sterile gauze gently over insertion site when there is approximately 5 cm of PICC left to
remove.

20. Continue until completely removed then apply direct pressure to insertion site with sterile gauze until
bleeding is controlled, usually 2-5 minutes.

21. Compare length of catheter using catheter markings with catheter length recorded at time of
insertion. (See progress note, x-ray report, or interagency referral form for initial length.)

22. Remove SecurAcath® (if applicable).

22.1 Fold edges of SecurAcath® anchor base downward. Place a finger under back edge of device
to help begin folding motion.
22.2 Place one hand near insertion site to stabilize the tissue. Hold folded anchor base horizontal to
skin and lift anchor out of insertion site.

NOTE: If skin appears to be growing over SecurAcath® legs skip folding steps and move
directly to cutting the SecurAcath®.

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22.3 Resistance to removing SecurAcath® while folding requires cutting base with blunt tip scissors
in half lengthwise along blue groove.
22.4 Place one hand near insertion site to stabilize tissue. Use a swift, deliberate tug to remove
each half of anchor base separately. Flexible anchor will straighten as it is pulled out and will
not cause tearing or trauma to the tissue.

NURSING ALERT:

 If you suspect PICC has broken because it pops or length is shorter than documented, immediately
apply an occlusive dressing over insertion site.
 Immediately contact interventional radiologist and monitor patient condition.

23. Ensure bleeding has stopped.

24. Apply 2x2 gauze with sterile petroleum jelly and transparent dressing over insertion site and leave
on for minimum of 24 hours.

25. Instruct patient to remain in supine or sitting position for 30 minutes after removal.

NOTE: If culture and sensitivity of PICC line is ordered: After completion of step #21 place
PICC tip on sterile field and after completion of step #25 use sterile scissor and cut 2-
3 cm from distal PICC end and drop directly into sterile container. Send to lab for
culture and sensitivity.

26. Discard PICC in appropriate waster container.

27. Document:
 condition of exit site
 length of catheter
 patient response
 if PICC tip was sent for culture

J.2 RESISTANCE TO REMOVAL

PROCEDURE

NOTE: Resistance to PICC removal may be caused by venospasm, phlebitis, thrombus, or

presence of a fibrin sheath.

NOTE: Before initiating following steps try trouble shooting by having patient change
position by lifting their arm at a 90 degree angle away from their body and slightly
backwards and turning their neck to look over their opposite shoulder than side of
PICC insertion.

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1. Apply a sterile dressing to insertion site.

2. Apply a warm compress to upper arm for 20 minutes to relax vein.

3. Remove dressing and attempt removal again starting from steps 16 in section J.1.

4. Stop procedure if resistance continues.

5. Apply a sterile dressing over insertion site.

6. Secure catheter to skin below dressing.

7. Notify MRP/Interventional Radiologist.

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REFERENCES:

Adler, A. (2016). Peripherally Inserted Central Catheter (PICC) Removing. Retrieved from
CINAHL.

Broadhurst, D., & Ulman, A. (2017). Management of Central Venous Access Device Associated
Skin Impairment. Wound Ostomy Continence Nursing. Lippincott, Williams & Wilkins.

Caple, C., & Schub, T. (2016). Peripherally Inserted Central Catheter (PICC) Care: Performing-an
Overview. Retrieved from CINAHL.

Centers for Disease Control, (2011). Guidelines for the prevention of intravascular catheter-related
infections, 2011. Atlanta, GA: CDC.

Davis, M.B. (2013). Pediatric Central Venous Catheter Management: A review of Current Practice.
JAVA Vol 18 No 2 p.93 -98.

Infusion Nurses Society. (2016). Infusion nursing standards of practice. Norwood, MA: Lippincott,
Williams & Wilkins.

Infusion Nurses Society. (2016). Policies and procedures for infusion nursing. Norwood, MA: Infusion
Nurses Society.

