SIP protocol for the insertion of PICCs

Developed by the GAVeCeLT group (an open study group called “Gli Accessi Venosi Centrali a Lungo Termine”), it consists of a set of 8 strategies to be implemented in case of PICC insertion, with the aim of eliminating or minimizing complications such as:

• failure of the positioning manoeuvre (points 1,2 and 5);
• accidental arterial puncture (points 4 and 5);
• nervous damage (points 4 and 5);
• arrhythmias (point 7);
• malpositions (points 6 and 7);
• malfunctions (point 7);
• venous thrombosis (points 3, 7 and 8);
• dislocation (point 8);
• infection (point 1).

Let's see in detail what the SIP protocol requires.

The 8 strategies of the SIP protocol (Safe Insertion of PICCs)

The SIP protocol develops from the concept of "zero targeting", namely the need to eliminate preventable complications.

Although no strategy alone can be sufficient to reduce these complications to zero, guidelines and recommendations have been identified that, working in synergy, can give effective results.

We speak, therefore, of "bundles" to refer to that set of clinical behaviors that must be simple to apply for each patient and that can minimize or eliminate certain complications.

The SIP protocol, presented by GAVeCeLT in 2010, consists of the following 8 strategies:

1. Hand washing, aseptic technique and maximum barrier protection;
2. Ultrasound examination of all veins of arms and neck;
3. Selection of the most appropriate vein in terms of size, position and depth;
4. Clear ultrasound identification of the median nerve and brachial artery;
5. Echo-guided venipuncture;
6. Ultrasound control of the jugular vein during catheter progression;
7. Use of the intracavitary ECG method to verify tip position;
8. Fixation of the catheter by "sutureless device".
   
   

SIP-2 protocol: the 2017 update

In 2017 the GAVeCeLT group presented the update of the protocol (SIP-2), which takes into account the latest latest news in terms of prevention of complications from PICC planting.

Below is the text of the SIP-2 protocol, also available on the GAVeCeLT website:

1) Systematic ultrasound exploration of all the veins of the arm (from the elbow to the armpit) and of the major veins of the subclavicular and supraclavicular area, following the RaPeVA protocol (Rapid Peripheral Vein Assessment).

2) Hand hygiene, skin disinfection with chlorhexidine 2% in alcoholic solution and use of the maximum barrier protections (non-sterile mask and cap, sterile gloves, sterile gown, large sterile field on the patient and long probe-cover for the ultrasound probe).

3) Selection of the most appropriate vein in terms of depth and calibre, depending on the calibre of the planned catheter (ratio 1:3 between the external diameter of the catheter and the internal diameter of the vein), using the ZIM system: if the ideal venipuncture site is located in the yellow zone of ​​Dawson, tunnel the PICC to get the emergency site in the green zone.

4) Clear ultrasound identification of the brachial artery and of the median nerve before proceeding to venipuncture (and therefore, use of ultrasound scans that allow clear identification of the nerve).

5) Out-of-plane ultrasound-guided venipuncture in short axis, using appropriate micro-introduction kits (echogenic 21G needle, nitinol soft straight tip micro-guide, good quality micro-introducer-dilator).

6) Control and direction of the catheter (tip navigation) through ultrasonography of the supraclavicular region (visualization of the catheter in the subclavian vein and in the anonymous vein), particularly in cases in which there are obstacles to progression or when changes in the P wave to the intracavitary ECG are not appreciated.

7) Control of the central position of the tip (tip location) using the intracavitary ECG method, in the modified variant in the case of patients in atrial fibrillation, possibly corroborated by the tip location using transthoracic echocardiography (CEUS: contrast enhanced ultrasonography).

8) Positioning of cyanoacrylate glue at the emergency site + fixation with sutureless systems (preferring subcutaneous anchoring systems in patients at high risk of dislocation) + covering with transparent semi-permeable dressing with good breathability (high MVTR - moisture vapor transfer rate).

Delta Med PICCs are available in different sizes and gauges and have been designed to guarantee maximum patient and operator safety. Find out more about our PICCs or contact us to talk with one of our professionals.