PICC removal

IVRUS, BSN, RN · Jul 27, 2011

There seems to be this wave of fear-mongering lately on behalf of the INS, which strikes me as desperate attempt to force some credibility by threats where it hasn't been earned . Even worse, none of the threats seem to have any basis in reality.
Negligence is doing something that no reasonable person in that situation would do. There are many practice recommendations, particularly from the INS, where there is no overwhelming consensus and policies may vary from one hospital to another, which means there is no basis for negligence because you followed your facility protocol rather than a moderately influential practice group's poorly substantiated recommendation.
My facilities policy not only does not say to apply a gel after PICC removal, it specifically prohibits it. Applying a gel does not provide an occlusive seal. Imagine if you have a leak in a tire, would putting some vaseline on it seal the leak? Probably not. Another issue is safety; If there is an open track to a vein where the vein is exerting negative pressure into that track, is it a good idea to put vaseline in the track? Absolutely not, this (vaseline emboli) has been attributed to at least one death. Is the threat of air embolus following PICC D/C significant enough to support such a risk? Nope, there has never been a reported case of air emboli following removal of a PICC. Are there safer and more effective options? Yes, an occlusive dressing is far more likely to successfully occlude the opening, and it's unlikely that the dressing could be pulled into the vascular system. Occlusive dressings can be placed in one motion with removal of the PICC resulting in minimal time between removal of the line and occlusion of the tract. We don't allow vaseline soaked dressings either, these just make it more likely that the occlusive dressing will fail and provide no advantage over an occlusive dressing alone.

Muno,

I am familiar with your distain for INS, however, It IS the standard across the nation to "seal" the site with ointment and then place an occlusive dressing over the site to prevent AE. I don't believe an occlusive dressing is sufficient by itself. I've also not heard of an emboli of vaseline. Please provide referrance. And if that were truly the case, without the ointment, that pt would have suffered a AE, for sure.

xtxrn, ASN, RN · Jul 27, 2011

Muno,
I am familiar with your distain for INS, however, It IS the standard across the nation to "seal" the site with ointment and then place an occlusive dressing over the site to prevent AE. I don't believe an occlusive dressing is sufficient by itself. I've also not heard of an emboli of vaseline. Please provide referrance. And if that were truly the case, without the ointment, that pt would have suffered a AE, for sure.

I guess the hospitals/nursing homes I've either worked or been in have left the US ... NONE of them in the N. Illinois city I'm in use any sort of "seal". And neither I (have had several PICCs) nor the patients I've seen/worked with who had PICCs bought the farm due to lack of a 'seal' .... They (and I) got pressure held by a nurse, and a snug bandage. :twocents:

IVRUS, BSN, RN · Jul 27, 2011

I guess the hospitals/nursing homes I've either worked or been in have left the US ... NONE of them in the N. Illinois city I'm in use any sort of "seal". And neither I (have had several PICCs) nor the patients I've seen/worked with who had PICCs bought the farm due to lack of a 'seal' .... They (and I) got pressure held by a nurse, and a snug bandage.

Well honestly, just because you haven't been privy to this practice, does NOT mean that those "in the know" and those with infusion savy, don't utilize this in their daily practice. I am glad in one way that you haven't been part of legal action where this protocal was not followed and the patient did END up buying the "FARM". It has happened.. Thankfully, not to U.

xtxrn, ASN, RN · Jul 27, 2011

Well honestly, just because you haven't been privy to this practice, does NOT mean that those "in the know" and those with infusion savy, don't utilize this in their daily practice. I am glad in one way that you haven't been part of legal action where this protocal was not followed and the patient did END up buying the "FARM". It has happened.. Thankfully, not to U.

And just because you use this in your area doesn't mean that all other nurses (and I've done plenty of IV/central lines/PICCs-- don't have to agree with you to have 'savy' ) are going to contribute to someone croaking because they didn't use a dab of goop :) Each facility has their own procedure manuals (and lawyers) and decides what data they use to make those procedures :) You follow different procedures- whoopee for you:) It's not the cornerstone of the continuation of mankind!! :lol2: :lol2: :lol2: :lol2: It must s**k to have so many idiots to have to explain things to :lol2: :lol2:

You're kinda wishing I'd been sued, so I'd understand how deeply you feel about this, huh? :lol2: :lol2: I HAVE been sued (along with 3 other co-workers including the DON and admin) for something totally unrelated -- and it IS horrible, and I've gotten very bent out of shape over some of the issues related to that situation. It hurts to be involved in legal action, and colors views on the accusations they used.

