PICC ACE

There are a number of studies which confirm the accuracy of CVP's from a PICC line,so don't worry about that. Most open-ended catheters are labelled for pressure monitoring. Valved PICCs like Groshongs are not.

Stop the TPN,resuscitate the pt. No big deal. General rule of thumb is that if you have to stop TPN for whatever reason,start D10% at the same rate as the TPN. Watch blood sugars and treat them as needed--if there was loads of insulin in the TPN,they could go up. And with running pressors and being septic-ish,the BG's are going to go wild anyway. Does your hospital's TPN orders include standing orders for what to do if TPN has to come off? My former hospital had the D10% and blood sugar checks as part of the basic TPN order set. Z.

I,too,would be interested in hearing of your idea and helping in any way I might. PM me. Zed

This should be a fairly straight-forward study,especially since it sounds like you are limitting it to one floor. First of all,do plenty of Googling and medline research so you don't waste time 'reinventing the wheel'. This should also give you ideas on how other phlebitis studies have been set up. Next,make sure you become very familiar with the phleblitis scale as described in the INS SOP's. Then you need to decide when and how frequently to assess the IV sites on the patients to get a large enough sample to be significant. Will you be able/need to do it every day for a 3-month period,every Tuesday AM for a few months,etc. This will establish your prevalence. (I would not leave this data collection to the floor nurses as they generally,and sadly,lack the experience and training to evaluate such things accurately and consistently.) The factors listed by iluvit should be included in your data collection (for all pt's,not just those who show any evidence of phlebitis) for you to draw meaningful conclusions from your study. Good luck, Z.

I hate Alaris. The med library and programmability are good features. The actual mechanics of the set-up are bad,however. We have innumerable problems with air alarms--the design of the tubing is such that it is impossible to eliminate some of the little air bubbles and the pump will alarm for the minutest little bubble. More than once I have had to just pitch the whole tubing set and start over. It should not take 10 to 20 minutes to get an infusion running properly,especially in an ICU. Furthermore,the piggyback sets are sometimes unreliable and will not infuse at the rate you think you have them set at. Finally,I have had more than a few Alaris 'brains' whose buttons go bad--that is,I will hit a button once but it registers as two pushes. So "100" can turn into "1000". GRRRRR Z.

This situation exemplifies two additional aspects of central line placement. First of all,the statement "line OK to use" or "line in good position" is useless. How does a rad know that a line is OK to use? OK to use means not just with tip in proper position but also with good blood return,not plugged/ruptured/defective,not stuck through an artery into the vein,etc,etc. Also "in good position" means different things to different people. Define "good". "Good" for a knowledgeable interpretter of line CXR's means "lower 1/3 of SVC at or near the CA juncture" (SIR,AVA,INS). "Good" for anyone else might be anywhere from rt ventricle to contralateral IJ to aortic arch (seen 'em all). What I want to know when I read a CXR report for line placement is where the tip lies anatomically,e.g. "lower SVC 1.5 cm above CA juncture". That,plus MY assessment of the line's patency and function is what makes a catheter "OK to use". The second issue is the importance of getting a repeat film after a significant line adjustment.A few years ago,there was a tragic case in Pennsylvania. A neonate had a line placed and the initial reading was that it was too low and needed to be pulled back a few cm. Either no one actually adjusted the line or there was no repeat film,and the line eroded through the atrium. Results-ruptured heart--tamponnade--dead infant--big lawsuit. Moral of the story? Reshoot after an adjustment.

Any central line,including PICC's,can indeed cause arrythmias if placed too deep. The tip of the line may "tickle" the heart tissue enough to trigger something. If the radiology read was to pull back 6cm,the line may have been much too deep,but the issue of optimal placement unfortunately vfaries from rad to rad. ST changes are associated with repolarization or perfusion issues with the ventricles--iscemia,injury,strain,etc. These changes would be unlikely to be related to a central line/PICC tip in the atrium. Kudos to your staff for getting the line properly adjusted! Z.

Agree with all the above postings on attaching a transducer--no problem at all to do so. Furthermore,it is also our practice to draw labs from a line that has yet to be x-rayed. Just no infusion of meds until placement is confirmed. Z.

