PICC removal - page 2

by agldragonRN | 17,627 Views | 58 Comments

i work ltc and my job does not allow staff rns to remove picc even if we are iv certified. the md comes and removes them. the doctor came today and removed left upper arm picc from my patient. i gave him all the supplies (gauze,... Read More


  1. 1
    Quote from xtxrn
    I've had 3 (or 4?) PICCs removed, and they stuck a couple of 2x2's on it with a bandaid, and a little pressure for a couple of minutes, and called it a day- first one was in 2007, and I lived to tell about it I've removed countless subclavians, and a couple of PICCs, and measuring the PICCs was never part of it. We check the end, and document the usual site condition, catheter intact, and any problems.

    I go to the surgeon tomorrow re: getting rid of the Hickman-- they use conscious sedation for that (when they put it in, evidently I was 'unconsciously sedated' as the CRNA told me I snored

    It stinks that you have to go through so much hassle, and that an MD has to come to remove the PICCs at the LTC... never had to deal with that- or noted any co-workers NOT pulling it themselves when ordered.

    When PICCs first came about, RNs were certified to INSERT them- I was never interested in that- seemed like too much invasiveness for my pay grade
    Well, you were truly "blessed" not to suffer an air embolism s/p removal if a 2x2 and bandaid is all they put on it!
    agldragonRN likes this.
  2. 1
    I was taught that you measured the catheter and made sure the tip is intact.
    agldragonRN likes this.
  3. 2
    Quote from IVRUS
    I would never just look at the markings on a PICC and say.... Oh, it's all there... Some PICC's start their cm markings at the distal end, whereas others start their cm markings at the proximal end. Did you place 43cm? And is the PICC measuring 43 cm now that it is out? Okay, I'm cool with that. but how do you make sure the "tip is intact" as you put it? If you chart that very thing, you're setting yourself up for a losing lawsuit.
    How did you determine that? Was a microscope brought to the bedside and you verified that the tip was intact?
    Was the catheter cut at an angle, and now it is straight across...ooopppps.
    And, unfortunatly, some of the markings, aren't easy to see, or decipher.
    A 3fr IV catheter, has markings so timy, that ya' better have good eyes, or good bifocals to see them, heaven forbid I'm looking at a 1.9 or 2 french line.
    For the Groshongs, thankfully they have a black tip which is how you know, it's all there!
    The next time you pull one out...look CLOSELY at the tip...you will see that it is slightly rounded...that is how you know the tip is intact. If it is not it will look similar to the tip of an IV catheter...cut off.

    No microscope needed.

    If you are not checking the tip and just measuring it...then you are not doing your job (and in my opinion, not charting clearly) either because if just the tip has broke off you won't pick up on that if you just simply measure it, as the tip is too small..you have to LOOK at it.

    We chart the length it was put in, we chart what the length was when we started the removal and look to make sure all the numbers are there and chart, "PICC line secured at 6 cm removed with tip intact." In fact, this is the policy of how to chart it.

    You are incorrect that charting "tip intact" sets you up for a lawsuit. The tip is THE END. That is pretty definitive.

    The PICC lines that we use in our unit, the markings are clear, so there is no question of where it is.

    So that is why the MD didn't feel the need to measure it...because the tip condition is visible to the naked eye.
    agldragonRN and wooh like this.
  4. 1
    Quote from BabyLady
    The next time you pull one out...look CLOSELY at the tip...you will see that it is slightly rounded...that is how you know the tip is intact. If it is not it will look similar to the tip of an IV catheter...cut off.

    No microscope needed.

    If you are not checking the tip and just measuring it...then you are not doing your job (and in my opinion, not charting clearly) either because if just the tip has broke off you won't pick up on that if you just simply measure it, as the tip is too small..you have to LOOK at it.

    We chart the length it was put in, we chart what the length was when we started the removal and look to make sure all the numbers are there and chart, "PICC line secured at 6 cm removed with tip intact." In fact, this is the policy of how to chart it.

    You are incorrect that charting "tip intact" sets you up for a lawsuit. The tip is THE END. That is pretty definitive.

    The PICC lines that we use in our unit, the markings are clear, so there is no question of where it is.

    So that is why the MD didn't feel the need to measure it...because the tip condition is visible to the naked eye.
    Well, I too believe that the tip should be inspected, BUT, the tip is NOT always rounded my friend. Sometimes PICC's are cut to alleviate extra catheter outside of the IV site. And charting TIP intact is not appropriate.. IN a court of law, they WILL quiz you on how that determination was made. They will say... "and how is it that you were able to tell that the tip was intact?" "Microscope" etc. So, charting, "Tip intact to the Naked eye, tip straight across, or rounded, or angled" (not that angling is done that much) is a better way to chart it.
    However, we can agree to disagree.
    And, the MD didn't feel like he should measure it, because many MD's aren't infusion savy. Sad, but true.
    agldragonRN likes this.
  5. 3
    Quote from IVRUS
    Well, I too believe that the tip should be inspected, BUT, the tip is NOT always rounded my friend. Sometimes PICC's are cut to alleviate extra catheter outside of the IV site. And charting TIP intact is not appropriate.. IN a court of law, they WILL quiz you on how that determination was made. They will say... "and how is it that you were able to tell that the tip was intact?" "Microscope" etc. So, charting, "Tip intact to the Naked eye, tip straight across, or rounded, or angled" (not that angling is done that much) is a better way to chart it.
    However, we can agree to disagree.
    And, the MD didn't feel like he should measure it, because many MD's aren't infusion savy. Sad, but true.
    So how many times have you been sued over a tip? Just sayin'.

