Preventing PICC line migration during dressing change

[Gree Nie]

What are your tips for keeping the PICC line in place during a dressing change? I am having trouble keeping the line from migrating out during the dressing change. Especially for lines with a longer external length, and where I need to reposition the securement device and move and curve the line so it fits nicely under the dressing window. I know some people use steristrips, but I haven't figured out the perfect time/place to use them.

We use the 3M securement dressings, which is basically an adhesive securement device and a pretty tegaderm-type 3-part dressing. I tape down the part of the line outside of the dressing down, but it isn't enough. Today, as I was removing the dressing, the dressing adhered at the insertion site and pulled at the line, and it sort of sprung out. I had to send the patient for an x-ray and want to make sure I do better next time!

My basic procedure is: Use clean gloves to remove dressing and securement device. Pull dressing off toward insertion site Change into sterile gloves and cleanse with the antiseptic. Let dry. Apply securement device and dressing. Once I'm in my sterile gloves I can secure the line with my fingers, but it's while I'm removing the dressing and securement device. I don't feel comfortable holding the line with my clean gloves, but perhaps I should and its okay because I'm going to use antiseptic after anyway? I just think that area should only be touched with sterile gloves.

[neonn965]

We use two nurses to do a PICC dressing change, but it's NICU. The helper's whole job pretty much is making sure the PICC doesn't migrate while the other nurse does the dressing. We often use a sterile swab to hold the line down at the insertion site during times of a lot of manipulation, but you could also use a sterile 2x2 or something else I would imagine.

[iluvivt, BSN, RN]

If you have a lot externally visible...more than a few cms,most transparent dressings will stick to the PICC line,especially polyurethane, and that makes it difficult to get it off and often it gets pulled out a few cms.The other thing I see is when the biopatch or similar patches that have a radial slit and the radial slit is not lined up with the PICC and they get stuck and its pulled on to get it off..When that happens moisten the patch with some saline flush.Try dressing your PICCs with Steri =strips and make sure all or most of the amt externally visible has been secured with steri=strips up to your securment device.I always take my dressing off side by side and I rarely pull out any and if I do it's a small amt such as a half of a cm or 1 cm....It's the side technique I believe...I slowly peel off the steri strips when my hand is is holding down the other section of steri=strips that is still adhered.Once everything is off....I position the PICC.the way I want it to flip and temporarily tack down the tails so I can cleanse the site.We use quite a bit of SecurAcaths and that makes it so easy to dress.I want to commend you for taking such good care of your PICC lines.Tip position is terribly important as the farther away you get from the cavoatrial junction EVERY complication increases and it's not just a little bit.

[Wuzzie]

Also, always peel the dressing toward the insertion site. We use the ones with the CHG gel patch. I peel the dressing all the way around up to the patch. I put a finger over the line at the insertion site (on the outside of the remaining dressing), gently press down and secure the line and then sort of roll/stretch the dressing over my finger toward the insertion site. It's a little hard to explain but it works really. If I can swing it I happen to be in lab tomorrow and I'll try to video it for you.

[Gree Nie]

@Neon965 I should have specified that I'm a rural community nurse so it's just me. There is no option for another set of hands. The second set to hold the line would be ideal! I woke up in the middle of the night thinking 'sterile guaze!' Lol. Thanks for the confirmation

[Gree Nie]

@iluvivt Thank you for the description. I have seen videos of the biopatch but we don't use them unfortunately it looks like they would help with keeping the line in place.

So do you peel dressing off with clean gloves then switch to sterile to take off steri strips and cleanse? Or switch to sterile and remove steristrips, reposition, steristrips the tail and cleanse. I've seen both ways and am trying to figure out which is better. Fo you consider everything under the dressing sterile from the beginning or only sterile after it's been cleansed? Does that make sense?

[Gree Nie]

@wuzzie we don't use the bipatch otherwise that would be perfect but I'm thinking I could hold it at the insertion site, over the dressing and peel as you say, then pick up sterile gauze and hold the exposed line down while I take off the dressing attached to the insertion site. Thanks for the explanation!!

[Wuzzie]

@wuzzie we don't use the bipatch otherwise that would be perfect but I'm thinking I could hold it at the insertion site, over the dressing and peel as you say, then pick up sterile gauze and hold the exposed line down while I take off the dressing attached to the insertion site. Thanks for the explanation!!

Yes you can do that but make sure you are pulling it horizontally in a rolling motion towards the insertion site. If you use any vertical pull it may dislodge the line.

[brownbook]

Excuse me if this is dumb as dirt stupid. I've not done PICC dressing changes. But if the patient is mentally or physically capable could they help? Give them stetile gloves and a face mask. (I don't know how sterile this process needs to be.) Ask them to press here or hold this? Or even a family member could help be a second pair of hands?

[Wuzzie]

Excuse me if this is dumb as dirt stupid. I've not done PICC dressing changes. But if the patient is mentally or physically capable could they help? Give them stetile gloves and a face mask. (I don't know how sterile this process needs to be.) Ask them to press here or old this? Or even a family member could help be a second pair of hands?

I wouldn't do it. Too much risk. Even smart people do dumb things sometime.

[InfusionNewbie RN]

I am a new Home Care Infusion RN with no hospital experience and a poor orientation experience, leaving me to do a lot of self-guided learning. One question I have not found an answer to is - how FAR can the PICC line be safely pulled out then pushed back in when doing dressing change?

Quote

@iluvivt stated: I always take my dressing off side by side and I rarely pull out any and if I do it's a small amt such as a half of a cm or 1 cm....,

That's the closest answer to my question I've been able to find, but want to confirm that 5mm - 1cm pull and push is acceptable?

How much migration would be considered too much to push back in and would require an x-ray?

Thank you!

[Wuzzie]

16 minutes ago, InfusionNewbie RN said:

That's the closest answer to my question I've been able to find, but want to confirm that 5mm - 1cm pull and push is acceptable?

How much migration would be considered too much to push back in and would require an x-ray?

We don’t push any of the migrated line back in. We allow a max of 2 cm migration out on a line that was initially positioned correctly before we get a CXR and possibly replace the line.

Are you pulling the dressing away from the insertion site or toward it? We don’t really have a big issue with lines migrating much during dressing changes.