PICC line issues, blood draw tips.

[Nurse.NoFilter]

I am a new LPN working at a LTC facility. Some day I will return to school for attain my RN, but for now I feel content practicing as a nurse, gaining new knowledge and experience every day! In our facility RN's & LPN's have the same responsibilities besides that RN's can start emergency IV meds(as far as I know that is the only difference for us, and believe me I have asked and read policies to cover myself).

I have drawn blood only one time, on a supervisor who had beautiful veins. We had a order to draw blood for labs for a resident that has a PICC line(which was being used to infuse 0.9% Sodium Chloride). We held the IV and attempted to flush the PICC line, the first port flushed easily with 10mL saline but we coul only draw 2 mL back out of the port to waste(prior to drawing the blood sample). So we tried the other port, the 2nd port flushed with some difficulty, and we could not draw back at all to waste. Then we looked for another vein to draw blood from, but this resident had tiny veins or veins I couldn't see. Obviously we had to hold the residents IV and informed the following shift in hopes they could get the blood draw The doctor was in and suggested we try to flush the ports with Cathflo.

Please give me some tips on where you look for veins on people who have tiny hard to see veins.

Sorry its so long, maybe its a new nurse thing, or I'm just OCD and love details.

[traumaRUs, MSN, APRN]

Hi and welcome to AN, the largest peer to peer nursing network. Here is a resource for you about best practices:

Best practices in phlebotomy - WHO Guidelines on Drawing Blood - NCBI Bookshelf

[icuRNmaggie, BSN, RN]

The time to instill cathflo is when the PICC starts to get sluggish. Check blood return at the start of the shift so that you have time for the cathflo to dwell and break up that fibrin tail. This is probably an RN responsibility; check the policy.

People of advanced age have such fragile veins that you may not need a tourniquet if they are hydrated.

Let the arm hang over the side of the bed. Gravity helps to distend the vein. I go for the first vein I see. Use a butterfly needle.

Ask to shadow whomever in your facility is really good at venipunctures.

[Nurse.NoFilter]

I guess I should mention this residents right arm was contracted, so no access to veins there. Left arm had the PICC line in it..I placed the tourniquet below the PICC line which may have obscured my ability to see some veins. Can a tourniquet be placed above the PICC line? (Seemed lime a bad idea to me) Thank ya'll for the replies, I appreciate the information!

I will ask if I can follow someone who is good at venipuncture, but I don't know how likely that will be as the blood draws seem scattered.

[KelRN215, BSN, RN]

I guess I should mention this residents right arm was contracted, so no access to veins there. Left arm had the PICC line in it..I placed the tourniquet below the PICC line which may have obscured my ability to see some veins. Can a tourniquet be placed above the PICC line? (Seemed lime a bad idea to me) Thank ya'll for the replies, I appreciate the information!

I will ask if I can follow someone who is good at venipuncture, but I don't know how likely that will be as the blood draws seem scattered.

Definitely not. No tourniquet, no BP cuff, nothing of the sort on the arm with the PICC.

I'd trouble shoot the heck out of that PICC before doing a peripheral stick. I've known some kids whose PICCs only drew when they held their arm straight out at a 90 degree angle to their body.

[dream'n, BSN, RN]

Agree with KelRN, Picc lines and ports can be very positional. Try raising the arm above the head and other possible maneuvers. Most of the time I'm able to get great blood return after readjustment of the limb.

[RunBabyRN]

Did anyone think to obtain an order for CathFlo? If repositioning didn't work, this should be the first option, unless these were stat labs.

Definitely no tourniquets above a PICC.

[anon456, BSN, RN]

In addition to repositioning the arm, sometimes if you change out the hub at the end of the PICC it will draw back. This opens the PICC to infections and should be changed using sterile technique. Cathflow works well, too. Sometimes even instilling the heparin in the PICC works, because the previous person may have forgotten to flush with it. It can sit for about 30 minutes and then try drawing back. If you have a problematic PICC, after it gets declotted and working again, especially if the patient is getting frequent meds or blood draws through it, a drip of 3mL/hour saline can help keep it open between uses. You will need an order for this.

[IVRUS, BSN, RN]

Remember Heparin flush prevents fibrin build-up, it won't lyse it if it is already present. Also, I agree that changing your cap can work, but it too is not usually the culprit in your occlusion. A continuous drip, won't necessarily prevent fibrin build-up either. Since EVERY lumen of the patient's IV catheter must yield a blood return, I too would employ nursing interventions first: Have the patient turn their head and cough; Reposition the extremity; Raise/lower the HOB etc, but if all fails, then obtain an order for Cathfo (no W at the end of this medication). This should be administered by a Licensed Professional whose scope of practice allows him/her to administer IV push medications and one needs to be educated on clearing thrombotic occlusions, or in this case clearing a persistant withdrawal occlusion (PWO)

[ontheway2crna]

Sometimes just flushing a lumen with not only 1 but 2 or 3 10 ml NS flushes gets it working and drawing better too.

[Stcroix, ASN, PhD, RN]

Whenever flushing a PICC with a 10ml flush, 'pulse' the flow rapidly. It has been shown that the turbulence helps clear fibrin from the lumen. I have had luck clearing lines that won't pull using this flushing technique.

[applesxoranges, BSN, RN]

Not saying this is it, but once we had a PICC line kink in the patient. The physician who attempted to "correct" it said he had never seen it before.