Lynn Hadaway Associates, Inc.

Too Many Questions, Not Enough Time

2010-08-05T14:44:00.002-04:00

I know that many of you are waiting on my answers to the questions sent in numerous emails. I apologize for the delay in my reply, however all extra time has been devoted to work on the Infusion Nursing Standards of Practice. Some of you may have been reviewers for the first draft and we appreciate your feedback. Now the committee is going through all of those comments and making decisions about the final draft. Many of your questions will be addressed in this new document, but I guess that does you no good if your need was urgent. After this process is complete, I hope to be able to return to writing my blog on a regular basis.

Please remember that questions received through an email to me will only be addressed on my blog. I can not answer urgent needs, however I am available as a contracted consultant for those immediate or extensive needs. More information is available on our website also.

I will be doing lots of travel this fall giving 3 new presentations. You can find these locations on a new calendar recently added to our website. Go to Lynn Hadaway Associates, Inc and click on the Calendar icon at the top of the page. The presentations are listed by the name of the local chapter that is sponsoring the meeting. The titles of these presentations are:

Stop the Infusion Confusion: Care and Maintenance of Needleless Connectors

Disappearing IV Teams - Justified or Not?

PIV and PICC: Limitations and Alternatives

I will also be giving 3 presentations at the annual conference of the Association for Vascular Access in late September. I hope to see you at a national or local chapter meeting very soon.

Catheter Repair and Infection Risks

2010-05-28T12:29:00.003-04:00

What should be the procedure for managing a Groshong midline catheter when the hub is broken and is completely separated and missing? I found this situation when visiting a patient in home care. The catheter was simply taped to the patient's arm and covered with a transparent dressing. Although the break occurred on the same day that I visited, I am concerned about skin cells constantly shedding and bacteria that have migrated into the opened lumen. I believe that my trimming isn’t enough as organisms may have traveled deeper into the catheter itself and then once flushed, now have a direct migratory route into the vascular system.

I can understand your concern about infection but think we need to review the basic causes of catheter related bloodstream infection. The first source of CRBSI is the skin but not in the way that you have described. On insertion, the skin antisepsis agent and cleaning process will remove about 80% of the organisms. As the catheter passes through the skin, the remaining organisms attach to the catheter by an adhesive substance from the organism. Then they create the slimy substance known as biofilm. About 80-85% of the biofilm is the protective slimy substance and the remaining portion is the organisms. Within the first week of dwell, the catheter has more biofilm on the extraluminal surface.

The other avenue for organisms to enter the catheter is through the catheter lumen. Every time we use the catheter for any purpose, organisms enter and begin the process of creating biofilm. After the first week, catheters have more biofilm on the intraluminal surfaces. You did not mention how long this midline had been in place, but I would suspect that there was already a significant amount of biofilm growing on the intraluminal surfaces of this midline catheter when you found it. While there are no published outcomes of infection rates following catheter repair, my opinion is that your repair would not increase the risk of CRBSI as there is already biofilm present inside the lumen.

My greatest concern would be for air embolism due to this open catheter. You mentioned that this was a Groshong catheter. So one would assume that the internal valve would prohibit air from entering the lumen. However, there is at least one case report in the literature of air embolism from a Groshong catheter. This can occur because fibrin has accumulated on or around the catheter tip and is preventing the valve from closing properly. You also mentioned that the entire external catheter segment was covered by a transparent dressing. If this dressing was totally adherent to the skin, air in the amount needed to produce an air embolism would not enter the catheter. However if this dressing was not totally adherent, air can easily enter the catheter lumen. This was a midline catheter and would have a smaller risk of air embolism than a centrally placed catheter tip, however air embolism from peripheral catheters has been published.

You also did not mention how much longer the therapy was needed. That fact should be considered when deciding to repair or remove and place a new catheter. Your options would be to:

repair the existing catheter, which would require withdrawal to trim the catheter thus changing the tip location
remove the broken midline and insert a new one in a different location
remove the broken midline and manage the remaining therapy with a short peripheral catheter, depending upon the pH and osmolarity of the fluids being infused.

Other factors to consider would include:

the condition of the insertion site and upper arm such as presence of redness, tenderness, and/or edema.
presence of fever or any other signs or symptoms of bloodstream infection or other catheter complication.

Since I was not assessing the patient, I can not tell you which option would be the best. This decision requires knowledge of biofilm and the pathogenesis of CRBSI and a thorough assessment of the patient.

CVC for extremes of pH and osmolarity

2010-03-15T10:03:00.005-04:00

I have been searching for articles that support the practice of using central venous catheters when the drug pH or osmolarity is out of the accepted range. I can find no studies or articles that give me the science behind the practice. In order to have more influence over the physician I need this evidence. Please help.

