Changing the PPV on PICC Line

MunoRN, RN · Mar 7, 2018

If the PICC has clamps then that generally means it is a non-valved PICC, in which case you should be clamping before removing any device that leaves the lumen open, whether it's a displacement cap or syringe.

There's no reason to be changing the cap however when drawing blood, the cap should not be changed more often than every 5-7 days. And there's also no reason to waste 10ml of the patient's blood, blood is valuable stuff, a waste of 2-3 times the lumen volume is sufficient and a larger (Power) lumen on a PICC is only 1.2 ml.

IVRUS, BSN, RN · Mar 7, 2018

If the PICC has clamps then that generally means it is a non-valved PICC, in which case you should be clamping before removing any device that leaves the lumen open, whether it's a displacement cap or syringe.
There's no reason to be changing the cap however when drawing blood, the cap should not be changed more often than every 5-7 days. And there's also no reason to waste 10ml of the patient's blood, blood is valuable stuff, a waste of 2-3 times the lumen volume is sufficient and a larger (Power) lumen on a PICC is only 1.2 ml.

How one flushes an IV catheter depends on the needleless cap on its end. Valved or non-valved, it doesn't matter. There are Negative, Neutral and Positive displacement devices. If your needleless cap is a Positive displacement cap, then you should NOT clamp the IV catheter before the removal of the syringe, but rather flush, remove the syringe and then after a few more seconds = CLAMP. Positive displacement caps "sense" the removal of the syringe and after its removed, it will force fluid out of the cap and through the IV catheter to prevent reflux of blood.

Also, if one is doing blood draws through the needleless cap, it should be changed s/p. The blood drawn into the cap becomes a perfect medium for bacterial growth.

iluvivt, BSN, RN · Mar 7, 2018

A few things...Not all institutions change the needlless connectors(NC) after blood draws so you need to actually look at your policy. There are antiseptic NCs on the market and clear NCs that you can see the housing and therefore any blood residue so you can flush it out.Also agree with Muno....10 ccs is way too much of a discard and it's not necessary. Since it can get confusing on how much to discard many institutions have discard volumes that take all the priming volumes of their CVADs into account so 3 to 5 ccs is an example of what is generally adequate. If a patient should have an older high profile port you may need a tad more than 5cc.I would advice to actually look as your are withdrawing the discard because you can tell when you are getting blood without any flush solution in it.A common mistake is to use your discard as the specimen so have a process that discards it right away so you never mix it up with the draw.Also,flush really well after any blood draw and if you are using 2 mls after a blood draw IMO it is not enough.We double our flush after any blood draw.Many of our thrombotic occlusions occur from improper blood drawing technique.

IVRUS, BSN, RN · Mar 7, 2018

A few things...Not all institutions change the needlless connectors(NC) after blood draws so you need to actually look at your policy. There are antiseptic NCs on the market and clear NCs that you can see the housing and therefore any blood residue so you can flush it out.Also agree with Muno....10 ccs is way too much of a discard and it's not necessary. Since it can get confusing on how much to discard many institutions have discard volumes that take all the priming volumes of their CVADs into account so 3 to 5 ccs is an example of what is generally adequate. If a patient should have an older high profile port you may need a tad more than 5cc.I would advice to actually look as your are withdrawing the discard because you can tell when you are getting blood without any flush solution in it.A common mistake is to use your discard as the specimen so have a process that discards it right away so you never mix it up with the draw.Also,flush really well after any blood draw and if you are using 2 mls after a blood draw IMO it is not enough.We double our flush after any blood draw.Many of our thrombotic occlusions occur from improper blood drawing technique.

I agree that not all institutions change their caps after they draw blood from them, but then I have to wonder, even with those that have a clear housing, are you clearing ALL traces of blood? And, since CRBSI are many times started with the needleless connector, why wouldn't you change it? I know some manufactures don't advocate for it, but I think it needs to be rethought.