The ISMP recently put out an updated list of what they have determined to be "high-alert" medications. That is,medication which have a "heightened risk of causing significant patient harm when they are used in error". The list is a long one and pretty much includes everything given in an ICU from paralytics to pressors to even KCl. One of the recommended strategies for improving safe administration of these meds includes a redundant manual double-check. (If you want to see the list,go to : http://www.ismp.org/ and find the high-alert medication list.) My hospital's powers-that-be decided to make our jobs even more infernal by requiring us to have a second person not only sign off on the med but go to the room and actually witness the med be hung,the pump programmed,follow the tubing to the patient,etc. Made for an awful lot of ticked off nurses,as you might guess. We are trying to overturn this policy change,but not look like we are ignoring the need for patient safety. I would like to hear from others what their hospitals have done about these medications. Thanks, Z.

Dang--that was one hard-a$$ test! Passed with 118 correct. I used the Dennison book and the Ahrens book. Will agree with above comments on Dennison book and CD--book is WAY too much and in outline form. CD is good way to practice and underestimated my actual score. The Ahrens book was easier to read but it,too,has its share of typos in the quiz answers. My scores on the practice tests in that book were closer to actual. The one reminder I have is to read the questions CAREFULLY---hypokalemia and hyperkalemia and hypercalcemia all look the same after staring at a screen for an hour. I went back and rechecked every one of my answers and good thing I did cuz I made some silly mistakes the first time through. Good luck to the rest of y'all. Z.

Pt's with high INR's,low PLT's,on an anticoagulant gtt,in DIC,etc are certainly at higher risk for bleeding from a stick. However,the thing to keep in mind is the location of the vessel to be cannulated. Arm veins are easily compressible,versus deep veins like the subclavian and therein lies the difference. IR dept's tend to prefer that INR's be lowered before doing their procedures,and rightly so,because an arterial stick or traumatic complication would be catastrophic. High INR's are not an absolute contraindication for a PICC. Choose your site well,make one stick,minimize tourniquet time,skip or minimize the skin nick,etc. The site may ooze a little more than others but that can be taken care of easily. The only thing that I would do different from my usual procedure is to open an extra box of 4X4's to start. Can't recall where I saw it,but there was an article published within the last year that tracked outcomes for PICC placements relative to INR's...gist of the results were minimal number of complications,mostly just a few oozy sites that needed a dressing change. One thing I try to impress on new PICC nurses is to approach EVERY pt as if they had an INR of 10,PLT's at 10,WBC's at 0.10--no margin for error with ANYONE--and things go better. Good luck, Zed

catamounts... I have a brief powerpoint on abd. compartment syndrome. PM with your email addy if you want a copy. Zed

