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

[icuRNmaggie, BSN, RN]

The positive pressure end cap must be changed after every blood draw on both PICCs and other central lines. Clogged caps should not occur if staff use correct technique for infusions and blood draws.

[FlyingScot, RN]

icuRNmaggie said:

The positive pressure end cap must be changed after every blood draw on both PICCs and other central lines. Clogged caps should not occur if staff use correct technique for infusions and blood draws.

We used to do this but have changed that practice to weekly cap changes unless the line flushes or draws sluggishly without any documented increase in line complications. I haven't had much trouble with our current caps but the white ones are notorious for clogging.

[SleeepyRN]

Asystole RN said:

Certain types of PICCs and some needleless access devices will have valves in them that will require a certain threshold of either pressure or vacuum to overcome the valve. It's not much though.

THAT'S the word she used. Valves. I couldn't remember. Very interesting.

[SleeepyRN]

Asystole RN said:

Certain types of PICCs and some needleless access devices will have valves in them that will require a certain threshold of either pressure or vacuum to overcome the valve. It's not much though.

I felt so bad for the Access nurse a few weeks ago, because she had driven 2 hours to get to our location to unclog a PICC. I was told in report that she would be coming. I hadn't even had a chance to assess the PICC myself before she arrived.

I gave her the Cathflo. She came back to me saying it wasn't clogged. She even showed me a good flush and a blood return. She was very nice and understanding about it. She told me it actually happens quite often. I still felt bad for her for drive time. If I had only attempted a blood return myself first.

I trust fully that when the order was placed that there was no return. The access nurse suggested that before obtaining an order for Cathflo, to have 2 nurses attempt a flush and return. But I know that we DO. We don't order them willy nilly.

[Annie Wilkes RN]

I'm glad you posted this. I HATE WHEN THIS HAPPENS!

[Julius Seizure]

FlyingScot said:

We used to do this but have changed that practice to weekly cap changes unless the line flushes or draws sluggishly without any documented increase in line complications. I haven't had much trouble with our current caps but the white ones are notorious for clogging.

Interesting. We do cap changes with every tubing change (every 4 days)

[thinwildmercury]

Our PICC RN tells us that this is a partial occlusion which puts pt at risk of clots if not corrected. If MD has not ordered alteplase prn we are to rrequest it. It has worked for me every time.

ETA: This is after trying to change the cap and repositioning the pt's arm a million different ways. Every pt with a PICC has an order to never use anything other than a 10 ml syringe on the PICC as well.

[iluvivt, BSN, RN]

O.K. a lot going on here but let me address the original questions. First, you are having a type of occlusion. It will either be a complete occlusion or a partial occlusion:

Complete-you are unable to instill or withdraw

Partial-you are able to instill (may still be sluggish) but NOT withdraw blood

Next you have the causes, which may be mechanical, thrombotic, non-thrombotic or caused by a drug or mineral precipitate. You need to rule out each one out based upon your assessment or that of a clinician with experience with vascular access and central lines. For example, if your PICC was working fine and all lumens were patent with good blood returns and you change the dressing and caps and suddenly you are getting a downstream occlusion alarm, there is a pretty good chance that you created a mechanical occlusion when you changed the dressing and you need to look there first!

Rule out drug or mineral precipitate (this would a non-thrombotic cause): Do a quick review in your mind of all the medications the patient has received or is receiving via the line in question because inappropriate concentrations or incompatible mixtures can cause medications to precipitate within the catheter lumen. Ok this can get tricky if you are not a chemist, pharmacist or if you have not been an IV nurse for a very long time but if you remember a few key things in this category it will help. If you are administering infusions or mediations a too alkaline or acidic infusion may cause precipitation or if you are administering something back to back with either a low or high ph and you do not flush well a precipitate may occurs, In these cases a thrombolytic will NOT be effective, You must use either a weak acid or base to restore patency since these occlusion respond to ph changes.

Now let's look at thrombotic causes. Catheters can develop a thrombus or clot within or around catheter. These occur because of changes in blood flow, hypercoagulability, vessel trauma, blood reflux inadequate or improper flushing and catheter maintenance or combinations of these factors. A fibrin sheath, tail or sleeve can develop or an intraluminal or mural thrombus that can partially or completely occlude the catheter. This is when you want to instill tPA to clear your line. In the situation you descried I suspect you had a persistent withdrawal occlusion (PWO) and the line needs to be treated as soon as possible. Do not put off treating a PWO, even if you are able to easily instill medications and fluids. This is seems to be a lack of knowledge in this area and many nurses believe they need to wait until there is a complete occlusion before they instill tPA.

So check on the first two causes and then consider thrombotic causes,which are the most common causes of catheter occlusion (about 55 to 58 percent).

[Asystole RN]

SleeepyRN said:

I felt so bad for the Access nurse a few weeks ago, because she had driven 2 hours to get to our location to unclog a PICC. I was told in report that she would be coming. I hadn't even had a chance to assess the PICC myself before she arrived.

I gave her the Cathflo. She came back to me saying it wasn't clogged. She even showed me a good flush and a blood return. She was very nice and understanding about it. She told me it actually happens quite often. I still felt bad for her for drive time. If I had only attempted a blood return myself first.

I trust fully that when the order was placed that there was no return. The access nurse suggested that before obtaining an order for Cathflo, to have 2 nurses attempt a flush and return. But I know that we DO. We don't order them willy nilly.

Don't feel bad, if she works for an outside vascular access agency like I did then feel assured that she was well compensated for her time and expertise.

I LOVED those kind of calls.

[IVRUS, BSN, RN]

FlyingScot said:

Not true and not EBP. You should use only a 10 ml syringe or larger unless you are using a special large bore 5ml syringe to avoid damaging the line.

OP were the PICCs ever de-clotted before they were replaced? If they were I agree this patient is probably hyper coagulable and may need either Heparin or Citrate as the final instillate rather than saline. I've had this happen to a handful of my patients. One of my port patients has an oncologist that orders Alteplase instead of Heparin for her port. Not really something I'd recommend.

Flying Scott.... I must disagree totally with you here. RuthB is correct. When withdrawing from an IV catheter, smaller syringes exert less negative pressure and will often yield you a blood return, while the 10 cc syringes will not. A 3 cc syringe as less surface area and usually won't collapse an IV catheter like a 10 cc syringe will do with withdrawal.

[FlyingScot, RN]

IVRUS said:

Flying Scott.... I must disagree totally with you here. RuthB is correct. When withdrawing from an IV catheter, smaller syringes exert less negative pressure and will often yield you a blood return, while the 10 cc syringes will not. A 3 cc syringe as less surface area and usually won't collapse an IV catheter like a 10 cc syringe will do with withdrawal.

Interesting because our Bard rep says the complete opposite. I'll have to investigate further.

[bloatedputti, MSN, RN]

We are speaking of blood withdrawal and syringe size, not infusion.