PICC line blood draw

[greyL]

What's the proper way to draw blood from a picc line? The other day I flushed with 10 cc's of NS, then wasted 10, then drew blood. But the lab called to say that the results looked wrong (extremely low hemoglobin level) and that the blood probably had saline in it. Another nurse told me that I'm supposed to waste more than I flush and that I did it wrong. Is that correct?

[greyL]

~*Stargazer*~ said:

Okay, I just thought of a more supportive way to communicate that last part of the above message, but the window of time for editing is past, so I'd just like to say that I'd like to encourage you that next time you need to do a procedure with which you are unfamiliar, to look up the P&P first. Sorry to sound harsh above. Sometimes I just need to think for a little while to find the right words.

It was because I just followed the way my preceptor showed me to do it. And because I had never had a problem with drawing blood from a PICC line before; though admittedly, I don't do it very often because I don't see a lot of PICC lines in my unit.

I do agree that I should have looked at the P&P, though looking at the P&P in the past for other procedures has never really gotten me answers (like when I looked for our policy of what size gauge to use for blood transfusion) This is the first time I've looked and it's showed me what I really needed to know.

[OCRN3]

It is a very old fashioned policy, it doesn't help that the nurses and doctors that work there have been there 20 plus years either. :). I've been there 15 years and I'm considered newer :) LOL!

Sent from my iPhone using allnurses.com

[PacoUSA, BSN, RN]

I always recap the flush syringe that I use to waste. That way I know it is the waste. Our policy is to flush and waste 10cc, flush again 10cc and change cap. Always remember to pause continuous fluids. I once drew blood on a PICC simultaneously getting D5NS and glucose came back 800 ... Redraw with paused fluids was 175. Be warned lol.

[Asystole RN]

edimo said:

Wait a minute...so someone who has a PICC would have to be poked anyways for a blood draw? Why?!

At my facility, we use PICCs quite a bit and we normally do not flush prior to blood draw, waste 6 ml, and flush with 10 ml of saline if line is in active use. Add in heparin flush if it's not which is in a pre-filled syringe (pharmacy supplies it to us, not in Pyxis). Caps changed every 4 days but also with blood cultures

Not all PICCs are the same.

As you may know there are power injectable and non-power injectable. There are also different materials and different lumen sizes. The catheters may be trimmable or non trimmable. Some are antithrombogenic and some are antimicrobial.

Most acute care nurses are familiar with 5Fr double lumen power injectable PICCs but depending upon the facility they may routinely use other PICCs such as 3Fr or 4Fr single lumens. Although one CAN draw blood from these lines, there may be a higher rate of intraluminal thrombosis. At about $75 per dose, per PICC lumen, of Cathflo (considering a PICC costs in the $100-$200 range) this can get pretty expensive.

Keep in mind also that the more you are accessing the PICC, the more manipulation, and the more you are changing the needless access devices (NAPs) the more chances that line may be seeded with bacteria. This doesn't take into account what the patient may have infusing. For example, you would not stop a TPN infusion to draw blood.

For a facility, the risk of blood draws may outweigh the benefit of reducing peripheral sticks.

I routinely place PICCs for blood draws at my facility but there are occasions where a particular patient may not use their PICC for blood draws.

Keep in mind also that the poster's place of employment may not be an acute hospital hospital and may not be staffed with registered nurses who are trained in fully utilizing PICCs.

Asystole RN, CRNI, VA-BC

[TU RN, DNP, CRNA]

I just did a very brief ROL and couldn't find too much evidence on CLABSIs secondary specifically to CVC blood draws. I'm also curious about the incidence of loss of patency and microembolization secondary to frequent CVC blood draws. Previous poster mentioned EBP regarding the topic, could you perhaps cite some scholarly articles? I'll be sure to use my hospital's database when I go in to work tonight for more information (if I have time )

The policy in my hospital is scrub, flush with 10 of NSS, waste 10 of blood (which I don't agree with), luer lock vacutainer for blood samples, flush with 10 of NSS (however some MDs will specifically order to flush with 20). I usually scrub afterwards too because a minuscule amount of blood remains on the tip of the lock, which could very well end up as a medium for bacterial growth. You also need a physician's order to use the line for blood draws in my facility.

IR at my hospital will outright refuse to place a PICC if one of the indications is blood draws. The only rationale for this I've been able to ascertain from the docs is that it increases infection rates. Our MICU tends to have higher central line infection rates, but I believe that is expected considering the acuity of illness and number of central lines. I have also heard from MICU nurses that the part of our policy where a physician's order is needed to draw from CVCs is often overlooked. Correlation? I don't know. It's hard to get evidence considering the difference in acuity.

Another thing that sparks my curiosity is the potential for clotting lines or microemboli. Now I haven't seen any literature on this related to CVC blood draws, but it seems rational to think that if more blood occupies a line more frequently due to blood draws, the likelihood of aggregation along the inner lining or tip of the CVC (a foreign object as far as the body sees it) would be increased. For both infection and embolism prevention, it makes sense that a larger volume flush would serve to "clean the line" after a blood draw.