I had my Hickman taken out last week...a much bigger hole leading up through the tunnel to my jugular vein...no goop. 2x2s and Tegaderm.... and 6 days later, I'm still kicking

MunoRN, RN · Jul 27, 2011

Muno,
I am familiar with your distain for INS, however, It IS the standard across the nation to "seal" the site with ointment and then place an occlusive dressing over the site to prevent AE.

Sealing the site with an ointment is not a "standard". A standard is something that has universal agreement, where examples of the standard not being followed are very hard to find and constitute true legal negligence. As you'll notice in this thread, use of an ointment is not universal, there are also professional practice sources that don't advocate the use of an ointment (for instance: Mosby's, http://www.medscape.com/viewarticle/508939_8, and others).

I don't believe an occlusive dressing is sufficient by itself. I've also not heard of an emboli of vaseline. Please provide referrance.

http://www.ncbi.nlm.nih.gov/pubmed/2241775

And if that were truly the case, without the ointment, that pt would have suffered a AE, for sure.

Our issue with the ointment is that decreases the ability of the occlusive dressing to do what it is intended to do; occlude. I agree that AE should be avoided as effectively as possible, which we believe consists of an occlusive that has not been compromised by a lubricant which will negate the seal, but you seem to overestimate the probability of an AE related to PICC removal, what is the incidence of AE following PICC removal?

xtxrn, ASN, RN · Jul 27, 2011

Good articles :)

IVRUS, BSN, RN · Jul 28, 2011

Sealing the site with an ointment is not a "standard". A standard is something that has universal agreement, where examples of the standard not being followed are very hard to find and constitute true legal negligence. As you'll notice in this thread, use of an ointment is not universal, there are also professional practice sources that don't advocate the use of an ointment (for instance: Mosby's, http://www.medscape.com/viewarticle/508939_8, and others).
http://www.ncbi.nlm.nih.gov/pubmed/2241775
Our issue with the ointment is that decreases the ability of the occlusive dressing to do what it is intended to do; occlude. I agree that AE should be avoided as effectively as possible, which we believe consists of an occlusive that has not been compromised by a lubricant which will negate the seal, but you seem to overestimate the probability of an AE related to PICC removal, what is the incidence of AE following PICC removal?

Hello... That article is NOT r/t Removal. Ointment DOES NOT decrease the ability of the TSM.. It enhances it.

It is "standard," to seal with ointment. If you were called into a court of law because your pt suffered an AE, would they go by your own standards, or would they check out INS standards. It will BE INS.

IVRUS, BSN, RN · Jul 28, 2011

And just because you use this in your area doesn't mean that all other nurses (and I've done plenty of IV/central lines/PICCs-- don't have to agree with you to have 'savy' ) are going to contribute to someone croaking because they didn't use a dab of goop :) Each facility has their own procedure manuals (and lawyers) and decides what data they use to make those procedures :) You follow different procedures- whoopee for you:) It's not the cornerstone of the continuation of mankind!! :lol2::lol2: It must s**k to have so many idiots to have to explain things to :lol2:
You're kinda wishing I'd been sued, so I'd understand how deeply you feel about this, huh? :lol2: I HAVE been sued (along with 3 other co-workers including the DON and admin) for something totally unrelated -- and it IS horrible, and I've gotten very bent out of shape over some of the issues related to that situation. It hurts to be involved in legal action, and colors views on the accusations they used.
I had my Hickman taken out last week...a much bigger hole leading up through the tunnel to my jugular vein...no goop. 2x2s and Tegaderm.... and 6 days later, I'm still kicking

Wow, didn't know I was talking to an idiot, but rather a fellow medical professional, but hey, thanks for enlightening me. :yeah:

