PICC removal

[agldragonRN]

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, alcohol swabs, etc.) and asked if he needed the measuring tape because i know the catheter needs to be measured and compare with the original length. the doctor said no he does need it and he won't measure it. doctor removed picc and put dressing, and charted and left. then my supervisor came and i told him the picc was just removed by the md. he asked me if i had measure it. i told him no that i asked the md if he needed the measuring tape and he said no. my supervisor said it was my responsibility to measure the catheter and chart it. i told him why when it was the md who removed the picc and not me. plus he was the primary doctor. if i had removed the picc myself, then of course i would measure the catheter. i was not even in the same room with the doctor when he was removing it.

what do you guys think? this is the first time an md came to my shift (3-11) and removed a picc so i didn't know what to do.

thanks,

angel

[IVRUS, BSN, RN]

dead horse begging to rip

ivrus-- people don't agree with your insistence- you don't agree with those who don't agree with you

is this going to go on forever

:cheers: is there any chance to agree to disagree ??

hello.... someone asked me to site where i got my info, dead horse or not, some people want to do things following standards. i merely sited them.

agreed... amen.

[xtxrn, ASN, RN]

Hello.... Someone asked me to site where I got my info, Dead horse or not, some people want to do things following standards. I merely sited them.

Agreed... Amen.

Great :) Let's go get a fruit smoothie and hang out at the beach

[IVRUS, BSN, RN]

Great :) Let's go get a fruit smoothie and hang out at the beach

Sorry, I'm in the midwest... No good beaches here.. Just an arch, and hot pavement.

[xtxrn, ASN, RN]

Sorry, I'm in the midwest... No good beaches here.. Just an arch, and hot pavement.

I'm in the midwest also....:) Meant it in the same way as 'sending chicken soup' if someone doesn't feel well

[cherrybreeze, ADN, RN]

my facilities policy not only does not say to apply a gel after picc removal, it specifically prohibits it. applying a gel does not provide an occlusive seal. imagine if you have a leak in a tire, would putting some vaseline on it seal the leak? probably not. another issue is safety; if there is an open track to a vein where the vein is exerting negative pressure into that track, is it a good idea to put vaseline in the track? absolutely not, this (vaseline emboli) has been attributed to at least one death. is the threat of air embolus following picc d/c significant enough to support such a risk? nope, there has never been a reported case of air emboli following removal of a picc. are there safer and more effective options? yes, an occlusive dressing is far more likely to successfully occlude the opening, and it's unlikely that the dressing could be pulled into the vascular system. occlusive dressings can be placed in one motion with removal of the picc resulting in minimal time between removal of the line and occlusion of the tract. we don't allow vaseline soaked dressings either, these just make it more likely that the occlusive dressing will fail and provide no advantage over an occlusive dressing alone.

i do not think a comparison between an arm and a tire is relevant or appropriate. different "materials," if you will, plus the workload of a tire is different from the workload of an arm (or chest or neck, but i'm specifically talking about piccs, so it would be arm). skin is softer and more flexible than the rubber of a tire. you don't have the pressure from the inside with an arm than you do with a tire. bodies aren't filled with air to the tune of say, 44ppsi. apples to oranges.

i had my hickman taken out last week...a much bigger hole leading up through the tunnel to my jugular vein...no goop. 2x2s and tegaderm.... and 6 days later, i'm still kicking

what scares me the most here is not necessarily the fact that an ointment wasn't used, it's that they used a tegaderm. tegaderm is not occlusive. we don't use them when an occlusive dressing is required (either picc removal, chest tube removal, whatever).

that article, as i pointed out earlier, documents the effect (death) of vaseline entering a vein, putting vaseline in an open tract that communicates with a vein clearly presents some risk. the question then is if the risk is justified based on the severity of the threat and lack of other, safer options. the incidence of post picc removal ae is zero, there are no documented cases of this ever happening. in terms of other options, a tegaderm by itself is both safer and more effective. an occlusive dressing, which relies on adhesion to the skin surrounding the site, is not enhanced positively by a lubricant that negates the adhesive abilities of the dressing. less adhesion = more likely seal will not be patent.

the title of the article is:

