PICC line flush solution

[UM Review RN, ASN, RN]

OK, here's the scenario:

Mr. Hypothetical is getting intermittant IV medication through the single-lumen PICC line at least six times a day.

It's not a Power Picc, just a regular one.

Supposing that there is no hospital protocol to follow, what solution(s) will you choose to flush the line and why?

[vashtee, RN]

I've only flushed with normal saline, because that's what I've been told to do. (I'm a student.) :)

I've heard about heparin flushes, but none of the hospitals I've worked in use them.

[iluvivt, BSN, RN]

First of all you need to find out what type of PICC line you have exactly. A Bard Groshong PICC has a two way slit valve with a rounded distal end, b/c of this valve Bard markets this product as requiring only NS flushes. This does not mean that Heparin can not be used nor will it damage the catheter in any way. Bard also makes a SOLO PICC with 2 valves that are in the proximal tails,and it is open-ended. This is also marketed as needing only Normal Saline,but again Heparin may be used. The only other PICC with a valve design on the market is the PASV (Pressure Activated Safety Valve) with a valve in the proximal tail. All other PICCs on the market are open-ended. Each Health Care Organization needs to formulate their own policies regarding flush frequency and Heparin volume and strength. There is no current consensus or recommendation on these issues other than they must be flushed after intermittent use,after blood draws and to maintain patency (varies from daily schedules to every week schedules). Some facilities choose to only use NS on their valved PICCs b/c in theory the valve is supposed to keep blood out of the line and promote patency. Open-ended non-valve PICCs tend to develop thrombotic (clot-off) more readily and therefore you may see the use of Heaprin as a final flush or more and/or more frequent flushing schedules.

The flush should always be at least 2x the priming volume of the line plus the volume of any add-on devices. If heparin is used the volume and strength vary from 10 units per ml to 1000 units per ml. Here is a sample of our protocol. we chose to standardize all our flushes and continue to use Heparin (unless pt is HIT positive) b/c we have less occlusion problems. Flush with 10 ml NS followed by 5 ml Heparin (10 units per ml) after intermittent use and q 12 hours. After blood draws 20 ml NS then the same 50 units of Heparin. If you have stopped an infusion to give a med or draw blood and you are going to hook the cont infusion back up immediately you can just use the NS. The recommendations to flush any CVC is to use a pulsatile push-pause method on all flushes,as this technique will again promote patency. There is research also indicating that thrombotic occlusions also increase pts risk for infection,so not only do you want to keep the line patent you want to keep the infection risk low. Every Hospital should have a flush protocol . You may find it in the Central venous Catheter protocol and procedures.since a PICC is a CVC. So you can see flushing of any CVC is important and should be done immediately after use and on the selected schedule. The most frequent cause of occlusion that I see at the hospital that employees me is lack of or inadequate flushing g after a blood draw. Have your saline ready and immediately perform that pulsatile push pause flush. Do not forget to scrub the cap for about 15 sec or 10 good swipes around the threads of the cap and use aseptic technique and good hand hygiene before working with any CVC. Hope this helped you find your answer. Mary

[Virgo_RN, BSN, RN]

If there were no facility policy, I would use NS, because I have been taught that NS is just as effective as heparin but does not carry the risk of causing HIT.

[chevyv, BSN, RN]

I agree with another poster that you need to find out what kind of PICC it is. If there is no need to flush with hep. (grosh. type) then I would flush with saline.

[iluvivt, BSN, RN]

Just for the record NS has only been proven as effective as heparin in promoting patency ON PERIPHERAL lines only. The debate rages on its use on CVCs. WE did a small trial without the heparin and used only NS and I can tell you we had a lot more occlusions.

[Eirene, ASN, RN]

10 ml NS with turbulent flush.

[chenoaspirit, ASN, RN]

If it were a type of PICC that hep was ok to use, I would first flush with NS, then follow with 3 ml hep to prevent occlusion. We have so many occluded PICCS due to the policy of no heparin.

[zacarias, ASN, RN]

I notice that triple lumens always draw blood well...probably the lumen is bigger and less catheter length?

[gtmoore]

Agree with the other posts that it depends upon the type of PICC line whether heparin should be used or not. If the person is getting at least 6 meds through IV daily, why not consider running the line at KVO?

Another thing to consider whether or not to use heparin is if the patient is on lovenox or arixtra, heparin is contraindicated. Also, if the patient is in with a bleed or suspected bleeding, you don't want to use heparin. Hope this helps.

[mama_d, BSN, RN]

Our facility's policy is to use NS only unless otherwise indicated by manufacturer.

I agree, we have seen alot more occlusions since we went heparin free. If we have a line that is being sluggish, and there's no contraindications, we'll throw a little hep flush in and let it dwell for the shift, then try to aspirate it out (and hopefully blood return with it) when it's time for blood draws at end of shift.

[Virgo_RN, BSN, RN]

Just for the record NS has only been proven as effective as heparin in promoting patency ON PERIPHERAL lines only. The debate rages on its use on CVCs. WE did a small trial without the heparin and used only NS and I can tell you we had a lot more occlusions.

How frequently were they being flushed? Our study supported the use of NS only, so long as CVCs are flushed Q8hr.