PICC lines - page 2

Our mostly LTC,re-hab facility is getting more admits who have PICC lines. Ive not had to care for patients with PICCs in the past and would appreciate any information you can give me about them,such as: 1. How do you maintain... Read More

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    Originally posted by renerian
    You can put a substance in it called urokinase. You gentley instill it with a tb syringe. You tape the syringe to it. You let it sit. Little by little it will hopefully break up the clot in the line. Need an order and sometimes we could not get this product due to decreased supply. When you are done withdraw the med and flush it. May then need an order for heparin to keep the problem from recurring. I have seen alot of piccs clot off without heparin. This is how our policy reads to do this proceedure. Sometimes lines may appear to be clotted though and repositioning the client or raising their arm above their head will help.

    Our facility policy for that problem was to call the IV Team, although we'd try the repositioning or arm-raising first.

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  2. 0
    The PICC lines that are Groshongs have a special valve that supposedly prevents backflow of blood into the catheter that may clot it off. Policy at our facility is to flush with saline q 8hr if not being used. We also use a "clotless clave" - CLC 2000 - on the end, that exerts a continuous positive pressure within the cath, to also prevent blood backflow.
    The RADPICC catheters - usually dual lumen - that the Radiologists put in with ultrasound and fluoro, are open-ended (no Groshong valve) and need to be flushed per policy; at our facility that is q 12 hr with 100units/cc heparin, 1cc per port. We also use the CLC-2000 with these lines. Based on the literature I've seen, I'd like to see only saline used to flush any of the PICCs, as long as the CLC-2000s are used, but our facility hasn't adopted this as policy. Yes, I have explored the channels; people seem to have other priorities.
    Nothing but 12cc syringes used to flush.
    No iodine contrast, only because you can't inject fast enuf to get good contrast filling, and you aggravate your carpal tunnel just injecting 10 syringes' worth just to get 100cc of contrast in!! I refuse to do it, and the Radiologists don't want to, so I'll try to start an IV if pt needs contrast CT study. We don't inject thru them with the power injector, either, if anyone was wondering.
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    If your facility doesn't have a Protocol for PICC they need to develop one now. This week I discharged 2 pts. to LTC with PICC lines. In both cases I got a phone call about care of the line. PICC maintence is by facility protocol. Some things are standard i.e. nothing smaller than 10 cc. but others are by policy i.e. SASH or not to. Get your DON to develop a protocol for your facility.
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    Does my heart good to hear that you discharge patients with the PICC still in, ConnieRNF! I work at a subacute Rehab hospital and you wouldn't believe the number of patients we get from the hospitals that have their PICCS, or whatever, yanked. (Hospitals claim it is to prevent liability on their part.) Of course, they then end up being sent back to the hospital to have another put in so we can do our blood draws. Would make more sense to leave them in until they are discharged home!

    I was taught to ONLY use a 10CC syringe. And for blood draws, instill 10cc NS, draw out and waste 10cc blood, withdraw amt of blood needed for tests, instill 20cc NS (unless you are withdrawing a lg amt of blood; then make sure you put back in AT LEAST twice what you draw out), then instill 8cc Heparin. However, at one hospital where I work through agency, I noticed that they do not instill NS BEFORE withdrawing blood. But their lab also doesn't follow the "Red, Yellow Blood Goes Plop" thing for tube fills, either. (Something that the Rehab Hospital insists upon.)
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    Sorry about mixing up your name, RNConnieF! Many apologies!!! Too many working hours and not enough sleep, methinks.
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    Yep always at least a 10cc syringe so you do not blow the catheter........LOL that would be bad huh?

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    My hospital has a protocol for picc care similar to those listed. We do not use heparin, as I learned in nursing school that recent studies show no difference in normal saline vs heparin. We use 10 cc syringes and flush q8 hours at least. Our lines hardly ever clot off.

    But why do some lines have more difficulty flushing than others, does that mean it is going to stop working? Or there is something wrong with it? During orientation nurses told me to document which port had difficulty flushing if I did have it.
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    Quote from megs1813
    But why do some lines have more difficulty flushing than others, does that mean it is going to stop working? Or there is something wrong with it? During orientation nurses told me to document which port had difficulty flushing if I did have it.
    There could be many factors.

    Could be the lumen of the catheter, obviously the thinner catheters will be more difficult to flush. There could be a thrombus "blood clot" in the lumen of the catheter either partially or totally obstructing flow. A fibrin sheath could form around the catheter obstructing flow or even a physical deformity of the catheter itself.

    My facility uses Activase or "Cathflo" to unclog any central line...runs about $75 a treatment.

    Here is a great explanation of occlusions http://www.cathflo.com/catheter/occlusions.jsp
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    Care and assessment post PICC insertion

    1 First verify that you you have a confirmed central tip location. If there was 4 cm externally visible when placed and there was a confirmed low SVC placement with 4 cm visible...check your cm visible. You should be able to see that through the transparent dressing. If you are using it to administer any IV medication YOU are responsible to know where it is
    2 Look at the dressing...it must be clean dry and intact with all the borders secure..no drainage at the site...if there is gauze at the site ..the dressing can only stay in place 48 hrs....if a biopatch at the site and a transparent dsg in place and CDI..that can stay in place a week. if you do not know you need to change it.
    3 The caps must be changed at least weekly with a scrub of the junction between that hub and cap for 15 sec before a new cap is applied
    4...Assess for patency of all the lumens.....does it have a brisk blood return and flush with ease (consistent with the size of the lumen(s). If you are able to instill easily but not withdraw it needs to be treated with Tpa (2 mg of cath-flo)....Never leave an occluded lumen or one with a persistant withdrawl occlusion as I described
    5.....Assess now for local and systemic complications. Assess for s/sx of thrombosis...most are clinically silent...but not all....assess for pain ,aching or sense of fullness in the neck....face...jaw armpit..assess for swelling in the arm esp the hand and fingers..assess fro a pronounced venous pattern on the chest and upper arm. ALWAYS compare the PICC arm to the other arm fro comparison. Is there any new leakage at the site..often a sign of thrombosis and/or occlusion b/c of back pressure
    6. treat the line with respect...scrub the cap for 15 seconds prior to each use.....flush after use per your policy with NS and heparin (check your policy)..never force flush and always assess patency using a 10 ml syringe or greater
    7. Check your pts WBC count when done...is it increasing? does the pt get chills during or after a flush?Do your dressing and cap changes on time...this is critical....biofilm is in the cap by day 5 so never forget to change caps. Always have yourr flushed ready to go after giving your medication..otherwise you can clot the line off and you will have to deal with that? When the line is no longer needed and you are sure of that.....get an order to DC it..amke sure you follow your protocol and use an air occlusive ung and dressing

    its not TRUE that NS flushes are just as good as heparin. Those studies were done in the early 90s and only applied to peripheral IVs. Current studies indicate that occlusion rate is lower with heparin. INS still recommends its use on Central lines. Some facilities choose not to use it over concern about HIT (still 1-2 percent of the population). Lots of research going on looking for alternate flushes that are effective.

    What kind of cap are you using? and I can tell you how to flush properly...how to flush properly is a big thing..and the technique you use depends upon the type of cap you will be using
    Last edit by iluvivt on Oct 30, '10
    xiaxiap1202 likes this.
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    Can you please describe what happens when "they blow" and how fast this can happen? What are the signs and symptoms of a blown PICC? Chest pain, SOB, etc?? Thanks :-)

    Quote from kewlnurse
    We use a 10 cc to flush, had a few blow with 5cc, and always infuse with a pump, never to gravity. Change the dsg q week and prn

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