A peripherally inserted central catheter is also referred to as a PICC line. This type of catheter is placed in the antecubital vein (a large vein in the inner elbow area) and is threaded into a large vein above the right atrium of the heart (see Figure 12–4). The PICC line can remain in place for many weeks or months, avoiding the need for a new IV every few days. It can be used to deliver chemotherapy, antibiotics, transfusions, and IV nutrition. When the PICC line needs to be used for an infusion, IV tubing is connected to the end of the catheter. When it’s not in use, the IV tubing is disconnected and the catheter is flushed.

Figure 12–4: Peripherally inserted central catheter (PICC) line

How it’s put in

The PICC line may be inserted in your child’s hospital room or in an operating room or interventional radiology room by a nurse or doctor. Many children receive sedation medications to help stay relaxed and still during the procedure. Your child will be positioned on a flat surface, and he will need to keep his arm straight and motionless during the procedure. An injection to numb the area is given to decrease discomfort during insertion. A special needle is used to place the PICC line into the arm vein. The catheter is then threaded through the needle. Once the line is in place, a chest x-ray is taken to ensure it is positioned properly.

Brian had his Hickman® pulled when he started maintenance, but two weeks later he developed pancreatitis and needed total parenteral nutrition. Since he was still on active treatment, he was given the choice of another Hickman® or a PICC, which he decided to try. It was inserted right in our room with no anesthetic other than the morphine pump he was already on for the pancreatitis pain. He pushed his PCA button (the control that allows patients to administer their own doses of pain medication) moments before it was inserted because he was not sure what to expect. The procedure was uncomfortable, but not terribly painful. They did an x-ray to make sure that it was in the right place.

Care of the PICC line

The PICC line, like the external catheter, requires care to prevent problems. A nurse will teach you how to change the dressing, flush the line, change the injection cap, and inspect the site for possible signs of infection if your child will be going home with it. The line must be flushed after every use, or at least every day. You should get plenty of practice under the supervision of a nurse until both you and your child are comfortable with caring for the line. The care required for your child’s PICC line may be slightly different from what has been described in this section, because institutional preferences vary.

Kelsey had a PICC line in her right arm, and she would not straighten it out, but kept it a little bent. I definitely think she was protecting it, and also I think when she tried to straighten it, it pulled on the suture and on the dressing in an uncomfortable way that could have been painful, so she just wouldn’t try. I had to do a heparin flush every day and change the dressing twice a week. She could not tolerate Tegaderm®, so we used another kind of porous adhesive bandage, and doused it with Detachol®, which dissolved the adhesive within a few minutes, allowing us to get the bandage off quite easily. The Detachol® was a godsend for her, as removing the adhesive was a source of unnecessary pain. (For more information about Detachol®, see the section “Adhesives” later in this chapter.)

Several companies make colorful sleeves to cover PICC lines. A web page that describes several types of them can be found at https://themighty.com/2017/08/picc-line-covers.

Risks

The problems associated with a PICC line are similar to those of any external catheter. Veins may become irritated, infection can occur, or the line can be accidentally torn or moved.

Irritated veins. Within the first few days of insertion, the vein where the catheter is located may become irritated. Signs of irritation include swelling or pain in the area. Often, the discomfort can be eased by placing a warm cloth on the vein. Elevating the arm on a pillow is also sometimes helpful.

Infection. Meticulous care using sterile techniques is extremely important to reduce the risk of infection. The dressing over the exit site should be changed every week or if it becomes wet, soiled, or peels up. Injection caps must also be regularly changed using sterile techniques when the line is not in use, and the line must be flushed on a regular basis. Signs of infection include redness, swelling, pain, drainage, or warmth around the exit site. Fever, chills, tiredness, and dizziness may also indicate that the line has become infected. You should notify the doctor immediately if any of these signs are present or if your child has a fever above 101° F (38.5° C).

Torn catheter. Accidents sometimes happen, and a hole or tear in the line can occur. Careful handling of the catheter can help prevent these accidents. You should suspect a torn catheter if fluid leaks out of the line, especially during an injection. If a tear is found, you should try to find the hole, fold the line above the tear, tape it together, cover it with sterile gauze, and immediately notify your child’s doctor.

Displaced catheter. As with other external catheters, a PICC line must be securely taped to prevent movement. Signs of a displaced catheter include chest pain, burning or swelling in the arm above the exit site or in the chest, fluid leaking around the catheter, or pain when fluid is injected into the line.