Our internal medicine doctors are asking when to place a PICC line for endocarditis. They are of the opinion that they should treat through a short peripheral catheter until the patient is afebrile with negative blood cultures then place the PICC for the remainder of the long term therapy.
I am of the opinion that the medications given through a peripheral catheter will do too much damage to the veins, and the patients will require several IV starts since their vasculature would not last with the pH of the medications being given. Since we follow the bundles with our insertion, I believe that it is best to insert the PICC line right away. That is my opinion because it makes sense, and not based on any referenced articles. We do not have any infectious disease physicians at our facility to discuss with.
The closest set of guidelines that I know of is:
Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009;49(1):1-45.
You can download this document by clicking here. This document discusses the management of treating endocarditis as a catheter-related infection. You could share this set of guidelines and discuss them with your physicians about applying this to management of patients with endocarditis caused by other factors.
Sunday, November 22, 2009
Dressing Alternatives for Central Venous Catheters
We are considering the Aquacel® and Calcium Alginate dressings for our central venous catheters. Is one preferred over the other to apply to a bleeding central line insertion site? And is there a difference between the two? And when you do use it, is the dressing then treated as a gauze dressing, and changed at 48 hours?
Both products are absorbable dressing materials used on draining wounds. There are numerous websites that have information about both types of dressings and these can easily be found with a Google search. A PubMed search did not reveal any studies about using either of these dressings on any type of central venous catheters. So there is no evidence about their effectiveness on bleeding from a CVC site, nor anything about the differences in outcomes between the 2 types.
Because this would be an additional material placed under tape or a transparent membrane dressing, my opinion would be that it should be changed every 48 hours according to the current standard for changing a gauze and tape dressing. But again, there is no research to use as evidence for either of these products on a CVC site.
Both products are absorbable dressing materials used on draining wounds. There are numerous websites that have information about both types of dressings and these can easily be found with a Google search. A PubMed search did not reveal any studies about using either of these dressings on any type of central venous catheters. So there is no evidence about their effectiveness on bleeding from a CVC site, nor anything about the differences in outcomes between the 2 types.
Because this would be an additional material placed under tape or a transparent membrane dressing, my opinion would be that it should be changed every 48 hours according to the current standard for changing a gauze and tape dressing. But again, there is no research to use as evidence for either of these products on a CVC site.
Wednesday, November 11, 2009
Multiple attempts for 1 PICC introducer?
During a PICC insertion, is it acceptable to use the same needle a second time if the first attempt failed? Our PICC team has been doing this, unknown to the Infection Prevention folks and we are quite concerned. One thought is that it is under sterile conditions, therefore OK. What are your thoughts?
PICC insertion is a sterile procedure while insertion of a short peripheral catheter is a clean, no-touch procedure. Regardless of the sterility for the procedure, you can never make skin sterile. The best skin antiseptic agents and application techniques will only remove about 80% of the organisms on the skin. That is because the other 20% lie in the lower layers of the epidermis and can not be reached by our application techniques. This is the reason that we should now be using a back and forth scrubbing method with chlorhexidine - this will reach the maximum amount of organisms.
When the introducer needle passes through the skin, there will be organisms that attach to the needle. These organisms are then taken into the bloodstream. This needle only resides for a very few minutes and is then removed. To reuse this needle could transfer skin organisms to the new site, however I am not aware of any studies citing this as a reason for any type of catheter-related infection. That does not mean that a local site infection can not be associated with this practice though.
Additionally, every time a needle is used, the sharpness is reduced. So the second use of this needle could be more painful for the patient.
To save money, I know this is a common practice for PICC insertions. But there is no evidence that I know of to support or reject this practice.
This should never be done with a short peripheral catheter however. One catheter should only be used for one attempt. If that attempt fails, a new catheter must be used for the second attempt. Here is the difference - the introducer needle for a PICC will only reside in the vein for a few minutes and then is removed. This does not allow time for the organisms to start making biofilm that produces infection. But with a short peripheral catheter, the catheter is left inside the vein which will allow the attached organisms to produce a local site infection. This has been reported and is considered dangerous practice.
PICC insertion is a sterile procedure while insertion of a short peripheral catheter is a clean, no-touch procedure. Regardless of the sterility for the procedure, you can never make skin sterile. The best skin antiseptic agents and application techniques will only remove about 80% of the organisms on the skin. That is because the other 20% lie in the lower layers of the epidermis and can not be reached by our application techniques. This is the reason that we should now be using a back and forth scrubbing method with chlorhexidine - this will reach the maximum amount of organisms.
