PICC catheters The introduction of in the Netherlands and the role of nurses regarding insertion, complication management and care

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Einleitende Bemerkungen der SIGA-FSIA Venöse Infusionszugänge sind in der Behandlung von Patient:innen im Bereich der Anästhesie ein Standard, wobei die Studierenden die Einlage und Einlagetechnik während des zweijährigen Nachdiplomstudiums und mit sachkundiger Begleitung durch die Ausbildner:innen mittels des Cognitive Apprenticeship perfektionieren können. Zunehmend übernehmen die diplomierten Expert:innen Anästhesiepflege in der Schweiz, wie bereits auch schon weltweit, nebst den bereits ausgeführten Tätigkeiten in der pflegerischen Behandlung und dem Komplikationsmanagement auch zusätzliche Aufgaben bei der Einlage von zentralvenösen Kathetern wie beispielsweise der PICC-Line.

Ton van Boxtel, Mitbegründer des World Congress for Vascular Access (WoCoVA) und CEO des Global Vascular Access Network, geht im vorliegenden Artikel auf die peripher eingeführten Zentralkatheter (PICC) in den Niederlanden ein. Er erklärt unter anderem, dass das interprofessionelle Team die Infusionstechnologie bei Patient:innen verbessern kann.

In der Schweiz setzt sich der Verein NEVAM (Nurse experts for vascular access and maintenance) für die Förderung von Pa- tientensicherheit und -qualität im Umgang mit venösen Zugängen ein. Am 3. September 2022 wurde in Zürich der erste NEVAM-Kongress mit knapp 200 interessierten Teilnehmer:innen durchgeführt (wir berichteten im Anästhesie Journal 04/22). Die nächste Austragung findet am 16. September 2023 in Zürich statt. Notieren Sie sich bereits jetzt das Datum in Ihrem Kalender.

Introduction

Vascular access is important for almost all patients treated in a hospital. Many patients still suffer from the complications of unprofessional vascular access in practice. Unfortunately, patients often accept complications caused by this unprofessional practice.

With the start of NEVAM (Nurse Expert for Vascular Access and Maintenance) in Switzerland on 3 September 2022, an important step was taken towards improving vascular access for all patients. NEVAM also connects to the Global Vascular Access Network (GloVANet) where major vascular access societies from many countries in the World share innovations, knowledge and literature at the World Congress on Vascular Access (WoCoVA).

An increasing role of the nurses

Historically, vascular access and infusion technology was the terrain of physicians. Nurses played only a role in observation and administration of the prescribed medication.

In more recent years, we see an increasing role for the nurses where the key strategy is working as an interprofessional team to improve infusion technology for patients. Examples from other countries can help in this process of improving skills and increasing taking responsibility. For example, the multidisciplinary Vascular Access Team in Rome (Italy) with nurses and physicians, is inserting all types of Vascular Access Devices (VADs) and is involved in sharing knowledge in courses and congresses. The Catholic University in Rome even offers a master program on vascular access. This master program even found the way to Madrid in Spain. Historically vascular access and infusion technology is seen as a role for physicians. They decided what vascular access device (VAD) was inserted. The chosen device was inserted by the physician and all decision on the treatment and complication management were taken by the physicians.

All professionals involved should be aware of the two groups of VADs that are available and naming should be based on these two groups.

Nurse anesthetists and other experts involved in vascular access learn from other countries on state of the art and best practices in infusion technology. In this article the focus will be on describing the practice on Peripherally Inserted Central Catheter (PICC) in the Netherlands.

This means that a PICC is a Central Venous Catheter (CVC) and despite the insertion in a peripheral vein, the tip is in the lower third of the Superior vena cava, (SVC), Cavo Atrial Junction (CAJ) or in the Right Atrium (RA).

In more recent years we see an increasing role for nurses, both, in insertion of VADs

Cvad

and the use and complication management. The nurses’ role in countries differs based on hierarchy, reimbursement, and culture. Next to education, nurses can and should take more responsibility in infusion treatment. If a complication occurs, many protocols suggest consulting the ordering physician and let him/her solve the problems.

