drawing blood from picc line

SusanKathleen, RN · Feb 14, 2009

Slightly off topic - I was flushing a double lumen PICC a few days ago. One line was dedicated for blood draws, but I couldn't flush it. I'm still a student, so I asked my clinical instructor to try. She could not budge it either. We called the PICC nurse, and she told us to try again, and this time push harder. I was not willing to do that. Am I wrong in thinking that could shake something loose - and perhaps not have a good outcome? So the nurse assigned to the pt went in and pushed harder -and it flushed. I kiddingly told the nurse that we "loosened it up" for her, but I was a little unnerved that the PICC nurse didn't some and take a look. When I asked the preceptor nurse about it, she stated that the PICC nurses are "aggressive" with PICC flushes anyway.

So.....I'd like a few comments about what is protocol in your unit when this happens.

Virgo_RN, BSN, RN · Feb 14, 2009

Sometimes you do have to push pretty hard to flush. You'll get a sense of that as you gain experience.

iluvivt, BSN, RN · Feb 15, 2009

Any CVC can become occluded or have what is called a PWO (persistent withdrawal occlusion). APWO is where you can instill but not easily withdraw blood. If the CVC (a PICC is a type of CVC) has a PWO it needs to be treated with Tpa. Also wanted to weigh in:

1. YES YES YES you can draw blood from a PICC line. That is one of the benefits of them. You just need to perform the task properly.

2. YES you can pre-flush b/f a blood draw b/c you are going to turn around and discard it anyway. I find the pre flush very helpful with the valved PICCS ( Groshong,PASV and SOLO).

3. Always have all your necessary equipment ready and at hand and flush immediately after the draw with a pulsatile push pause method.

4. Provide good cap care...scrub injection cap or PD cap with a vigorous 15 sec scrub of alcohol or GHG (whatever your facility uses)

5. One reason not to use a PICC is if it is a dedicated line being used for TPN. Some facilities will not allow this b/c of increased infection risk that these patients have. it is a matter of frequent access and manipulation of the system and not the temporary interruption of the TPN that is the concern here.

SusanKathleen, RN · Feb 15, 2009

Thanks for the great info, iluvivt! If you don't mind, I have another question, which neither my preceptor nor CI could answer:

If the line is plugged, how do you get the tpa in? How does that work?

Thanks again.

kmoonshine, RN · Feb 15, 2009

Thanks for the great info, iluvivt! If you don't mind, I have another question, which neither my preceptor nor CI could answer:
If the line is plugged, how do you get the tpa in? How does that work?
Thanks again.

Here's some info: http://doctors.shorehealth.org/nursing/iv/DECLOT%20ACCESS%20DEVICE-3-WAY.pdf

Obviously, follow the P&P at the facility you work at.

SusanKathleen, RN · Feb 15, 2009

Thanks, kmoonshine!. We didn't have a protocol for this particular PICC. Pt. came in from another hospital and it was already in. It had no valves! Nowhere to clamp off. Darndest thing. But thanks for the info. Much appreciated.

Regards, Susan K

iluvivt, BSN, RN · Feb 16, 2009

Just remember that if use a PICC from another facility....please verify where the tip is before you use it for infusion therapies. It is OK to attempt to withdraw from it and get some blood. Personally I do not like or use the stopcock method to administer Tpa though it is still considered an acceptable practice. I use a syringe method. Please see IVT forum as i just wrote out the step by step guide for this. None of our IV nurses like it either. I would prefer to feel how much resistance there is in the line. I do not also agree with the nurse that said to push harder to flush. If you have to push that hard to flush....something is wrong and the line needs to be evaluated. If to much force is applied the PICC may seemingly work and flush but what can happen and often does is that either a pinpoint hole can occur anywhere along the PICC and/or you can get a catheter aneurysm (more common with silicone catheters,especially in the tails). This catheter damage can appear days after the incident. I have seen many of these aneurysms on the groshong PICC and then I check the chart and as I suspected Tpa was given in that lumen recently (within 48 hours or so). The pinpoint holes will manifest themselves as patient complaints of burning or discomfort during the infusion. So if your patient has a PICC that has been recently treated with Tpa and/or someone forced a flush AND is complaining of burning along the course of the PICC (especially in the arm) suspect that you may have a damaged PICC. SO never force a flush...that is bad and incorrect advice. The line needs further assessment b/c something physical or mechanical is causing a problem.

Magsulfate, BSN, RN · Feb 16, 2009

If I can't get blood from a picc, I will lower the head of the bed and raise the feet. Basically putting the patient in a trendelenburg position. If that doesn't work, I will get heparin flush and flush the port(s) and wait 10 minutes or so and try again. Most of the time these two together will work.