Proper line care and proper site care will go a long way to reduce CRBSI's---this has been well documented and I'm sure that facilities that are ignorant of the CDC guidelines and IHI bundles are in the minority in this country,but even so the incidence of CRBSI's is not zero. Having rates under the NNIS guidelines shouldn't be the goal,ZERO CRBSI's should be the goal. Anything that we can do to get closer to that goal is a good thing,and if CHG bathing can get us closer to that goal,why not consider it? Here's another study just out: Critical Care Medicine. 37(6):1858-1865, June 2009. Climo, Michael W. MD; Sepkowitz, Kent A. MD; Zuccotti, Gianna MD, MPH; Fraser, Victoria J. MD; Warren, David K. MD; Perl, Trish M. MD, MSc; Speck, Kathleen; Jernigan, John A. MD; Robles, Jaime R. PhD; Wong, Edward S. MD Abstract: Objective: Spread of multidrug-resistant organisms within the intensive care unit (ICU) results in substantial morbidity and mortality. Novel strategies are needed to reduce transmission. This study sought to determine if the use of daily chlorhexidine bathing would decrease the incidence of colonization and bloodstream infections (BSI) because of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) among ICU patients. Design, Setting, and Patients: Six ICUs at four academic centers measured the incidence of MRSA and VRE colonization and BSI during a period of bathing with routine soap for 6 months and then compared results with a 6-month period where all admitted patients received daily bathing with a chlorhexidine solution. Changes in incidence were evaluated by Poisson and segmented regression modeling. Interventions: Daily bathing with a chlorhexidine-containing solution. Measurements and Main Results: Acquisition of MRSA decreased 32% (5.04 vs. 3.44 cases/1000 patient days, p = 0.046) and acquisition of VREdecreased 50% (4.35 vs. 2.19 cases/1000 patient days, p = 0.008) following the introduction of daily chlorhexidine bathing. Segmented regression analysis demonstrated significant reductions in VRE bacteremia (p = 0.02) following the introduction of chlorhexidine bathing. VRE-colonized patients bathed with chlorhexidine had a lower risk of developing VRE bacteremia (relative risk 3.35; 95% confidence interval 1.13-9.87; p = 0.035), suggesting that reductions in the level of colonization led to the observed reductions in BSI. Conclusion: We conclude that daily chlorhexidine bathing among ICU patients may reduce the acquisition of MRSA and VRE. The approach is simple to implement and inexpensive and may be an important adjunctive intervention to barrier precautions to reduce acquisition of VRE and MRSA and the subsequent development of healthcare-associated BSI. The studies I've mentioned offer promising results and need further replication,but I won't be suprised to see CHG bathing becoming more and more a part of ICU care. Z.

Nyteshade- Looks like no one has actually succinctly answered your original question,so without further ado.... If your pt's line flushed easily and gave you a good blood return (roughly and unscientifically defined as >5ml in Z.

Thanks for the replies,c0n.. and Neo.. Why the MWF Friday schedule? Any specific concerns using it daily? TY

not long ago,results were published showing a reduction in catheter-related blood stream infections through the use of chg for bathing icu patients: effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients archives of internal medicine,2007, vol. 167, no19, pp. 2073-2079 i am looking to hear from anyone who has attempted to replicate these results or who currently uses chg wipres or soap for patient bathing. i would like to get my floor to consider the possibility. thanks.

Maybe you mistyped but the correction equation is to add 0.8 mg/dl to the calcium for every 1g/dl drop in Albumin. The reason is the high degree of binding between Ca and Alb. Both Calcium and Albumin need to be watched and replaced as needed,but generally low Calcium would be the priority one since it has so much to do with coagulation,neuromuscular conduction and cardiac contractility. A run or two of Calcium Chloride or Calcium Gluconate can quickly correct the hypocalcemia. Low Albumin on the other hand is less of a priority. You can raise Alb levels with a quick infusion of 5% or 25%,but there is a good chance that it will just leak out of the vascular system and not give you the expected results. There's more to the whole situation but hope this helps. GL

Not a lot of concrete published data. Here is the main reference I have for you: Journal of Infusion Nursing Volume 26(5), September/October 2003, pp 285-293 Drawing Blood Samples From Vascular Access Devices: Evidence-based Practice Frey, Anne Marie RN, BSN, CRNI The article is mainly a review of the literature with recommendations based on same. Recommends against the reinfusion method. A reference specifically for your situation would be: Cosca PA, Smith S, Chatfield S, et al. Reinfusion of discard blood from venous access devices. Oncology Nursing Forum. 1998; 25( 6):73-76. The article recommends against reinfusing the blood due to the chance of injecting clots. Good luck.

Reference for the above is the Infusion Nurses Society standards of practice from 2006. "Therapies not appropriate for peripheral-short catheters include continuous vescant therapy,parental nutrition,infusates with pH less than 5 or greater than 9,and infusates with an osmolality greater than 600 mOsmol/L."

CAN you do so? Sure,it's done all the time. SHOULD you? That's a little different. When deciding if a med needs to be infused centrally or not,one of the considerations is the pH of the solution. Very high (alkaline) or very low (acidic) pH solutions should be given centrally. If given peripherally,there is a high risk of damaging the inner lining of the vein and causing phlebitis or thrombus. Vancomycin is one the more acidic drugs out there,with a pH of 2-2.2,no matter how it's prepared. For comparison,the pH of normal stomach acid is 1-3.