Lynn-McHall Wiegand, D., & Carlson, K. (Eds.). (2011). AACN procedure manual of critical care (6th
ed.). St. Louis, MO: Elsevier Saunders.

McGee, W., Headley, J., & Frazier, J. (Eds.). (2010). Quick guide to cardiopulmonary care (2nd ed.).
Irvine, CA: Edwards Lifesciences LLC.

Mosby’s Skills (2012) Peripherally Inserted Central Catheter (PICC): Blood sampling and Catheter
Removal. Elsevier Inc.

Regina Qu'Appelle Health Region Laboratory Services. (2017). Lab services manual

Safer Healthcare Now (2012). Getting started kit: Prevent central line infections.

Revised by: Teresa Vall, Lisa Roland, Jana Lowey, CNE’s, RQHR
Date: September, 2013

Revised by: Kim Hunt, Lisa Roland, Jana Lowey, Kim Rapchalk, Dana Lamers, Tara Griffiths, Sarah
Harder, CNEs
Date: May 2017

Approved by:
Date:

June 7, 2017 Keyword(s): Central Line, PICC, Power PICC

Regina Qu’Appelle Health Region
Health Services
Nursing Procedure Committee

Approved: June 7, 2017 Page 23 of 35

 APPENDIX A

PEDIATRIC AND ADOLESCENT CENTRAL VENOUS ACCESS

DEVICE PROTOCOL

RN must obtain order stating “follow pediatric CVAD protocol”

Short term Tunnelled Implanted Peripherally

Central Intravascular Venous Access Inserted
Venous Line Catheter (TIC) Device (IVAD) Central
(CVL)* Catheter (PICC)
< 1 year Pre flush with 5mL 5mL 10mL 5mL
0.9% saline
< 1 year Agent used to 50u/mL 50u/mL heparin 50u/mL heparin 0.9% saline
maintain heparin *Mix 1ml of *Mix 1.5ml of
patency *Mix 0.5ml of 100u/ml 100u/ml
100u /ml heparin + 1ml heparin + 1.5
heparin +0.5 N/S ml N/S
mL N/S
< 1 year Final Volume 1mL 2mL 3mL 5mL
< 1 year Flushing EOD EOD Q Monthly EOD (clamped)
frequency of OR
unused lumens Q 7 days PASV
(clampless)
> 1 year – Pre flush with 5-10mL 5-10mL 10mL 5-10mL
18 years 0.9% saline
of age
> 1 year – Agent used to 100u/mL 100u/mL 100u/mL 0.9% saline
18 years maintain heparin heparin heparin
of age patency
> 1 year – Final Volume 1mL 2mL 3mL 5mL
18 years
of age
> 1 year – Flushing EOD EOD Q Monthly EOD (clamped)
18 years frequency of OR
of age unused lumens Q 7 days PASV
(clampless)

*Includes midlines, cut downs and femoral lines.

 NB for all CVAD limit heparinization to no more than 3 times/24 hours

If greater than 3 times/24hr required:
 For single lumen run IV fluid continuously in between meds
 For dual lumen divide fluid amount between lumens and run continuously
 Explore with attending physician changing the strength of heparin solution. For example
 50u/mL versus 100u/mL. Physicians’ order required.
 Attending physicians may override this protocol if they feel the amount of heparin will not
jeopardize the child’s coagulation status. Physicians order required.

 CVAD’s inserted for purpose of hemodialysis are used exclusively for that purpose, therefore without the
express written consent of the nephrologist those lines may not be used. Hemodialysis lines generally
contain a much stronger heparin concentration. Heparin in the CVAD used for hemodialysis should be
withdrawn and discarded, not flushed through catheter and into patient’s cardiovascular system.

