[SWAT_RN]

Howdy all, recent events make me have to ask...
I was taught if a PICC became clogged, non-functional, get the order for tpa and follow p&p yada, yada. Well, we tried that x2 and the sucker was still plugged tight. I'm thinking it's going to need to be replaced. We contacted the IR staff and one of the techs came up to the ICU and pushed a wire through the obstruction. This opened up the PICC but I have to wonder about the safety of doing that. The INS reference I have doesn't mention this as an option and a quick internet search didn't turn up anything either. This particular tech has a VERY confident, superior demeanor and I just wonder if this is an acceptable solution to this issue.
Thanks for your input!

[dianah]

You might (discretely) inquire of the Radiologist or one of the Radiology Nurses if this is protocol. You might approach it thus: "I was concerned when a PICC was recently declotted by the tech, using a wire. Wouldn't this push any clot or debris into the pts vascular system??? Is this technique a last-ditch effort? Is it written as protocol?" etc. I have to assume (yes, I've gotten in trouble before, for assuming things!) this tech checked with the Radiologist and received his/her OK for the wire "intervention."
My other thoughts are: was sterile procedure followed? There should have been a sterile field, the wire sterile, and at the VERY least, the tech should have worn sterile gloves and possibly mask (am I old-fashioned, here??). PICC hub should have been cleansed/disinfected, and wire length measured before insertion, so it didn't extend beyond the tip of the PICC. (It WAS a PICC in the SVC, right?? Not just a triple-lumen with its tip in the forearm .somewhere . .)
Would it have been very difficult to place a new PICC line in this particular pt? Perhaps the Radiology staff knew this, and chose the wire technique (risk VS benefit) to preserve what little access was available.

It's so hard to trouble-shoot this, not knowing the pt or the details! Hope you can find the answers you seek. Keep asking questions! --- Diana

[sbivrn]

I agree with Diana. Where did the clot go if not into the patient's vascular system? This is not an INS standard of practice. This should not be let go. Many people cover a lack of knowledge with bravado!

[Angie O'Plasty, RN]

I've never heard of that either. Most of our clogged lines are DC'd if the clotbuster doesn't work.

[Sweetooth EMT-P, RN]

umm...would really be a bummer if the wire shears the catheter!

swtooth

[jer_sd]

In the past I have used the wire technique to unclog picc lines and even g-tubes. The risk of clot is real, but I have seen multiple rads exchange picc lines over a wire for similar situation. I do not advocate doing this blind since therisk of rupture of catheter is higher. Personaly as a radiology rather myself, another midlevel provider or Dr. make the decision to use a wire, if teh rad tech did that without direction or an order I would have a huge issues with that action. If he was following an order that is documented somewhere then he may have been acting within the standards of the facility depending on his job description ect...

Jeremy

[sbivrn]

Over the wire exchange of a PICC line is a totally different issue. The validity and safety of the procedure is well documented. We accomplish this quite safely at the bedside. This is also done in Radiology. You cannot compare declogging a g-tube with a wire, to declotting a central line in the same manner. It is foolhardy and puts the patient at risk.

[jer_sd]

Originally Posted by sbivrn

Over the wire exchange of a PICC line is a totally different issue. The validity and safety of the procedure is well documented. We accomplish this quite safely at the bedside. This is also done in Radiology. You cannot compare declogging a g-tube with a wire, to declotting a central line in the same manner. It is foolhardy and puts the patient at risk.

If you have a nonfunctioning PICC (clogged) and exchange it over a wire at bedside you run the same risk for embolic material, just as using a 1cc syringe to unclog the PICC. the ammount of embolic material should be minimal and should be well tolerated by the patient unless there is a right to left cardiac shunt, pph or orther condition. Which is why I can choose to make that decision compared to removing the line and replacing it. If I was a staff RN or rad tech there is no way I would make that call but my role is different as a NP.Think about when you strip a fibrin sheath on a perm cath that is a larger volume of material released intravascular than a clogged PICC line, or even IV administration of MAA causes pulmonary embolisms (used in vq scans).There is risk to any procedure done in nursing and medicine in my practice occasionally I will recandulate a picc line with a wire especialy if the patient has limited veins even under ultrasound guidance. You may not agree with the practice and I do not advocate doing it to all patients but there is a wide variety of care provided for central lines, and I have yet to see documented proof that this action will put my patients in serious harm. I do not read as many articles as I should so please feel free to share refrences.have a great weekend,Jeremy

[suzanne4]

A radiology tech from IR has no business declotting a catheter of any type. If there were any issues, they would be hung to dry. And what happened with the clot that they busted thru? It is travelling around that patient's veins and arterties, until it gets hung up somewhere.

They are not even covered to do that.

It is one thing if the radiologist decides to do this, but the IR tech has no business attempting this...............completely out of their realm of responsibilities.

[sbivrn]

Perhaps I have been unclear. I do not do over the wire exchange for clotted PICCs. The result would be no different than that to which I am objecting. Our two options are to use Activase to declot the picc or to pull it. Never to stick a wire into it.