PICC line question

[FDBMath]

Hello everyone,

I am a second semester student and have a question. My med-surf clinical instructor stated that removing a PICC line is a sterile procedure. I questioned (in a nice way) why that is the case. She really couldn't answer. I get why inserting them and site care would be, but I don't get why the d/c would need to be. Everything I have found about it just says it is with no reason given as to why. I have no problem doing it using sterile technique, I just am curious why it needs to be.

Any of you more experienced and educated nurses know why the removal would be sterile?

Thanks!

[neuron]

Basically the answer I got was because it needs to be sterile on insertion and care. I asked if that is the case, why doesn't pulling a foley need to be sterile?

A foley doesn't go into the bloodstream. Sometimes a central line is sutured (IJ central line). It takes precision to remove (via my friend). There is risk for bleeding or air embolism. The line could already be infected and potentiate the patient to sepsis or other complications. It makes sense to not breath on the site (ie wearing a mask) and having the patient wear a mask or turn their head in the opposite direction when the dressing is changed. We learned that in school. When the catheter is removed, you have to hold a sterile dressing over the site, right? In order for it to come out, so that would be a sterile technique. Just my input.

[Nurseinprocess]

Considering that I have had more than one pt actually pull their own picc line out , I would have to agree with you that it does not necessarily need to be a sterile procedure.

[Wuzzie]

We mask, clean the site and use sterile gloves. We have the patient as supine as possible. When I pull the line I do so slowly and coil it around my fingers to keep it from flapping around. We do this because there is a chance, albeit small, that a vessel spasm may cause the line to become, for lack of a better term, stuck. When that happens we re-dress the site with the coiled line under the dressing and wait for about 30 minutes to let the vessel relax. We only use sterile gloves and mask for the purpose of protecting from infection during the time the line is re-dressed. We have gone away from using antibiotic ointment in favor of a dab of plain sterile Vaseline covered by a Tegaderm. Our ID people do not want us using antibiotic ointment because there has been a huge bump in the number of allergic reactions to it. I tried to clarify with a previous poster who spoke of a patient dying from an air embolus from a line being pulled but have not received that clarification so far. There are numerous cases of air emboli related deaths happening with traditional CVCs, Sheaths and Apheresis catheters but to date there is no documented instance, that I could find after an exhaustive search, of it happening with a PICC. Despite this I will continue to proceed with due caution when removing PICCs because I do not want to BE the first documented case!

[iluvivt, BSN, RN]

Of course I know what a PICC line is as I have been placing them and caring for them since 1989.Institutions can choose whatever policies they want but I will always advice the absolute best practice.I had to mention risk for AE as this was a question about removal.Although the risk for AE from PICC removal is extremely extremely small it is still the best idea to consistently remove all tupes of CVADs the same way. Use aseptic technique at the point of removal and use the precautions necessary to prevent AE

[Wuzzie]

Of course I know what a PICC line is as I have been placing them and caring for them since 1989.Institutions can choose whatever policies they want but I will always advice the absolute best practice.I had to mention risk for AE as this was a question about removal.Although the risk for AE from PICC removal is extremely extremely small it is still the best idea to consistently remove all tupes of CVADs the same way. Use aseptic technique at the point of removal and use the precautions necessary to prevent AE

Please read my post again. I wasn't doubting your knowledge one bit but you used the term "percutaneous" when describing the incident of the patient dying after removal. Since all central lines with the exception of SCAPs are percutaneous I was asking for clarification of what type of line was involved with this patient death. It is pertinent because, again, we are discussing PICCs and as far as I can tell there's has been no documented case of an air embolus related to PICC removal. We both know the risk of embolus is significantly higher with other types of lines which, I suspect, was the case in the death you witnessed. I was simply asking for clarification. No need to be offended and start chest thumping. Regardless, had you read the last line of my previous post you would have noticed that we are in agreement about taking all precautions possible to prevent adverse events related to the removal of central lines.

[Kaisu]

Students ask the greatest questions. I love this.

[ffooxx]

Removing a PICC is very much like changing a dressing, you get the same supplies, sterile tray etc and you maintain asepsis just like you would with a dressing change. Why wouldn't this be an aseptic procedure? Its an opening that leads to a major blood vessel in person's body.

[iluvivt, BSN, RN]

Please read my post again. I wasn't doubting your knowledge one bit but you used the term "percutaneous" when describing the incident of the patient dying after removal. Since all central lines with the exception of SCAPs are percutaneous I was asking for clarification of what type of line was involved with this patient death. It is pertinent because, again, we are discussing PICCs and as far as I can tell there's has been no documented case of an air embolus related to PICC removal. We both know the risk of embolus is significantly higher with other types of lines which, I suspect, was the case in the death you witnessed. I was simply asking for clarification. No need to be offended and start chest thumping. Regardless, had you read the last line of my previous post you would have noticed that we are in agreement about taking all precautions possible to prevent adverse events related to the removal of central lines.

