Binkey

Working for home care, I once had a woman asking for a refill of her son's IV meds..."He is out of Gancy-clover" "Can you send some more? She meant Ganciclovir. DD

Yes.. You would flush both lumens and many protocols delinelate a q 12 hour flush. So, If it is a open ended IV catheter, both lumens would be flushed q 12 with saline and heparin. However if it is a groshong, the lumen that you will use for IVAB will be flushed before and after the IVAB with 5cc NS (or per your P&P). The other lumen should be flushed at least once a week with NSS. As far as which port to use... Normally a DBL lumen PICC will have one lumen that will be larger than the other. (Remember the smaller the number, the larger the lumen) I will save the larger lumen for my blood draws as it will yield better. However, be sure to flush before and after with saline and if you're drawing through an injection port, Change the port afterwards. Also remember, to give your injection cap a good scrub with an alcohol wipe before you access it with your syringe. I teach my students to do a 30 second scrub like a "juicer" prior to. In addition, make sure your drsgs changes are done at periodic intervals per sterile technique. We do ours weekly along with the injection cap and PRN. Those PRN times are important however... whenever your drsgs are loose or soiled that is a PRN time. If the cap is comprimised (I've seen them covered in feces and CHEWED as flat as a pancake) Those are way past a prn time. Hope this helps.. DD

As an educator for infusion therapy, I encourage the use of warmth for an infiltrated IV site, but only if you have an isotonic solution or you have had an extravasation of a vinca-alkaloid. Everything else should have ice as you want to decrease the uptake of these damaging fluids by the tissue. As for as elevation of the extremity, I leave that up to the patient... If the patient feels better with it elevated, I do so. Studies have not proven a benefit one way or the other with elevation. If the arm was swollen 4-5X from baseline, You definetly should have contacted the MD. Your worries include arterial compression from all the accumulated IV fluid. Was the IV fluid going to fast? Not necessarily... But certaintly it appears to be neglect from nursing as they should have "caught" it way before you had this gross infiltrate. An incident report, I believe also should have been filed as they are an internal tool to monitor quality of care.. which in this case was lacking. Hope this helps.. DD

INS discourages the use of midclavicular IV catheters.. Not midlines. In years past, midclavicular IV catheters (ones that terminate in the subclavian vein, or midway below the clavicle) were placed in large numbers especially in homecare, however, thrombosis rates soared with catheter tips terminating in this area. Therefore, INS states that you either have a true Peripherally Inserted Central Catheter aka (PICC) or a midline which as the previous poster stated, should be viewed as a long peripheral IV. DD

While it is true that blood can be drawn from A PICC, it is important to remember that some will give you a better blood returns than others. A 3 FR PICC is usually unreliable in yielding a return due to its smaller size. 4 or 5 Fr PICC"S will do better, but remember it is a slow steady withdraw on the syringe as the blood not only has to come a long way, but you don't want to collapse the catheter with a brisk withdraw method and negative pressure on the syringe barrel. Be sure to change injection caps after the procedure if you aren't doing a direct connect. DD

Kevin, One way is to contact your local pharmacies and ask them if they hire RN's who have good IV skills (because they will want you to have that as a prereq). Omnicare is one company that services LTC facilities and they have nurses who are on call FT or PT or per-diem and many go around and place hard to get peripheral IV's and midline and PICC's. If they have an education dept, they may "certify" you as well for their placement. Hope this helps. DD

A midline IV catheter should terminate before the axillary vein in the upper aspect of the upper arm. Therefore, though it is in a bigger vein than that which is in your forarms, it still doesn't have the blood flow that will yield a good return, in many cases. The material that the catheter is made from also plays a part. Some are softer than others and will collapse easier with gentle aspiration. 3fr midlines generally don't yield a brisk return and aspiration is discouraged. So, if you want to draw labs, place or have placed a 4fr midline (or ideally a PICC where blood flow is approx. 2 Liters/minute) they will yield better. Drawing from a peripheral, except at the time of insertion becomes problematic as well. With small catheters and the diminished blood flow in our peripheral vasculature, blood sampling is not only unreliable through a catheter, but also one must take in to consideration what that negetive aspiration is doing to the endothelium of the tunica intima. Hope that helps DD

Dayshiftnurse, #1- As long as your not needing to infuse that blood in a short time frame, you can infuse it via a 22g 1" IV catheter over a three to four hour time frame. Then, that same line can be used to administer plts or albumin after line flushing. And, as long as that line is still patent, an IVIG infusion can be given after that. Running Blood and Plts at the same time into different lines can create a fluid overload problem for some (the very old and very young are most susceptible). #2 - If a medication was such that it could not be discontinued - ie Heparin gtt - then a second line should be placed to infuse the blood. If however, it is a maintenance fluid that can be stopped, stop it, disconnect the maintenance fluid and place a sterile end cap onto its tip, flush the line and then connect the IV catheter to your preprimed NS "Y" set and blood component. #3 - NS should be the only carrier to be used with blood. No other medication or solution is appropriate. (Dedicated line) In addition, there may be no right or wrong re. the primary or secondary scenario. Can a Heparin gtt infuse by itself without a mainline? Of course it can. If however, a heparin gtt is ordered as well as a liter of saline at its own rate, your main concern is compatibility. Then, do you have a pump that will allow you to infuse two medications simultaneously, or does one medication stop while the other infuses? If compatibility is not an issue, and your pump is a dual chamber (or allows for multiple infusions) they can both infuse at the same time. Can that IV catheter accept the flow rate of both infusions together? The answer to that is usually yes... A 22g IV catheter can handle a flow rate of approx. 2L an hour (35mls/min) As far as the slip-lock, or non-leur-lock ext set goes.. Don't use it! Yes, you always want an ext set on your IV catheters, but they need to be leur-lock in nature. ie. they need to be the kind that has a male fitting, which then goes into the female and screws into place. Hope this helps..DD