When the introducer needle passes through the skin, there will be organisms that attach to the needle. These organisms are then taken into the bloodstream. This needle only resides for a very few minutes and is then removed. To reuse this needle could transfer skin organisms to the new site, however I am not aware of any studies citing this as a reason for any type of catheter-related infection. That does not mean that a local site infection can not be associated with this practice though.
Additionally, every time a needle is used, the sharpness is reduced. So the second use of this needle could be more painful for the patient.
To save money, I know this is a common practice for PICC insertions. But there is no evidence that I know of to support or reject this practice.
This should never be done with a short peripheral catheter however. One catheter should only be used for one attempt. If that attempt fails, a new catheter must be used for the second attempt. Here is the difference - the introducer needle for a PICC will only reside in the vein for a few minutes and then is removed. This does not allow time for the organisms to start making biofilm that produces infection. But with a short peripheral catheter, the catheter is left inside the vein which will allow the attached organisms to produce a local site infection. This has been reported and is considered dangerous practice.
Low dose tPA by infusion
I have heard that some facilities use a tPA drip (small dose in say 50ml fluid) to treat clot/fibrin around central catheters. Have you heard of this and , if so, do you have any info about it?
Yes, this can be a common procedure in some hospitals. The instillation procedure for locking a catheter with tPA will not allow the drug to reach the fibrin/thrombus inside the vein around the catheter. The infusion of low dose tPA will resolve this problem however.
I have seen protocols for 10 mg of tPA in 50 mLs of fluid infused through each catheter lumen over 3 to 4 hours. There may be protocols for even lower doses.
Go to PubMed at http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed and search for these articles using "low dose tissue plasminogen activator". You will find several reports of this procedure.
You can go to the Cathflo website for drug information, http://www.cathflo.com, however the low dose infusion is not a labeled indication so the manufacturer does not have any information on their website about this procedure.
There are concerns about doing this in patients on a general nursing unit and I have heard that some hospitals require the patient to be monitored in ICU. I have also heard of this infusion being given in the radiology suite as well.
Yes, this can be a common procedure in some hospitals. The instillation procedure for locking a catheter with tPA will not allow the drug to reach the fibrin/thrombus inside the vein around the catheter. The infusion of low dose tPA will resolve this problem however.
I have seen protocols for 10 mg of tPA in 50 mLs of fluid infused through each catheter lumen over 3 to 4 hours. There may be protocols for even lower doses.
Go to PubMed at http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed and search for these articles using "low dose tissue plasminogen activator". You will find several reports of this procedure.
You can go to the Cathflo website for drug information, http://www.cathflo.com, however the low dose infusion is not a labeled indication so the manufacturer does not have any information on their website about this procedure.
There are concerns about doing this in patients on a general nursing unit and I have heard that some hospitals require the patient to be monitored in ICU. I have also heard of this infusion being given in the radiology suite as well.
Monday, November 2, 2009
How Much Heparin for Locking a Catheter?
We are currently having discussions about flushing protocol, 1 vs 2 mL of heparin 100 units per mL per lumen on an open-ended catheter. Should 1 mL be used with multiple lumens? How much heparin is too much? When should we concerned?
Heparin for catheter locking is getting lots of attention these days or maybe I have just devoted lots of my attention to this issue recently. There are numerous issues with heparin as a catheter locking solution, however there are no alternative solutions that have been cleared by the US FDA yet. So we are left to address the many issues with heparin.
The goal is to avoid having the dose of heparin lock solution produce any effect on the patient's coagulation values. This means that the lowest concentration of heparin should be used. A couple of years ago, the Infusion Nurses Society released a set of flushing protocol cards recommending that 10 units per mL be used for locking all central venous catheter. You can order these cards at the INS website. In the US, heparin locking for peripheral catheters was eliminated about 20 years ago. Your question asked about using 100 units per mL, however I would recommend that you change to 10 units per mL. The only time that 100 units per mL is recommended is when you are de-accessing an implanted port.
With the 10 mL dose, there is evidence that the catheter remains patent and you avoid the risk of giving too much heparin. For hospitalized patients with frequent medication doses, you could reach a therapeutic level in some patients with 100 units per mL every 2 or 3 hours. With 10 units per mL, the volume becomes less of an issue.