    I only have to be responsible for the PICC's used in MY unit that I remove....not every PICC manufactured on the market. All of the ones in our unit have the rounded tips.

    Intact...has a meaning. Intact means it is in it's original state. So if it comes out rounded out of the package and then comes out of the PATIENT in the same condition...that is the definition of intact.
    agldragonRN, AmericanRN, and eagle78 like this.
  6. 2
    I've been blessed a lot with the health issues i've had, even though several have been life threatening.... but a PICC line, while being a central line, isn't major surgery to insert OR remove....it's not rocket science I've had nurses who removed mine be appropriately careful. I'm much more concerned about air emboli while the line is still in. It takes a lot of air for an air emboli...always been taught (for a LONG time) that it takes close to a full IV tubing (without extensions) to pose a serious risk.

    With the PICC being as long as it is (vs a subclavian line), there's a lot more space with fluid in it (flushes, IV fluids, etc), and that's going to help with any tiny amount of air that COULD be in the hub of the PICC, during removal. My sites have always been covered and pressure held....never had a problem. A clot, then scab, forms pretty quickly. Unless I picked it off, pried the insertion site open, and blew with a tiny hose, my risk wasn't any big deal.

    When I've removed PICCs, our protocol never included any type of ointment or goo to 'seal' the area. Ointments don't totally seal anything- just lube things up, or make a mess- lol.

    Facilities I've worked for abandoned the antibiotic ointment after line removal (or during routine care) a long time ago, since the goo is just one more thing on the site that messes with any natural seal formed by the body. JMHO based on MY experiences.
    Altra and agldragonRN like this.
  7. 1
    Quote from xtxrn
    I've been blessed a lot with the health issues i've had, even though several have been life threatening.... but a PICC line, while being a central line, isn't major surgery to insert OR remove....it's not rocket science I've had nurses who removed mine be appropriately careful. I'm much more concerned about air emboli while the line is still in. It takes a lot of air for an air emboli...always been taught (for a LONG time) that it takes close to a full IV tubing (without extensions) to pose a serious risk.

    With the PICC being as long as it is (vs a subclavian line), there's a lot more space with fluid in it (flushes, IV fluids, etc), and that's going to help with any tiny amount of air that COULD be in the hub of the PICC, during removal. My sites have always been covered and pressure held....never had a problem. A clot, then scab, forms pretty quickly. Unless I picked it off, pried the insertion site open, and blew with a tiny hose, my risk wasn't any big deal.

    When I've removed PICCs, our protocol never included any type of ointment or goo to 'seal' the area. Ointments don't totally seal anything- just lube things up, or make a mess- lol.

    Facilities I've worked for abandoned the antibiotic ointment after line removal (or during routine care) a long time ago, since the goo is just one more thing on the site that messes with any natural seal formed by the body. JMHO based on MY experiences.
    I too would be worried about air-emboli while in-situ, because if you had a non-valved IV catheter and the injection cap "accidentally" came off, or was removed when the syringe was removed, air emboli is a problem and concern. However, depending on the size of the PICC, or any CVC, their could be a track through the skin into the vein that stays open once the catheter is removed. That is why it should be immediatly covered with a gel to seal the track shut. The is not only common sense, it is an Infusion Nurses Society (INS) standard.
    It should NOT, however, be used at the site for routine care.
    If you didn't follow this standard and your pt suffered an air embolism as a result of this neligence, a successful lawsuit with you being the loser will result.
    agldragonRN likes this.
  8. 1
    Quote from BabyLady
    So how many times have you been sued over a tip? Just sayin'.

    I only have to be responsible for the PICC's used in MY unit that I remove....not every PICC manufactured on the market. All of the ones in our unit have the rounded tips.

    Intact...has a meaning. Intact means it is in it's original state. So if it comes out rounded out of the package and then comes out of the PATIENT in the same condition...that is the definition of intact.
    Here is the defintion of Naivete: Lack of experience; Gullible.

    Here is the defintion of Litigious: Subject to lawsuits.
    agldragonRN likes this.
  9. 1
    Quote from kainos
    So would your boss have preferred you to dig through the sharps container looking for the PICC after the MD deposited it there???
    Not blaming or anything, but next time, she might want to stay with the MD during removal or a procedure on her patient, especially as this is LTC. Doctors are few and far between, so just to keep up with the going-ons on your patient. And I'm sure the doctor would not have minded if you had requested he keep the PICC line so you could measure it.

    It's team work, sometimes all this, "he should, you should, they should", Not my fault, not my responsibilty just bugs things down.
    It should be " what can I do to make things better?"HOw can I help to make life easier?' It's more of the attitude.

    You also got into trouble not because you were wrong, but because you did not follow policy. Each and every hospital has their own policy, when there is a policy, you should try as best as possible to follow it. There are rules to live by.
    agldragonRN likes this.
  10. 0
    Quote from ivrus
    well, you were truly "blessed" not to suffer an air embolism s/p removal if a 2x2 and bandaid is all they put on it!
    well, this is what pretty much the doc did, 2x2 and paper tape.


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