This section has detailed steps and videos that describe how to set up TPN, do your own dressing and cap change
1. Pumps
While there are 4-5 commonly used pumps, the ones that I have tried are the CADD prizm and the Curlin. I have used both the pumps. CADD uses only one battery but it is very noisy and makes a like a whirring sound every few seconds that would disturb my sleep at night and test my patience in the morning hours. Even though the pump is in a backpack, you can hear the noise loud and clear. I wish I had used the Curlin from the beginning instead of the CADD pump. The wonderful thing about Curlin is that it is a much quieter pump and once the pump goes in the backpack, the sound isn't really annoying. The downside is that it uses 2 batteries and is slighter bigger than the CADD. The weight of the CADD and Curlin is as follows:
CADD - 20 oz (including 9V battery)
Curlin - 17.5 Oz
If I were to do this all over again, I would request my home health agency to allow me to try two to three pumps before I decided on the one best for me. In my situation, a quiet pump was the deal breaker. I don't carry my backpack, so weight is not an issue. Moreover, the weight depends more on how much your TPN bag will weigh rather than the weight of the pump. Curlin also permits a range of programming options for TPN infusion as well as any separate medications. Also, both pumps need timely maintenance for which we send them back to our agency in an asset box given by them in exchange of new pumps.
CADD and Curlin pump setup videos below
1. Pumps
While there are 4-5 commonly used pumps, the ones that I have tried are the CADD prizm and the Curlin. I have used both the pumps. CADD uses only one battery but it is very noisy and makes a like a whirring sound every few seconds that would disturb my sleep at night and test my patience in the morning hours. Even though the pump is in a backpack, you can hear the noise loud and clear. I wish I had used the Curlin from the beginning instead of the CADD pump. The wonderful thing about Curlin is that it is a much quieter pump and once the pump goes in the backpack, the sound isn't really annoying. The downside is that it uses 2 batteries and is slighter bigger than the CADD. The weight of the CADD and Curlin is as follows:
CADD - 20 oz (including 9V battery)
Curlin - 17.5 Oz
If I were to do this all over again, I would request my home health agency to allow me to try two to three pumps before I decided on the one best for me. In my situation, a quiet pump was the deal breaker. I don't carry my backpack, so weight is not an issue. Moreover, the weight depends more on how much your TPN bag will weigh rather than the weight of the pump. Curlin also permits a range of programming options for TPN infusion as well as any separate medications. Also, both pumps need timely maintenance for which we send them back to our agency in an asset box given by them in exchange of new pumps.
CADD and Curlin pump setup videos below
2. Infusion/TPN setup
As per the prescription decided by my doctor for total amount of calories to be infused, the pharmacy at my home health agency prepares the weekly supply of tpn bag mix that has proteins(amino acids), sugar(dextrose) and fats(lipids) and other trace minerals. This information is printed on top of each bag. I also get MVI (multivitamin) vials separately, and based on need I receive dual chamber bags for lipids to keep the bags stable. Antacids are also given but I didn't use them as they caused itching. Bags must be kept refrigerated and each bag should be brought close to room temperature before starting infusion. In my case, once a bag is out for use, it can last up to 24 hrs, we never try to use expired bags. Below is a full TPN setup video to prepare my bag mix but here is a summary of how we do it, make sure you do it in a sterile way too.
b. Remove the cover from the needle. Pull back the plunger to draw back air. Draw up as much air into the syringe as you will draw up from the bottle. (Example: 10cc air when drawing up 10cc of multivitamin.)
c. Insert the needle into the bottle. Hold the bottle upside down and inject the air into the bottle by pushing on the plunger.
d. Pull back on the plunger slowly until you have drawn up the correct amount. Push the air out. Remove the needle from the bottle.
e. Wipe the injection port on the TPN bag with a new alcohol swab. Insert the needle into the center of the bag’s injection port. Slowly push the plunger on the syringe, injecting the solution into the bag. Remove the needle.
f. Gently rock the bag back and forth to mix the medication into the TPN bag.
Repeat this procedure for each medication or vitamin additive. Dispose off the needles in the needle/sharps box provided. The TPN bag is now ready.
