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?

[MunoRN, RN]

Asystole RN said:

Out of all the conferences and meetings I have never heard a leading expert claim there was zero risk, and I have personally met Lynn and heard her speak. The INS Standards clearly state that there is a risk.

Obviously any manipulation involves some degree of risk. Do I personally think that the risk outweighs the benefits? Absolutely not, many of the lines I place are in fact for frequent draws.

What I was attempting to point out was that in the world of PICCs, there is no binary solution. In a facility with a multitude of variables, I can see where they may clamp down upon PICC manipulation. Do I agree with it? No. Do I understand it? Yes.

There have been discussions on this topic with Lynn on another site but she has stated directly that she doesn't believe blood sampling increases the risk of thrombosis. (Whether or not the INS or Lynn actually qualify as 'experts' is debatable however).

[KelRN215, BSN, RN]

greyL said:

I'm sorry, I don't mean to be difficult, but I'm unsure how this would work out. Hep flushes have to be scanned on a COW and witnessed by another nurse.

I don't get PICC lines a lot because I'm in CPCU. That particular night that I drew blood from a PICC line they had floated me to ICU.

I suppose I would have to call the doctor each time for a PRN order? =/

You have to witness a heparin flush? For real? Sorry, that's one of the dumbest things I've ever heard. You're not starting a heparin drip, you're doing a maintenance flush.

When I worked in the hospital, nurses had the ability to order heparin flushes as "standard of care" orders and they then appeared on the MAR/could be scanned. No, you don't have to call the MD every time for a PRN order. That would be a spectacular waste of time. The patient has a PICC, the appropriate orders for flushes q 8hr and PRN should already be entered.

[K+MgSO4, BSN]

Some hospitals require double check for PINCH meds. Potassium, Insulin, Narcotics, Chemotherapy, Heparin (all anticoagulants).

[youngheartoldhead]

it's very important that you use a new syringe to collect your sample. (dont use the one you flushed with).

there should be caps on the end of the picc (nurse side). hopefully your pt was given a package of picc line supplies , if so they will be in there. but before you do that or anything else with a picc line, please spend some time going over picc line care and management. (google). even though i've had several pts with piccs over the years, I still review the material if its been a while. go over changing caps, securing the tubing, correct flushing tech (some piccs have specific directions on how much, how fast and at what point to disconnect the syringe: after clamping , or before) piccs can be a big deal if not managed well. Good luck to you

[Anna Flaxis, BSN, RN]

greyL said:

It was because I just followed the way my preceptor showed me to do it. And because I had never had a problem with drawing blood from a PICC line before; though admittedly, I don't do it very often because I don't see a lot of PICC lines in my unit.

I do agree that I should have looked at the P&P, though looking at the P&P in the past for other procedures has never really gotten me answers (like when I looked for our policy of what size gauge to use for blood transfusion) This is the first time I've looked and it's showed me what I really needed to know.

Okay, so now you know, right? And in the future, don't let less than helpful P&Ps prevent you from referencing them prior to performing any procedure with which you are unfamiliar. If the P&P does not adequately answer your question, it is best to ask the charge nurse for further information. If you do not feel safe performing a procedure, you should not do it.

It does sound to me like someone else pointed out, that you may have accidentally switched your waste and draw syringes. This would explain the very low hemoglobin result. As I mentioned before, having a consistent ritual every time you draw will help prevent this in the future. Some people place the waste in the sharps immediately. Some have a signal, like recapping the waste syringe. Some use the flush syringe (flush, then withdraw waste into same syringe without disconnecting) so that it is obvious by the label on the syringe which is the waste, or lay out the work space systematically (waste syringe *always* placed at far end of work surface, draw syringe *always* placed at near end) etc. I suggest you have some sort of ritual to prevent getting the syringes mixed up in the future.

Good luck!

[KelRN215, BSN, RN]

K+MgSO4 said:

Some hospitals require double check for PINCH meds. Potassium, Insulin, Narcotics, Chemotherapy, Heparin (all anticoagulants).

My hospital required a double check for all of the above. Intravenous heparin is a high risk medication. But a heparin flush? My God, we'd do nothing but watch each other flush lines if we had to double check heparin flushes in oncology.

[wooh, BSN, RN]

KelRN215 said:

My hospital required a double check for all of the above. Intravenous heparin is a high risk medication. But a heparin flush? My God, we'd do nothing but watch each other flush lines if we had to double check heparin flushes in oncology.

Yeah, similar to when there was a mix-up for a while for us where fluids that had potassium had to be double checked. Plain old regular IV fluids, like D5NS with 20mEq of KCl. Thankfully that got fixed.

[metal_m0nk, BSN, RN]

LadyFree28 said:

^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.

You use 3 mL syringes to draw on PICC lines?

How many PICC lines have had to be replaced after you've had your hands on 'em?

OP - Did the patient have saline running when you drew your labs and did you remember to postpone the infusion beforehand?

[MunoRN, RN]

metal_m0nk said:

You use 3 mL syringes to draw on PICC lines?

How many PICC lines have had to be replaced after you've had your hands on 'em?

OP - Did the patient have saline running when you drew your labs and did you remember to postpone the infusion beforehand?

So long as the line is patent it makes no difference, and actually doesn't make that much difference even if the line isn't patent.

[LadyFree28, BSN, LPN, RN]

Quote

You use 3 mL syringes to draw on PICC lines?

It is protocol at my facility to waste with 3 mL syringes.

Quote

How many PICC lines have had to be replaced after you've had your hands on 'em?

NONE

[ArtClassRN, ADN, RN]

The proper way is to use whatever technique that prevents infection of the line or contamination of the sample and maintains the patency of the line.

[Cinquefoil]

It sounds like the safest option to prevent excessive pressure from being applied to a PICC line is to use a 10 cc syringe.

It also sounds from the link above like there are safe ways to use smaller syringes down to about 3 cc, but that the odds of those ways actually BEING safe in practice depends a LOT more on the user being meticulous (and on the gods of Luck and Chance).

How many 100% meticulous nurses do you know??

This is why we're using disinfecting port protectors on all IV lines at work now- because who do you know that always "scrubs the hub" for 15-30 seconds, then lets it dry the same amount of time before accessing? Even though doing it any other way is proven to be less safe and to risk serious complications?