The PICC question: To cut or not to cut?
By Lynn Hadaway, RNC, CRNI
President
Lynn Hadaway & Associates
Milner, GA
Since publication of the first studies in the late 1970s, the number of peripherally inserted central catheters (PICCs) has increased from one manufacturer’s brand to multiple configurations from 10 manufacturers. This variety offers features and benefits that work best for individual environments and patients. While research has addressed many questions, many remain unanswered. The issue of cutting or trimming a PICC to a patient-specific length is one of the remaining areas of concern.
We do not live in a one-size-fits-all world. Manufacturers must make difficult decisions about the "best" catheter length to offer. Today, a greater variety of catheter lengths are available, thus increasing the need to critically examine the practice of cutting or trimming catheters. Variables affecting catheter length include the insertion site above or below the arm fold, the intended tip location in the superior vena cava or midclavicular area, and a left- or right-sided insertion.
The instructions for use (IFU), or package insert, is one of the most valuable tools for this decision. Some PICC manufacturers include in their IFU directions for trimming or cutting, while others do not.
PICCs are made of two types of plastics: silicone and polyurethane. Most manufacturers use only one polymer, while some have catheters made from both types. These plastics can be a solid piece of tubing or constructed in layers. Are there differences between these materials that would impact the clinical decisions about cutting? What are the considerations for layered catheters? What are the clinical outcomes associated with cutting or not cutting plastic? The answer to these questions can not be found in available clinical studies.
Straight or angled?
Most manufacturers recommend straight 90-degree cuts, while one continues to recommend a 45-degree angle. Scissors are usually supplied with the catheter, but one manufacturer offers a tool designed for cutting their products. Experienced clinicians offer anecdotal experience with scalpel blades. Again, studies can not be located that examine the clinical outcomes with the methods or instruments.
Most PICCs have a guidewire inside the catheter lumen to make insertion easier. Guidewire, stylet, or obturator refers to a flexible wire made of a single strand or multiple-twisted strands, and possibly coated with a lubricant to allow for easier removal from the catheter lumen. When cutting the catheter, the guidewire must be withdrawn from the catheter lumen and stabilized. Methods for accomplishing this include bending the guidewire on the external end of the catheter hub or using sterile tape to secure the guidewire to the external hub. PICCs recently introduced are designed with methods to retract and lock the guidewire in the desired position. The goal is to prevent the guidewire from re-entering the catheter lumen. Only the catheter should be cut, not the guidewire. Also, the guidewire should never be the leading edge as it travels up the vein.
Keeping within sterile field can be difficult
Sterile technique is imperative when cutting any catheter. The sterile field must be large enough to accommodate the procedure, and some PICCs are as long as 70 cm. Once the guidewire is retracted, the length is further increased until the cut is complete. Frequently, the flexible guidewire can cause challenges in keeping the catheter length on the sterile field, especially for clinicians inexperienced with the procedure or working in a limited environment such as a patient’s home.
Tunneled catheters and implanted ports are usually cut during the surgical insertion procedure. Some clinicians are comfortable applying the same technique to PICCs, but not all. Tunneled catheters and implanted ports enter veins with a greater diameter and are advanced for shorter distances to reach the desired tip location. PICCs are inserted into smaller veins and come in contact during the procedure or when working in a limited environment, such as a patient’s home. Disruption of this layer can increase the risk of phlebitis and thrombophlebitis. Therefore, it is not feasible to generalize the same procedure for all types of vascular access devices.
Lack of outcomes data causes concern
The lack of published data investigating clinical outcomes of such questions is the primary reason for questioning the practice of cutting PICCs. Does this practice lead to a positive, neutral, or negative patient outcome?
On the positive side, a catheter length tailored to each patient could prevent complications. Kinking of excess catheter length could impede flow rates. The bulk under the dressing could be uncomfortable for the patient or compromise the dressing integrity. Catheter stabilization could be more difficult, leading to catheter damage from stretching or breaking. These problems increase the fear of catheter embolism, catheter migration into or out of the vein, and subsequently, an increased risk of infection.
On the negative side, the unaided human eye cannot visualize the condition of the catheter tip. The manual act of cutting the PICC could lead to rough or jagged edges on the internal catheter tip, increasing the possibility for thrombus formation and subsequent catheter-related infection. Many patients are already predisposed to thrombus formation because of alterations in their fluid or nutritional status, changes in their clotting factors related to diseases such as cancer, and changes in the pattern of blood flow because of the catheter presence. Contamination during this additional step also could increase the risk of infection.
Measurement of the anticipated venous pathway provides an indication of the catheter length needed. This measurement is not always exact, resulting in catheter length cut too short to reach the required tip location. Obtaining a second catheter for one procedure increases costs.
Obtaining PICC info is challenging
It is quite common today for patients to freely move throughout the spectrum of health care with the same PICC in place. With each transfer between the hospital, home care, long-term care facility, or ambulatory clinic, the infusion needs may change. Obtaining the necessary information pertaining to the PICC with each transfer can become a challenge. Complete knowledge about the gauge or French size, the PICC’s internal and external length, the original tip location, and the method for verifying its location are crucial pieces of information when making decisions about the fluids and medications that might be needed. A reliable method for supplying this information should be created to ensure good clinical decisions.
In home care, more consideration is given to the patient’s age, occupation, and daily activities. What method of securing the catheter will work best for each patient: sterile tape or suturing? What type of dressing performs best and is preferred by the patient? The patient and caregivers must understand signs and symptoms of thrombus, infection, and phlebitis; how to assess the integrity of the dressing and catheter; and when to call for professional help.
Finally, the length of catheter removed from the vein at the end of therapy or in the event of a complication must be assessed and documented. The catheter must be measured and compared with the inserted length to ensure complete removal. If the catheter has been cut, this information must be available to any clinician that comes in contact with the patient.
Standards of practice must be based on sound scientific research. At present, there is a severe lack of research regarding cutting PICCs. While diversity in product design can be advantageous, it can also add to the confusion. Until clinicians have the necessary information upon which to base clinical decisions, we must adhere to the manufacturers’ recommendations for each specific PICC brand. Until we have more knowledge about this issue, the best tools for making clinical decisions will be a thorough examination of factors related to the patient, clinical environment, staff knowledge and expertise, and the chosen product.
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