IV push into PICC...

Daytonite, BSN, RN · Sep 14, 2007

If you have an infusion hanging, there is no reason to inject any Heparin at all. You do SAS. Think about the rationale behind this. Why do you inject Heparin into the line at all? To prevent clotting from occurring. If you have an infusion going on, you have fluid continually running through the line to keep it patent, so the Heparin isn't needed.

In addition, you need to know what kind of PICC line you have. If the PICC has a Groshong tip, Heparin is not needed to close and lock the line at all. It is because of the way the groshong slit works.

Always look for the rationales behind what you are doing. I currently have a PICC line because I am receiving chemotherapy. I was also an IV therapist who inserted PICC lines. I am always appalled at the nurses who insist on flushing my PICC with Heparin despite that fact that it is a Groshong and I have provided them with the specific instructions by the doctor who inserted it NOT to flush it with Heparin.

IrishIzCPNP, MSN, RN, APRN, NP · Sep 14, 2007

I understand the rationale. I do. I just wondering what other people were taught.

We were never told to skip the hep with a large volume. Sure it makes sense but this is not the type of thing that they should expect us to make assumptions on.

So when I'm taught one thing and expected another thing on a competency by somebody really not involved with the class...who do you go with? #2 makes more sense so I'm just trying to cover my rear with what is the norm.

We also have not gone into the types of PICCS and honestly don't expect we will. I wonder if in the pt orders it's written "do not flush with hep". I know I've seen similar things. So I wonder if it's not something regularly taught. I don't see us learning it in the future.

Daytonite, BSN, RN · Sep 14, 2007

Oh, I see. OK. Well, let me first tell you that the groshong tip is a patented invention. It is a small slit that works like a one way valve. It is now being incorporated into a number of catheters that are used for instillation of fluids into patients, not just PICC lines. Initially, when you heard the word Groshong, it was associated automatically with a PICC line, but that is not true anymore. It is now being put in dialysis cathethers and other central lines because of it's safety feature. The biggest one is that is will not allow blood to come back into the catheter if the distal end (the one closest to the outside of the body) accidentally is uncapped. And, for central lines this potentially eliminates the complication of air embolism is the distal cap comes off and the patient takes a deep breath.

The issues of flushing these central lines, PICCs included, is usually addressed in most facility policies. Here is the exact policy on flushing of central lines from the last facility I worked as an IV therapist 10 years ago, so you can see the slight differences in flushing.

CARE AND MAINTENANCE OF CENTRAL LINE CATHETERS

SASH = Saline, Antibiotic (or other Medication), Saline, Heparin

SAS = Saline, Antibiotic (or other Medication), Saline

(Substitute D5W for Saline when Amphotericin is given)

Blood Draws--Remember to flush the line with 10cc's Saline prior to draw, discard 3cc's of blood, obtain specimen, and then flush with a minimum of 10-20cc's after the draw.

Peripheral IV - Flush with Normal saline 1cc, q8h or before and after meds.

Non-Tunnelled Central IV line (Triple Lumen Catheter) - Heparin (100 units/cc) 2.5cc's daily per lumen. SASH, same volume with meds.

Hickman - Heparin (100 units/cc) 2.5cc's daily or SASH, same volume with meds.

Groshong - 0.9% NS 5cc's daily, or SAS, same volume with meds

PICC (this would be a PICC without a groshong tip) - Heparin (100 units/cc) 2.5cc's daily. SASH, same volume with meds.

Groshong PICC - 0.9% NS 5cc's daily, or SAS, same volume with meds

Implanted Port - Heparin (100 units/cc) 5cc's daily or SASH, same volume with meds.

These are the instructions I was given when my PICC line was inserted in July, so they are a little more current! My PICC has a groshong tip. [attach]5740[/attach] PICC line Instruction Sheet

Hope that gives you something to consider. I would pull the facility policy on flushing central lines the next time you are in clinicals and print it/copy it. Good weapon to have in your orificenal. Honestly, when you are doing a demo for an instructor, and you still harbor some confusion, cite rationales and ask for their rationale as well. I was a member of INS (Intravenous Nurses Society) and a Certified RN, Intravenous (CRNI). All of the procedures surrounding the flushing of these catheters are based on research that was done by nurses, many of them CRNIs or CENs who know their stuff when it comes to this! If you can find it written in an INS standard of care, you can at least defend your answer and sound collegiate about it! Even I would give you points for that!

IrishIzCPNP, MSN, RN, APRN, NP · Sep 14, 2007

Thank you for taking this time. I'm going to print out your information on that other tip and just have it in case I ever come across one.

Another question if you don't mind...

Do you pinch off tubing before the Y for a compatible med? I thought you pinched for one that wasn't compatible but if it was compatible you just left it.

There is also confusion as to whether or not you have to pause the pump. Some of us say no and some say yes...again probably because the information was presented differently when we were put into groups for the labs.

I'm just trying to see what other people do and have been told.

This seems to be your thing...so you are probably a good one to ask.

Daytonite, BSN, RN · Sep 14, 2007

Do you pinch off tubing before the Y for a compatible med? I thought you pinched for one that wasn't compatible but if it was compatible you just left it.

You pinch off the tubing before the Y-Connector before you inject anything into the IV line. If you don't, whatever you inject will not only go down the IV line, but also backflush UP the IV line as well. When it goes up the IV line it will mix with any incompatible solution. A good rule of thumb is to just always assume that everything is incompatible and SAS it. Just do it as a habit. Then you never have to worry about what is compatible or not compatible. The first time you accidentally mix Dilantin with D5W in an IV line you learn a hard lesson about incompatibility because you have to change the entire IV tubing because of the precipitate that forms in the tubing. It's like concrete.

There is also confusion as to whether or not you have to pause the pump. Some of us say no and some say yes...again probably because the information was presented differently when we were put into groups for the labs.

You would only pause the pump if it is going to take some time to inject the drug. The pump is going to detect an occlusion in the line when you pinch the tubing off. It's just a matter of how long it will take before the pump alarm sounds. So, I would say it depends on how lazy a person is. It only takes a moment to stop a pump, inject the drug, and then turn the pump back on. The danger is that some people forget to turn the pump back on. Lazy people don't want to get into trouble for forgetting to turn the pump back on (usually because it's happened to them before). I had a constant conversation going on in my head "turn the pump back on" or "check to see the pump is working before you leave the room". Nursing is about multi-tasking all the time and observing, observing, observing--everything including the IV pump, that the IV is dripping, that the IV site looks OK, that the patient looks comfortable and is breathing. . .

This seems to be your thing...so you are probably a good one to ask.

Yes, this was my thing. I was nationally certified in IV therapy and worked on IV teams for 6 years. I estimate that I probably started 36,000 IVs while working as an IV therapist and who knows how many more working as a med/surg nurse. I also inserted PICC lines, maintained, declotted and repaired Hickman and implanted ports.