Declotting PICCs

[Mommy TeleRN, RN]

I am a new nurse and I recently spent some time with the PICC team. They were called to declot a PICC. I was glad to see this because I work nights/weekends when the PICC team isn't readily available. The PICC nurse said it was quite appropriate for a floor nurse to first try and declot/troubleshoot before calling in the PICC team (worst case scenarios I guess they redivase).

Anyway, we use Groshong piccs. Her technique was to declot with heplock and a TB syringe. Here is the interesting part - today I was reading our P&P on central lines and it had a section on declotting PICCS and it said to use a 35-50 cc syringe with Heplock!

So I'm confused on if you would use a tiny syringe or a huge syringe? lol I'm wondering if the p&p was written before we used Groshongs maybe? Is the P&P right or is the PICC nurse right? Maybe the P&P needs updated?

[CritterLover, BSN, RN]

they both need updated.

heparin does not break down clots.

it is no more effective in "decloting" than saline is.

heparin is used in the case of a dvt or a pe to prevent the clot from growing, while the body's natural "clot buster" breaks down the clot. if desired, some man-made thrombolytic (alteplase, reteplase, streptokinase, urokinase) can be added to help the body break the clot down faster.

we use heplock in ivs/central lines to prevent clot formation, not to break down clots.

the correct drug for decloting is one of the thrombolyics. we used to use reteplase, but now strictly use alteplase ("cathflo activase").

now, on to the question of syringe size.

do not use a tb syringe.

how wrong she was for using a tb syringe depends on how she was using it.

if the line is only partially occluded (can flush but can't aspirate) then a 5 or 10 cc syringe (depends on hospital policy) filled with the thrombolytic can be used to simply instill the drug into the line, like giving an iv push med. if she used a tb syringe here, then more than likely no harm was done.

if the line is completely occluded, then a vaccuum must first be created in order to allow the agent to reach the clot. basically, you suck the air out, and then (without letting more air get in) replace that air with the thrombolytic. there are a couple of ways to do this. a tb syringe would most likely be unsuccessful in creating that vaccuum. again, probably no harm done, but very ineffective.

if, however, she had a completely occulded line, and instead of creating a vaccuum, was using the tb syirnge to "force" the drug into the line, this is a big, huge no-no. completely against standards of care, and could have caused the line to rupture.

[CritterLover, BSN, RN]

here is ucsf's policy on how to declot a central line. it doesn't have pictures, but does a pretty good job of explaining the two ways to create a vaccuum:

http://www.resourcenurse.com/referencemtls/policiesandprocedures/iv_therapy/declottingcentrallineswit%20tpa.doc

http://72.14.253.104/search?q=cache:htehcehxjyuj:www.resourcenurse.com/referencemtls/policiesandprocedures/iv_therapy/declottingcentrallineswit%2520tpa.doc+picc+declot&hl=en&ct=clnk&cd=34&gl=us

(these two links are the same; i can't figure out which one will work)

i used to be able to find vanderbilt's policy on-line; i'm not sure why i can't find it today. i think it might have had pictures showing the stopcock method, since it is kind of tough to understand with just words.

cathflo's website has a video that can be ordered. i think it is free:

https://www.cathflo.com/professional/index.jsp

eta: both of the links for ucsf work; you need to have microsoft word to use the first link. the second one will work without word.

[Mommy TeleRN, RN]

Thank you both very much. I asked my preceptor and she had all the same response. I looked at the Cathflo as well as Bard's site.

While I am not 100% sure if she was putting much pressure behind the TB syringe, I think it would be unsafe for me to attempt to use one because the increased pressure can rupture the line.

I'm still not really sure why the policy says to use helpock. I know the PICC team uses some type of thrombolytic when needed (not sure if it's Cathflo or not) and I'm not sure of their instillation method as I didn't get to watch that particular procedure. Our P&P just says if order needed for Activase to follow the product instructions.

I'm certainly glad to have researched this further!

I'm still a little confused about the purpose of the injection caps since there is a luer lock on the end of the catheter. What is the purpose of these?

Thanks!!!!

[CritterLover, BSN, RN]

i'm still a little confused about the purpose of the injection caps since there is a luer lock on the end of the catheter. what is the purpose of these?

thanks!!!!

they keep the end sterile, and closed (since though the end of the catheter has a leur lock connector, it is "open.")

those caps should be changed weekly/with every dressing change.

[ONC-RN]

Thanks, the extra tips on creating negative pressure with a 12cc syringe and Alteplase to declot totally occluded PICCs really helped and got the job done!