"lung embolism caused by vaseline following insertion of a venous catheter"

i don't think it's a valid argument in the discussion of removal. the tract, as mentioned earlier, collapses quickly after removal of the line. in the case from the article, the line was in, so obviously that tract was still very much present. you're twisting it to fit your case. one case relating to insertion of a line does not support doing or not doing a particular procedure upon removal of that line.

i looked up the official synopsis last night at work for our policy. their first issue was that they couldn't get it to work, even to a small degree. they used a coffee stirrer in a piece of foam to simulate a picc tract as it exited the skin, hooked it up to -10 to -15 cm h2o of suction (same as negative intra-thoracic pressure with inspiration) and applied petroleum jelly to the opening. even after repeated applications the petroleum wouldn't maintain a seal for any amount of time, the jelly was always pulled apart at the opening by the negative pressure.

did this experiment also include the application of an occlusive dressing with the petroleum jelly? was the coffee stirrer manipulated in any way to simulate how picc tract behaves after the line is removed? the *actual* tract does not, at any point (line in or removed), resemble a piece of hard plastic. while i can appreciate what this little experiment was trying to prove, it does not include very relevant factors and variables. if they are using this to write policy, i'm frightened.

the clincher though was from risk management who vetoed the idea based on something called the "mulder rule" the mulder rule states that doing something that fda required labeling says specifically not to do is considered automatic malpractice. all petroleum jelly is required by the fda to carry the same warning; "do not use on deep wounds / puncture wounds". a picc insertion wound could certainly be argued to be a "puncture" type wound. there was even a question on the part of risk management of whether or not this would be considered a felony, although it sounded like it most likely would not, just negligence, which is still pretty bad.

as far as the vaseline goes....do places use actual vaseline? our policy was sterile, triple antibiotic ointment. from a single use packet. a picc site could loosely be termed a puncture wound, sure...but you know that is not what is meant by the wording to layperson consumers on a container of vaseline.

as far as the op and measuring.....our policy is to measure piccs. it's part of the standard cvl documentation. our piccs are "cut to fit," though, too, so all of the ends look the same....blunt and cut. i've never had one whose measurements did not match the original. they might be slightly longer, due to some stretching from being in place for x amount of time. not the other way around, though.

[xtxrn, ASN, RN]

My reactions to other adhesives limited what they could use. Tegaderm was a known dressing that I can tolerate. :)

Thanks for sharing.

[cherrybreeze, ADN, RN]

My reactions to other adhesives limited what they could use. Tegaderm was a known dressing that I can tolerate. :)

Thanks for sharing.

I do understand that, I am sensitive to adhesives as well. It does make it more risky though, sadly.

[MunoRN, RN]

i do not think a comparison between an arm and a tire is relevant or appropriate. different "materials," if you will, plus the workload of a tire is different from the workload of an arm (or chest or neck, but i'm specifically talking about piccs, so it would be arm). skin is softer and more flexible than the rubber of a tire. you don't have the pressure from the inside with an arm than you do with a tire. bodies aren't filled with air to the tune of say, 44ppsi. apples to oranges.

i agree, which is why we tried it with something more similar to skin and with the exact same pressure, we tried it with an iv practice arm and exact same negative pressures, and found that it didn't work. while it's true that our arm wasn't a real arm, the fact that it didn't move at all and the puncture hole never changed should have made a seal easier to achieve. i'm not really sure what the theory that it will work is based on since petrolatum is viscous and has no connective structure. obviously, this wasn't meant to be an experiment we were hoping would win a nobel prize. we were weighing a variety of factors; we had a list of cons, yet our list of pros didn't include any evidence that this a problem worth taking risks on, and there was no evidence that this was effective. if we couldn't replicate the proposed effect, then we weren't left with many factors to outweigh the risks. as rudimentary as our experiment was, it was infinitely more evidence than the ins based their recommendation on, which was nothing.

did this experiment also include the application of an occlusive dressing with the petroleum jelly? was the coffee stirrer manipulated in any way to simulate how picc tract behaves after the line is removed? the *actual* tract does not, at any point (line in or removed), resemble a piece of hard plastic. while i can appreciate what this little experiment was trying to prove, it does not include very relevant factors and variables.

we did use a tegaderm film dressing as a sort of control, and found no leak (using an atrium), suggesting no apparent advantage to adding ointment, only additional risks.