This is based on animal studies from the 1990's that demonstrated the extreme ranges of both solution pH and osmolarity increased the rates of thrombophlebitis. Those studies are:

1. Kuwahara T, Asanami S, Kawauchi Y, Kubo S. Experimental infusion phlebitis: Tolerance pH of peripheral veins. Journal of Toxicology Science. 1999;24(2):113-121.
2. Kuwahara T, Asanami S, Kubo S. Experimental infusion phlebitis: Tolerance osmolality of peripheral venous endothelial cells. Nutrition. 1998;14(6):496-501.
3. Kuwahara T, Asanami S, Tamura T, Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: An experimental study in rabbits. Nutrition. 1998;14(2):186-190.

Also, go to the very first message I posted on this blog about changing physician's perceptions of infusing Vancomycin.

There are numerous other articles on outcomes of short peripheral catheters that have documented high rates of superficial phlebitis attributed to the irritation of many drugs.

The risk vs benefits of inserting a CVC must be assessed for each patient. When the irritating drug will be required for a very short period, it might not be feasible to insert a CVC. Or if the patient has other risk factors for CVC-related complications, you may be forced to infuse irritating drugs through a short peripheral catheter. When this happens, it becomes nursing responsibility to ensure the following:

1. always use the smallest gauge catheter (e.g. 24 g) in the largest vein possible. This promotes hemodilution in the same manner as the CVC does, although the actual vein diameters and amount of blood flow is much smaller.
2. always avoid areas of joint flexion (e.g. hand, wrist, antecubital fossa) as many solutions with extremes of pH and osmolarity are also vesicant medications that will cause tissue damage if they leak from the vein. Areas of joint flexion have an increased risk of infiltration/extravasation injury.
3. use a manufactured catheter stabilization device to prevent catheter motion inside the vein, a factor that increases mechanical phlebitis.
4. reduce osmolarity by more dilution of the medication if the patient's medical status will allow for the additional fluid. Dilution will not alter drug pH however.
5. frequently assess the site using the OPAL method
O-observe the site condition
P-palpate for induration or other complaints from the patient
A-aspirate for a blood return
L-listen for all patient complaints and do not try to explain away any pain as something that is common with a specific drug.

I wish you success with your efforts to educate physicians, nurses, any other key personnel about this important issue.

Don't Disconnect IV Administration Sets

2010-03-02T11:07:00.003-05:00

My father's recent hospitalization has revealed another serious issue with the ways of managing infusion therapy. The nurse was going to disconnect the IV tubing at a junction along the line so that she could change his gown. I stopped her and insisted that she remove the bag and cassette from the infusion pump and thread the entire system through the sleeve of the clothing. She told me it was ok and "that is the way they always did it." It was midnight following several hours in the ER and my patience was wearing a little thin especially with her explanation. I tried to explain the risk of contaminating the line then finally told her she had to do it my way.

This practice of disconnecting any IV administration set so that it makes changing clothing easier for the nurse is simply too great a risk of contamination. The open male luer end of the tubing and the open female opposite end creates too much opportunity to contaminate these pieces while clothing is loosely moved around. I know this has become common practice but I will never teach that this is acceptable practice and as you can see, will never allow it to be done on me or any family member.

In addition to contamination, there is the risk of accidentally connecting the wrong tubing back to the catheter. There are numerous adverse events including patient deaths from tubing misconnections. To learn more about this deadly possibility, go to Institute for Safe Medication Practices

I would encourage everyone to change this practice especially with the attention being given to catheter related bloodstream infection. There is no amount of accidental contamination that is acceptable - ever! So please thread the fluid container and tubing through the sleeve of the clothing in the same direction as the arm is going. It requires no additional time and is much safer for the patient.

Air Embolism from PICC Removal

2010-02-22T11:08:00.002-05:00

Should the patient be placed in Trendelenberg position for removal of a peripherally inserted central catheter (PICC)? What are the risks of air embolism when a PICC is removed?Are there any research-based statistics on this complication?

I recently finished a literature review on vascular air embolism for a manuscript, so I am familiar with what has been published on all vascular air emboli. First, there are no "research-based statistics" on the complication of catheter-related vascular air embolism (VAE). We know that VAE is associated with insertion, use, and removal of central venous catheters, however the majority of publications are single case reports, animal studies, or general review articles that explain the pathophysiology of VAE. Fortunately, this complication is relatively rare, which makes a well-written policy and procedure so critical to patient management when it does occur.

During catheter insertion, tubing or needleless connector changes, and catheter removal, air can enter the bloodstream. VAE has been documented to occur with all of these procedures. I have not located any case reports of VAE occurring with removal of a PICC, however this does not mean that it has not or can not happen. It just means no one has taken the time to write and submit a manuscript for publication if they have experienced VAE from PICC removal. I am also aware of at least one lawsuit involving VAE with a PICC during the use of the catheter for infusion.

