Picc Line Flushing

It depends on your facility. A lot of places are not using heparin anymore because of heparin induced thrombocytopenia. In that case, I believe that PICC lines need to be flushed every 4 hours with NS.

In my facility, we do use heparin, so the lines only need to be flushed with NS first (10ccs), then locked with heparin (3 ccs) every 24 hours and/or after every use, and yes we use at least a 10 cc syringe to flush.

It depends on facility policy and the type of picc.

Most manufacturers recommend that nothing smaller than a 10 cc syringe be used.

Our facility, however, allows 5 cc syringes to be used.

A 3cc or tb syringe definitely is a bad idea.

(the smaller the syringe diameter, the greater the pressure. However, it depends on the diameter of the syringe, not the number of cc's the syringe holds).

My guess is that those who are telling you to use a smaller syringe are doing so because if the line is partially occluded, you can force meds in with a smaller syringe. This is dangerous, since piccs aren't all that strong, and they could rupture. (in a completely open/patent line, you aren't really going to do any harm by using a smaller syringe.)

The safest thing to do is use nothing smaller than a 10 cc syringe. If you need to give a small volume of medicine (say insulin ivp), then add it to a 10 cc syringe that has saline (or whatever is compatible) in it. Ask pharmacy if you are unsure.

Piccs tend to clot off because they are so long -- there are plenty of places where a clot can form. Most facilities require heplock flushing. Two kinds of piccs don't need to be hep-lock flushed: the bard groshong, and the boston scientific pasv.

Some facilities use end-caps with a positive pressure valve that are supposed to negate the need for heplock.

You can also lessen the chances of a line clotting off by making sure you close the slide clamp before you remove the syringe.

Many facilities are trying to get away from using heplock flushes because some people have very bad reactions to even small quantities of heparin. When heplock is routinely used to flush central lines, it can be easy to accidentally use heplock in someone that shouldn't have it.

Fyi, in general, it is a very bad idea to go against what the literature says, or what a manufacturer recommends, even if someone else tells you to do it. If the product fails and you were not following their recommendations, then the manufacturer won't stand behind their product. They will call it "operator error."

Flushing with anything less than a 10cc is syringe is a big no-no. It has to do with the pressure exerted from the syringe - and the smaller diameter syringe you use - the more pressure it exerts. Most PICC's are 4Fr or 5Fr (in adults) - smaller in peds. I have seen PICC's fracture from someone using a 3cc syringe to flush with - so it can, and will happen! So ALWAYS use a 10cc syringe when dealing with PICC's.

As for the use of heparin or not - really depends on the types of PICC's being inserted in your facility - try to find out if the are open ended catheters or closed ended (Groshong style). If they are Groshong style - no heparin is needed. If you use an open ended PICC line - you should flush capped lumens with Heparin (usually 3cc of 1:100 strength) when not in use (check with your facility policy regarding flushing protocols).

Brent.

From bard's website:

Quote

Answer: it is recommended that a 10 cc syringe or larger be used to infuse or flush catheters. This includes pediatric and neonatal catheters. Infusion pressures should never exceed 25 psi because pressures higher than that may damage blood vessels and viscus. A two-pound weight equivalent force on the barrel of a 3 cc syringe generates pressure in excess of 25 psi. The same two-pound weight equivalent force on the barrel of a 10 cc syringe generates less then 8 psi of pressure. Please refer to the instructions for use (ifu) (ifu) for further details.

Most piccs come with the 25psi pressure restrictions.

I believe the power injectable piccs can withstand higher pressure, but all I can find is that the bard power picc can withstand a power injector injecting contrast at 5cc/sec.

From the boston scientific website:

Quote

Do not use the catheter for high-pressure injections, i.e., diagnostic procedures. Ensure that the pressure alarm feature of infusion pumps used on the catheter does not exceed a maximum of 40 psi. (206 cm hg). Do not use small diameter syringes (less than 10 cc) for injection as they can create very high pressures, which may result in catheter rupture.

Where I work, PICCs are flushed Q8 with 10ml NS and we don't use heparin for them. PACs and such are hep-locked, though and we flush with 10ml NS then lock with 5ml heparin.

At the place I worked in Visalia as a student, they still locked PICCs with heparin.

Thanks for the links, Daytonite. Wonderful references...as usual.

I would like to point out that yes, we always use a 10cc syringe to flush our PICC's (per protocol and manufacturer's directions).

However, if you are attempting to draw from a PICC, it can sometimes be difficult, and you may think that your line is clotted. It can be positional and if you're having trouble getting blood return but can get it when your pt put their arm over their head it may in fact be a placement problem from the outset- always get an xray to check placement if this happens!

So, back to getting blood.. you can use a 5cc syringe BUT only to draw OUT of the picc. Not for infusing your flush! The 5cc syringe will exert more pressure on the line and usually will work. The other tip is to remove the end cap and luer lock your NS flush instead of using a blunt tip catheter. That works too. (usually)

Anyway, I just thought I'd throw out those tips I've learned from our IV team. They tend to get tired of us calling them because we believe our lines to be clotted when in fact it is an easy fix.

Yes, tPA might be needed to unclot a line, but it's not a usual occurrence. ?

Yup, i agree. 10 cc pre filled flushes are used, hardly ever see one anymore that requires heparin . Have had the iv company send about 50 heparin flushes on picc's that can't use it, was able to have them come pick it back up, which they were more than happy to do since it never should have been delivered to begin with. Actually can cause harm by bleeding at the catheter tip. If your drawing blood, make sure you flush with 10 cc, pull a waste tube, then when complete flush again and change the cap.

Thank you so much for all your feedback!

Small syringes should not be used for PICC flushing because they generate too much pressure. A 10cc syringe is used for the saline flush. If there is a heparin flush, it follows the saline and is administered with a 5cc syringe. Whether heparin should be used or not depends on the particular brand of PICC that has been used. PICC's that require heparin are out of favor because of the issue of heparin induced thrombocytopenia. See the manufacturer's recommendation printed in the little booklet packaged with the picc, or find the recommendation online. You must conform to your institutional policy AND manufacturer recommendation. For a good discussion of all this, see http://jcleahy.blogspot.com/2010/11/picc-lines-purpose-use-and-care.html

My facility instructs us to flush with 10cc saline and 1cc heparin Q8 hrs. We document on this in our MAR. I always double check my order, as some MDs will order without the heparin based on the Pt's current issues/past medical history. I still flush with 10cc saline before med admin, and 10cc saline/1cc heparin following med admin based on flush orders.