Code: P.11
Date: May 2002, reviewed July 2007, February 2008, February 2011
Author: Pediatric CDE

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 APPENDIX B

IV Tubing Changes

IV Bag change Tubing Change Time

Plain IV solution Every 96 hours Every 96 hours
(no additives) this
includes pressure
tubing

IV solution with Every 96 hours Every 96 hours

additives:
manufacturer or
pharmacy mixed
IV solution with Every 24 hours Every 96 hours
additives: nurse
mixed
IV solution with Every 24 hours Every 24 hours
Lipids
Propofol Every 12 hours Every 12 hours
Blood products Per orders Every 4 units or 24 hrs, whichever
occurs first.
Intermittent ___ Every 24 hours
medications

Code: P.11
Date: May 2002, reviewed July 2007, February 2008, February 2011, January 2012
Author: Pediatric CDE

Approved: June 7, 2017 Page 25 of 35

 APPENDIX C

HOW TO MEASURE A PICC

1. Assess catheter, insertion site and affected arm prior to any catheter management or procedure. (pg 2 PICC
procedure.)

2. Measure and document length of PICC from insertion site to proximal end of suture wing or StatLock® posts.
(See picture below)

3. Measure and document upon initial insertion and then once per shift and prn for pediatrics and once a week
following dressing changes and prn for adults.

4. If there are concerns that exterior length of the PICC line has changed, compare to the baseline
measurement and notify radiologist or physician.

**For pediatrics, always print off and include PICC procedure in the care plan so everyone can refer to it. Include
baseline measurement in the care plan and nurse’s notes. All other measurements should be in the nurse’s
notes.**

Code: P.11
Date: May 2002, reviewed July 2007, February 2008, February 2011, January 2012, August 2013
Author: Pediatric CDE

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 APPENDIX D
PICC line dressing using Statlock PICC Plus securement device
and PICC line with no suture

1. Open sterile dressing set at bedside table and assemble

supplies on sterile field.

 Add stat lock and transparent dressing

2. Add ChloraPrep® swab to field

3. Apply non-sterile gloves and roll the transparent dressing

back to expose the stat lock only .

 keep the insertion site covered with the transparent

dressing

SEE NOTE AT END FOR DIFFERENCES IN TECHNIQUE

WHEN PICC LINE SUTURE WING IS BUTTED UP TO THE
INSERTION SITE.

4. Remove the PICC from the Stat Lock securement device.

 Position the PICC to the side to enable proper cleansing

5. Remove the Stat Lock using alcohol swabs as needed.

6. Remove gloves, perform hand hygiene and don sterile

gloves.

7. Cleanse the exposed area, including the PICC line itself with
chlorhexidine swab using gentle friction and let dry 2-3
minutes.

Approved: June 7, 2017 Page 27 of 35

8. Apply skin protectant to the area where the new stat lock will
be applied

9. Attach the PICC line to the Statlock device.

 secure the PICC suture wings to the statlock posts and

close the doors

 Arrows point towards the insertion site

10. Apply Statlock to the skin.

11. Using a sterile 2x2 from sterile field, remove the remainder of
the transparent dressing.

12. Cleanse exposed area with chlorhexidine swab.

13. Apply the new Transparent dressing

 Apply dressing over insertion site including statlock,

ensuring the insertion site is within in the clear window.

 Avoid stretching the dressing

 Smooth from the center to the edge

 Mold with your hands around the statlock

14. Apply one of the tape strips supplied with transparent

dressing over the PICC lumen(s).

15. Write date on the 2nd tape and position distal to the first tape.

16. Measure from insertion site to Statlock posts and record in

the care plan.

17. Apply mesh netting to secure the PICC lumens securely

Code: P.11
Date: August, 2013
Author: Teresa Vall, Lisa Roland, Jana Lowey, CNE’s

Approved: June 7, 2017 Page 28 of 35

 Tegaderm™ Appendix E

Application Hints

1. Select a dressing size that will adequately cover the catheter and insertion site or wound. Ensure at least a one
inch margin of dressing adheres to healthy, dry skin.