Although nurses in the USA play a crucial role in infusion, we also see that Italy is at the forefront of an increasing role for nurses in both insertion of VADs, the use, care & maintenance, prevention and solving complications. This is where nurses can take more responsibility in analyzing the complication and solve the problem themselves or share a suggestion with the ordering physician.

The situation within the Netherlands

With the start of home infusion in Utrecht in 1992, organizing reliable VADs was a challenge. The introduction of the PICC in the Netherlands in 1997, was based on the need for improvement of home infusion and learning about PICC at a congress in the USA.

There were several hurdles to take before starting with PICCs for patients: u The PICC’s on the market did not have CE (allowance to the European market). u The representatives of the companies were not familiar with their own product. u Representatives had to be instructed on PICCs that they had in the portfolio, based on international literature and a practical symposium. u Protocols were written based on international examples. u Who (members of staff) should and could insert the PICC? u Users and caregivers had to be instructed.

With the support of an oncologist, and preparing all aspects of PICC insertion and care, the PICC was more and more accepted by patients and professionals.

Over time the use of PICC slowly increased and insertion of PICC was further developed by the Clinical Nurse Specialist (CNS). In the first few years PICCs were only inserted for home infusion patients and slowly finding its way into clinical use and throughout the whole country. The introduction of ultrasound guided PICC insertion in 2004 and around 2012 the use of ECG for tip positioning increased the knowledge and acceptance of the PICC as a CVC.

In the Universitair Medisch Centrum (UMC) Utrecht the PICC was introduced as an alternative for Centrally Inserted Central Catheters (CICC) like a Hickman or subclavian catheter. Particularly for immune suppressed hematology patients the complication rates for PICC were at least comparable with previous years using other CVADs. Furthermore, the results show 2.1 infections / 1000 catheter days on a total of 3746 catheter days in this study (1). On a national level, we see many variables influencing the Lengths of (hospital) Stay. (LOS) Short LOS has a high economic impact. For patients this can mean that part of the intravenous (IV) treatment can be given outside the hospital. In 2017 LOS was 4.5 for the Netherlands and 8.3 for Switzerland. Reliable and safe home infusion can contribute to further reducing the LOS (online source 1). Of course, not all patients are in favor of home infusion. Particularly for patients without a partner or social network, treatment in the hospital can be preferred. In recent years we see that the PICC is used in all hospitals, both, for children and adults.

In the UMC Utrecht an alternative route for PICC insertion was started in 2008 by the surgery / anesthesiology department initiated by anesthesiology workers. Today an official Vascular Access Treatment (VAT) has been installed inserting Midlines, PICCs and Difficult Vascular Access (DIVA) for a specific group of patients. The PICCs are inserted by trained nurses and nurse anesthetists, using ultrasound for accessing veins and ECG technics for tip positioning. Important is, that the PICC insertion is performed in a clean room, not involving radiology for 99 % of the PICC procedures. All patient data, ultrasound and ECG images are directly saved in the patients record. For nurses as the main users and caretakers of the PICC, it is important to prevent complications and to have the skills and knowledge to analyze and treat possible complications.

Most frequently seen complications are: u Infection u Occlusion, partial and total u Thrombosis

Most complications can be prevented by choosing the right VAD, the right materials, and the right vein for insertion. All inserters should be well trained and have to have the skills and knowledge of performing a sterile procedure, use of ultrasound, and prevent complications during treatments. All vascular access specialists including nurses, physicians, nurse anesthetists, etc. should also be competent to teach and share up to date knowledge to trainees.

Materials

Since the introduction of the power-injectable polyurethan intravenous catheters, the incidence of catheter rupture by pressure has been diminished. This means that smaller syringes can be used. A 3 ml syringe can produce 55 pound per square inch (PSI) pressure.

The right Needle Free Connector (NFC) is important to prevent infections and occlusion. An easy to disinfect, neutral NFC should be a standard part of the VAD (Fig 3).

If a neutral NFC is used, clamping with an open-ended catheter is only needed when the NFC is replaced. Valved catheters do not reduce complications if the care protocol is followed.

Fixation and a semi-permeable dressing protect the VAD from pistoning and is protected against external infection risks (Fig 4).

Recent innovations such as the end cap to protect the NFC for infections and sealing the insertion site with cyanoacrylate glue. Glue prevents leaking and oozing and makes care of the insertion site easier and safer (2).

