Flush and blood return

[nursemomof3boys]

Question please,

If a picc is clogged up, will you still be able to freely flush with saline?

In this case, I was able to flush both lumens but could not get blood return.

Please help by responding

thanks

[GailAnne]

To look at this very simply, a PICC is a pipe, if it's clogged or partly clogged, then the fluid will either go down very sluggishly, or not at all....no different than if the pipes off your kitchen sink are clogged. The kitchen sink either doesn't drain or drains slowly.

So, if the PICC instills without difficulty you know that's not the problem,

First, have you made sure to instill before withdrawing to activate the valve?

Are you using proper syringe size and easy pressure so as not to collapse the PICC?

Have you tried repositioning the pt, having them cough, do valsalva manuever (if okay for them to do) in case the openning is sucking on the vein wall?

Have you ensured that the PICC is free of twists and kinks...oddly, sometimes it's possible to instill but not withdraw in some instances of a twisted PICC.

You are likely looking at a fibrin tail of fibrin sheath on the outside of the PICC, this needs fluro to confirm and may be dealt with using tPa. Usually an infusion of tPa (not just instilling in the line) is needed.

Hope that helps.

G

[iluvivt, BSN, RN]

This is most likely a PWO (persistant withdrawl occlusion) or in other words you are able to EASILY instill but it will not withdraw blood at all or easily. Yes you may have a fibrin tail or sleeve. After you have confirmed the PWO by checking other possible causes then its really easy to solve. Just instill the 2mg of Tpa (cathflo)...this needs to be reconstituted with 2.2 ml SW...instill..check in q 30 min..leave in up to 2 hrs...if it a PWO...I like to leve it in for a minimum of 1 hr. Here is an important concept that many do not realize...all PWOS...need to be treated......YOU should not leave a PWO unless the cathetetr will be coming out soon ( I say within 24 hrs). Often a PWO is the first thing you will see just before a total occlusion occurs....you also must treat (as in give the Tpa and attempt to obtain a blood return) to decrease the pts risk for infection...you must always treat a compete occlusion as well..these are often from blood clotted in the line and this also puts the pt at an increased risk for infection. so always treat a PWO and always treat an occlusion that is thrombotic...this is the current standard of care....you may also need a repeat dose..if you repeat leave that in for at least 2 hrs. We never start with the big guns of an infusion as the Tpa instilled and used properly is unbelievably effective Now... there are occlusions that are non-thrombotic and that takes a little detective work and there are a few agents to reverse certain drug or mineral precipitates as Tpa WILL not and does NOT work on this type of occlusion.

[justdeda]

Keeping in mind the potential hazards involved in a slow flushing PICC, I considered asking the doc to prescribe cathflo when my 6-month plus, weekly dressing change patient presented with a stiff flush on the Vaxcel PASV. Then I asked for a trial of Heparin 300u, post NS flushes first, with the intent of moving on to cathflo if it was unsuccessful. To my immense surprise (as well as relief- I see the patient in her office in my town, but she lives 2 hours away, and the time-consuming cathflo treatment would be very inconvenient for her), this was successful. I taught the patient to pulse-flush, and followed her by telephone after one and then three days, when she reported that her balloon-pump infusion duration had gone down from 40-60 minutes, to 30 minutes, as ordered. After two consecutive weeks of Heparin flushes TID, the patient had a strong blood return, as well as increasingly less stiff flushes during dressing changes. I'm sharing this as an addendum to and confirmation of ILUVIVT's always-on-target, educated reply. As a postscript, the pharmacy representative was adamant that the PASV does not take Heparin-- hopefully this episode has re-educated her.

[iluvivt, BSN, RN]

YES justeda .....good job....you are correct just because a PICC has a valve on the distal end, such as a Groshong...or in the external tail as in a PASV...does NOT mean you can not or should not use heparin. In other words, it is NOT contraindicated. A valved catheter just gives you the option to use a saline only flush b/c in theory they have lower occlusion rates. I say "in theory" b/c I personally believe and have seen lower occlusion rates with the use of low dose Heparin on all types of CVCs. We do use Heparin on all our CVCs. What you were able to provide was individulaized care...all of these things matter...frequency of the flush.....type of valve/LAD used......quality of the flush...flush solution used..(ie. NS...Heparin..others)....believe it or not there is an entire technology involving flushing CVCs..and maintaining patency of the lines....I can suggest some articles if anyone really interested

[piccme]

I would really appreciate a few articles on this! At my hospital, I have orders for hep flushes and the hospital is questioning the need for it. I find it keeps piccs working optimally longer.

[iluvivt, BSN, RN]

The INS put out some catheter care flushing guidelines cards in 2008...they got many of the experts together and reviewed all the pertinant literature and came up with the guidelines...I have a copy of thre main artice they used if you would PM with your E mail I will forward it to you from mine....but the point is they recommend a low dose Heparin for CVCs b/c all the evidence still shows that overall the safety is still good with potential reduction in risk of infection,thrombosis and occlusion. The risk of course is HIT type2 which is the immune mediated type...HIT type 1 is usually mild and self-limiting. Again in medicine and nursing there is that question.... does the benefit outweigh the risk????..apparently in this case it appears to be for now YES. Saline flush only for CVCs does increase the pts risk for infection, occlusion and thrombosis. Now on PIVS numerous studies done in the 90s showed no difference between NS flush and Heparin flush. There is ongoing research in the use of other loc solutions such as ethanol ,thrombolytic and antibiotic loc so in the future we may see the recommendations change. Of course, health care organizations can decide not to use it but once you really start reading about it and read the studies you can see its many benefits