2. Prepare the catheter insertion site or wound according to your institution’s approved protocol.

3. To ensure good adhesion, clip excess hair where the dressing will be placed. Do not shave the skin because of
the potential for microabrasions.

4. Make sure skin is free of soaps, detergents, and lotions. Allow all preps and protectants to dry thoroughly
before applying the dressing. Wet preps and soap residues can cause irritation if trapped under the dressing.
Additionally, adhesive products do not adhere well to wet or oily surfaces.

5. Do not stretch the Tegaderm™ dressing during application. Applying an adhesive product with tension can
produce mechanical trauma to the skin. Stretching can also cause adhesion failure.

6. The adhesive of Tegaderm™ dressing is pressure-sensitive. To ensure best adhesion, always apply firm
pressure to the dressing from the center out to the edges.

7. To tailor a dressing for a special application, use sterile scissors to cut the dressing into desired shapes or sizes
before removing the printed liner. For best results and ease of application, cut the pieces so that a portion of
the frame remains on at least two sides.

8. For subclavian and jugular sites, apply the dressing with the patient’s head turned away and neck extended as
expected in normal movement. This helps prevent contamination of the site from respiratory secretions and
stress on the dressing when the patient moves.

Removal Hints

Support the skin when removing Tegaderm™ dressing. For removal from I.V. sites, also stabilize the catheter to
prevent dislodgment. Use one of the following removal techniques based on your patient’s skin condition and your
own personal preference:

 Gently grasp one edge and slowly peel the dressing from the skin in the direction of hair growth. Try to peel
the dressing back over itself, rather than pulling it up from the skin.
or
 Grasp one edge of the dressing and gently pull it straight out to stretch and release adhesion.
or
 Apply an adhesive remover suitable for use on skin to the adhesive edge while gently peeling from the skin.

*To aid in lifting a dressing edge, secure a piece of surgical tape to one corner and rub firmly. Use the tape as a tab
to help you slowly peel back the dressing.

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 PICC Dressing change with SecurAcath
This document is intended to provide guidance for PICC dressing change with SecurAcath
NOTE: SecurAcath is intended to stay insitu the entire life of the PICC line
APPENDIX F
1. Measure and record external length: From insertion site to PICC suture wings.
NOTE: IF PICC LINE HAS DISPLACED 5CM OR MORE FROM ITS ORIGINAL
POSITION PLEASE CONTACT INTERVENTIONAL RADIOLOGY FOR A PICC
LINE CHECK.
Measurement

2. Perform hand hygiene and set up sterile field.

3. Don non-sterile gloves

4. Remove dressing

5. Perform hand hygiene and apply sterile gloves

6. Cleanse insertion site with chlorhexidine swab using a cross hatch technique
(only one swab is needed). Note: For blood or exudate on the catheter
or SecurAcath, apply saline soaked gauze and cleanse with sterile saline
prior to cleansing with chlorhexidine.

7. Cleanse both sides of the SecurAcath with a chlorhexidine swab.

8. To clean the underside of the SecurAcath, You can lift the SecurAcath less than 30-45 degrees, but don’t twist it.

9. Cleanse the entire area of skin that will be under the new dressing with chlorhexidine swab, using a cross hatch
technique.

10. Cleanse the entire length of PICC catheter up to including the body of the PICC,
with a chlorhexidine swab.

11. Let chlorhexidine dry (approx 2-3 minutes) and apply new dressing.

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 PICC Removal with SecurAcath
This document is intended to provide guidance for PICC removal with SecurAcath
NOTE: SecurAcath is intended to stay in situ until the PICC line is discontinued.
APPENDIX G
1. Clean work surface with appropriate disinfectant. Allow to dry.

2. Position the patient supine or sitting with the arm at 45 to 90 degree angle with the
insertion site below the level of the heart.

3. Set up sterile field, adding occlusive dressing.

4. Wash hands and apply clean gloves.

5. Remove dressing, remove gloves and cleanse hands.

Apply sterile gloves.