Setting up the pump and tubing
TPN and bagpack setup videos below
As per the prescription decided by my doctor for total amount of calories to be infused, the pharmacy at my home health agency prepares the weekly supply of tpn bag mix that has proteins(amino acids), sugar(dextrose) and fats(lipids) and other trace minerals. This information is printed on top of each bag. I also get MVI (multivitamin) vials separately, and based on need I receive dual chamber bags for lipids to keep the bags stable. Antacids are also given but I didn't use them as they caused itching. Bags must be kept refrigerated and each bag should be brought close to room temperature before starting infusion. In my case, once a bag is out for use, it can last up to 24 hrs, we never try to use expired bags. Below is a full TPN setup video to prepare my bag mix but here is a summary of how we do it, make sure you do it in a sterile way too.
- Wash our hands very thoroughly with soap and water, dry with a clean towel. We make sure not to touch anything after washing our hands.
- The TPN bag is already out as it needs to be at room temperature a few hours before infusion is started, we remove the TPN bag from the refrigerator at least 2 to 4 hours before the infusion time depending on weather year round. We are not supposed to warm the TPN bag in the microwave, under a lamp or direct sunlight. Sometimes, when we forget, we run a towel in the dryer to warm it up and wrap it around the bag and put it under a comforter. Another option is to keep it under slow running tap water for few minutes. That warms it up faster.
- Along with the TPN bag, we also take out one pair of multivitamin vials from the refrigerator.
- We check the expiration date on the bag label.
- We inspect the bag for anything unusual like leaks or cloudiness or floating particles.
- We collect the needed supplies for setting up the TPN ( pump, tubings, Multivitamin syringe, alcohol swabs, gloves, TPN bag, multivitamin vials( 2 bottles)
- We put on a pair of gloves and then use sanitizer nicely over it.
- Next step is to inject multivitamins into the TPN bag.
- We follows steps as given below:
b. Remove the cover from the needle. Pull back the plunger to draw back air. Draw up as much air into the syringe as you will draw up from the bottle. (Example: 10cc air when drawing up 10cc of multivitamin.)
c. Insert the needle into the bottle. Hold the bottle upside down and inject the air into the bottle by pushing on the plunger.
d. Pull back on the plunger slowly until you have drawn up the correct amount. Push the air out. Remove the needle from the bottle.
e. Wipe the injection port on the TPN bag with a new alcohol swab. Insert the needle into the center of the bag’s injection port. Slowly push the plunger on the syringe, injecting the solution into the bag. Remove the needle.
f. Gently rock the bag back and forth to mix the medication into the TPN bag.
Repeat this procedure for each medication or vitamin additive. Dispose off the needles in the needle/sharps box provided. The TPN bag is now ready.
Setting up the pump and tubing
- I use the Curlin pump, Curlin tubing and Vygon curled tubing as that gives me extra length to move around.
- We put new batteries in the curlin pump (2 batteries).
- Remove the tubings from their covers and carefully connect them as shows in the video making sure to keep everything sterile.
- We insert the tubing into the curling pump aligning the orange cap and blue caps with the slits in the pump. Then we close the cover/handle of the curlin pump to lock the tubing in place.
- One end of the curled tubing set goes into the TPN bag. On the TPN bag, we wipe the protective seal with alcohol and then break it and then wipe again. Then we insert the tubing end into the TPN bag opening after removing the tubing cap. This takes a light push and rotate motion to align it properly.
- Next step is to turn on the pump and prime the tubing. Your home health company would send you a programmed pump, after the initial screening process, click on “options”, “prime” and hold the prime button till the TPN flows till the end of the tubing just leaving about a cm at the end to avoid overflowing the liquid out of the tubing and not leave much air inside either.
- Next step is to put this set up into the bagpack. We make sure to secure the TPN bag in place and also the pump. (see video).
- We take out the swab cap, wipe the cap carefully with 2 alcohol swabs in circular motion, applying enough pressure to clean it well.
- Wipe the end of the tubing with alcohol, then we remove the tubing cap and wipe it with alcohol again. Then we twist the tubing onto the cap applying gentle pressure just enough to push it in and then rotate it till its secure, making sure not to make it too tight.
- We wipe around the connection point with alcohol one last time, just to remove any dextrose that might have spilled while connecting the tubing to the cap.
- Press “run” on the pump which starts the infusion.
- Once infusion is done which could take anywhere between 10 – 15 hrs, we stop the pump, put on gloves, use sanitizer, then twist and remove the tubing from the cap, wipe the cap nicely with alcohol, flush the line with saline, lock it with heparin and then put the swab cap over it. Discard the used up TPN bag and tubings and gloves.