I was not upset in any way....just explaining my level of experience so others can feel confident in the information I share.Yes you are correct there are no reported cases of AE upon PICC removal. The CVAD in question was an Internal Jugular that had been in place for 5 days. It was discontinued with the patient sitting up in the chair.I share this because there are nurses who do not know that this can happen and its so easily preventable that no one should suffer from this fate!

[Royalq]

Hmmm. Im a second semester student too! My instructor pulled a PICC line thursday and she didnt do it sterile. She did clean technique. Wash hands, gloves, remove dressing, new gloves, and pulled it out, then applied pressure with gauze.

[dudette10, MSN, RN]

You need to remove tbe dressing with non=sterile gloves then once all dressing material is off you need to complete the remainder of the procedure using aseptic technique.This would entail removing and suture materials or Secureacath devices then with the pt in the correct position you remove the central line and apply a sterile vaseline gauze or sterile ointment to seal the tract then apply some sterile dry gauze then apply an occlusive dressing.The reason this is sterile is that there is a skin to vein tract and this is considered a wound. This skin to vein tract can allow air into the vascular system and create an air embolism that can kill your patient.The vaseline gauze will seal the tract and the sterile dressing will prevent any microorganisms from entering.Anyone who is just using plain gauze is mistaken and I advice you to change your practice immediately and if policies do not state this they need to be changed as an AE is a never event.I have seen a pt die from a nurse who discontinued a percutaneously placed CVAD with the pt sitting up and not sealing ths skin tract.The pt began to seize then coded and died. Unfortunately ,it was not the only one I have seen.

This is what I don't understand about your explanation. How do you keep sterile when removing the catheter? Once I touch the part of the PICC that is not sterile (essentially everything not under the dressing), I'm instantly "dirty." If I begin to pull that section which WAS under the dressing, isn't that not sterile? If it was sterile, why do I have to re-sterilize an area considered sterile when I change a dressing?

[dudette10, MSN, RN]

When I pull the line I do so slowly and coil it around my fingers to keep it from flapping around. We do this because there is a chance, albeit small, that a vessel spasm may cause the line to become, for lack of a better term, stuck. When that happens we re-dress the site with the coiled line under the dressing and wait for about 30 minutes to let the vessel relax. We only use sterile gloves and mask for the purpose of protecting from infection during the time the line is re-dressed.

When you coil the line under the dressing, do you put the entire line underneath the new dressing or only the part that was originally under the dressing and inside the patient?

If you put the whole line under the dressing--unless you are able to sterilize the entire line AND the hub--you've essentially put bacteria under an occlusive dressing.

[MunoRN, RN]

We mask, clean the site and use sterile gloves. We have the patient as supine as possible. When I pull the line I do so slowly and coil it around my fingers to keep it from flapping around. We do this because there is a chance, albeit small, that a vessel spasm may cause the line to become, for lack of a better term, stuck. When that happens we re-dress the site with the coiled line under the dressing and wait for about 30 minutes to let the vessel relax. We only use sterile gloves and mask for the purpose of protecting from infection during the time the line is re-dressed. We have gone away from using antibiotic ointment in favor of a dab of plain sterile Vaseline covered by a Tegaderm. Our ID people do not want us using antibiotic ointment because there has been a huge bump in the number of allergic reactions to it. I tried to clarify with a previous poster who spoke of a patient dying from an air embolus from a line being pulled but have not received that clarification so far. There are numerous cases of air emboli related deaths happening with traditional CVCs, Sheaths and Apheresis catheters but to date there is no documented instance, that I could find after an exhaustive search, of it happening with a PICC. Despite this I will continue to proceed with due caution when removing PICCs because I do not want to BE the first documented case!

I would avoid using petrolatum directly on or in the puncture site, this presents the potential for the petrolatum to enter the vessel, and there has been at least one documented case of death due to petrolatum emboli that entered through a CVC tract. What's safer, and more effective, is to use a gauze either pre-impregnated with petrolatum or to add the petrolatum to gauze and make sure you work it in.

The benefit of using air embolism precautions when removing a PICC isn't established either through evidence or even just theory, once the line is removed it's no different than a peripheral site. I would say it doesn't hurt, so why not, but there is certainly an aspiration risk that is not really outweighed by any potential benefit.