The issue is in fact diminished blood flow in the arm and the increased risk of thrombosis--remember Virchow's triad? With no movement in the arm,the action of the 'muscle pump' on the blood/valves/vein system is lost. As such,a stroke-affected extremity is a relative contraindication to IV/PICC placement. http://www.iv-therapy.net/node/396

I have been asked to collaborate with a research/educational project regarding vascular access in the burn patient. We aren't finding a whole lot of good data to back up current practices. So, a few questions for you burn nurses: -Does your unit routinely replace central lines? -Have you used intraosseus access for initial fluid resusc. in adult patients? -When you have no other choice but to go through damaged tissue for an IV,CVC or art line,how do you dress the site and secure the line? -How does your central line infection rate run? -Do you have any words of wisdom/tricks of the trade to share? Thanks in advance.

RN2B..when you say they don't work well,do you mean they are clotting off completely or that you just aren't getting good flow rates? Have you tried a TPA dwell to remove the fibrin build-ups? My original question was inspired by my facility's reaction to this year's heparin scares/shortages. The initial knee-jerk reaction was to say no heparin in any line. Period. Just use saline for everything. That included PICC's,ports,all CVC's and HD cath's. Our HD people,wisely, started using Citrate 4% and that's what we in the ICU's used for our CRRT patients. So 2 weeks ago,when I took a pt. off CRRT,I locked the line with Citrate. A few rooms down,a different nurse used Heparin after his machine crashed (we can use Heparin again according to the powers that be). Then a different pt. received HD by the HD staff and her line was locked with TPA since she's had some occlusion problems in the recent past. I was hoping to hear from someone involved in the trials for some of the new solutions,like Taurolidine,high-dose Citrate (40%) or the methyline blue/citrate combination.

This is sort of a poll--What are you HD nurses using to lock your patients' catheters after treatment? Heparin? If so,what concentration? Any one using anything else,like Citrate,TPA or the mysterious 'blue solution' in the clinical trials? Thanks for the input.

There are two good articles that you might want to check out. From Nursing2004,Vol 34,No.2 "Drawing Blood through a central venous catheter" by Nancy Moureau. It's brief,but she describes nicely the steps for both the discard method and the mixing or 'push-pull' method,which while not especially popular may have its benefits. She also mentions not discarding blood prior to drawing cultures. The second and more in-depth article is Anne Marie Frey's piece from the Journal of Infusion Nursing Vol 26,No.5 2003, "Drawing blood samples from vascular access devices." It is the most recent and most referenced publication on the subject. The one thing I'd point out is that the recommendation is to discard at least three times the lumen volume of the device. This amount will vary with the catheter's length and lumen size. This works out typically to 3-5ml's or less for most devices. In almost all cases,10ml of waste is excessive and iatrogenic blood loss has been shown to have negative outcomes for pt's. Here is the full list of references I have on the subject--can't recall where I snipped it from,though. 1. Frey A. Intravenous therapy in children. In: Hankins J, Lonsway R, Hedrick C, Perdue M, eds. Infusion Therapy in Clinical Practice. 2nd ed. Phildephia: WB Saunders; 2001:561-591. 2. Miller K. Decreasing diagnostic blood loss for patients in critical care units. Dimensions in Critical Care. 1999;18(1):46-54. 3. Andrews J. A QI project to reduce nosocomial blood loss. Dimensions in Critical Care. 1998;17(2):92-99. 4. Vincent J, Baron J, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. Journal of American Medical Association. 2002;288(12):1499-1507. 5. Keller C. Methods of drawing blood samples through central venous cathegers in pediatric patients undergoing bone marrow transplant: Results of a national survey. Oncology Nursing Forum. 1994;21(5):879-884. 6. Cosca P, Smith S, Chatfield S, et al. Reinfusion of discard blood from venous access devices. Oncology Nursing Forum. 1998;25(6):1073-1076. 7. Holmes K. Comparision of push-pull versus discard method from central venous catheters for blood testing. Journal of Intravenous Nursing. 1998;21(5):282-285.