PICC line flushing question

[newgraduategal]

If the patient is getting meds through an IV line every 12 hrs, do we stilll need to aspirate blood before flushing PICC line with normal saline?

[MunoRN, RN]

But not aspirating a brisk, free flowing blood return may mean that the tip is covered with Fibrin. That fibrin is a precurser to Bacterial contamination and Thrombus. Not getting a blood return is serious, and If your patient develops problems and it goes into a court of law, your documentation which neglects to reflect that you had a brisk blood return will be problematic as it is STANDARD of practice to get a blood return from all central catheters.. Single, double and so forth.

It's not actually a legal standard of care. We confuse these definitions by using the term "standard of care" for things we'd like to be a standard of care (practice recommendations, etc), but that doesn't actually make it a legal standard of care which is much different. A legal of standard of care is one where you would find universal agreement and compliance, where failure to follow that is so rare and out of the normal practice that it is legally considered negligent. As you can see from the previous posts, aspirating for blood return with every medication is by no means practiced at the level that would constitute a legal standard of care.

There is still ongoing debate and variations in practice that prevent this from being a legal standard of care, and personally I'm agreement with the side that says there isn't any significant effects that frequent aspiration increases the risks (line occlusion, biofilm growth, etc), but it's not a settled issue.

[IVRUS, BSN, RN]

Wow... You have a PICC team which needs education! Are the nurses, or is any nurse on the team CRNI's? The Central line which does NOT yield a blood return, but flushes well, is a catheter which needs CATHFLO

[IVRUS, BSN, RN]

'It's not actually a legal standard of care'

Totally disagree! I know that you yourself don't care for INS, but Their STANDARDS are brought into a court of LAW when an INFUSION issue is in question. Checking for brisk blood is standard of care, and I really have to question why anyone would think it unnecessary. Just because everyone isn't doing it, doesn't mean that the educational deficits aren't in play. There are nurses ALL over the globe, who don't practice appropriately...So, does that mean that we should throw out INS standards of care? Are you a CRNI? I suppose you are going to tell me that it doesn't matter what infusion "experts" say. Well, if one doesn't listen to them, who do you listen too? Someone with a fraction of experience/knowledge? Now, I'm not saying that I, or anyone else can't learn.. We all can, but to consistently refute for the sake of argument, is silly, imo.

[MunoRN, RN]

INS standards, and others, are brought into a court of law as evidence of practice recommendations, not as definitions of a legal standard of care. It is confusing since we call practice recommendations "standards of care", even though they are distinct from a legal standard of practice. Failing to follow a legal standard of practice is grounds for the loss of your license. Following a practice that is not anywhere near that settled, particularly when following facility protocol, is not grounds for loss of license.

As I pointed out earlier, I agree with the need to check for blood return, although I don't agree with some of the recommendations, as their isn't one single standard put forth even from the IV therapy community. For instance, I don't agree with the need to check for blood return on a peripheral IV before any and all infusions and medication administrations, yet this is advocating by some IV experts, and disputed by others. I don't agree that blood return needs to be checked on a PICC before every medication push, it does need to be done routinely although what the frequency recommendation is also varies.

[firstinfamily, RN]

Yes, a blood return should always be obtained before any IV medication is infused as stated in the above posts. I have found that when blood cannot be aspirated often the clave needs changed and that remedies the problem for the most part. We used PICC lines more for ABT infusions and blood draws so you want the line to have a blood return not only for safety and protocol but also for patient convenience.

[iluvivt, BSN, RN]

I agree with IVRUS DO IT! If you are using any CVC you are responsible for doing a complete assessment. One piece of that is checking for a brisk blood return in every lumen.If you are unable to achieve that some kind of nursing action needs to follow. The CVC needs to be assessed. A history of the line should be completed and a review of what could be causing lack of blood return whether it be mechanical, thrombotic or a drug or mineral precipitate. I am happy if nurses check for a blood return at least once a shift and PRN but they must check and document that they received a brisk blood return. Yes... it is just one assessment piece but an important one that leads you to solve a problem or at least address it.

Let's just say you completed your assessment and ruled out a mechanical problem and a drug or mineral precipitate and if you have an IV nurse you can call them in for a consult. You can instill easily but you can consistently withdraw any blood so you have a persistent withdrawal occlusion (PWO). You have made sure you do not have any s/sx of a secondary malposition and you know you had a tip placement of cavoatrial junction and there is no change in the amount externally visible. You just happen to know there was an am blood draw...yes you probably have a partial thrombotic occlusion and you need to treat with some Cath-Flo (Tpa).

Every time I hear that checking for a blood return is not necessary I think of the port case that I read a few years back. A man receiving chemo had a malpostioned port with the tip not even in a vessel. It was accessed and Adriamycin was being given to this man, who had a very curable Cancer. Unfortunately, not ONE nurse checked for a blood return nor was it ever documented. The patient deteriorated and was transferred to an ICU and when the IV nurse came along to perform a routine port needle change she did not get a blood return and stated to investigate . She noticed that the drainage from the chest was suspiciously similar to the Adriamycin...not good! The man died as the tip of the catheter was somewhere in his lung. I can find the article again if anyone is interested

[sistrmoon, BSN, RN]

As an Onc nurse, it is drilled into us to check and document blood return during chemo. That case blows my mind.

[VANurse2010]

I find this discussion interesting, but frankly even if you do get blood return each and every time you really have no idea if the catheter is actually in the SVC or misplaced in the brachiocephalic or azygous or whatever - so it all seems moot.

[IVRUS, BSN, RN]

I find this discussion interesting, but frankly even if you do get blood return each and every time you really have no idea if the catheter is actually in the SVC or misplaced in the brachiocephalic or azygous or whatever - so it all seems moot.

You're right, not getting a brisk, freeflowing blood return may mean that the catheter has migrated, but that is a prime example of an IV catheter in which you must determine the cause, the best that you can. Is it not yielding a return, because it is malpositioned, or is it a precipitate, or is it fibrin/or clot formation? I would obtain an order for Cathflo, then if the catheter gave me my return s/p use, then great, if not, CXR is needed. Again, a catheter which does not yield a freeflowing blood return, is a malfunctioning catheter!