PICC removal

IVRUS, BSN, RN · Jul 29, 2011

OK. My since having just had a Hickman removed (yes, I know they're different since the Hickman is tunneled, but the tract is more significant with a Hickman- the PICC goes directly into the vein- or has a minimal tract to get through the SQ tissue, fat, and muscle- at least 3-4 I had...don't know of any tunneled PICCs) , with a very defined tract to my right ext jugular....and the cuff of tissue having to be cut out to remove the catheter. The surgeon told me that the tract would collapse very quickly, and be permanently 'shut' within minutes, as long as I didn't strain w/lifting-. Also said that the opening to the jugular would self seal- they didn't have to put a tourniquet around my neck . He stuck 2x2s and Tegaderm, and told me to leave it alone for at least 48 hours- then it was a done deal. He cut the edges of the entry site (essentially a stoma at that point) to approximate them. His concern was bleeding (I'm on Pradaxa for PEs) and asked me to please not bleed enough to have to go to the ED that night .
If the jugular (and tract) were at risk for AE, it makes sense that there would be some oozing if the vessel was open enough to allow for an AE...
With a PICC, the entry site is right at the skin. The nurses taking my PICCs out have always been more concerned about holding pressure- and thus sealing the site- than with any glop application :) The biggest rationale I've heard for not applying anything gooey is that it's another way to introduce bacteria--- yes, it should be kept from any bacteria from the dressing and antibiotic properties of the ointment of choice, but the skin around the area isn't sterile...and aren't antibiotic ointments bacteriostatic, not bacteriocidal- colonization can turn to infection????
JMHO

The application of gel, is not to prevent infection, but rather as a seal over the tract made with the catheter's removal. Has the "gel or ointment" just come out of a tube or a jar in your patient's room? No, I can't imagine that it did. Usually an individual packet of gel is ideal, but if it is a tube which you just purchased because you're in home care, that will work too.

And yes, the track usually closes, but what about the time the MD is in a hurry and just removes it, and "slaps" a 4x4 and tape over it... R U at risk? YES. That's why there are standards for pt care.

xtxrn, ASN, RN · Jul 29, 2011

The application of gel, is not to prevent infection, but rather as a seal over the tract made with the catheter's removal. Has the "gel or ointment" just come out of a tube or a jar in your patient's room? No, I can't imagine that it did. Usually an individual packet of gel is ideal, but if it is a tube which you just purchased because you're in home care, that will work too.
And yes, the track usually closes, but what about the time the MD is in a hurry and just removes it, and "slaps" a 4x4 and tape over it... R U at risk? YES. That's why there are standards for pt care.

OK. :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3:

Dead horse is now drawing flies, and maggots are eating its flesh.....

Is there a problem with different people having different experiences? Or is it more important to be right? We're not all living the same thing, in nursing or personally :)

Even if the ointment is not to prevent infection, the minute it hits the skin, it's contaminated and kissing up to impaired skin integrity. Even if it comes from a sterile container.

Are all of the healthcare facilities in the US being negligent if they don't do what your employer endorses??? You guys (and the INS-- the beloved and omniscient INS) are the only ones who can absolutely do the best job? Even with no AEs on record to prove/disprove this? What about the people who didn't get some seal who are just fine? They don't count either ???

It's not a competition. :) If it will make you feel better, I'll chew up a wad of gum and slap that puppy on my Hickman site

Passion is a good thing- preaching- not so much :)

BabyLady, BSN, RN · Jul 29, 2011

nurses are spoiling the doc too much. everything is on the nurse yet the doc is the one who is making tons of money. i offered him the measuring tape and he told me he did not want to measure it and i'm expected to collect the catheter and measure and chart it? it's like some of the nurses at work who chase down the cnas to tell them a patient wants something when it could have taken half the time if that nurse just did that something for the patient.

you don't have to over-analyze it and you are not responsible for supervising the physician in any way.

this is what i would chart: picc removed by dr. jones.

then chart how the site was dressed. i might write a couple of words if the site appeared to be red, the amount of bleeding, etc, but since you did not remove the picc, you are not responsible for how it was removed any more than you would be responsible if you were an or nurse of how a surgery was performed.

dr. jones is responsible for charting his own procedures, not you.

