PICC line reflux and occlusions

iluvivt, BSN, RN · Jul 2, 2011

I will speak in general terms so I am not giving medical advice...as an RN when you are working with this type of line these are some things to consider.

1. If you are using a positive displacement LAD (leur activated device)or cap you do not need to perform positive end pressure flushing b/c as you disconnect the syringe from the cap..that type of cap performs that function for you...when you are using any open ended non-valved PICC with a clamp on the tails with a positive displacement LAD..then the proper way to do it...is to flush...disconnect your last flush syringe...then clamp...if you clamp and disconnect you have then bypassed the the positive displacement feature of the LAD. In the case of a SOLO..and make sure it is a SOLO....you just flush..then disconnect...you can perform a pulsatile flush if you like but there is no evidence to prove this has any benefit with decreasing thrombotic occlusions....many IV experts now say perform a smooth and steady flush. There are 2 slit valves near the hub end of the SOLO on the tails..there is a chance with the extra positve pressure flushing one could in theory be keeping one of the vavles open,,thus causing reflux .

2 Now ....I know the SOLO is marketed as a "can use saline only flush" as most valved CVCs are BUT an anticoagulant as final flush (heparin being the most common) does definately decrease thrombotic occlusions. heparin concentration may need to be increased to 100 units per ml..3-5 ml or the use of another anticoagulant lock can be used

3. Pts that increased chest or abd pressure ( ie.vomiting and coughing and intubated pts) have a higher rate of occlusion and malposition.

4. The tip location needs to be viewed on the CXR...if the tip is up against the wall...seen often from the left side..remedial action needs to be taken b/c blood can reflux into the distal tip a bit easier not to mention any IV meds can irritate the wall of that section of the vein

5 too forceful or improper Tpa administration can damage the delicate valves....was it done correctly...Tpa should never be forced into a catheter of any kind..there are very specific techniques to administer tpa for total thrombotic occlusions

Increase flush volume to at least 10 ml NS and double it if you see blood in the line ..make sure the pt is not sleeping in such a way as to put pressure on the line..remember let the PD LAD do the work of the positive displacement....many occlusions happen after a blood draw due to inproper and inadequate flushing procedures..make sure you are changing the LADs/caps/valves no more frequently than every 72 hrs but no longer than 7 days..there is a lot of literature on the technology of catheter flushing out there.....will post more as I think about it...

IVRUS, BSN, RN · Jul 2, 2011

Hi, I'm new to this site and I hope that I'm posting this question in the right place.
I'm an RN and I'm having a difficult time caring for my own PICC line. It is a double lumen Bard Power PICC Solo. I use MaxPlus positive displacement caps. The problem is, I have frequent spontaneous blood reflux that fills my lines. This has caused several occlusions (requiring expensive cathflo treatments) and I've only had the PICC in for about 4months. I am on twice daily antibiotics and IVIG. I have poor venous access so I need this PICC line.
Do you all have any suggestions? Is there anything I can do to prevent the blood refluxing? It happens multiple times daily. I am careful to use the positive pressure flushing technique. The PICC line nurses at my hospital have not been able to figure out what is causing this problem. They say it shouldn't happen. I had another Power PICC with the same problem that was pulled and replaced for this reason, constant blood reflux and frequent occlusions.
I would greatly appreciate any advice.

I Totally Agree with ILUVIVT :yeah: ... In practice, if I get called because of an occluded line, 99% of the time it is a Solo Power PICC. Thanks ILUVIVT for your post.

iluvivt, BSN, RN · Jul 3, 2011

A problem with blood reflux could

Also indicate catheter fracture,as in a hole somewhere in the catheter.i see most often in silicone catheters esp after tpa has been given.

alzrn · Jul 3, 2011

Thank you iluvit and IVRUS. My experience has primarily been in peds med surg and ortho outpatient nursing. I have not had the opportunity to work with many PICCs until now!

You've given me some good tips to consider. I had been taught to always use the push pause flush method to clear the line and the positive pressure flush technique while disconnecting. I never thought that this might negate the effect of the positive displacement cap. I will have to be mindful of this.

I will also have to watch rest and sleep positions to make sure that the line is not being compressed. I can see how that would cause reflux. Have you ever had a patient with reflux while sitting or resting in semi-fowler's position? Do you know what would cause that (assuming patient is not actively vomiting or coughing)?

When do you decide a chest x-ray is needed to confirm tip location? Only for suspected malposition or in the case of frequent occlusions also? Do you view the x-ray yourself or trust the radiologist's opinion that the tip is in proper position. It is quite disconcerting to think of the tip resting against the vein wall, especially when vessicant meds are being used.

How would you assess for catheter fracture beyond what is visible externally? Wouldn't there be leaking at the insertion site or any other clues?

iluvivt, BSN, RN · Jul 3, 2011

Well you ask some really good questions. Yes the idea of a push pause technique or pulsatile flush came about in the 90's and many are still performing a flush this way. There are several ways to classify a cap or LAD but for this discussion we will just say they can be negative,neutral or positive displacement. The RN absolutely needs to know what kind of LAD is on their CVC so they flush it properly. There has been a lot of controversy about the positive displacement valves causing an increased infection risk in the literature so many have switched to the neutral caps. As far as catheter fracture goes there can be many symptoms...the patient may complain or report a feeling of pain or a cool sensation or an aching sensation at the location of the hole. If you have a pt that is getting Vancomycin through a PICC and during infusion they complain of pain at a very specific place in their arm along the course of the PICC suspect a fracture. If the fracture is close to the catheter skin junction you will often get backtracking or leaking at the insertion site. I ALWAYS must know the history of the catheter...how long has it been in place.....where is the tip....has it had Tpa recently...has there been recent problems of any kind....has the patient had excessive physical activity...any crutch use.

