No blood return

[Calgon-take.me.away]

I have a question for you. I have a patient, has had several PICC lines, all of them seem to deteriorate very fast. When we check for blood return on them, the first three or four times it is good, then they go bad. The patient is getting Vanco, which I know is very caustic, but does this compromise the blood return? He now has a dopuble lumen in the Subclavian and after only 4 days, again no blood return.

The question is,,,even if the doctor has been called, has been notified that there is no blood return, gives orders to administer the antibiotics, should I?:redlight:

My direct supervisor came in with me to access the line, found no blood return. I told her I did not feel comfortable giving the IV, she stood there while I was starting the med.

Needless to say, I made sure that all RN's involved charted their hearts out on this patient, as well as I did

By the way, this is a LTc facility and the patient is a quad, which to get a new PICC involves much discomfort for the patient to be sent out

[TazziRN, RN]

No blood return does not mean that the line isn't patent. Even with periph IV's that's true. If you can flush easily (carefully, of course!!) then it's safe to infuse. Still inform the doc, but it's okay.

[Blee O'Myacin, BSN, RN]

Were you concerned about the line infiltrating? Like Tazzi said, if you could flush easily, then you could still give the vanco. I think that more harm would come to the patient if the vanco isn't given. The doc was notified, and said to give it anyway as well. You could have had an x-ray done to confirm placement, but more than likely, a fibrin sheath formed around the tip of the PICC. If appropriate for the patient, a heparin flush could be used to clear the line.

I hope this line wasn't D/C'ed due to no blood return without checking for placement first. What was the ultimate outcome? Is the patient stable enough for a port-a-cath placement?

If you were truly concerned about the PICC not being in the right place and feared infiltration, then a peripheral IV should have been started and the vanco given (very, very slowly) with frequent assessment of the IV site.

Blee

[JRD2002]

I would question whether or not everyone is flushing adequately after aspiration of blood. If the PICC is not flushed with at least 20ml of saline after each aspiration a fibrin sheath will form and blood return will be slow or non-existent. After a PICC stops giving a good blood return we usually administer Cath-flow and it really gets it going again.

Was the external length the same as when the PICC was placed?

If it is more than a 3cm difference then you would need to have a x-ray to confirm placement. Since the patient is a quad I doubt that the external length would change very much. I feel that your problem is probably someone unclear on how to properly care for the PICC.

[CoffeeRTC, BSN, RN]

I agree with all of the above. Proper flushing is necessary. I think our policy only calls for q 12h flushes...I do it every shift.

Do you have an IVT that can come out and check the line?

[aeauooo]

I've had people argue with me about this, because it seems counterintuitive, but flushing with a small syringe creates much higher pressure than flushing with a larger syringe. The only time I have seen a PICC go bad, other than clotting, is when they are flushed using a 3ml or smaller syringe - it can rupture the lumen. PICC should only be flushed with a 5ml or larger syringe.

[ICRN2008, BSN, RN]

I've had people argue with me about this, because it seems counterintuitive, but flushing with a small syringe creates much higher pressure than flushing with a larger syringe. The only time I have seen a PICC go bad, other than clotting, is when they are flushed using a 3ml or smaller syringe - it can rupture the lumen. PICC should only be flushed with a 5ml or larger syringe.

I agree with above- my facility's policy stated that only 10ml and above syringes could be used. Manual, pulsile flushing of the line with volume after med administration is the best way to prevent the line from getting clotted.

[cardiacRN2006, ADN, RN]

10ml syringes only or larger.

Usually a PICC gets clotted when it's not flushed. Is this an open-ended PICC that needs to he dwelled with Heparin?

[rnmi2004]

I would hope the reason the patient has had "several PICC lines" isn't due to simply not getting blood return! As other posters have pointed out, if not properly flushed a PICC will develop a fibrin sheath preventing aspiration of blood; however you can still infuse meds and IV fluids through it. Cathflo will usually take care of the fibrin sheath and allow the PICC to be used for blood draws again.

[GrumpyRN63, ADN, RN]

Agree with all, I'd give it if question of placement isn't an issue, may want the doc to order TPA/ altepase to try to reestablish blood return, a shame not to be able to draw labs if a central line is in place,,,