the thumb and forefinger of the nondominant hand Insert the Huber needle slowly through the skin directly into the septum of the circular reservoir until the back of the reservoir is reached Unclamp and gently withdraw to assess for the presence of blood, then slowly inject saline Watch for local infiltration, which may occur if the needle is not properly placed If local infiltration occurs, remove the Huber needle Blood drawing is accomplished through extension tubing after clearing the line of dead space volume If blood is being drawn, to mL must be drawn and discarded before collecting the amount necessary for testing Place a dressing over the site and secure the catheter with chevron-shaped silk tape Medications or intravenous fluids may be attached Normal saline flushes should be administered between medications Flush with mL of heparinized solution when medication or fluid administration is complete or after blood drawing is accomplished Remove the Huber needle Place a dressing or adhesive bandage over the site once the needle has been removed Peripherally Inserted Central Catheters To access a PICC, first scrub the access port per institutional protocol, using a twisting, frictional scrub for a minimum of 15 seconds and then allow for complete drying Using sterile technique, access the port of the lumen with a 10mL syringe filled with normal saline Aspirate to confirm blood return After confirming patency, flush using a pulsatile technique until all flush solution has been administered, thus clearing the line of blood, medication, and/or intravenous fluid Maintain pressure at the end of the flush to prevent the reflux of blood into the catheter; repeat for each lumen of the catheter Follow the manufacturer’s instructions for the clamping procedure at the end of the flush Nonpatent Catheters—Use of Fibrinolytics When tunneled CVCs or implantable ports are not readily accessed, the most common reason is presence of a clot The clinician should consider use of a fibrinolytic to assist in clot dissolution as long as it is not contraindicated Alteplase (2 mg/2 mL) For patients weighing less than 30 kg, alteplase can be instilled in an amount equal to the catheter priming volume plus 10%, not to exceed mL (2 mg) and should be allowed to dwell within the catheter lumen for 120 minutes For patients weighing more than 30 kg, a 2-mg dose should be instilled and allowed to dwell within the catheter lumen for 120 minutes Then, attempt to withdraw blood with a 5- to 10-mL syringe