You do not want the catheter pinched or occluded in any way b/c that can create a pressure change and cause reflux. Most of the problems I have seen with catheters being butted up against the wall of the upper SVC have been with left sided approach catheters ,especially when the MD did not quite measure accurately and barely made it into the SVC at all. So yes you want good hemodilution but you also want the catheter floating freely.

Ever good PICC nurse I know views the film after they place the line and if we disagree with he radiologist we certainly will have a discussion about it. You can trust your CXR read. The most important thing you can do to maintain a good tip position is to not pull out the catheter at ALL during dressing changes b/c every complication increases the farther away that tip gets away from the low SVC/cavo-atrial junction.

When BARD first put out the SOLO there were some complaints about the valves so they changed the pressure sensitivity so now it is the SOLO 2. I do find the SOLO 2 much better than the original SOLO.

There is no current recommendation about the frequency of CXRs after the initial line placement verification. So yes if there are any s/sx of malposition a CXR needs to be done. If there is a significant change in the amt externally visible on a CVC,especially a PICC a CXR needs to be done. A nurse also needs to know the original tip location and the amt externally visible. If a patient comes into a health care facility the RN must verify tip placement before using any line. This can be done be verify the it by medical records but what usually happens is that a CXR is ordered. A blood return alone does not guarantee that the CVC is safe to use,

alzrn · Jul 3, 2011

What does it mean when you get good brisk blood return but meet resistance or have a sluggish flush? Cathflo was recommended to restore function and it did so with one dose. Unfortunately the line remained patent only 1wk before the problem reoccured.

Do you have patients where you've had to use Cathflo frequently?

iluvivt, BSN, RN · Jul 4, 2011

Usually I see the reverse in that you can easily instill but not withdraw due to a fibrin sleeve or tail.. it was a good decision to instill the Tpa if the flush was sluggish. Yes ,we often have to instill Tpa many times BUT I can usually relate this a very recent blood draw or inadequate flushing techniques. My home care patients have a significantly low rate of thrombotic occlusion compared to my hospitalized patients. There are many more RNs touching the line with different and often poor habits and sometimes more frequent use. You will also get better results if you leave the Tpa in the PICC for at least 2 hours.

MunoRN, RN · Jul 5, 2011

You do need to use the "push-pause" technique with SOLO PICCs due to the valve. When we first started using the SOLO's, our quick reference guides posted on the floors did not include Bard's recommendation to use a push-pause technique. After adding that a push-pause flush needed to be done, the rate of line occlusions with the SOLO's dropped off substantially, although it still remained higher than non-SOLO PICC's. Heparin flushing and locking is optional with the SOLO PICC, we use a 10 unit/ml flush on our SOLO's except for lumen's dedicated to blood sampling that includes coags.

iluvivt, BSN, RN · Jul 7, 2011

You may not be interested in this much detail but INS does not recommend a pulsatile or push pause flush on any CVCs. There simply is no science to support the recommendation. The oval design of the SOLO hub will create a swirling effect from the flush EVEN with a gentle forward flush. I know that BARD recommends either a neutral or positive displacement LAD with the SOLO. and I have seen that some of the BARD reps have stated that the use of the pulsatile flush may enhance the function of the SOLO valve BUT still no science and NO current standard to do so. Of interest is that there is some evidence that may promote bioflim to adhere more easily to catheter surfaces. Again,the solution is to flush frequently,with the appropriate flush and if a patient is having problems you can tailor the care. So if frequent occlusions...... try a q 8 hr flush..use heparin as a final flush if you or not and if you are using heparin consider increasing the strength.

alzrn · Jul 7, 2011

Thank you, I really do appreciate all your advice.

I stopped using the positive pressure flush technique to allow the positive displacement LADs to work properly. I've also been using a smooth steady flush instead of the push-pause method. Unfortunately I am still seeing blood reflux problems.

The reflux occurs while resting and sitting upright. I've watched it happen as I'm typing here at my computer. It is almost unbelievable to see. The blood flows right up to the SOLO valves but does not go past the valve. When I see this happen I always flush with 20cc NS and finish with 3cc 100u heparin.

What do you think is causing this? I don't think the PICC is damaged. I observed this for the first time on the day that the PICC was placed, before I even used it. I shouldn't have been malpositioned then either.

If I could stop the reflux I might be able to prevent the occlusions...

MunoRN, RN · Jul 7, 2011

You may not be interested in this much detail but INS does not recommend a pulsatile or push pause flush on any CVCs. There simply is no science to support the recommendation. The oval design of the SOLO hub will create a swirling effect from the flush EVEN with a gentle forward flush. I know that BARD recommends either a neutral or positive displacement LAD with the SOLO. and I have seen that some of the BARD reps have stated that the use of the pulsatile flush may enhance the function of the SOLO valve BUT still no science and NO current standard to do so. Of interest is that there is some evidence that may promote bioflim to adhere more easily to catheter surfaces. Again,the solution is to flush frequently,with the appropriate flush and if a patient is having problems you can tailor the care. So if frequent occlusions...... try a q 8 hr flush..use heparin as a final flush if you or not and if you are using heparin consider increasing the strength.

The recommendation for a pulse flush is actually from the manufacturers instructions for use, not just something that the reps are suggesting on their own. In general, it's probably best to follow the manufacturers instructions unless you have a good basis for not doing so. What evidence are you referring to that shows this may increase biofilm adhesion?