PICC line dressing changes difficulty

[Gyh]

I have been a nurse for a few years but recently I had to start doing more PICC line dressing changes. I have a patient with a PICC line that moves every time I take the clear dressing off as if it doesn't want to stay in the arm. As soon as dirty dressing is removed the line will without any reason come out by 1-2 cm. Patient has had a couple of x-rays at this point and the line is out by 9cm. Have any of you had PICC lines that move so much and any words of wisdom to keep it from coming out during dressing changes?

[K+MgSO4, BSN]

Does it nor have an anchoring device such as a stat-lok? Otherwise you may need a second pair of hands in sterile gloves to anchor the line while you change the dressing.

[iluvivt, BSN, RN]

Ok...It is coming out because nurses are pulling it out 1 to 2 cm with each dressing change.The average SVC is 7 cm long so if the original tip placemat was at cavoatrial junction or low SVC a loss of 7 cm or more is significant. So you can clearly surmise that if there is a change of more than 7 cm the odds are it's tip is now at the top of the SVC or at the brachiocephalic/SVC junction. This is considered suboptimal and now the patient is at increased risk for every complication including thrombosis and infection. Even with a stat loc or other adhesive type securenent device it can still be pulled out if done incorrectly or if someone did not line up the radial slit in the CHG patch with the PICC. We use SecurAcaths on most of our PICCs which is a device that anchors the PICC to the skin with wires.They are the best invention! If you don't have those try removing the old dressing by peeling from the side and not from the top down or bottom up.If you peel from the side you can peel off the TSM dressing and steri strips easily.If the PICC is getting stuck in a CHG patch..just moisten it with some sterile NS from a prefill... it will puff right up and come off .Take your stat lock off last and put a temporary strip of tape on the tails only and tell pt to hold still if they can.Have everything ready before you even take the old dressing off.I did not give you each step but if you want more detail about the dressing and needleless connector change procedure ..let me know.

[NICU Guy, BSN, RN]

9 hours ago, K+MgSO4 said:

Otherwise you may need a second pair of hands in sterile gloves to anchor the line while you change the dressing.

This is what we do with every dressing change. Once the transparent dressing is removed, a second person places a sterile finger on the PICC line. The PICC nurse places fresh Mastisol around the site, re-coils the Picc line, and places a new transparent dressing.

[Gyh]

Thank you for the info I will definitely try the suggestions! Unfortunately I don't have another nurse to help since I go to patient homes but I will try to use steri strips to steady it more. The PICC came out 2 cm during 2 dressing changes (1cm each drsg change) and the other 4 cm the PICC came out under the drsg before the first dressing change was due. It was placed and was out 3-4cm extra first time I saw it. 1st Drsg change was done early d/t being soiled. PICC line was at 7 cm during my first drsg change which was really shocking to me since it had a statlock and was under the clear drsg. The drsg was wet with serious exudate, biopatch was soaked. Could the combo being a new PICC with not using gauze to absorb exudate cause it to come out by 4 cm? I am used to PICC lines being out 2-4 cm and once in a while moving no more than 1 cm during a Drsg change if any. With this PICC being out 8-9 cm now it feels very far out and flimsy. Coiling might help but I don't know how I can pull it off with out pulling it out more.

[erniefu, BSN, RN]

Anything more than 4-5 cm out and you need to x-ray. The danger with it being that far out is that it can coil, rendering the PICC useless (its out of position) and can cause emboli. A PICC pulled out can be fixed by a PICC nurse with over the wire picc exchange.

[Wuzzie]

17 hours ago, Gyh said:

The drsg was wet with serious exudate, biopatch was soaked. Could the combo being a new PICC with not using gauze to absorb exudate cause it to come out by 4 cm?

There should not be that much drainage from a PICC line site. It's more likely it got wet bathing/showering. If it truly is exudate that line needs pulled. Also, never use gauze under a Tegaderm dressing. We used to do it if we changed the dressing every 48-72 hours but that practice has been forbidden.

9 hours ago, erniefu said:

Anything more than 4-5 cm out and you need to x-ray. The danger with it being that far out is that it can coil, rendering the PICC useless (its out of position) and can cause emboli. A PICC pulled out can be fixed by a PICC nurse with over the wire picc exchange.

This is absolutely correct but point of clarification. What Erniefu is saying is guidewire technique to place a new line. Do not mistake this as a recommendation to guidewire and reposition the same line.

[2BS Nurse, BSN]

I use a piece of coban (on the distal, luer lock end) to temporarily secure the line while removing the dressing. The coban is easy to remove before sterile gloving.

