Found cap off port of PICC

Specialties Infusion

Published

Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

What is the best solution when you have found the cap off of one lumen of a triple lumen PICC? The catheter is non-valved; the clamp was clamped. The PICC is used for intermittent dosing of an antibiotic. The nurse caring for the patient assessed the PICC at the beginning of the shift, and everything was intact. Hours later, when she went to administer the medication she found the lumen "capless." This patient has smoking priviledges. My concern is that the patient goes outside for the smoke break, and despite having a sleeve over the PICC, the PICC is exposed.

The supervisor told the nurse to wipe the lumen with alcohol, put a new cap on the port of the lumen, and label the lumen with tape that states, "Do not use."

The nurse and supervisor asked my opinion of the situation (d/t my many years of critical care experience). I suggested to the supervisor to call the infusion nurse at the pharmacy. I looked in the policy book, but there was nothing that addressed the problem. I haven't been to work since this occurrence, but I am very concerned for this patient (resident).

Thanks for any advice given!

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Specializes in Vascular Access.
What is the best solution when you have found the cap off of one lumen of a triple lumen PICC? The catheter is non-valved; the clamp was clamped. The PICC is used for intermittent dosing of an antibiotic. The nurse caring for the patient assessed the PICC at the beginning of the shift, and everything was intact. Hours later, when she went to administer the medication she found the lumen "capless." This patient has smoking priviledges. My concern is that the patient goes outside for the smoke break, and despite having a sleeve over the PICC, the PICC is exposed.

The supervisor told the nurse to wipe the lumen with alcohol, put a new cap on the port of the lumen, and label the lumen with tape that states, "Do not use."

The nurse and supervisor asked my opinion of the situation (d/t my many years of critical care experience). I suggested to the supervisor to call the infusion nurse at the pharmacy. I looked in the policy book, but there was nothing that addressed the problem. I haven't been to work since this occurrence, but I am very concerned for this patient (resident).

Thanks for any advice given!

I agree with one thing that your supervisor said... Wipe off the lumen with alcohol (do it vigorously) and place a new injection cap on it... However the rest of the advice is not appropriate. You never "just cap off any lumen" and say, DO NOT USE. In this case I would attempt to aspirate blood from the lumen (approx 5-7 cc) and then flush the line with saline and heparin flush solution. If you aren''t able to aspirate, or flush, call for a Cathflo 2mg order and then have a knowledgable nurse instill it. Alert the MD to this finding and observe the pt for S/S of CRBSI. :nurse:

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Could not have said it better.

The supervisor told the nurse to wipe the lumen with alcohol, put a new cap on the port of the lumen, and label the lumen with tape that states, "Do not use."
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I agree with one thing that your supervisor said... Wipe off the lumen with alcohol (do it vigorously) and place a new injection cap on it... However the rest of the advice is not appropriate. You never "just cap off any lumen" and say, DO NOT USE. In this case I would attempt to aspirate blood from the lumen (approx 5-7 cc) and then flush the line with saline and heparin flush solution. If you aren''t able to aspirate, or flush, call for a Cathflo 2mg order and then have a knowledgable nurse instill it. Alert the MD to this finding and observe the pt for S/S of CRBSI. :nurse:

I do not know if I would agree with using an unsupervised capless PICC.

The risk for infection is way beyond the red zone. Unknown debri and/or bacteria could have been introduced into the capless PICC, simple aspiration will not a be suitable measure to cleanse the interior of the PICC line.

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Specializes in Vascular Access Nurse.

At the facility I work in, we would most likely pull the PICC and insert a new one. We do the same if a PICC is found without a dressing. Hope this helps!

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.
I agree with one thing that your supervisor said... Wipe off the lumen with alcohol (do it vigorously) and place a new injection cap on it... However the rest of the advice is not appropriate. You never "just cap off any lumen" and say, DO NOT USE. In this case I would attempt to aspirate blood from the lumen (approx 5-7 cc) and then flush the line with saline and heparin flush solution. If you aren''t able to aspirate, or flush, call for a Cathflo 2mg order and then have a knowledgable nurse instill it. Alert the MD to this finding and observe the pt for S/S of CRBSI. :nurse:

I have to disagree with you re: flushing a lumen that has not had a cap on it for a time. Perfect set up for introducing bacteria into the bloodstream!

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Specializes in Vascular Access.
I do not know if I would agree with using an unsupervised capless PICC.