TPN and bagpack setup videos below
3. Dressing change
This is a very crucial step in your linecare. After about 3-4 months of having the PICC line, we started doing our own dressing change but I understand that not every patient has the prerogative to do so due to various reasons. My family member learnt how to do it from our nurses; initially we were very nervous and worried but with practice we gained confidence and became experts and now we has been doing it once a week (its a good idea to do it twice a week with a new line as skin deposits residue underneath the dressing area). You need to be really focused and vigilant while doing your own dressing change as you don't want to compromise the sterility of the site/insertion point or migrate the line out, hence one must not get distracted. It's also important to keep the area moisture free and keep it from getting wet, I let fresh air go back and forth through my dressing and also sit in sunlight to keep my skin cells healthy and breathing. I also find it safe to apply natural ointment, oil or moisturizer on my skin outside the border/periphery of my dressing.
There are various kinds of dressings available in many shapes and sizes like tegaderm, IV3000, sorbaview, wound dressing etc, although I've tried some of them I personally prefer both Sorbaview SV40XT and Mepilex as it is a window/wound dressing with tape strip and suits my skin and also comes with a shield (Sorbaview SV40XT) that you can use to secure the lumens. Eventually, your skin tells you what it doesn't like, so be careful that your skin does not develop rashes, bruises etc. I use Aplicare/Actasept or Medstream dressing change kit that contains many items including Chloraprep/Betadine and alcohol swabsticks, some people also prefer betadine over chloraprep. Below is a full dressing change video for more details but here is a summary of how we do my dressing change, make sure you do it in a sterile way too.
We try to slightly change the position of the griplok with every dressing change to avoid irritation of the skin at the same point. Although skin prep has done an excellent job with protecting the skin, it still helps to do this. We also try to rotate the dressing position a bit to let the skin breathe from the sides.
Some dressing kits come with alcohol and betadaine instead of chloraprep. Some people are sensitive to chloraprep it seems and betadaine works well for them. However, it seems like chlorahexidine is really powerful for killing any bacteria, so I have been consistently using it.
This is a very crucial step in your linecare. After about 3-4 months of having the PICC line, we started doing our own dressing change but I understand that not every patient has the prerogative to do so due to various reasons. My family member learnt how to do it from our nurses; initially we were very nervous and worried but with practice we gained confidence and became experts and now we has been doing it once a week (its a good idea to do it twice a week with a new line as skin deposits residue underneath the dressing area). You need to be really focused and vigilant while doing your own dressing change as you don't want to compromise the sterility of the site/insertion point or migrate the line out, hence one must not get distracted. It's also important to keep the area moisture free and keep it from getting wet, I let fresh air go back and forth through my dressing and also sit in sunlight to keep my skin cells healthy and breathing. I also find it safe to apply natural ointment, oil or moisturizer on my skin outside the border/periphery of my dressing.
There are various kinds of dressings available in many shapes and sizes like tegaderm, IV3000, sorbaview, wound dressing etc, although I've tried some of them I personally prefer both Sorbaview SV40XT and Mepilex as it is a window/wound dressing with tape strip and suits my skin and also comes with a shield (Sorbaview SV40XT) that you can use to secure the lumens. Eventually, your skin tells you what it doesn't like, so be careful that your skin does not develop rashes, bruises etc. I use Aplicare/Actasept or Medstream dressing change kit that contains many items including Chloraprep/Betadine and alcohol swabsticks, some people also prefer betadine over chloraprep. Below is a full dressing change video for more details but here is a summary of how we do my dressing change, make sure you do it in a sterile way too.