MunoRN, RN · Jul 30, 2011

Wow, "poorly substantiated practice recommendations".. Hmm.. You must think that INS has a bunch of uneducated "boobs" working and writing the standards. Sad. But you are wrong.
The INS standards represent the scope of practice and offer evidence based criteria essential to the delivery of safe and competent care.
Practice recommendations and standards of care are different, truly, but remember standards which read in part that the nurse "shall" carries a greater weight (Remember the 10 commandments?) than saying a nurse should do something. In a court of law, did the nurse comply with the standards, or didn't she/he? Without exception, these are the standards by which nurses are held to.
Though reported cases of AE s/p PICC removal may not be published, that only doesn't mean it Hasn't happened, or couldn't happen. Remember that if a catheter's been dwelling for a long period of time, a fibrin sheath can become well defined. There is a documentated case of a CVC being removed and then 30 minutes later the man went out to smoke, with his first drag, deep inhalation of cigarette smoke, he also "sucked" in an air embolus which extended from the insertion site of the now removed PICC , to his lungs all along a strong fibrin sheath.
A TSM is NOT sufficient in and of itself to seal the site and prevent an air embolism. You need a complete seal around the site, which is why a gel, and a TSM is needed.
But, hey Muno, thanks for the lively discussion and WE can agree to disagree.

Evidence based Practice Recommendations supported by no evidence would have a level of evidential support fairly described as "poor".

That case of the smoker wasn't a PICC.

Why is it you don't believe a TSM seals 360 degrees around the site?

I'm still not clear if you're suggesting that Nurses should go against their facility's policies?

IVRUS, BSN, RN · Jul 30, 2011

Evidence based Practice Recommendations supported by no evidence would have a level of evidential support fairly described as "poor".
That case of the smoker wasn't a PICC.
Why is it you don't believe a TSM seals 360 degrees around the site?
I'm still not clear if you're suggesting that Nurses should go against their facility's policies?

I am advocating that a nurse, knowing what is appropriate and in the best interest of their pt, advocate for best practice to produce optimal patient outcomes. I've gone to my education liason in a hospital setting and showed them standards, and got P&P changed. We all need to be pt. advocates.

And, I never said the smoker incident was from a PICC... I said CVC only.

Are you a Certified RN in infusion therapy?

casi, ASN, RN · Jul 30, 2011

What are you measuring for when you pull a PICC and what are you comparing it to. When patients come to the TCU I work we very very rarely have records of PICC insertion so we really don't know how much was inserted into the body to compare it too. I chart "PICC d/ced at 2100, tip appears intact."

IVRUS can you post some links and resources to your information. I have never heard of applying vaseline to a PICC site. Is this a new standard as it seems a lot of nurses here haven't heard of it before? Thanks in advance for your knowledge.

xtxrn, ASN, RN · Jul 30, 2011

Should I test the Hickman site??? Maybe go submerge in the tub and see if I cause bubbles ?????

agldragonRN · Jul 30, 2011

you don't have to over-analyze it and you are not responsible for supervising the physician in any way.
this is what i would chart: picc removed by dr. jones.
then chart how the site was dressed. i might write a couple of words if the site appeared to be red, the amount of bleeding, etc, but since you did not remove the picc, you are not responsible for how it was removed any more than you would be responsible if you were an or nurse of how a surgery was performed.
dr. jones is responsible for charting his own procedures, not you.

thank you so much! :up: :up: :up: i did not want to argue with my supervisor as he pulled the "for patient's safety" card but it is not in my job description to supervise the physician. yes i am an advocate for my patient but in this case i will not tell the doc to measure the catheter especially he told me already he would not be measuring it. yup i charted similar to what you wrote.

