According to INS position papers, a licensed physician or licensed register nurse (as determined by state regulations) who is educated and has demonstrated competency can insert a PICC. The RN must have demonstrated competency and proficiency in intravenous therapy including the insertion of short peripheral catheters and have a solid understanding of central venous catheters. Additionally, the RN should complete an educational program for PICC insertion. The educational program must include both theoretical content and clinical instruction on an anatomical model. Once the nurse has validated initial competency, there must be an ongoing continuum of competency.

PICC Training is recommended with a minimum of 8 hours to reduce your liability and promote safe practice. The term PICC qualification applies to the process of completing the Basic training then performing supervised insertions until competency is achieved. Upon completion of your supervised insertions, you are qualified to insert PICCs independently. PICC Excellence provides training for beginners and advanced inserters that includes all the required curriculum and competencies. Training options include: Group training, DVD Self Study Training, Online Self Study Training, or contracted on-site training. Each of these training options must be accompanied by precepted/supervised insertions at your place of employment or at another arranged location. Email or call us and we will be glad to answer questions you may have on setting up the best training program for you or your facility.

The next level for the PICC inserter would be to achieve a CPUI™ (Certified PICC/Ultrasound Inserter) designation. PICC Excellence offers a program intended to provide the vascular access clinician validation of a higher level of knowledge and practice in the field of PICC placement. PICC Certification™ is intended to be recognized throughout the healthcare community. It is a process by which an association grants recognition to an individual who has met predetermined standards specified by that association or agency. PICC Certification™ does NOT verify competency. Rather, PICC Excellence™ is certifying that the applicant has met specific standards of knowledge and training specific to PICCs as a credentialing process.

There are lots of indications when a PICC is the most appropriate CVAD to use. Here are a few of the most common indications:

• Short term nutrition PPN or TPN
• Chemotherapy lasting less than 1 year
• IV Infusions for patient with bleeding disorders no matter the PTT or INR
• Patients with less than three veins for more than three days of IVs
• Medications known to damage the intima of veins, ie irritants
• Patients receiving IV infusions longer than 5 days (Especially when irritating antibiotics or Phenergan are involved) (Give phenergan rectally or IM whenever possible)
• More than 3 restarts of IV in 24 hours
• Open chest wounds, tracheostomy or radial neck surgery contraindicating chest line placement
• Heparin infusions where number of hematomas are more than available veins (Midline).
• Complications with peripheral IVs, more than one infiltration, more than one phlebitis indicating that the patient is sensitive to the medication infusion or push meds
• Medications when pH or osmolarity indicate irritation will occur with peripheral IV (pH less than 5 greater than 9, osmolarity greater than 500)
• Dopamine or Dobutamine PICC ASAP
• Immediately place a PICC for burn patients, if area of skin is available.
• Immunocompromised patients requiring hospitalization and IVs (be sure to use Chlorhexidine/Chloraprep!)

Computerized Tomography (CT) is a scan that enables 3D visualization of tissue at various angles for a more complete picture. Blood vessels and other soft tissue cannot be seen on conventional x-rays. CT scans enable visualization with  greater detail. Catheter patency must be verified by flushing the catheter with a 10cc syringe and sterile saline confirming normal flushing action without resistance. Free-flowing blood return may also be verified prior to procedure, followed by flushing. All contrast must be warmed to body temperature prior to power injection. A chest x-ray or other means of verification of tip placement prior to each CT injection is recommended.

The FDA has sent a reminder to radiologists, radiologic technologists, radiologic nurses, and IV team nurses about the potential for serious patient injury when vascular access devices not designed to tolerate high pressures are used for power injection of CT or MR contrast media. That reminder specifies that prior to initiation of power injection the user should:

1. Check the labeling of each vascular access device for the maximum pressure and flow rate designation.
2. Know the pressure limit setting for your power injector and how to adjust it. Understand that if recommended pressure is exceeded, the device may weaken even if no rupture is obvious, and the weakened device could fail when used again.
3. Ensure that the pressure limit set for the power injector does not exceed the maximum labeled pressure for the vascular access device(s).
4. Be aware the pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow from kinks, curves and compression. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device such as catheters, ports and extension tubing.
   

Indications for CT Power Injection
Patient Evaluation of:

Cysts Tumors /Masses Aneurysm Metastases Pulmonary Emboli

Thrombosis (Clots) Thrombolytic Strokes Trauma Abscesses Appendicitis

Why do ruptures occur?
The pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow (e.g., kinks, curves, compression). To maintain the flow rate required for a CT or MRI study, a power injector may generate high pressures. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device(s). If you do know the maximum pressure that the vascular access device can withstand, be sure to adjust your power injector so that it doesn't exceed this limit. It is important to understand that if the recommended pressure for a vascular access device is exceeded, the device could be weakened even though no rupture is evident, and the weakened device could fail to operate properly when it is used again.

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