Picc Line Question

[sophtheorn]

I'm a recent new grad and I am kind of confused about picc lines. If you have a double lumen picc line does it matter which side you use for blood draws/infusions or are they the same?

Also, are you supposed to take the cap off to draw blood or do you just attach the vaccutainer (sp?) right to the cap?

Thanks!

[blondy2061h, MSN, RN]

Iatrogenic anemia is actually one of the main causes of hospital associated mortality. The even bigger issue is that it's not your blood to waste, someone else's own blood deserves some respect.

If patients are dying from losing the extra 5ml with blood draws, you need to be checking CBCs more often and transfusing.

[MunoRN, RN]

If patients are dying from losing the extra 5ml with blood draws, you need to be checking CBCs more often and transfusing.

I think that's what's called a viscous cycle. Addressing the problem of lab draw related anemia and the resulting transfusion risks by drawing more blood and giving more transfusions would seem counterproductive.

The complications associated with iatrogenic blood loss (blood loss caused by us, not by an illness or injury) are due to both anemia and transfusion related complications. Two studies found that lab draws were responsible for 30-50% of transfusions in ICU patients.

The extra 5cc certainly isn't solely responsible for the problems related to iatrogenic anemia, but it does significantly increase the blood loss since the waste often accounts for more of the loss than the draw itself.

When drawing a coag from a line that has been heparin locked, 10cc is appropriate, otherwise there is no evidence to support a 10cc waste and quite a bit that supports 2-3 times the lumen volume. There are still some policies out there are are outdated (by about a decade) which shouldn't be a huge problem since part of Nursing's professional responsibility is to advocate that the policies they follow reflect current standards and knowledge.

[blondy2061h, MSN, RN]

This is one of the problems nurses face. If evidence supports one thing and policy contradicts that, you're still putting yourself at risk if you violate policy and especially if policy is just excessive without being explicitly dangerous. And yes, thanks, I know what iatrogenic means.

[Irish RN]

At my facility we scrub the hub, flush with 10 mL NS, waste 10 mL blood, draw 10 mL blood (usually), flush with 20 mL NS, and then change the cap. No sterile technique. I only scrub the hub initially, not in between each step because the cap is never exposed. I leave the syringe attached until I have the next one right there.

[betterlatethennever]

I agree with munoRN. 10mls of waste for each lab draw is too much. Picc lines are in the SVC and the blood flow is extremely fast.

[limaRN, BSN, RN]

I'm almost a new grad and the facility that I am doing clinical at uses a 3 way stop cock. Flush the line with NS 'waste' the blood, take your blood sample, push the 'wasted' blood back into person, then flush again. This way no blood is actually wasted, is a 3 way stop cock not what most hospitals supply?[/quote']

I was also taught to return the "wasted" blood back to the patient.

[IVRUS, BSN, RN]

As Lima RN stated, I too advocate for the "mixing" method. This method works great as long as the syringe that you are using DOES NOT become detached at any time while the method is underway. That means: Hook on a 5 cc empty syringe and then withdraw 5 cc of blood, then keeping the syringe attached, reinfuse, withdraw again, and do it for four times. Then the fifth time is my specimen and that specimen goes into my blood tube. This works well to prevent unneccessary waste and iatrogenic anemia. Also remember that the larger syringes (10cc) should NOT be used for withdraw as they generate too much NEGATIVE pressure.

Now, if the nurse removes the waste syringe, he or she should NEVER reinfuse it.

And to answer the original post as to which lumen is to be used, that sometimes depends on facility P&P. In addition, the catheter manufacturer may have information in their IFU's. Take for instance the ARROW triple lumen, some feel that the brown port should be used for blood withdraw/collection as it is a 16 gauge versus the white and the blue may be 18 gauges. Given that the 16 gauge is a bigger lumen, some designate it for blood drawing. Others advocate that one should always draw from the proximal lumen of the IV catheter so as NOT to ever mix with anything that has been infusing above it. (Though infusions should stop for one minute prior to your draw)

Hope this helps.

[RNsRWe, ASN, RN]

This thread made me remember something I was curious about, but am "out of the loop":

I know someone who was d/c'd from hospital with a double-lumen PICC. Hospice nurse comes once per week to change the dressing. I've never been there when this was done, but I can see the date changed on the outside of the dsg.

So my question: Shouldn't the nurse be flushing the lumens with NS to make sure the lines remain patent? Family recalls each dsg chg but doesn't recall any syringes being used. Also wondering if caps are routinely changed each week at home....or not?

HHA nurses, hospice nurses, can you give me a clue?

[IVRUS, BSN, RN]

I know someone who was d/c'd from hospital with a double-lumen PICC. Hospice nurse comes once per week to change the dressing. I've never been there when this was done, but I can see the date changed on the outside of the dsg.

So my question: Shouldn't the nurse be flushing the lumens with NS to make sure the lines remain patent? Family recalls each dsg chg but doesn't recall any syringes being used. Also wondering if caps are routinely changed each week at home....or not?

If the family is giving the IVF or IVAB at intervals throughout the day, the only reason I would want the Hospice nurse to flush it, would be to ensure that it has a brisk blood return. Also, Injections caps are usually changed weekly WHEN the dressing change is performed. Not changing the caps leads to increased infection probabilities.

[horrorxgirl]

The ICU that I have been doing my mentorship in uses vamps on their central lines so no blood is actually wasted.

[RNsRWe, ASN, RN]

If the family is giving the IVF or IVAB at intervals throughout the day, the only reason I would want the Hospice nurse to flush it, would be to ensure that it has a brisk blood return. Also, Injections caps are usually changed weekly WHEN the dressing change is performed. Not changing the caps leads to increased infection probabilities.

No meds are currently being given through PICC. It was just left in place to make it easier for EOL comfort meds/fluids, if indicated later. Which is why I was wondering this, about the flush. Sorry, I didn't make that clear! I wonder how long an "unused" PICC remains....well....."good". I'm never there when it's being changed, but I think I'll ask some questions next time I visit....I don't want to see this poor soul end up with a clogged PICC when he really needs it to work, y'know? Or an infection from unchanged caps...?

Thanks for your info, it's appreciated :)

[KelRN215, BSN, RN]

No meds are currently being given through PICC. It was just left in place to make it easier for EOL comfort meds/fluids, if indicated later. Which is why I was wondering this, about the flush. Sorry, I didn't make that clear! I wonder how long an "unused" PICC remains....well....."good". I'm never there when it's being changed, but I think I'll ask some questions next time I visit....I don't want to see this poor soul end up with a clogged PICC when he really needs it to work, y'know? Or an infection from unchanged caps...?

Thanks for your info, it's appreciated :)

For my patients who are home with PICC lines, the family (or the patient if they are able to) is instructed to flush it q8 or q12 depending on the protocol of the hospital where they came from. I've never heard of putting a PICC in just in case it might be needed later- too much of a risk of infection to have an unnecessary line sitting in someone.

Presumably the nurse IS flushing the line when she's changing the caps- I've never not flushed a line during a cap change. I know there are some parts of the world where the standard of care is to flush a central line once/week when the patient is home. I am not sure if they flush with higher concentration heparin when it's flushed that infrequently.