The risk for infection is way beyond the red zone. Unknown debri and/or bacteria could have been introduced into the capless PICC, simple aspiration will not a be suitable measure to cleanse the interior of the PICC line.

Guys,

The line is undoubtedly already seeded with biofilm... and even if It was pulled and tip cultured.. One will not find, or capture the biofilm as it is in side the IV catheter. Removal of this IV catheter won't do much as the new IV catheter will also quickly be seeded with biofilm. So, this situation that the patient was found in, isn't ideal, but I truly believe that this approach is the best. We can agree to disagree, however.

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Specializes in Vascular Access Nurse.
Guys,

The line is undoubtedly already seeded with biofilm... and even if It was pulled and tip cultured.. One will not find, or capture the biofilm as it is in side the IV catheter. Removal of this IV catheter won't do much as the new IV catheter will also quickly be seeded with biofilm. So, this situation that the patient was found in, isn't ideal, but I truly believe that this approach is the best. We can agree to disagree, however.

I guess I don't understand why a new PICC would be seeded with biofilm if the old PICC (and it's biofilm) were removed.

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Specializes in Vascular Access.
I guess I don't understand why a new PICC would be seeded with biofilm if the old PICC (and it's biofilm) were removed.

Removal of this IV catheter won't do much as the new IV catheter will also quickly be seeded with biofilm.

After a short dwell, it will be, just like the one that is being replaced.

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Guys,

The line is undoubtedly already seeded with biofilm... and even if It was pulled and tip cultured.. One will not find, or capture the biofilm as it is in side the IV catheter. Removal of this IV catheter won't do much as the new IV catheter will also quickly be seeded with biofilm. So, this situation that the patient was found in, isn't ideal, but I truly believe that this approach is the best. We can agree to disagree, however.

Whether it is sealed with biofilm, uranium, kryptonite, trojan condoms or magic fairy dust you will not find a single MD, NP, hospital, infusion center that will condone the use of a contaminated PICC.

No offense but that is a very poor rationale, just because there is a biofilm does not mean the line is impervious to infection or foreign matter. If that rationale held true then there would be no such thing as PICC line infections, food poisoning, CDiff etc...

Biofilms can help in preventing infections but are far from the uber pathogen resistant mega films you make them out to be.

To put it simply, using a PICC line that was compromised is below the set standards of practice...even in Mexico.

P.S.

Locking off a lumen...free

Replacing a PICC...few hundred

14 days of ABX, blood Cx, replaced PICC, lengthened hospital stay, gambling with the patients well being...priceless.

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Specializes in Vascular Access Nurse.
Removal of this IV catheter won't do much as the new IV catheter will also quickly be seeded with biofilm.

After a short dwell, it will be, just like the one that is being replaced.

Ah, I'm sorry.....I guess I was thinking of biofilm as being a bad thing, and the fewer microorganisms the better. (http://www.cdc.gov/ncidod/eid/vol7no2/donlan.htm). I mean, yes almost every CVC has some biofilm, but you would think that one that was contaminated would have more.

Replacing a PICC is definitely more expensive and uncomfortable for the patient, and I can see circumstances where the PICC would be capped off and left in. My employer usually errs on the side of caution and would rather spend the money than leave the PICC in. When a PICC is found without a cap or a dressing, we almost always pull it and insert another if needed, but I know that every hospital has it's own standards/protocols. :twocents:

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Specializes in Vascular Access.
Ah, I'm sorry.....I guess I was thinking of biofilm as being a bad thing, and the fewer microorganisms the better. (http://www.cdc.gov/ncidod/eid/vol7no2/donlan.htm). I mean, yes almost every CVC has some biofilm, but you would think that one that was contaminated would have more.

Replacing a PICC is definitely more expensive and uncomfortable for the patient, and I can see circumstances where the PICC would be capped off and left in. My employer usually errs on the side of caution and would rather spend the money than leave the PICC in. When a PICC is found without a cap or a dressing, we almost always pull it and insert another if needed, but I know that every hospital has it's own standards/protocols. :twocents:

But will it have more, or enough to cause a CRBSI? That's why strict monitoring s/p is needed. It is a risk versus benefit thing. Since a new PICC will also become seeded eventually, did the opening of this IV catheter (though it was clamped and one need not be worried about air emboli or blood loss) cause bacteria to enter, and how soon was this discovered???

To arbitrarily replace with its added risks for the patient in this case is premature in my opinion. That's my :twocents:.

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