According to the Infusion Nursing Standards of Practice, the volume of locking solution should be equal the priming volume of the catheter lumen plus the internal volume of any extension sets that have been added, then multiplied by 2. For instance, a PICC will usually hold about 0.5 mL plus the added extension set usually holds about 0.5 mL, equaling a total of 1 mL. Double this volume to 2 mL of heparin 10 units per mL. This is the method for assessing the correct amount for each catheter. The type of catheter determines how much the priming volume. A PICC will not hold as much as a tunneled, cuffed catheter. An implanted port will hold the most volume because you must add the priming volume for the catheter, the port body, and the port access needle and attached extension set. Add these numbers, then multiple by 2 to arrive at the total volume required to adequately fill the catheter system.
This calculation should be used on each catheter lumen. Most hospitals have created a convenient chart based on these calculations for the specific brands and types of catheters used. This chart is then made available to all primary care nurses to ensure consistency among all staff.
This volume will assure that the entire catheter lumen has been adequately filled and there will be some overspill into the vein. However, the concentration is low and should not have any affect on coagulation. This locking solution is then flushed into the catheter lumen when it is used the next time. Aspiration of heparin lock solution is only done with hemodialysis catheters where the heparin lock solution can be as much as 5000 units per mL.
Heparin for catheter locking is getting lots of attention these days or maybe I have just devoted lots of my attention to this issue recently. There are numerous issues with heparin as a catheter locking solution, however there are no alternative solutions that have been cleared by the US FDA yet. So we are left to address the many issues with heparin.
The goal is to avoid having the dose of heparin lock solution produce any effect on the patient's coagulation values. This means that the lowest concentration of heparin should be used. A couple of years ago, the Infusion Nurses Society released a set of flushing protocol cards recommending that 10 units per mL be used for locking all central venous catheter. You can order these cards at the INS website. In the US, heparin locking for peripheral catheters was eliminated about 20 years ago. Your question asked about using 100 units per mL, however I would recommend that you change to 10 units per mL. The only time that 100 units per mL is recommended is when you are de-accessing an implanted port.
With the 10 mL dose, there is evidence that the catheter remains patent and you avoid the risk of giving too much heparin. For hospitalized patients with frequent medication doses, you could reach a therapeutic level in some patients with 100 units per mL every 2 or 3 hours. With 10 units per mL, the volume becomes less of an issue.
According to the Infusion Nursing Standards of Practice, the volume of locking solution should be equal the priming volume of the catheter lumen plus the internal volume of any extension sets that have been added, then multiplied by 2. For instance, a PICC will usually hold about 0.5 mL plus the added extension set usually holds about 0.5 mL, equaling a total of 1 mL. Double this volume to 2 mL of heparin 10 units per mL. This is the method for assessing the correct amount for each catheter. The type of catheter determines how much the priming volume. A PICC will not hold as much as a tunneled, cuffed catheter. An implanted port will hold the most volume because you must add the priming volume for the catheter, the port body, and the port access needle and attached extension set. Add these numbers, then multiple by 2 to arrive at the total volume required to adequately fill the catheter system.
This calculation should be used on each catheter lumen. Most hospitals have created a convenient chart based on these calculations for the specific brands and types of catheters used. This chart is then made available to all primary care nurses to ensure consistency among all staff.
This volume will assure that the entire catheter lumen has been adequately filled and there will be some overspill into the vein. However, the concentration is low and should not have any affect on coagulation. This locking solution is then flushed into the catheter lumen when it is used the next time. Aspiration of heparin lock solution is only done with hemodialysis catheters where the heparin lock solution can be as much as 5000 units per mL.
Wednesday, October 21, 2009
Syringe Size for Heparin Locks
I noticed in your booklet on the BD website what looks like a 3 ml syringe with Heparin. Who makes that and can it be used with central lines??? Are there any with 5 cc of heparin?
Several companies manufacturer prefilled syringes in smaller sizes with 3 and 5 mL of heparin lock solution. BD Posiflush is a syringe designed with the same diameter as a 10 mL syringe. It is intended to lower the pressure coming from the syringe tip and to prevent syringe-induced blood reflux. Click here to learn more about this syringe design.