[iluvivt, BSN, RN]

On 1/1/2020 at 6:09 PM, erniefu said:

Anything more than 4-5 cm out and you need to x-ray. The danger with it being that far out is that it can coil, rendering the PICC useless (its out of position) and can cause emboli. A PICC pulled out can be fixed by a PICC nurse with over the wire picc exchange.

This is incorrect as a general rule.We aim to leave 3 to 8 cm externally visible as it's easier for us to maintain and to add a Securacath (must have at least 3cm to as apply it ). What you need to know is the original amt left externally visible and its original tip anatomical location.As I stated above the average SVC is 7 cm long, so for example, if the PICC nurse leaves 5 cm externally visible with a tip placement at the CAJ and you assess there is now 6 cm there is no need to worry unless you have other s/sx of a secondary malposition.So you need to know all the data when you are going to assess it and perform a dressing and needleless connector change.Also I I stated every complication is increased as you get away farther away from the cavoatrial junction and it's especially thrombosis.I actually have a chart that shows the risk in percentages.What we have decided asa team is to verify tip placement if we have greater than 3 cm difference and of course it's relative to its original tip placement.Most PICC don't suddenly start coiling if there is a change in the amount externally visible.Coiled PICCs usually occur with power injection,excessive or strong coughing or vomiting.It can also occur with initial insertion but most PICC nurses now use a tracking system for insertion. If you steri strip from over the CHG patch all the way down to the stat loc it will keep it in place Line the radial slit of the CHG patch with the PICC line .If you don't do this it's much harder to peel everything off and what often happens is you lose a few cms.I have done thousands of dressing changes and once you learn how to do it correctly it's easy to do it by yourself but you bc still need to hypervigilant and not pull any out..

[Wuzzie]

4 hours ago, iluvivt said:

This is incorrect as a general rule.

I read it as it was 4-5cm further out than originally placed (ie: 4 cm original external measurement now 9 cm external) in which case that would indeed be a problem.

[2BS Nurse, BSN]

7 hours ago, iluvivt said:

This is incorrect as a general rule.We aim to leave 3 to 8 cm externally visible as it's easier for us to maintain and to add a Securacath (must have at least 3cm to as apply it ). What you need to know is the original amt left externally visible and its original tip anatomical location.As I stated above the average SVC is 7 cm long, so for example, if the PICC nurse leaves 5 cm externally visible with a tip placement at the CAJ and you assess there is now 6 cm there is no need to worry unless you have other s/sx of a secondary malposition.So you need to know all the data when you are going to assess it and perform a dressing and needleless connector change.Also I I stated every complication is increased as you get away farther away from the cavoatrial junction and it's especially thrombosis.I actually have a chart that shows the risk in percentages.What we have decided asa team is to verify tip placement if we have greater than 3 cm difference and of course it's relative to its original tip placement.Most PICC don't suddenly start coiling if there is a change in the amount externally visible.Coiled PICCs usually occur with power injection,excessive or strong coughing or vomiting.It can also occur with initial insertion but most PICC nurses now use a tracking system for insertion. If you steri strip from over the CHG patch all the way down to the stat loc it will keep it in place Line the radial slit of the CHG patch with the PICC line .If you don't do this it's much harder to peel everything off and what often happens is you lose a few cms.I have done thousands of dressing changes and once you learn how to do it correctly it's easy to do it by yourself but you bc still need to hypervigilant and not pull any out..

If you've done thousands of dressing changes, you should post a video! I don't know that our policy would allow steri strips under the dressing.

[erwindt, MSN, RN]

Let me just say, as a PICC nurse, if you are not familiar or proficient with PICC dressing changes, get help. PICCs are rarely or even hardly sutured due to risk of infection, unlike IJs, Subs, and Femoral. The stabilization device, StatLock, can be very sticky to your gloves, and is also tricky to remove it from the PICC, if you are not familiar with it. PICC dressing changes should only be done every 7 days or per facility policy, but as they say, the less manipulation, the less risk of infection. One time, I was doing my PICC dressing changes, and one nurse told me, "it's OK, I change the dressing for you". I kindly ask her if it was OK for me to check on it. Of course, the BioPatch was placed upside down. When I remove the sterile dressing she applied and changed the BioPatch, the PICC just started to come out like a worm from the patient's arm. I fast flush it and the patient felt weird on her neck. I ask the nurse if she accidentally pulled it out and push it back in, but she claimed to have no idea. As a PICC nurse, I know what happened, but because I didn't observe how she change the PICC dressing, I can't point fingers. I had the resident ordered portable x-ray and confirmed PICC to be on patient's IJ. I removed it, and placed a new one on the opposite arm. I avoid over-the-guidewire because of the risk of infection, especially since the patient had the PICC for over 2 months now.

Like anything in nursing, ASK IF YOU DON'T KNOW, RATHER THAN GUESSING AND CAUSING HARM TO THE PATIENT.