Never, did I say that I wished you were sued, what I said was that I'm glad you haven't been privy to a lawsuit involving a AE. Don't take it out of context. In addition, just because they removed your Hickman catheter and didn't use "goop" doesn't mean that they shouldn't have used it. The size of most Hickman catheters along with the tunneling of the catheter, provides a long tract in the SQ which without "goop" could be a direct migratory pathway for air. Thank God you're still "KICKING"

xtxrn, ASN, RN · Jul 28, 2011

Wow, didn't know I was talking to an idiot, but rather a fellow medical professional, but hey, thanks for enlightening me.
Never, did I say that I wished you were sued, what I said was that I'm glad you haven't been privy to a lawsuit involving a AE. Don't take it out of context. In addition, just because they removed your Hickman catheter and didn't use "goop" doesn't mean that they shouldn't have used it. The size of most Hickman catheters along with the tunneling of the catheter, provides a long tract in the SQ which without "goop" could be a direct migratory pathway for air. Thank God you're still "KICKING"

Yeah, the doc talked to me about the tract going into my jugular, and that some bruising may show up dependently from the jugular, but slapped a couple of 2x2s on with a Tegaderm (I can't have the foam tape for a stronger pressure since the adhesive literally causes blisters full of serous fluid wherever the tape touches- still have a funky flaky scar from April 2010 from foam tape at a PICC site). You would have been mortified when he accidentally clipped the Hickman in half trying to loosen the cuff...had enough to grab, and it all came out fine :) --it's SO nice to be rid of that thing

I worked at places that did not use ointment with PICCs or other central lines when they're removed. And the only cleanser for dressing changes with my PICC and Hickman was chloro-prep makeshift preps (Medicare doesn't cover Chloro-preps, and they're too expensive for out of pocket- had to make due with an OTC antiseptic with chlorohexi-something ...I don't remember the whole name- it's quite late, or early :lol2: :lol2: :lol2: - LOL..... and got my own dressings; did all of my own Hickman care). It all worked out. :)

I've found different protocols in the same city for some things (like one place counted Phenergan with the narcs....one facility let LVNs start IVs but not give push meds, and another wouldn't let them start IVs, but could give IVPBs- both could maintain the fluids...Here, the LPNs aren't allowed to do much of anything, even though they've been nurses for ages, and know a lot.

Oh well.... JMHO :)

MunoRN, RN · Jul 29, 2011

Hello... That article is NOT r/t Removal. Ointment DOES NOT decrease the ability of the TSM.. It enhances it.
It is "standard," to seal with ointment. If you were called into a court of law because your pt suffered an AE, would they go by your own standards, or would they check out INS standards. It will BE INS.

That article, as I pointed out earlier, documents the effect (death) of vaseline entering a vein, putting vaseline in an open tract that communicates with a vein clearly presents some risk. The question then is if the risk is justified based on the severity of the threat and lack of other, safer options. The incidence of post PICC removal AE is zero, there are no documented cases of this ever happening. In terms of other options, a tegaderm by itself is both safer and more effective. An occlusive dressing, which relies on adhesion to the skin surrounding the site, is not enhanced positively by a lubricant that negates the adhesive abilities of the dressing. Less adhesion = more likely seal will not be patent.

Legally, Nurses are expected by courts to follow their facility policies and the Standards of Care. I think you may be getting confused by the INS's use of term "standard" when referring to their practice recommendations. Standards of care and practice recommendations are not the same thing. Some of the INS's practice recommendations could be considered Standards of care, but that doesn't mean that all of the INS recommendations are therefore Standards of care. When an issue arises in court where facility policies and Standards of care don't apply, they may then defer to practice recommendations, where a Nurse's expectation to follow those recommendations would be considered based on the strength of the recommendation and if it's reasonable to expect that the nurse would have been aware of the recommendation. The ointment recommendation is not only not based on strong, unequivocal evidence, it's based on absolutely no evidence at all, and the recommendations are not publicly available.

Are you suggesting that the best way for a Nurse to protect themselves legally is to defy their facility policy to instead follow a poorly substantiated practice recommendation?