A multidisciplinary insertion and care team should be responsible for all VADs in a hospital including port, PICC and other CVC insertions. This allows spreading ‘up to date’ knowledge, skills and research for further innovations.

Infections can be prevented by conducting a sterile procedure for insertion and using a sterile or no-touch method based on guidelines and protocols (3).

CRBSI, Catheter Related Blood Stream Infections

Measurements to be taken if the IV line is blocked

Normal saline is used for flushing. In some cases, a buffer should be used before flushing with normal saline. Although many protocols for locking VADs, still include a heparin solution, studies show that a normal saline lock solution is sufficient to prevent occlusion (4, 5). To prevents adhesion of biofilm inside the catheter, a push pause technic should be applied. Understanding the effects of handling, are important and should be part of the VAD training.

Occlusion should be analyzed and consequences for patients on the IV treatment should be included in solving the problem. Occlusion can be prevented by choosing the right materials and procedures. Partial occlusion should give a signal for an intervention to restore patency. Depending on the reason for partial occlusion, a suitable solution should be determent together with the hospital pharmacy. Total occlusion should be treated using the deblocking vacuum method.

A stopcock is connected to the occluded catheter. A small syringe with the deblo-

Dressing change

cking solution (Urokinase, Tissue Plasminogen Activator (TPA) or another solution depending on the cause of occlusion) is connected to one side. An empty 20ml syringe is connected to the other side. With the stopcock open between the catheter and empty syringe. Pull maximal vacuum followed by switching the stopcock to the solution. This procedure should be repeated for maximum effect. The solution should be leave for one hour, before testing functionality. In most cases, this procedure is very effective. If the procedure is insufficient, it can be repeated. If done properly, the deblocking solution will not enter the patient’s vascular system, and therefore not have an anticoagulant effect.

A short video on YouTube explaining the method, using TPA or Urokinase when blood is causing the total occlusion O. For other possibilities, drugs for example causing the occlusion, other drugs for deblocking can be used.

All deblocking procedures should be conducted based on a physician’s order. Thrombosis is a complication that can be prevented by a basic rule for choosing a VAD that is not exceeding a third of the u Transparent dressing should be changed every 5–7 days u Gauze dressing should be changed every 2 days

If gauze is use to support a winged needle (port) with transparent dressing (5–7 days) u Chlorhexidine impregnated dressing should be considered in patients older than 2 month u With a well-healed tunneled CVAD consideration may be give to no dressing

Fig. 5: Fixation with dressing Infusion Nursing Standards of Practice, 2021 vein diameter without, measured without tourniquet. Using ultrasound allows easy measurement prior to insertion using the Zone Insertion Method (ZIM) (6) method and Rapid Central Vein Assessment (RaCeVA) for PICC insertion.

Next to these precautions, placing the tip of a CVAD at the CAJ results in the lowest risk for thrombosis 2.6 % versus 41.6 % (7).

Conclusions:

Nurses should have knowledge about symptoms for thrombosis such as redness, pain and swelling.

As part of taking responsibility for the treatment, care & maintenance, nurses should observe and report if any of the symptoms for thrombosis occur. Before reporting to the physician, difference in arm size and swollen area, should be measured and be part of the analysis. An important source of information can be found in the Infusion Nurses Society (INS) standards of practice 2021 (3).

PICCs are a reliable and safe CVADs that can improve intravenous practice for patients both, in and outside of the hospital. With an experience in PICC insertion at the bedside in a dedicated room and care & maintenance, for more than 20 years it is clear that PICCs have shown an important CVAD in the range of VADs.

If clinicians are well trained and keep up to date with vascular access innovations, PICC insertion can be inserted at the bedside and even outside the hospital. More training of all clinicians involved on the selection, availability and use of the best materials, equipment, like ultrasound is needed to offer patients the best possible intravenous treatment.

Online sources: https://ec.europa.eu/eurostat/web/products-eurostat-news/-/ddn-20200114-1 https://www.youtube.com/watch?v=YWZK9DNRpNs

References: www.siga-fsia.ch

Contact:

Ton van Boxtel CEO, GloVANet / WoCoVA

ton@wocova.com www.wocova.com