agldragonRN · Jul 30, 2011

what are you measuring for when you pull a picc and what are you comparing it to. when patients come to the tcu i work we very very rarely have records of picc insertion so we really don't know how much was inserted into the body to compare it too. i chart "picc d/ced at 2100, tip appears intact."
ivrus can you post some links and resources to your information. i have never heard of applying vaseline to a picc site. is this a new standard as it seems a lot of nurses here haven't heard of it before? thanks in advance for your knowledge.

you are measuring the length of the catheter when the picc is pulled and compared it to the original length. we have a record of the xray of the picc with measurements in centimeters. this record is from the hospital and i always look for this when i do new admission/readmissions (assuming the patient has a picc). i have a couple times called the hospital after the patient arrived and this info is missing and asked hospital to fax it to me.

we are not supposed to use the picc without this information. however, if the hospital cannot fax it to me for some reasons, i will get a t.o. from the md to use the picc without this information.

MunoRN, RN · Jul 30, 2011

I am advocating that a nurse, knowing what is appropriate and in the best interest of their pt, advocate for best practice to produce optimal patient outcomes. I've gone to my education liason in a hospital setting and showed them standards, and got P&P changed. We all need to be pt. advocates.
And, I never said the smoker incident was from a PICC... I said CVC only.
Are you a Certified RN in infusion therapy?

What your evidence that this produces better outcomes?

You seemed to say it was a PICC when you said "he also "sucked" in an air embolus which extended from the insertion site of the now removed PICC"

I am not certified in Infusion therapy, I just prefer solid rationale and evidence to "because I told you so" reasoning.

I looked up the official synopsis last night at work for our policy. Their first issue was that they couldn't get it to work, even to a small degree. They used a coffee stirrer in a piece of foam to simulate a PICC tract as it exited the skin, hooked it up to -10 to -15 cm H2O of suction (same as negative intra-thoracic pressure with inspiration) and applied petroleum jelly to the opening. Even after repeated applications the petroleum wouldn't maintain a seal for any amount of time, the jelly was always pulled apart at the opening by the negative pressure.

The clincher though was from Risk Management who vetoed the idea based on something called the "Mulder Rule" The Mulder rule states that doing something that FDA required labeling says specifically not to do is considered automatic malpractice. All petroleum jelly is required by the FDA to carry the same warning; "Do not use on deep wounds / Puncture wounds". A PICC insertion wound could certainly be argued to be a "puncture" type wound. There was even a question on the part of Risk Management of whether or not this would be considered a felony, although it sounded like it most likely would not, just negligence, which is still pretty bad.

IVRUS, BSN, RN · Aug 1, 2011

On page S58 in the 2011 Infusion Nurses Society Standards of Practice, practice criteria for Nontunneled CVAD's read as follows:

F. Caution should be used in the removal of a non-tunneled CVAD, including precautions to prevent air embolism. Digital pressure should be applied until hemostasis is achieved by using manual compression and/or other adjunct approaches such as hemostatic pads, patches, or powders that are designed to potentiate clot formation. The nurse should apply petroleum-based ointment and a sterile dressing to the access site to seal the skin-to tract and decrease the risk of air embolus. When removing the CVAD, the nurse should position the pt so that the CVAD insertion site is at or below the level of the heart to reduce the risk of air embolus.

In addition,

Here is an interesting article..

http://www.thefreelibrary.com/Near-fatal+air+embolism%3a+fibrin+sheath+as+the+portal+of+air+entry.-a0110813712

xtxrn, ASN, RN · Aug 1, 2011

[color=mediumturquoise]dead horse begging to rip

ivrus-- people don't agree with your insistence- you don't agree with those who don't agree with you

is this going to go on forever

:cheers: is there any chance to agree to disagree ??