Picc Line Flushing

deeDawntee, RN · Aug 9, 2007

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.

CritterLover, BSN, RN · Aug 9, 2007

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."

brent_25, RN · Aug 9, 2007

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.

CritterLover, BSN, RN · Aug 9, 2007

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.

nursekatie22, RN · Aug 9, 2007

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.

Daytonite, BSN, RN · Aug 12, 2007

Arms. . .I inserted picc lines as an iv therapist. Two weeks ago I had a picc line inserted to have chemotherapy. It has a groshong tip. With a groshong tip, you must place positive or negative pressure on the line for any fluid to enter or exit the lumen of the catheter. This is a safety feature of the groshong tip. Groshong tips are being put on many types of catheters these days because of this safety feature. When there is no activity on the line, the catheter stays completely closed up. Hence, there is no need for any heparin to be used to keep the catheter primed; normal saline will suffice. If the picc catheter does not have a groshong tip then heparin needs to dwell in the catheter when it is not in use. One of the most obvious values of this is that it prevents accidental air embolism, a potentially fatal event, from happening if the distal end of the catheter should somehow fall off.

10cc syringes are the smallest syringes that should be used to flush them. Any smaller sized syringe creates a pressure turbulence in the catheter during flushing that could cause the catheter to rupture if enough force is exerted upon it. The only time we used tb syringes on these picc lines was when we were using de-clotting agents since the amounts we had to draw up were so small.

I am downloading and attaching the picc line instructions I was given when my picc line was inserted two weeks ago. As it turned out I was hospitalized two days later. I took a copy of this paper with me and it was hung over my bed. Still, not all the nurses read it or followed the instructions. My oncologist wants the line flushed daily with 10cc of saline. The home health nurses are saying "in his dreams!" their protocol is to change the dressing once a week and flush them twice a week if they have groshong tips. In the hospital, when one of my antibiotics was completed, the nurses often just disconnected the iv line--period. No flushing was needed because with the iv pump stopped, the groshong tip automatically closed and blood clotting in the picc lumen was never an issue. Thank you to the inventors who came up with this invention. They deserve every penny of the royalties they are collecting on the patent.

http://www.nursingcenter.com/prodev/ce_article.asp?tid=535139 -- this is an excellent nursing article on picc lines and their care.
http://www.thebody.com/content/art1786.html - facts about iv catheter lines

suzy253, RN · Aug 12, 2007

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

GeminiTwinRN, BSN · Aug 17, 2007

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. ?

steelcityrn, RN · Aug 17, 2007

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.

arms · Oct 19, 2007

Thank you so much for all your feedback!

jcleahy · Dec 8, 2010

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