What is best practice for inserting PICCs in children in regards to cutting the catheter? Is it acceptable, not advised or restricted? We have a nurse practitioner inserting PICCs in children up to 6 months of age who is stating that it is an "INS standard" not to cut the catheter. I cannot reference that anywhere - wonder if it may have been a manufacturer's instruction? Does is dependent upon insertion site? What is your position on this issue?
While the Infusion Nursing Standards of Practice do not use the word "cutting" the catheter, it does imply that this is not best practice. Go to page S39 Standard 38 Catheter Selection, Practice Criteria Section III Peripherally Inserted Central Catheter (PICC). The first statement is, "The length of the selected catheter should allow for appropriate placement without alteration of tip integrity; caution should be used and manufacturer's labeled use(s) and directions should be strictly adhered to when tip alteration is required."
So can you physically cut the catheter at the bedside without altering the integrity of the tip? According to work published by Janet Pettit, all tips have jagged edges or irregular pieces coming off the tip when it has been cut. Here is the complete reference:
Pettit J. Trimming of peripherally inserted central catheter: The end results. Journal of the Association for Vascular Access. 2006;11(4):209-214.
This journal is listed on Ingenta.com and CINAHL.com, but not on Medline or PubMed yet.
This article used high powered microscopes to examine the tips after cutting with various cutting tools. The study clearly showed that there are uneven edges both before and after cutting. It is possible to think that uneven edges could increase the risk of vein thrombosis but there is no clinical data correlating cut catheters to the incidence of vein thrombosis yet.
We do not live in a "one-size-fits-all" world. So when you can choose a catheter length that does not require trimming, that would be the ideal situation. But that specific length is not going to be available for every patient. This risk of cutting must be weighed against the benefit of having a catheter length specific for that patient's needs. Extra external catheter length means that it will be difficult to manage the dressing and could increase the risk of infection if this catheter becomes pulled in or out of the vein. Neither situation is good. So you must choose the approach that presents the least risk for each patient.
Personally I have never liked the idea of cutting catheters at the bedside because I have serious concerns about the integrity of the tip being created. Until we have more clinical data, this issue remains unresolved.
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4 comments:
I am a little confused by this- the PICC tip has "an uneven edge before and after" trimming? So what difference would trimming make? It seems that if the edge of the catheter is already slightly uneven before trimming, the uneven edge we create is a non-issue. On our POWER piccs, the manufacturer specifically states the PICCs are to be trimmed and provides scissors in the PICC kit.
Microscopic examination of some catheter tips in this study showed that they were not smooth right out of the package. But in looking at the other pictures, in my opinion, the trimmed catheters have a much greater problem with rough edges.
Trimming catheters has always been an unresolved issue since the very beginning with PICCs in the 1970's. One manufacturer did some work on this problem and created a special tool for cutting catheters. The Pettit article found this tool to produce the best catheter edge.
All catheter manufacturers have instructions for trimming their catheters to length. The manufacturer is basing these instructions on their knowledge of the catheter and the material it is made from. However, we do not have any clinical studies on actual patient outcomes associated with trimming catheters. The best tool to use is still controversial. Given the fact that thrombosis with PICCs can be high, I do believe it is time to do these studies and answer these questions. Lynn
I agree, we should not alter unless we no other choice. For neonates, my greatest concern with not trimming is instability inward migration. Standard neonatal catheters come in 30cm lengths and 30cms is seldom required. Inevitably, you end up with large amounts of stacked coiled catheter that needs to remain stable and secure under your bioclusive dressing along with your two greatest risks for infection and tamponade.
You have a valid point for the neonatal population and for anyone really. This is a huge part of the question about trimming to length. We need longer catheters when making the insertion at the antecubital fossa. Now we are inserting several inches above the ACF by using ultrasound. Also all patients are not the same size. So we need more options on catheter length.
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