As for the point on accuracy of lab results on blood drawn from a CVC versus peripheral phlebotomy, I've not seen in my own practice any significant changes between the two samples. Pt A had a double lumen PICC which the previous RN had been drawing her q.6.h. BMPs from for hyponatremia. When I resumed the assignment for night shift, I noticed there was no physician order to draw blood from this line. I called the on call who said no such order existed and to draw the old school way. Considering if I drew from this line would be a violation of our policy, I instead apologized to my patient, explained the policy and rationale behind the policy, and drew via peripheral phlebotomy. An hour or so later when the lab resulted, I noticed no significantly different changes between previous RNs labs drawn via the CVC and my own labs drawn from a peripheral vein on the opposite extremity. This is by no means a stratified research study, but nonetheless that's my low level, isolated case study.

TU RN

[wooh, BSN, RN]

If the 1 and 2 fr piccs I regularly use aren't clogging, I think 3 and 4 fr piccs can handle a few blood draws.

And while stopping cardiac drips might be an issue, stopping TPN is not. Use aseptic technique, minimize NEEDLESS entries, use lots of flushing after the blood draw.

Advocate for your patients, use the technology we have, change policies that haven't been reviewed since 1995, get training for staff.

[Asystole RN]

wooh said:

If the 1 and 2 fr piccs I regularly use aren't clogging, I think 3 and 4 fr piccs can handle a few blood draws.

And while stopping cardiac drips might be an issue, stopping TPN is not. Use aseptic technique, minimize NEEDLESS entries, use lots of flushing after the blood draw.

Advocate for your patients, use the technology we have, change policies that haven't been reviewed since 1995, get training for staff.

Generally the IFUs, at least for Bard Access Systems, says that the minimum of a 4Fr should be used for blood draws. The rationale for not interrupting TPN infusions is from the high risk of CLABSI associated with TPN and interrupting the closed system. The world of NICU is very different from the world of the adult population. What gauge catheter do you use for blood transfusions?

What I was trying to say is not all facilities are the same and not all PICCs are the same. One has to take into account the type of facility, their staffing and training, the type of PICCs in question, their occlusion and CLABSI rates etc etc etc. It is not a black and white issue, there is no binary solution.

Take it as you will but here is an excerpt from the 2011 INS Standards of Practice, Standard 57

Quote

A. Blood sampling for laboratory testing from a central vascular access device (CVAD) should be considered based on an evaluation of benefits versus risks. Benefits include avoidance of anxiety, discomfort, and dissatisfaction associated with venipuncture in patients who require frequent blood tests and/or those with difficult vascular access. Risks include increased risk for occlusion and catheter-related bloodstream infection (CR-BSI) due to increased hub manipulation and potential for inaccurate laboratory results, although there was no significant increase in occlusion, infection, or other complications in peripherally inserted central catheters (PICCs) used for blood sampling in one study.17-19 (V)

C. Caution should be exercised when interpreting drug levels with a CVAD-obtained blood sample...Some studies have shown elevated drug levels with blood sampling from CVADs; factors negatively influencing accuracy include sampling from implanted ports, silicone catheters, and from the same catheter lumen used for drug infusion.18,23-30 (IV)

D. Caution should be exercised when interpreting coagulation values with a blood sample obtained from a heparinized CVAD. Current literature does not support blood sampling for coagulation levels via heparinized CVADs...

[wooh, BSN, RN]

Aseptic technique. And using common sense. Perhaps drug levels and coags shouldn't be drawn from a PICC. Doesn't mean CBCs and chem panels can't be.

If NICUs and peds hospitals can pull off minimizing peripheral sticks by using aseptic technique, then I'm thinking we can trust adult nurses to use a CHG wipe. Wiping a port isn't a specialized skill.

[MunoRN, RN]

Asystole RN said:

Although one CAN draw blood from these lines, there may be a higher rate of intraluminal thrombosis. At about $75 per dose, per PICC lumen, of Cathflo (considering a PICC costs in the $100-$200 range) this can get pretty expensive.

That certainly seems possible but according the 'experts', INS and Lynn H, that's just a myth.

[Anoetos, BSN, RN]

I usually waste more than I flush. Flushing is for line clearing and patency, so I can't really see the point of a policy of flushing with 10 or more, but I am certainly willing to be educated on it.

Other than that, after you flush you can move the pts arm around...lol.

[MendedHeart]

Quote

At our facility they rather not use the PICC line to draw blood.....

Sent from my iPhone using allnurses.com

We dont draw from any line if Infectious disease is following unless they say its ok

[Asystole RN]

MunoRN said:

That certainly seems possible but according the 'experts', INS and Lynn H, that's just a myth.

Out of all the conferences and meetings I have never heard a leading expert claim there was zero risk, and I have personally met Lynn and heard her speak. The INS Standards clearly state that there is a risk.

Obviously any manipulation involves some degree of risk. Do I personally think that the risk outweighs the benefits? Absolutely not, many of the lines I place are in fact for frequent draws.

What I was attempting to point out was that in the world of PICCs, there is no binary solution. In a facility with a multitude of variables, I can see where they may clamp down upon PICC manipulation. Do I agree with it? No. Do I understand it? Yes.