I too wonder why they weren't accessing the Port in the hospital, and then I'd wonder why she didn't demand it be done in that setting. Another question is "how long has it been since it had been flushed?" My concern is that if it has been a while, when it is finally flushed, what type and how much bacteria are we flushing into the vascular system that has sheared off of the biofilm? If it is not patent, then it should be removed ASAP to prevent unnecessary bacterial collection/contamination from the ever growing fibrin accumulation which could also lead to thrombus formation. DD

My first thought is: Is this a pt who is immunocomprimised? If so, he or she may be more prone to infections, however, that doesn't necessarily correlate to an increased frequency of drsg changes to the PICC catheter. Each time you do a sterile drsg change, you increase the possibility of introducing more organisms, especially if strict sterile technique is not adhered to with this procedure. In our organization, sterile dressings to all catheters over 3" in length are done every 7 days and prn. If the pt's dressing is C/D and intact the 7 day interval is fine, and in some cases actually preferred. Site infections that occur before the 10 day interval, usually are a result of poor antispesis, or questionable insertion techniques. After 10 days, the infections of a CVC or usually due to improper hub cleansing/manipulation or bacteria introduced in the delivery of medications (tubing, cap changes). Hope this helps. DD

We teach our students that if the catheter is over 3" in length, use no less than a 10cc syringe to ascertain patency. DD

Kathy76, Like many abbreviations, KVO can be problematic. KVO can be 0.2cc/hr or up to 50cc/hr. Normally, unless the facility that you work for has a set flow rate for what KVO is for that institution, you shouldn't accept that abbreviation as an order. ie. Dr. states or writes, "decrease IVF to KVO" without having a specific P&P in writing for your facility, pinpoint that MD.. "Hey doc, can that be 5 or 10cc/hr?" then write the order clarification to reflect that. DD

Dear RNKC25, If your brother had TPN infusing via one lumen and continuous Lasix gtt via a peripheral line, then they were probably using the second lumen of the PICC for all the ancillary meds (IVP meds and IVAB). In the hospital did he have two simultaneous infusions running? If not, then one was being used for the TPN, while the other was used for the rest. In addition, It could be that they were given the Lasix IVP in the hospital, and I'm sure had RN coverage, but in the Rehab, perhaps it behoved them to do a low dose gtt, secondary to the lack of RN's and the inability to have an LPN give IVP medications. (This is especially true if you are in KC MO. as LPN's in MO. can not give IVP medications except under life threatening circumstances.) Numerous factors could be in play here, but you are doing good to keep your eye out for your sibling. I hope he gets better soon! DD

Any catheter that is centrally placed (tip in SVC) should yield a blood return upon gentle aspiration of the syringe. However, if it is a PICC, that catheter should be a 4 French or greater as the 3 French's inner lumen is such that it doesn't yield a blood return very easily. Remember as well that one should use slow, gentle aspiration of the syringe barrel in order to obtain that return so the catheter doesn't collapse. If a centrally placed catheter won't yield a return try some nursing interventions such as: 1. Have the pt turn his or her head and cough. 2. As long as it isn't contraindicated, have them take a deep breath and hold it. This increase in vascular pressure will sometimes free a catheter as it sucking up the vein wall. 3. Reposition a pt. ie, if they are lying on their side, have them lie on their back. 4. Raise the arm on the side that the catheter is in. Failure to get a blood return from a central catheter is a real problem. In the case of a Triple Lumen Catheter, each lumen should yield a return as each on exits into the vascular system at a different spot. When a catheter doesn't yield a return it may have a fibrinous tail or fibrin accumulation covering the exit site of that lumen. This fibrin is a mixture of formed blood elements, immunoglobulins etc. Fibrin development is inevitable, but you don't want it there. You may be able to infuse, but negative aspiration doesn't give you a return. This fibrin is a precurser to bacterial colonization and thrombus. The lumen that won't yield needs Alteplase (cathflo) to be instilled in it to restore patency. DD

Adriadawn, Try finding an Omnicare pharmacy in your area. Many of these pharmacys have infusion nurses that do just that... go around and start IV's. They place peripherals, midlines and PICC lines mainly in the geriatric population. They are the leading company in the US to provide pharmaceuticals to LTC facilities, but they also start the lines in these settings. An infusion nurse working for them will get called to place the line, and then he or she goes to that facility inserts the IV then documents his or her procedure and leaves after educating the pt's nurse on what was done. It really helps that pt to have an experienced nurse place the line. Hope this helps:wink2: DD