PICC Ports that won't Flush

[*4!#6]

I am looking for suggestions on what to do when a PICC port won't flush. I am paranoid about dislodging a clot or breaking the catheter, causing an embolus. What do you do when you attempt to flush with saline and the port just doesn't flush?

Do you apply pressure and try to force the flush? Do you use heparin? Do you use alteplase? Call vascular access? What is your opinion

[beckster_01, BSN, RN]

I have the patient move their head/neck/arm in case the line is positional. If that doesn't work than I ask for an alteplase order, per hospital policy.

[blondy2061h, MSN, RN]

We have a standing order for tPA 2mg/2ml for PICCs/CVLs that won't flush. You kind of push it gently to instill it, then push more in a few minutes, and work it in like so. We leave it in for 30 minutes then aspirate it back. Sounds like you might be talking about a home care setting though.

[rn undisclosed name]

The dwell time can actually be extended up to 2 hours and then it can be repeated once. Once you get a blood return you want to make sure you withdraw enough to make sure the TPA does not go into their circulation. I also recently read you can do sodium bicarb for some clots (medication related), however, I have not yet done that.

[Good Morning, Gil]

PICC ports don't flush because people aren't flushing them regularly or they are not flushing adequately after drawing blood from them. (though I can understand why this happens from time to time when people get extremely busy, but I always flush ports that do not have fluids running through them when I do my assessment, if possible (nothing critical going on)). However, there are times when the line is just positional as a PP said. Turn their head to the opposite side of the PICC, and try raising their arm, as well. Our hospital has the same policy as the above PP, but refer to your policy where you work. There really shouldn't be a need for activase if the ports are being flushed regularly.

[KelRN215, BSN, RN]

Do as everyone else said... try moving their arm, turning their head, etc. to see if it's positional. We sometimes would take the cap off and try to flush a little heparin into it that way, then change the cap and recheck in an hour or so if it could be flushed with saline. If it truly wouldn't flush and needed tPA- it was hospital policy that the IV team had to instill it.

[classicdame, MSN, EdD]

Replace cap with a new one. Sometimes a clot forms in the cap because a nurse did not flush and clamp with positive pressure. Ask your dept mgr to get a copy of the Infusion Nurse Society standards. Very helpful. Welcome to INS1 - Infusion Nurses Society

[IVRUS, BSN, RN]

First try gentle aspiration.... gently aspirate, then try to flush, gently aspirate and then try to flush... 9 times out of 10, I'll pull back a small fibrin strand and then I can discard that syringe and have another syringe with 5 cc NSS and flush through... IF gently aspiration does NOT work, then get an order for Cathflo, 2mg/2ml to declot.

I usually ask for a MD's order f, to include the drug and "may repeat x1"

99.9 % of the time, I get it open by direct connection and aspiration.

[turnforthenurse, MSN, NP]

Good suggestions from PP's. Never force flush, though!

[AMN74]

first try gentle aspiration.... gently aspirate, then try to flush, gently aspirate and then try to flush... 9 times out of 10, i'll pull back a small fibrin strand and then i can discard that syringe and have another syringe with 5 cc nss and flush through... if gently aspiration does not work, then get an order for cathflo, 2mg/2ml to declot.

i usually ask for a md's order f, to include the drug and "may repeat x1"

99.9 % of the time, i get it open by direct connection and aspiration.

i was going to say that i have my patient in every position possible, straightening the arm, moving the arm up, down, anything to try to gentle aspirate, i have them sit, stand, lay and move the arm and try gentle aspiration, i straighten out the catheter. if nothing works our home health agency uses cathflo 2mg/ml. we insert the cathflo, wait 2 hours, and then aspirate the cathflo (5-10 cc blood) works well. i was told by the cathflo representative that came in and gave a presentation a few years ago that even if the cathflo is pushed in and not aspirated, it's not that dangerous. she said it was like taking 2 325mg aspirins. i have only had one patient that i could get nothing to work on, and i had to send her to the er to have the picc replaced as they could not get it to work either.

[Scarlette Wings]

My comment would be that if you are uncomfortable working with lines ask for some training and attend any courses available. Read the Infusion nurses site, I believe that they have a magazine as well. Offer to observe when the lines are put in or work in whatever area that does line insertions. Shadow some ICU/IV team nurses or PICC nurses and realize with experience and education it will become easier.

I always worried when nurses act like they know it all and would just go do whatever to a line because they heard it worked and did not understand the rational or the potential for complications. I know of a nurse who discontinued a triple lumen subclavian line while the patient was sitting up in the wheelchair to leave and since the nurse thought it was "not that hard to do" they discontinued it and pulled it like it was a peripheral IV and just didn't realize the danger.

That patient made it down to the first floor in that wheelchair leaving when they had an air embolus and literally went unresponsive with chest pain and shortness of breath and they did a rapid response alert. Needless to say the Pt was re-admitted on our dime but thank heavens they did not die. Never be afraid to ask and learn, it is the nurse who is too sure of themself to ask for practice or information that kills people.