if they are using this to write policy, i'm frightened.

you prefer policy based on no evidence at all?

what scares me the most here is not necessarily the fact that an ointment wasn't used, it's that they used a tegaderm. tegaderm is not occlusive. we don't use them when an occlusive dressing is required (either picc removal, chest tube removal, whatever).

tegaderm film is classified as an occlussive dressing, more specifically a semipermeable transparent occlusive membrane. like other occlusive dressing such as hydrocolloids (duoderm) and other films, tegaderm film allows some osmotic vapor and gas exchange, but it does not permit airflow. the only way for a volume of air to move across the membrane would be if their was a constant negative pressure on the tract side of the membrane for a very long period of time, which would mean the patient is not breathing, which would probably be a bigger problem. you don't really see truly occlusive dressing materials these days, even coated foam tape is semipermeable, what do you use?

the title of the article is:

"lung embolism caused by vaseline following insertion of a venous catheter"

i don't think it's a valid argument in the discussion of removal. the tract, as mentioned earlier, collapses quickly after removal of the line. in the case from the article, the line was in, so obviously that tract was still very much present. you're twisting it to fit your case. one case relating to insertion of a line does not support doing or not doing a particular procedure upon removal of that line.

as i pointed out initially, and again later, the article answers the question that i hope occurs to anyone considering placing a viscous material into a wound that communicates directly with a vessel, which is what can happen if the ointment enters a vessel? as the article points out, petrolatum in a vessel can cause death, which i'm sure we can all agree is a serious medical condition. i'm not following your argument that the tract remains closed after the line is removed which means that the petrolatum cannot enter the vessel, if that's true (which it very well might be) then that would negate the need for an airtight seal in the first place.

as far as the vaseline goes....do places use actual vaseline? our policy was sterile, triple antibiotic ointment. from a single use packet. a picc site could loosely be termed a puncture wound, sure...but you know that is not what is meant by the wording to layperson consumers on a container of vaseline.

vaseline is a brand name for petroleum gel, aka petrolatum. yes, petrolatum can be found in many hospital store rooms, either alone or as part of a mixture. i'm not sure what you mean by saying that you don't use petrolatum but that you use antibiotic ointment instead, i don't know of any antibiotic ointments that don't use petrolatum as the main ingredient.

i'm not sure that i agree that fda mandated contraindication warnings apply less to health care professionals than they do to laypeople, if anything we are more likely to be held to a higher standard of knowledge regarding product safety warnings. the warning is there because deep wounds and puncture wounds may communicate with a vessel, in which case you wouldn't want petrolatum entering the vessel. placing petrolatum on a puncture that you know for sure communicates with a vessel would seem to make the warning more relevant rather than less relevant.

[zacarias, ASN, RN]

"the only way for a volume of air to move across the tegaderm membrane would be if their was a constant negative pressure on the tract side of the membrane for a very long period of time"

I don't understand the above sentence. How does air get across the membrane?

[MunoRN, RN]

"the only way for a volume of air to move across the tegaderm membrane would be if their was a constant negative pressure on the tract side of the membrane for a very long period of time"

I don't understand the above sentence. How does air get across the membrane?

Tegaderm is a semi-permeable dressing that does not actually allow the free-flow of air through it. It allows for osmotic exchange of vapor and gasses across the membrane.

[firstinfamily, RN]

RNs were allowed to pull PICCs where I worked sub-acute rehab. The ones we usually had were placed in the local hospital and we had to have the procedure paper from when the line was placed which told what the length was. I always measured the length of the PICC and documented accordingly. The diameter of the arm should also be measured at removal as if there is any local edema then you have a baseline to determine how much edema etc. Our MD never removed the PICC lines, RNs always did. I had problems getting the correct documentation from the hospital so make sure if the case manager is determining who is eligible for admission if they have a PICC that she/he gets the information with the other admission paper/computer work. I also agree that you cannot document what you did not do, and the MD should have measured the line, you can just document that the line was removed by Dr. SoSo and assess the site/dressing etc. You should check your nursing policy and procedure book and see what policy covers removal of PICC lines and who should do this. Most likely the Supervisor is going to get verbally attacked by their upper management person for not having the accurate documentation on the length, however, if you know the policy you will be prepared next time!!