Covidien also makes a prefilled flush syringe with heparin lock solution in multiple configurations. They also have a line of prefilled syringes that is designed to prevent syringe-induced reflux, although I can not locate information about that specific product line on their website. They have smaller fill volumes in 12 mL syringe sizes.
Excelsior Medical also makes a line of prefilled syringes that reduces syringe-induced blood reflux. They also have the widest range of concentration of heparin including 1, 2, 10 and 100 units per mL.
When choosing a prefilled syringe, make sure you choose one that is labeled with "terminal sterilization" rather than aseptic fill. You can find more details about the issues with prefilled syringes at Infection Control Resources. Look for Vol 4, No 4 Misuse of prefilled flush syringes-Implications for medication errors and contamination and Vol. 4, No. 2 Flushing vascular access catheters: Risks for infection transmission
Small size syringes can be used safely to give IV medications and to instill heparin lock solutions. The danger of catheter damage comes when the large amount of force is applied to a syringe plunger to overcome any resistance to the injection of fluid. ALL catheters must be assessed for their functionality prior to each and every injection or infusion. This is done with at least a 10 mL syringe filled with normal saline. If this flushed easily without excessive force being applied to the plunger, the catheter can be used for subsequent injections with smaller syringes. In fact, transferring a drug from a small syringe to a large syringe is not recommended as it carries numerous risks including contamination, loss of the drug dose, and improper labeling leading to medication errors.
So after you have assessed the catheter with at least a 10 mL syringe filled with saline and the catheter is judged to be open and patent, the appropriately sized syringe should be used to give the desired dose of medication, which includes the heparin lock solution. You have flushed with saline and given the dose of medication and flushed with saline again, thus establishing the patency of the catheter. The instillation of heparin lock solution from a 3 or 5 mL syringe would be safe as long as you have not used excessive force to flush the fluid through the catheter.
Remember the formula for catheter damage - force applied to the syringe plunger meeting resistance inside the fluid pathway (intraluminal or at the catheter tip) can lead to increased intraluminal pressure that causes catheter damage. No excessive force and no resistance means no risk of catheter damage. So syringe size is only one factor in the decision about catheter patency. Excessive force from a large hand to overcome resistance can occur with any size syringe, even a 10 mL size!
Several companies manufacturer prefilled syringes in smaller sizes with 3 and 5 mL of heparin lock solution. BD Posiflush is a syringe designed with the same diameter as a 10 mL syringe. It is intended to lower the pressure coming from the syringe tip and to prevent syringe-induced blood reflux. Click here to learn more about this syringe design.
Covidien also makes a prefilled flush syringe with heparin lock solution in multiple configurations. They also have a line of prefilled syringes that is designed to prevent syringe-induced reflux, although I can not locate information about that specific product line on their website. They have smaller fill volumes in 12 mL syringe sizes.
Excelsior Medical also makes a line of prefilled syringes that reduces syringe-induced blood reflux. They also have the widest range of concentration of heparin including 1, 2, 10 and 100 units per mL.
When choosing a prefilled syringe, make sure you choose one that is labeled with "terminal sterilization" rather than aseptic fill. You can find more details about the issues with prefilled syringes at Infection Control Resources. Look for Vol 4, No 4 Misuse of prefilled flush syringes-Implications for medication errors and contamination and Vol. 4, No. 2 Flushing vascular access catheters: Risks for infection transmission
Small size syringes can be used safely to give IV medications and to instill heparin lock solutions. The danger of catheter damage comes when the large amount of force is applied to a syringe plunger to overcome any resistance to the injection of fluid. ALL catheters must be assessed for their functionality prior to each and every injection or infusion. This is done with at least a 10 mL syringe filled with normal saline. If this flushed easily without excessive force being applied to the plunger, the catheter can be used for subsequent injections with smaller syringes. In fact, transferring a drug from a small syringe to a large syringe is not recommended as it carries numerous risks including contamination, loss of the drug dose, and improper labeling leading to medication errors.
So after you have assessed the catheter with at least a 10 mL syringe filled with saline and the catheter is judged to be open and patent, the appropriately sized syringe should be used to give the desired dose of medication, which includes the heparin lock solution. You have flushed with saline and given the dose of medication and flushed with saline again, thus establishing the patency of the catheter. The instillation of heparin lock solution from a 3 or 5 mL syringe would be safe as long as you have not used excessive force to flush the fluid through the catheter.