6. Cleanse insertion site with Chlorhexidine swab and let dry. If PICC has been in situ for
longer than one week, it may be helpful to apply saline soaked 2x2 gauze at insertion
site to help ease removal of SecurAcath.

7. Remove cover of securAcath by placing finger under the

device to stabilize (on side of SecurAcath that says HOLD).
Grasp tab on cover (on side that says LIFT) with other hand.

8. Lift tab to completely detach cover from anchor base.

9. Lift PICC line out of the SecurAcath® device.

10. Remove PICC line as per Nursing Procedure. Apply Pressure

for at least 2 minutes or until hemostasis is achieved. Cover
insertion site with occlusive dressing before removing SecurAcath®.
11. Hold edges of SecurAcath® anchor base downward.
Place a finger under back edge of device to help begin
folding motion.

12. Place one hand near the insertion site to stabalize the
tissue. Hold folded anchor base horizontal to the skin
and lift the anchor out of the insertion site.

NOTE: If skin appears to be growing over SecurAcath®

legs skip folding steps And move directly to cutting the
SecurAcath®.

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CODE P.11

13. If unable to remove securAcath by folding, cutting the base

may aid removal. Use blunt tip scissors to cut the anchor base
In half lengthwise along the groove.

14. Place one hand near the insertion site to stabilize the
tissue. Use a swift, deliberate tug to remove each half of
the anchor base separately. The flexible anchor will
straighten as it is pulled out and will not cause tearing
or trauma to the tissue

15. Ensure occlusive dressing is covering insertion site, secure with transparent dressing.
Dressing to remain intact for at least 24 hours or until epithelization occurs.

16. Inspect catheter for integrity and length. Note any damage or irregularities. Compare
with documented length at insertion, if required.

17. Remove gloves and perform hand hygiene.

18. Document in the patient’s health record date and time of removal, reason for removal,
condition of site and catheter (including length), patient’s tolerance of procedure and
patient teaching.

Approved: June 7, 2017 Page 32 of 35

 APPENDIX H

Pediatric Dosage:

For Patients >30 kg

Use adult dosing of 2mg/2mL

For Patients <30 kg >10kg

Reconstitute fibrinolytic agent according to preparation guidelines. Use 110% of intralumenal
volume, not exceeding 2mLs.

For Patients <10 kg

The suggested dose is 0.5 mg for any type of catheter, diluted with normal saline to an
appropriate volume to fill the catheter. There is no literature for this dosage; dose used at the
Hospital Sick Children (Toronto) under a hematology consult. Nursing staff must draw up 0.5
mg/0.5 mL and further dilute for lumen volume.

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CathFlo Algorithm APPENDIX I

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CODE P.11

APPENDIX J

CathFlo Reconstitution

PREPARATION OF SOLUTION

Reconstitute Cathflo® to a final concentration of 1 mg/mL:

1. Aseptically withdraw 2.2 mL of Sterile Water for Injection, USP (diluent is not provided). Do not
use Bacteriostatic Water for Injection, USP, for reconstitution as it has not been studied clinically.
2. Inject 2.2 mL of Sterile Water for Injection, USP, into the Cathflo® vial, directing the diluent stream
into the powder. Slight foaming is not unusual; let the vial stand undisturbed to allow large bubbles
to dissipate.
3. Mix by gently swirling until the contents are completely dissolved. DO NOT SHAKE. The
reconstituted preparation results in a colourless to pale yellow transparent solution containing 1
mg/mL Cathflo® at a pH of approximately 7.3.
4. Cathflo® contains no antibacterial preservatives and should be reconstituted immediately before
use. The solution may be used within 8 hours following reconstitution when stored at 2C-30C.
5. Withdraw 2.0 mL (2.0 mg) of solution from the reconstituted vial.

No other medication should be added to solutions containing Cathflo®.

Approved: June 7, 2017 Page 35 of 35