# PICC lines



## medic3521 (Apr 17, 2013)

Hello all, 

 I'm attempting to write a PICC line protocol for our department, our Medical Director gave us the green light to access them only in the event of Cardiac Arrest in lieu of an IV/IO and it has to be located on the extremity. The question is... Can cold fluid be infused through the PICC line? 

Thank you for your response!


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## Clipper1 (Apr 17, 2013)

You need to contact the PICC RN in the hospital you transport most frequently to for a policy and maybe an inservice for the 2 main types of PICCs.  This is the hospital which will be overseeing that port and it would be nice to know the training of the Paramedics using it.

If should be habit to check arms on any patient for various lines when you do BPs. 

Are PICCs the only central port you are going to be able to access?


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## VFlutter (Apr 17, 2013)

We use Bard Power PICCs at my work and I think we have used them while inducing hypothermia before but I am not sure if it is technically recommended by the manufacturer. I do not see why you wouldn't be able to. I will try to ask our PICC people. 

The only problem with PICCs is that they can kink or migrate if not used properly. Also most people do not flush them like they should at home or in SNFs so clotting can also occur. 

Personally, if the PICC does not smoothly flush and draw back blood I would not use it during an arrest/periarrest situation. Slamming Epi into a PICC that is up against the vessel wall or migrated into a small vein is not going to be very effective.


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## chaz90 (Apr 17, 2013)

I'm just trying to figure out why they'd be used in an arrest instead of an IO. Is this in case of inability to establish a peripheral line and IO equipment failure?


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## Handsome Robb (Apr 17, 2013)

We can use them if a patient is in extremis. 

Never been told I can't infuse through them, just don't go slamming meds into them as hard as you can.

Ill echo Chase and say I won't use it unless it flushes and draws smoothly. 

I continue to look for a second point of access even with the PICC.


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## Summit (Apr 17, 2013)

In a code, using a PICC is quite sensible if you know what you are doing with it. Particularly, it is way easier if you are otherwise required to attempt peripherals before an IO. Otherwise, a tibial IO is so fast (and out of the way in a code). I'll echo what was said above: contact a PICC RN at your receiving facility.


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## medicsb (Apr 17, 2013)

For an arrest or peri-arrest, no reason to attempt an IV or IO first.  Go for an IV while using the PICC for meds as you likely won't be able to give fluids rapidly via a PICC (though probably no worse than an IO).


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## medic3521 (Apr 18, 2013)

Thank you all for your response to my question. After I asked this question other problems became to light about the use of the PICC line. We were going to access the PICC line only in the event of cardiac arrest w/o attempting an IV or IO. The reasoning for this was speed, we thought it was going to be quicker to use the PICC line. Unfortunately that is not the case, and we can actually do more harm and decrease the chances for survival. 

Again thank you!


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## Christopher (Apr 18, 2013)

medic3521 said:


> ...and we can actually do more harm and decrease the chances for survival...



You only do more harm and decrease chances for survival if your attempts at PICC access interrupt CPR or defibrillation.

Otherwise a PICC is no more likely to be effective than an IV or IO. We still don't know how effective those are because we still don't know if our drugs are effective.

Accessing existing indwelling catheters during cardiac arrest should not be a priority unless we're talking about reversing a *known cause*. Otherwise, if this is a general "unknown etiology" or "suspected etiology" arrest, work on an IV or IO as normal and use the indwelling catheter if you're unable to successfully obtain other access.


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## medicsb (Apr 18, 2013)

medic3521 said:


> Thank you all for your response to my question. After I asked this question other problems became to light about the use of the PICC line. We were going to access the PICC line only in the event of cardiac arrest w/o attempting an IV or IO. The reasoning for this was speed, we thought it was going to be quicker to use the PICC line. Unfortunately that is not the case, and we can actually do more harm and decrease the chances for survival.



How is it that accessing the PICC would not be quicker than placing an IV or IO?  Elaborate on the harm or "other problems" of using a PICC.



Christopher said:


> Accessing existing indwelling catheters during cardiac arrest should not be a priority unless we're talking about reversing a *known cause*. Otherwise, if this is a general "unknown etiology" or "suspected etiology" arrest, work on an IV or IO as normal and use the indwelling catheter if you're unable to successfully obtain other access.



