No blood return from PICC...is it a problem??

[xoNurseRNxo]

I'm in home health and have a pt who recently had a PICC inserted for IV ABX infusion d/t osteomylitis. I tried drawing labs from PICC (singe lumen) but was unsuccessful. I was able to get less than 1cc of blood. His IV ABX infuses with no problems. Should I be concern? Are there tips to try to get blood return from PICC (e.g arm positioning)?

[morte, LPN, LVN]

may be problem. try positioning arm straight out from shoulder (patient lying down) supported of course. Have patient turn head in opposite direction. If you were trying to draw directly into tubes, you need to R/O bad tubes. Your can try drawing with syringe and putting into tubes from there. good luck

[ukjenn231]

You can also try replacing the cap and the dressing, if you are able to. If no blood return after troubleshooting, you may be able to (depending on your company, procedures, etc) be able to get a doctor's orders for CathFlo which is a small dose of TPA you instill into the PICC line to reestablish correct functioning.

[Double-Helix, BSN, RN]

Many PICCs are positional- but the position depends on the patient. Sometimes they work better if you have the patient lift their arm up for a minute before you try to draw blood. Or extend it straight to the side, or foreword, or have them reach across their body a little. Sometimes it's beneficial if you have them cough a few times beforehand as well.

If the patient is able, ask them what usually works when drawing blood.

[xoNurseRNxo]

Thank you all for your tips. I had pt lay flat with extended arm and had pt turn head opposite direction. I was able to easily obtain labs through PICC line. Once again THANK YOU ALL FOR YOUR HELP!!!

[Anna Flaxis, BSN, RN]

Lack of brisk blood return does indeed indicate a problem. Anything from a partial occlusion to a fibrin sheath to catheter tip migration to catheter pinch off. Any of these things can lead to extravasation and harm to the patient. If the patient has to stick their arm out every time to get blood return, you need to contact the physician and let them know.

[classicdame, MSN, EdD]

yes it is a problem. It could mean that the line is beginning to clot off. We use Cathflo in our facility to try to de-clot lines, but that may not be an option for you. Someone with PICC experience needs to assess. Meanwhile, you can replace the hub or port closest to you to see if the clot is there.

[Asystole RN]

Using a PICC line that does not draw blood is unacceptable.

Thrombus is a serious infection control issue, the thrombus must be cleared to prevent possible CLABSI. Should you activase the line and it still does not draw blood you need to verify placement, the lack of blood return may indicate spontaneous malposition.

[Anna Flaxis, BSN, RN]

I think the fact that it infuses with no problems, and the blood return was obtained by having the patient hold their arm out and turn their head to the opposite side, is more suggestive of pinch off syndrome or tip malposition than thrombus. I'd want a CXR to check and see if the catheter runs right through the pinch off point as well as to confirm tip placement.

[IVRUS, BSN, RN]

~*Stargazer*~ said:

I think the fact that it infuses with no problems, and the blood return was obtained by having the patient hold their arm out and turn their head to the opposite side, is more suggestive of pinch off syndrome or tip malposition than thrombus. I'd want a CXR to check and see if the catheter runs right through the pinch off point as well as to confirm tip placement.

Well, I don't agree here. Pinch off syndrome is unusual with a PICC, and more prevalent with those percutaneously placed lines which start in the subclavian and thread to the SVC.

Also pinch off syndrome will be noted within the first few hours after placement especially of they are using it frequently. And, with pinch-off syndrome, one must have the pt raise his or her shoulder and rotate back to seperate the clavicle and first rib. Extension of the arm, and turning of the head, doesn't necessarily produce those outcomes.

Fibrin buildup is my guess.

[Anna Flaxis, BSN, RN]

Yes, that's a good point that pinch off would be a rare finding for a PICC! Don't know what I was thinking.

[iluvivt, BSN, RN]

IVRUS is correct..I was just going to say what was said. If a mechanical issue has been ruled out it is most likely a persistent withdrawal occlusion (can easily instill but no blood return obtained) and should be treated with Tpa (cathflo). if it is a complete occlusion a drug or mineral precipitate needs to be considered as well.