PICC Line: Flushes, But No Blood Return

[SleeepyRN]

I'm curious as to why this would happen. This morning I was supposed to draw blood from a PICC line for labs. The patient let me know that the nurses the last few days have not gotten a return, so lab has been drawing his blood the last few days. Sure enough, neither port, medication nor blood, gave me a return, but flushed well and fluids ran perfectly well into the line.

I went to draw blood on my next pt with a PICC. I got no return from the red port, but got a good return from the other one.

I feel dumb asking. What is going on here? Other than in scenario #1, the PICC not being in correct placement, yikes, what are the possibilities for this?

Is it simply the beginning of clogging and thus will, for the time being, flush thin fluids but not thick fluids like blood? On both patients, I did have to push hard to flush.

However, an access RN once told me that some types of leur locks make it feel like you are meeting with a lot of resistance, but that it's normal and perfectly patent.

Confused

[Oh'Ello, BSN, RN]

Could be any number of things (Fibrin sheath, coag, dire need of a new cap). Even displaced PICCs can still have blood return. I'd get a chest x-ray to confirm placement and if its in the right place tPA that sucker.

[CountryMomma, ASN, RN]

Could be a small fibrin sheath acting as a one way valve at the tip of the picc. Allows fluid in but gets sucked against the line when being drawn.

[AmyRN303, BSN, RN]

Sometimes you'll get a little fibrin flap on the end of the lumen....kind of flaps over on one side so you can flush, but when you go to draw back, it occludes the lumen so you get no return. Try vigorously pumping the flush, maybe a few if fluid status isn't critical. Have the patient turn their head to the opposite side, reposition a few times and see what you get...We have an IV team which maintains our lines. If I get no return even after my interventions, I call the doc for an alteplase vial order and have the IV nurses unclot the line.

[annie.rn]

One if the IV nurses on the forum can give you a much more detailed answer, I'm sure, but the cause that immediately comes to mind is a fibrin sheath. That's a little flap of fibrin that forms over the outlet of the catheter. When things are being pushed through, the flap moves out of the way. When you try to aspirate, the suction causes the flap to pull back and occlude the opening therefore you get no blood return.

Ideally when a line doesn't return blood an order should be obtained to instill altepase. A non-drawing line shouldn't be left shift after shift.

Here's a good Medscape article that discusses a lot of the reasons for occlusions and how to fix them:

Medscape: Medscape Access

Here's an illustration of how a fibrin sheath can occlude a catheter on aspiration:

[annie.rn]

Sorry for the repeated info. In the time I was writing my reply, others replied w/ the same answer.

[AmyRN303, BSN, RN]

annie.rn said:

Sorry for the repeated info. In the time I was writing my reply, others replied w/ the same answer.

Mine as well...just shows how common the problem is!

[SleeepyRN]

Thank you all very much! We call the access RN to unclog them, so I'll make sure I get an order to do so if not already done before my next shift. I gave that in report, but I don't think the oncoming nurse was really listening. I completely agree that it should not be ignored shift after shift. I had picked up a night shift (not my usual shift) after being off a week. The nurses are usually pretty good with getting an access RN to come in. This I guess, somehow slipped through the cracks a couple days. Poor guy has the PICC for a reason, but has gotten poked a few mornings in a row now.

[annie.rn]

SleeepyRN said:

I completely agree that it should not be ignored shift after shift. I had picked up a night shift (not my usual shift) after being off a week.

I'm sorry if I came off as being accusatory ? You sound like a very conscientious nurse. My comment was directed at nursing staff in general. Where I work the PICC nurses don't de-clot the lines. I regularly see clotted lumens on lines going for days on end w/o anyone trying to do anything about it. They don't routinely get flushed, either. Frustrates me.

[SleeepyRN]

annie.rn said:

I'm sorry if I came off as being accusatory ? You sound like a very conscientious nurse. My comment was directed at nursing staff in general. Where I work the PICC nurses don't de-clot the lines. I regularly see clotted lumens on lines going for days on end w/o anyone trying to do anything about it. They don't routinely get flushed, either. Frustrates me.

Oh, no...I didn't take it that way at all. My sentences weren't strung very well together there. No worries. It DID irk me a tad that other nurses I would generally say are very on top of things, left it that way, knowing there was a problem, didn't try to find out the problem, or even bother giving me that bit of detail in report.

I'm greatful he was an AxO x3 pt who was able to tell me this. Now the next shift knows this has been an ongoing problem and can take the steps to remedy it. ?

[FlyingScot, RN]

Here's a real life example of a fibrin tail. Imagine my shock when I found this on the end of a PICC line I had just removed. Shudder!

[Pepper The Cat, BSN, RN]

This is a very interesting thread for me because my unit is having a heck of a time with one PICC.

Pt has ABI, Lupus Plus is being treated for TB. 3 different IV a/b. Basically gets an IV a/b q 2- 4 hours.really needs a PICC.

Those suckers just keep on blocking. After the 2nd blockage we started running IV TKVO between a/b and the PICC still blocks! Twice it has blocked while we are drawing blood! I have never had a PICC block while fluids are infusing or while drawing blood.

Any ideas?! I am wondering if it is connected to,her lupus