1、Peripherally Inserted Central Catheter - Groshong PICCEarly assessment will aid in successful insertionspreserve venous accessWARM, WARM, WARMremember your venous anatomy -Which layer of the vein is responsible for vasoconstriction/vasodilationanxiety causes venous constriction, warmth aids in vasod
2、ilationtopical anaesthetics: EMLA, Ametopeffects of topicalwarmth decreases vasoconstrictionPeripherally Inserted Central Catheter - Groshong PICCIf the vessel will not accommodate the required device e.g. 5Fr. Dual lumen - do not insert - this is not the appropriate device for the patientconsult th
3、e physician - can they manage with a smaller device?Heat: site, hand, axillaconsider use of anti-anxiety medications, conscious sedation, general anaestheticmicro-introducer - added skillconsider scope of practice - injectable anaesthetic, skin nickincreased catheter size may increase risk of phlebi
4、tis and thrombotic complicationscostPeripherally Inserted Central Catheter - Groshong PICCAverage rate of incidence is 30%difficult catheter advancement or misdirection of catheter during insertion may result from aboveVenous Valves: flushing, position, open/close fistVasospasm: heat, relaxation, an
5、aesthetics (fear)Tortuous veins, bifurcations:assess!Aberrant anatomy: example-Midline-venogram-vessel stoppedSclerosis, stenosis: early assessment and insertionPrevious devices, surgery, trauma: what devices, where and why removed - ASSESSPeripherally Inserted Central Catheter - Groshong PICCImprop
6、er position of introducer: insert at same angle of venous pathwayImproper positioning: supine, 90 degree angle, chin to shoulderMeasurement: know your anatomy, which vein you are cannulatingIf in doubt, measure for longest courseExisting intrathoracic devices:if inserting a PICC with another intrava
7、scular device in situ, use contralateral side if at all possibleChest Mass: lymphoma e.g. unable to advance, re-position, + flushing, x-ray Peripherally Inserted Central Catheter - Groshong PICCE.g. ICU patient - easy insertion, huge vein, basilic, good blood return, removed guidewire, applied dress
8、ingnoticed wire all curled up!Peripherally Inserted Central Catheter - Groshong PICCCatheter insertion with existing intrthoracic intravascular device:may increase incidence of insertion-related malpositionconsider potential for catheter entanglementutilizing an ipsilateral or contralateral approach
9、special considerations for radiographic confirmation-differentiating catheters may be difficultrepeat x-ray if either device is discontinuedconsider image guided placementaccurate pre-insertion measurementPeripherally Inserted Central Catheter - Groshong PICCSlow advancement!Flushing - have another
10、clinician flush example of snow plow going before yourelaxation - example - 15 yr. male with terminal caPeripherally Inserted Central Catheter - Groshong PICCSterile mechanical phlebitis: usually seen within first 48-72 hr and up to 1 weekhigher risk in femalescephalic vs. basiliclarge gauge cathete
11、rleft sided placementtreated with heat, ROM, rest, elevationshould improve within 24 hr.if no improvement - removeChemical: can occur with CVAD as well - HOW?seen with peripheral and Midlineerythema, pain, at catheter tip an beyondmay see edema, numbness, tingling, shoulder painThrombophlebitis:eryt
12、hema, edema, pain, numbness, tingling, face edema, collateral circulationPeripherally Inserted Central Catheter - Groshong PICCIntact endothelium is completely non-thrombogenic and does not react with plateletsinjury results in immediate disruption of venous endothelium producing vasoconstriction, i
13、nflammation and sloughing with exposure of the subendotheliumsubendothelium possesses a strong procoagulant and immediately releases potent coag. Factors to activate and recruit plateletsplatelet aggregation occurs with the formation of a heomstatic plugvenous constriction results in exacerbation of
14、 venous stasis and prolongs exposure of blood products to thrombogenic subendotheliumcontinued mechanical or chemical injury produces further inflammatory changes, venous constriction and thrombus formationPeripherally Inserted Central Catheter - Groshong PICCIncidence of clinically detectable thomboses estimated at 5%sclerosis/stenosisincreased risk of infectious complicationspost-thrombotic syndromevascular perforation, infusate extravasation, cardiac tamponadepseudotumor cerebripulmonary embolusloss of access, delay in treatmentrecatheterization
