PICC line blood draw

[greyL]

What's the proper way to draw blood from a picc line? The other day I flushed with 10 cc's of NS, then wasted 10, then drew blood. But the lab called to say that the results looked wrong (extremely low hemoglobin level) and that the blood probably had saline in it. Another nurse told me that I'm supposed to waste more than I flush and that I did it wrong. Is that correct?

[kcochrane]

Another flush with 10ml, waste 10ml and flush with 20 ml after the blood draw.

[Do-over, ASN, RN]

MunoRN said:

I'm disturbed how common wasting 10ml is. Keep in mind blood draws and wastes are the main cause of iatrogenic anemia, which is largest cause of blood loss in hospitalized patients.

2-3 times the lumen volume is sufficient, additional waste provides no additional benefit. A power lumen on a PICC has the largest volume and is 1.7 ml. Non-power lumens are less than 1 ml.

This.

[sapphire18]

Please don't waste 10cc with every blood draw...go by your facility's policy, but I usually flush with 5cc and waste 5cc- I do both with a single 10cc flush syringe. Also, make sure that anything infusing into any other ports is put on hold while you're drawing the blood. Just don't forget to turn them back on.

[LadyFree28, BSN, LPN, RN]

^This.

10 mL is WAYY too much blood to withdraw IMHO; usual rule of thumb is 5 mL max; I've used a 3 CC syringe to draw back and waste.

[KelRN215, BSN, RN]

MunoRN said:

I'm disturbed how common wasting 10ml is. Keep in mind blood draws and wastes are the main cause of iatrogenic anemia, which is largest cause of blood loss in hospitalized patients.

2-3 times the lumen volume is sufficient, additional waste provides no additional benefit. A power lumen on a PICC has the largest volume and is 1.7 ml. Non-power lumens are less than 1 ml.

I have never once wasted 10 mL drawing blood. That's unheard of in children. We waste 3-5 mL.

I also don't change caps after every lab draw. We change them once/week on PICCs and twice/week on CVLs per policy.

[Anna Flaxis, BSN, RN]

Asystole RN said:

Are you sure that you used the syringe with pure blood instead of accidentally grabbing the waste and filling the tubes? It is not uncommon to accidentally grab the waste on the table, especially when both the waste and draw are 10mL. Having seen this done multiple times, and nearly done it myself, I am willing to bet this is how you obtained such a large amount of saline within the sample to significantly contaminate the test.

Oooh, good point. I have a system that I follow every blood draw that helps me to not do this. I place the waste syringe on the far right corner of the work surface away from me, and the draw syringe on the close edge of the work surface near me. Every. Single. Time.

[KelRN215, BSN, RN]

~*Stargazer*~ said:

Oooh, good point. I have a system that I follow every blood draw that helps me to not do this. I place the waste syringe on the far right corner of the work surface away from me, and the draw syringe on the close edge of the work surface near me. Every. Single. Time.

Great thing about home health is that all my patients who need labs/have lines have their own biohazard boxes in their home. I throw the waste away immediately as I draw it. I also waste into the saline syringe so I don't mix them up.

[Anna Flaxis, BSN, RN]

That's great! For me, the sharps container is way across the room from the patient care area, and it's not portable. I think having a routine is the key, whatever routine works for you.

[pknurse]

Asystole RN said:

Consult your facility's P&P on drawing blood, if there is not a specific method described then the blood bank may give recommendations or your vascular access team. Minimally, twice the internal volume of the catheter should be flushed and wasted. For most PICCs this is somewhere around 1-2mL depending upon the size and length of the catheter.

This is the solid answer. Whatever the policies and procedures of the hospital are what must be done. You can actually receive disciplinary action for not following policy/procedures even if it aligns with evidence-based practice (e.g., aspirating on an IM injection).

[greyL]

So I looked up our policy, and it says we don't have to flush first. But now I'm in a predicament! Our policy says to flush with 20 mL NS after and if there are no IV fluids running, to also flush with 2mL hep flush.

I can't just get hep flushes whenever I want. We have to access them from pyxis and it is treated like a scheduled medication. What should I do about this?

[KelRN215, BSN, RN]

greyL said:

So I looked up our policy, and it says we don't have to flush first. But now I'm in a predicament! Our policy says to flush with 20 mL NS after and if there are no IV fluids running, to also flush with 2mL hep flush.

I can't just get hep flushes whenever I want. We have to access them from pyxis and it is treated like a scheduled medication. What should I do about this?

Take it out of the pyxis. When I worked in the hospital, this was a standard of care order that could be entered by nursing. I can count on one hand the number of times an MD ordered a 500 unit heparin lock flush prior to deaccessing a port-a-cath (precisely ZERO). This was something that had to be done and our 100 u/mL heparin was only stored in the pyxis. All you had to do was override and you could take it out. PICC lines that were not infusing IVF were to be flushed with heparin q 8hr- another standard of care thing. We did have 10 u/mL heparin flushes lying around though, along with saline flushes.

[SwansonRN]

\ said:

So I looked up our policy and it says we don't have to flush first. But now I'm in a predicament! Our policy says to flush with 20 mL NS after and if there are no IV fluids running, to also flush with 2mL hep flush. I can't just get hep flushes whenever I want. We have to access them from pyxis and it is treated like a scheduled medication. What should I do about this?

You could ask the MD to put it in as a PRN for blood draws?