Why would you not use the PICC first?  It makes no sense to not use it if it is working.


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## Christopher (Apr 18, 2013)

medicsb said:


> Why would you not use the PICC first?  It makes no sense to not use it if it is working.



They've got restrictions not commonly found in the other forms of EMS parenteral access. For probably the same reason we would likely not utilize a patient's ventilator during emergent care, I would avoid using their indwelling catheter without ensuring its proper operation (and that I understood its proper operation).

The pressure restrictions are the first I can think of, although most prefilled EMS syringes are at least 10cc. Another I can think of is the need to draw waste to ensure the line is free of heparin prior to bolusing. My other concerns is the possibility of the indwelling catheter being the etiology of the arrest (embolic, septic, mechanical).

Granted if I am aware of these, there is perhaps no reason I shouldn't utilize it in a code setting. I've used a PICC line on a septic shock arrest without any issues, but we still obtained contralateral large bore IV and utilized that once secured.


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## VFlutter (Apr 18, 2013)

Christopher said:


> The pressure restrictions are the first I can think of, although most prefilled EMS syringes are at least 10cc. Another I can think of is the need to draw waste to ensure the line is free of heparin prior to bolusing. My other concerns is the possibility of the indwelling catheter being the etiology of the arrest (embolic, septic, mechanical).



As long as you are not slamming a 3ml syringe I would not be too worried about the pressure. Worst case scenario you rupture the PICC line which isn't a huge deal during an arrest. You can still use the line if the rupture occurs at the distal portion. We have PICC repair kits to fix it later.

Most newer PICCs are no longer heparin locked. Just saline flushed and clamped. 

I would think etiology related to the catheter would be extremely rare. Line septemia would be the most common but if you to the point of cardiac arrest using the line isn't going to really hurt anymore than it already has.


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## Akulahawk (Apr 18, 2013)

The protocols I'm familiar with specify that we can only access a central line without a base order in codes. The medics I worked with were familiar with how to do it, but rarely had to. Essentially, we just flushed the line with 10ml NS, scrubbed the port, and used the line. While there's increased risk of a central line infection, it's not going to blow up into sepsis for a little while, so there's little immediate risk outside the potential for air embolism...

I've never had to access one outside of training, and outside of interfacility transports, I've never had a patient that I picked up in the community that had a PICC in place.


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## usalsfyre (Apr 18, 2013)

Our medics are currently accessing them in all circumstances. Short training class, talk about central line infection and away they go. Why would you stick the patient again to deliver a med when you have a working line? 


PM me with an email and I'll shoot you the protocol.


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## 18G (Apr 22, 2013)

I've never understood this big fear about accessing PICC lines in the field. They aren't complicated by any means and with minimal in-servicing any Paramedic should be able to access a PICC line. 

In cardiac arrest, why not? Its a vascular access site already established. Its a long catheter so if you need to give fluid fast it won't be ideal but for medications its perfect. 

Strict aseptic technique when accessing it is the biggest thing. And most times the PICC line is already accessed. As someone else said, heparin flush has not been shown to be any more effective then flushing with saline so heparin is starting to be used less and less in these lines.


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## Devilz311 (Apr 23, 2013)

Our protocol says we can access it after two failed IV attempts OR at Pt's request OR an unstable Pt. If you're pushing meds, nothing smaller than a 10cc can be attached due to pressure.  And prior to pushing drugs make sure you can flush 5-10mL NSS.

Portacaths and AV shunts need Medical Control's blessing to access. 

That's our policy in a nutshell. I love it when a Pt has a functional PICC. Makes my job a lot easier.


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## VFlutter (Apr 23, 2013)

Devilz311 said:


> Portacaths and AV shunts need Medical Control's blessing to access.



Do you carry the proper needles to access shunts and ports?


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## Devilz311 (Apr 23, 2013)

Chase said:


> Do you carry the proper needles to access shunts and ports?



Huber needle for the port, and the winged needle for the shunt, I forget the name and size of it.

The portacath is a sterile procedure, so it comes in it's own little pre-packaged kit with the drape and all.


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