2016 INS states that discard volumes of 6 to 9 mls were sufficient to remove glucose from the line. AND, they advocate for 10-20 mls of saline flush s/p draw, as well as for changing of the cap BEFORE cultures are drawn from the line. It is, however, imo, best practice NOT to draw labs from central catheters as it is a major factor in the potential for intraluminal contamination.

iluvivt, BSN, RN · Mar 7, 2018

IVRUS... There simply is not enough evidence for me to advocate for a needleless connector (NC) change with every blood draw (does not include cultures). In the hospital setting blood draws are performed far too frequently and this might mean an NC is being changed 6 to 8 times a day if not more.An example of this might be a typical am draw,a timed trough level,a repeat K level after replacement,oops it was not labeled properly and now it needs to be recollected,now the pt spikes a temp and we need cultures....see what I mean!.Not only does that increase costs but the system is opened.The truth is there is no easy answer for this problem. While its best to change the NCs with tubing changes we found it was not getting done consistently or being done properly. There is no easy way to label this small item and documentation was not being done.What we do is change it every 7 days with our dressing changes and perfoming a thorough hub cleansing.We have a zero rate of CLABSI for years now.Perhaps with more evidence I would be willing to change the NCs more frequently or just permit blood draws from patients that prove to be impossible to draw.

iluvivt, BSN, RN · Mar 7, 2018

IVRUS... There simply is not enough evidence for me to advocate for a needleless connector (NC) change with every blood draw (does not include cultures). In the hospital setting blood draws are performed far too frequently and this might mean a NC is being changed 6 to 8 times a day, if not more.An example of this might be a typical am draw,a timed trough level,a repeat K level after replacement,oops it was not labeled properly and now it needs to be recollected,now the pt spikes a temp and we need cultures....see what I mean!.Not only does that increase costs but the system is opened.The truth is there is no easy answer for this problem. While its best to change the NCs with tubing changes we found it was not getting done consistently or being done properly. There is no easy way to label this small item and documentation was not being done.What we do is change it every 7 days with our dressing changes and perfoming a thorough hub cleansing.We have a zero rate of CLABSI for years now.Perhaps with more evidence I would be willing to change the NCs more frequently or just permit blood draws from patients that prove to be impossible to draw.

IVRUS, BSN, RN · Mar 7, 2018

IVRUS... There simply is not enough evidence for me to advocate for a needleless connector (NC) change with every blood draw (does not include cultures). In the hospital setting blood draws are performed far too frequently and this might mean a NC is being changed 6 to 8 times a day, if not more.An example of this might be a typical am draw,a timed trough level,a repeat K level after replacement,oops it was not labeled properly and now it needs to be recollected,now the pt spikes a temp and we need cultures....see what I mean!.Not only does that increase costs but the system is opened.The truth is there is no easy answer for this problem. While its best to change the NCs with tubing changes we found it was not getting done consistently or being done properly. There is no easy way to label this small item and documentation was not being done.What we do is change it every 7 days with our dressing changes and perfoming a thorough hub cleansing.We have a zero rate of CLABSI for years now.Perhaps with more evidence I would be willing to change the NCs more frequently or just permit blood draws from patients that prove to be impossible to draw.

Thanks ILUVIVT.. I see that.

iluvivt, BSN, RN · Mar 8, 2018

IVRUS.I love reading your posts. I can tell you have passion for your speciailty.I will pm you later as I need your opinion as you have the expertise I need.

KelRN215, BSN, RN · Mar 8, 2018

A few things...Not all institutions change the needlless connectors(NC) after blood draws so you need to actually look at your policy. There are antiseptic NCs on the market and clear NCs that you can see the housing and therefore any blood residue so you can flush it out.Also agree with Muno....10 ccs is way too much of a discard and it's not necessary. Since it can get confusing on how much to discard many institutions have discard volumes that take all the priming volumes of their CVADs into account so 3 to 5 ccs is an example of what is generally adequate. If a patient should have an older high profile port you may need a tad more than 5cc.I would advice to actually look as your are withdrawing the discard because you can tell when you are getting blood without any flush solution in it.A common mistake is to use your discard as the specimen so have a process that discards it right away so you never mix it up with the draw.Also,flush really well after any blood draw and if you are using 2 mls after a blood draw IMO it is not enough.We double our flush after any blood draw.Many of our thrombotic occlusions occur from improper blood drawing technique.

I've always drawn my waste back into the NS flush syringe I just flushed with then used a new luer lock syringe for my sample that way it's obvious which is the waste- the one that says "normal saline flush."

It's never been standard practice anywhere I worked to routinely change caps following blood draws though sometimes it works out that way. For example, my CF patients typically went home with PICCs and PICC caps were changed once/week with the dressing change. That, along with weekly labs, were typically arranged on the same day of the week just for ease of scheduling with the home nurse. Our oncology kids often had home labs twice/week and for the kids with broviacs, the standard was to change the caps twice/week so that was just done with the labs.