- Wash hands thoroughly with soap and water
- Wear a pair of gloves and put enough sanitizer
- We get the new dressing kit ready before removing the old dressing
- Open the dressing change kit which comes with the basic supplies
- The additional supplies we use have to be added to the kit maintaining sterility
- Peel and drop the 4mm bio patch (comes in different sizes) into the kit without touching anything
- Peel the small griplok ( securement device that comes in different sizes) and drop into the kit
- Peel the dressing (since we use a different dressing and not the one that comes in the kit) and drop it into the kit
- Peel the skin protectant (skin prep) and drop into the kit
- Make sure the catheter is secured with a tape or steri strip before starting the process. This is to ensure that we don’t pull out the catheter when removing the old dressing
- Wipe the top and sides of the old dressing with alcohol prep/swab. We use adhesive remove to remove the old dressing as it very gently removes the adhesive without any pushing, pulling or pain. We start from the edges and loosen up the dressing from all the sides. Then pull up the dressing gently from bottom towards the top, again to ensure that line stays in place. Once we reach the insertion point, gently lift the dressing along with the biopatch. If you have put the biopatch correctly it will lift off very easily. There is no need to separate the biopatch from the old dressing. They come off together
- Remove the griplok using the adhesive remover gently
- Examine the site for anything unusual like redness, swelling, pus or any liquid discharge
- Get rid of the current pair of gloves
- Put sanitizer on hands
- Put on new sterile gloves provided in the dressing change kit
- Put the sterile drape under the patient’s arm
- Next step is to clean the PICC line site thoroughly. Start with alcohol sticks; there are 3 in one packet, start at the center and follow a spiral rotation from inside to out never coming back to the same point again. Do this with all the 3 alcohol swabs. Make sure to cover the surface of the catheter and wing as well
- Break the chloraprerp stick and let the chlorahexadine seep out on the spongy surface of the stick. Place the sponge at the insertion point gently and count upto 15-20 seconds. We do this so that the chlorahexadine can seep into the insertion point and kill any germs/bacteria, if present
- Then scrub the insertion point back and forth and in a circular manner, inside to out making sure never to come back to the same point. Clean thoroughly the catheter and the wing
- Wait for 30-40 seconds for the site to dry
- Put a thin layer of skin prep on the site (avoid the insertion point area). We put skin prep to provide a layer of protection to the skin from the dressing adhesive
- Wait a few seconds for the skin prep to dry
- We then secure the wing with a griplok (watch video for details). Before securing, we make sure your catheter is in a slightly curved C-shape. This helps to keep the line in place
- Put the biopatch on the insertion point. Make sure that the slit of the biopatch aligns with the catheter. If you put it at a 30 degree or 60 degree or 180 degree angle, it will be very difficult to take out the bio patch next time you change the dressing. It has to sit in line with the catheter
- Now we are ready to put the new dressing. We use sorbaview which has 2 parts to it. The main part goes over the PICC line insertion point and the wing and has a slit which aligns with the lumens. The second half called sorbaview shield is to secure the bottom part of the catheter but I prefer steristrips
- We secure the bottom part with two steristrips (see video)
We try to slightly change the position of the griplok with every dressing change to avoid irritation of the skin at the same point. Although skin prep has done an excellent job with protecting the skin, it still helps to do this. We also try to rotate the dressing position a bit to let the skin breathe from the sides.
Some dressing kits come with alcohol and betadaine instead of chloraprep. Some people are sensitive to chloraprep it seems and betadaine works well for them. However, it seems like chlorahexidine is really powerful for killing any bacteria, so I have been consistently using it.
4. Cap change
The PICC line/catheter whether single lumen or double lumen is protected by caps at the end that must be kept clean and sterile. The caps allows you to flush your line with saline, heparin, infuse medication/TPN, draw blood etc. The cap change protocol advices changing caps once a week or after a blood draw or sooner if need be. I have been changing my caps once a week for few years now and things have been ok so far. Caps are easy to change and it takes few mins. There are different brands of caps available, my home health company had me try 2 different types of which I liked one and have been using it ever since. It is softer to touch on my skin and does not have any rough edges.
Note: After replacing the caps, I also cover them with the Swab Cap. Although the caps provide good protection by themselves and do not allow anything enter into the catheter; yet swab caps offer a second layer of protection to the caps. Swab caps are tiny round caps as you can see in the video, and they easily slide on to the mouth of the cap by applying little pressure. I feel safer with the swab caps and have been using them every time I flush my line or change the caps. I am very thankful to my home health company for providing me this product. I am not sure if other companies provide them but if you request and provide the necessary information, your company might order them for you.
Below is a full cap change video for more details but here is a summary of how we do my cap change, make sure you do it in a sterile way too. What we use is: 2 caps since I have a double lumen catheter, 6-8 alcohol pads, a sterile drape, 2 saline flushes, 2 heparin flushes if you plan to lock the line after cap change, a pair of gloves, 2 masks ( one for me and one for the person changing my cap).