IVRUS, BSN, RN · Jul 29, 2011

That article, as I pointed out earlier, documents the effect (death) of vaseline entering a vein, putting vaseline in an open tract that communicates with a vein clearly presents some risk. The question then is if the risk is justified based on the severity of the threat and lack of other, safer options. The incidence of post PICC removal AE is zero, there are no documented cases of this ever happening. In terms of other options, a tegaderm by itself is both safer and more effective. An occlusive dressing, which relies on adhesion to the skin surrounding the site, is not enhanced positively by a lubricant that negates the adhesive abilities of the dressing. Less adhesion = more likely seal will not be patent.
Legally, Nurses are expected by courts to follow their facility policies and the Standards of Care. I think you may be getting confused by the INS's use of term "standard" when referring to their practice recommendations. Standards of care and practice recommendations are not the same thing. Some of the INS's practice recommendations could be considered Standards of care, but that doesn't mean that all of the INS recommendations are therefore Standards of care. When an issue arises in court where facility policies and Standards of care don't apply, they may then defer to practice recommendations, where a Nurse's expectation to follow those recommendations would be considered based on the strength of the recommendation and if it's reasonable to expect that the nurse would have been aware of the recommendation. The ointment recommendation is not only not based on strong, unequivocal evidence, it's based on absolutely no evidence at all, and the recommendations are not publicly available.
Are you suggesting that the best way for a Nurse to protect themselves legally is to defy their facility policy to instead follow a poorly substantiated practice recommendation?

Wow, "poorly substantiated practice recommendations".. Hmm.. You must think that INS has a bunch of uneducated "boobs" working and writing the standards. Sad. But you are wrong.

The INS standards represent the scope of practice and offer evidence based criteria essential to the delivery of safe and competent care.

Practice recommendations and standards of care are different, truly, but remember standards which read in part that the nurse "shall" carries a greater weight (Remember the 10 commandments?) than saying a nurse should do something. In a court of law, did the nurse comply with the standards, or didn't she/he? Without exception, these are the standards by which nurses are held to.

Though reported cases of AE s/p PICC removal may not be published, that only doesn't mean it Hasn't happened, or couldn't happen. Remember that if a catheter's been dwelling for a long period of time, a fibrin sheath can become well defined. There is a documentated case of a CVC being removed and then 30 minutes later the man went out to smoke, with his first drag, deep inhalation of cigarette smoke, he also "sucked" in an air embolus which extended from the insertion site of the now removed PICC , to his lungs all along a strong fibrin sheath.

A TSM is NOT sufficient in and of itself to seal the site and prevent an air embolism. You need a complete seal around the site, which is why a gel, and a TSM is needed.

But, hey Muno, thanks for the lively discussion and WE can agree to disagree. :rolleyes:

xtxrn, ASN, RN · Jul 29, 2011

OK. My :twocents: since having just had a Hickman removed (yes, I know they're different since the Hickman is tunneled, but the tract is more significant with a Hickman- the PICC goes directly into the vein- or has a minimal tract to get through the SQ tissue, fat, and muscle- at least 3-4 I had...don't know of any tunneled PICCs) , with a very defined tract to my right ext jugular....and the cuff of tissue having to be cut out to remove the catheter. The surgeon told me that the tract would collapse very quickly, and be permanently 'shut' within minutes, as long as I didn't strain w/lifting-. Also said that the opening to the jugular would self seal- they didn't have to put a tourniquet around my neck . He stuck 2x2s and Tegaderm, and told me to leave it alone for at least 48 hours- then it was a done deal. He cut the edges of the entry site (essentially a stoma at that point) to approximate them. His concern was bleeding (I'm on Pradaxa for PEs) and asked me to please not bleed enough to have to go to the ED that night .

If the jugular (and tract) were at risk for AE, it makes sense that there would be some oozing if the vessel was open enough to allow for an AE... :confused:

With a PICC, the entry site is right at the skin. The nurses taking my PICCs out have always been more concerned about holding pressure- and thus sealing the site- than with any glop application :) The biggest rationale I've heard for not applying anything gooey is that it's another way to introduce bacteria--- yes, it should be kept from any bacteria from the dressing and antibiotic properties of the ointment of choice, but the skin around the area isn't sterile...and aren't antibiotic ointments bacteriostatic, not bacteriocidal- colonization can turn to infection????

JMHO