Remember the formula for catheter damage - force applied to the syringe plunger meeting resistance inside the fluid pathway (intraluminal or at the catheter tip) can lead to increased intraluminal pressure that causes catheter damage. No excessive force and no resistance means no risk of catheter damage. So syringe size is only one factor in the decision about catheter patency. Excessive force from a large hand to overcome resistance can occur with any size syringe, even a 10 mL size!
Tuesday, October 20, 2009
Family Present During PICC Insertion?
Could you please give me your opinion regarding allowing family members to be present during a bedside PICC insertion? This has become as issue among the PICC team members I work with and I am hoping you could advise on the legal aspects also. We have 2 RN's in the room during insertion, and because this is an invasive and sterile procedure I personally feel family members should not be present. There has been occasions where the procedure may not go as expected and family members get upset. We want to establish standards of care for this and put it to rest.
I would approach this in the same manner as having parents present when a child needs an IV started. It depends upon the needs of the patient and the family. As always, I believe our care musts be centered around what is best for the patient rather than what is preferred by the caregivers.
The patient and family member(s) must always be prepared for the entire procedure. They must be educated about what to expect, what can potentially happen, why the procedure is needed, the risks, benefits, and alternatives. This is called informed consent. It may or may not result in a signed piece of paper but this education process is always required. If this information has been complete, the family member should be prepared for whatever the outcome of a PICC insertion may be.
If the patient wants a family member present, at least one person should be allowed to be present in the room. That family member should have the same knowledge as the patient. They must wear a mask and your assessment must determine if they will or will not be helpful to the patient. The situation could be that the patient wants someone present but the family member does not wish to see the procedure or visa versa. Having a family member present could also make the patient more relaxed and avoid problems associated with anxiety over the procedure. Each situation is different and requires a nursing assessment to determine what is best for that specific patient.
I can not think of any issues that would raise legal concerns by having a family member present. With the proper education, they should be prepared for what they will see and the possible outcomes. Of course, this is no guarantee that they will not pursue a lawsuit if there is a patient injury resulting from the procedure. If there is an injury causing permanent damages, the family member is another witness to what happened and this could be beneficial. Filing a lawsuit is directly related to the personal relationship between the patient, family and healthcare providers. If they feel you are all working as a team toward the same goals, the risk of a lawsuit is reduced.
One other factor is the space available in the room where the procedure is performed. I think it is reasonable to limit the number of family members present to one. I can see a definite advantage for some patients to have a family member present and would not have a problem with their presence. There is a trend now to allow family to be present during cardiopulmonary resuscitation. So I do not see a problem with them being present for a PICC insertion.
I would approach this in the same manner as having parents present when a child needs an IV started. It depends upon the needs of the patient and the family. As always, I believe our care musts be centered around what is best for the patient rather than what is preferred by the caregivers.
The patient and family member(s) must always be prepared for the entire procedure. They must be educated about what to expect, what can potentially happen, why the procedure is needed, the risks, benefits, and alternatives. This is called informed consent. It may or may not result in a signed piece of paper but this education process is always required. If this information has been complete, the family member should be prepared for whatever the outcome of a PICC insertion may be.
If the patient wants a family member present, at least one person should be allowed to be present in the room. That family member should have the same knowledge as the patient. They must wear a mask and your assessment must determine if they will or will not be helpful to the patient. The situation could be that the patient wants someone present but the family member does not wish to see the procedure or visa versa. Having a family member present could also make the patient more relaxed and avoid problems associated with anxiety over the procedure. Each situation is different and requires a nursing assessment to determine what is best for that specific patient.
I can not think of any issues that would raise legal concerns by having a family member present. With the proper education, they should be prepared for what they will see and the possible outcomes. Of course, this is no guarantee that they will not pursue a lawsuit if there is a patient injury resulting from the procedure. If there is an injury causing permanent damages, the family member is another witness to what happened and this could be beneficial. Filing a lawsuit is directly related to the personal relationship between the patient, family and healthcare providers. If they feel you are all working as a team toward the same goals, the risk of a lawsuit is reduced.
One other factor is the space available in the room where the procedure is performed. I think it is reasonable to limit the number of family members present to one. I can see a definite advantage for some patients to have a family member present and would not have a problem with their presence. There is a trend now to allow family to be present during cardiopulmonary resuscitation. So I do not see a problem with them being present for a PICC insertion.
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