• We put the mask on (patient and helper)
• We wear gloves, and use sanitizer on hands
• Open and spread the sterile drape on the table and prepare few Alcohol swabs
• Get the saline syringes ready by taking out air bubble from them, keep them on the drape
• Lift the cap and peal the packaging half way making sure not to pull out the cap or touch the surface; let them stay inside
• Connect the saline syringe to the cap one at a time without touching either the cap or the saline syringe
• Using the alcohol pad, scrub nicely the connection point of the hub and the cap on my hand. It is very important to clean the connection point thoroughly
• Repeat this step with another alcohol pad
• Turn the cap anticlockwise to unlock it and remove it from the hub
• Leave the second alcohol pad under the hub
• We wipe the outer surface of the hub thoroughly with 2 new alcohol swabs
• We cover the max plus cap with swab cap
• We lock with Heparin if needed
• Repeat the same steps to replace the other cap
The PICC line/catheter whether single lumen or double lumen is protected by caps at the end that must be kept clean and sterile. The caps allows you to flush your line with saline, heparin, infuse medication/TPN, draw blood etc. The cap change protocol advices changing caps once a week or after a blood draw or sooner if need be. I have been changing my caps once a week for few years now and things have been ok so far. Caps are easy to change and it takes few mins. There are different brands of caps available, my home health company had me try 2 different types of which I liked one and have been using it ever since. It is softer to touch on my skin and does not have any rough edges.
Note: After replacing the caps, I also cover them with the Swab Cap. Although the caps provide good protection by themselves and do not allow anything enter into the catheter; yet swab caps offer a second layer of protection to the caps. Swab caps are tiny round caps as you can see in the video, and they easily slide on to the mouth of the cap by applying little pressure. I feel safer with the swab caps and have been using them every time I flush my line or change the caps. I am very thankful to my home health company for providing me this product. I am not sure if other companies provide them but if you request and provide the necessary information, your company might order them for you.
Below is a full cap change video for more details but here is a summary of how we do my cap change, make sure you do it in a sterile way too. What we use is: 2 caps since I have a double lumen catheter, 6-8 alcohol pads, a sterile drape, 2 saline flushes, 2 heparin flushes if you plan to lock the line after cap change, a pair of gloves, 2 masks ( one for me and one for the person changing my cap).
• We put the mask on (patient and helper)
• We wear gloves, and use sanitizer on hands
• Open and spread the sterile drape on the table and prepare few Alcohol swabs
• Get the saline syringes ready by taking out air bubble from them, keep them on the drape
• Lift the cap and peal the packaging half way making sure not to pull out the cap or touch the surface; let them stay inside
• Connect the saline syringe to the cap one at a time without touching either the cap or the saline syringe
• Using the alcohol pad, scrub nicely the connection point of the hub and the cap on my hand. It is very important to clean the connection point thoroughly
• Repeat this step with another alcohol pad
• Turn the cap anticlockwise to unlock it and remove it from the hub
• Leave the second alcohol pad under the hub
• We wipe the outer surface of the hub thoroughly with 2 new alcohol swabs
- Lift the saline syringe and pull out the cap making sure its sterile
• We cover the max plus cap with swab cap
• We lock with Heparin if needed
• Repeat the same steps to replace the other cap
5. Showering with a PICC line
It can be a huge challenge to take a shower with a PICC line, I have to take a restricted shower and protect the line to prevent it from getting wet. Shower sleeves are available and I tried a few but none of them worked for me. So my nurse told me and I also found this tip from Oley.org where it was recommended to use "Press n Seal". I have been doing that all along with some additions and it has worked out very well to keep my line safe though it is still not the perfect solution and I have to be very careful. Press n Seal from Glad is available in all common food stores. It is a see through plastic wrap that sticks very well to the skin and this is a link, http://www.glad.com/food-storage/plastic-wrap/press-n-seal/ Please see the video for details on how I use it.
It can be a huge challenge to take a shower with a PICC line, I have to take a restricted shower and protect the line to prevent it from getting wet. Shower sleeves are available and I tried a few but none of them worked for me. So my nurse told me and I also found this tip from Oley.org where it was recommended to use "Press n Seal". I have been doing that all along with some additions and it has worked out very well to keep my line safe though it is still not the perfect solution and I have to be very careful. Press n Seal from Glad is available in all common food stores. It is a see through plastic wrap that sticks very well to the skin and this is a link, http://www.glad.com/food-storage/plastic-wrap/press-n-seal/ Please see the video for details on how I use it.