The primary cause of VAE during PICC removal would be the skin-to-vein tract and fibrin sheath, as both can remain intact following catheter removal. All catheters that have been indwelling for long periods of time will have a sturdy skin-to-vein tract that may require some time to close and is dependent upon the patient's healing processes. The fibrin sheath can also be quite strong especially if the catheter has been in place for a long period. The connection of these two points can serve as a conduit for air to enter the circulation once the PICC has been removed. Although not documented with a PICC, it has been reported with another central venous catheter. The line was removed and about 30 minutes later the patient went outside to smoke a cigarette. The deep inhalation drew air into the circulation which was later seen on a scan filling the intact fibrin sheath left by the catheter. So in theory, it can happen with a PICC if the factors all come together correctly - the skin-to-vein tract, the fibrin sheath, standing up and taking a deep breath, and a non-occluding dressing. The chances of all these factors lining up perfectly to cause a VAE with removal of a PICC are probably very small, but it could happen.

The other risk factor for VAE with catheter removal is the catheter exit site in relationship to the patient's heart. Many times we focus on the type of catheter - such as a nontunneled central line or a tunneled central line or a PICC. What we should be teaching is that the catheter's exit site should be at or below the level of the heart for all procedures involving any type of central venous catheter. When the insertion site is in the axillosubclavian or jugular veins, the only way to get this exit site at or below the level of the heart is for the patient to be placed in a flat supine or Trendelenberg position. For a PICC, the patient may not require either of these positions to have the exit site at or below the level of the heart, but this depends upon the point of insertion on the upper extremity. In infants, PICCs may also be inserted in the veins of the scalp or saphaneous vein in the lower extremity. The scalp vein would require a flat supine or Trendelenberg position while the site in the lower extremity would not.

A PICC is a central venous catheter, although many people may not have this understanding. For this reason the nursing care for a PICC should be the same as other central venous catheters. The patient's position for removal is one variation to that rule however. Trendelenberg position is not required for PICC removal as long as the upper extremity can be positioned correctly in relation to the patient's heart. An occlusive dressing, defined as a petroleum-based ointment and gauze, completely covered and firmly secured with tape or a transparent membrane dressing, is required for all central venous catheters including PICCs. This dressing should remain in place until the site has healed or at least 24 hours.

The treatment costs for VAE can be extreme, especially when air moves to the brain and produces severe neurological problems. The patient outcome can include a stroke or neurological deficits that last for the remainder of the patient's life. Pulmonary involvement can mean death with a large VAE. VAE is now on the list of hospital-acquired conditions that will no longer be reimbursed. And catheter-related VAE has been the cause of many lawsuits against hospitals. Prevention of VAE is always the best approach for both clinical and financial reasons.

Studies on Backpriming

2010-02-18T10:53:00.003-05:00

I just read your Nursing2004 article on back priming. It was very helpful to have the technique spelled out so clearly. The pictures were great. I have no bibliography listed for this article. I am specifically looking for a research-based article comparing back-priming with using a new tubing for each new secondary med. Can you give me some guidance?

Unfortunately, this is an area of clinical practice that has received no attention and no research. There are several studies on IV administration sets, but many of them have purposefully excluded any examination of secondary piggyback sets and primary intermittent sets. The remaining studies have included no information about these additional set uses for medication delivery, so we are left to wonder if they did or did not include them. Virtually all administration set studies have looked at the length of time a primary continuous set can be left in use without increasing the risk of bloodstream infection. I am sorry to say but there are no studies, especially studies comparing different methods.

For anyone interested, the article mentioned in the question is
Hadaway L. I.V. Rounds: Delivering multiple medications via backpriming. Nursing2004. 2004;34(3):24, 26.

The absence of studies means that we are left to base practices on general principles of infection prevention. Any time an IV administration set is connected and reconnected, there is concern about several issues. One is how to maintain the male luer end of that set in a protected manner. As you know, the sterile components of all IV sets are the fluid pathway, the spike on the upper end and the male luer on the lower end. When removed from the packaging, both ends are covered with a plastic cap to maintain their sterility. With each use, the sterility of the male luer end must be maintained by adequate covering with either a new blunt plastic cannula or a new sterile dead end cap. It is not acceptable to use the foil package of an alcohol pad or to leave these male luer ends uncovered, yet it is frequently done.

There is another practice called looping, where the male luer end is inserted into a needleless connection higher on the same set. There is no evidence to support this practice and therefore it is not recommended, yet it is frequently done.

The second issue to consider is how well the needleless connectors are being cleaned before each attachment of a set or syringe. While we do not have copious amounts of data, we do have some information showing us that one quick swipe with an alcohol pad is not sufficient. We do have one small study showing that 15 seconds of vigorous scrubbing of all surfaces - top and sides - with both 70% alcohol or chlorhexidine gluconate/alcohol combination products will prevent passage of microorganisms through the connector. So you will need to consider how well your nursing staff performs this cleaning step with each and every attachment to the primary continuous infusion set and/or the catheter hub.

Finally the backpriming method brings up issues of compatibility. It may not work as well in critical care units where there are numerous drugs admixed in the primary fluids. In those situations, normal saline is used as the "carrier" fluid and all secondary sets are piggybacked into this line. All backpriming is done with the normal saline, eliminating the concerns about drug incompatibility.

The bottom line is that current thoughts from experts in the field focus on frequent connection and disconnection as a source of introducing microorganisms into the administration set and/or catheter. These organisms attach to the plastic catheter where they form a biofilm. Breakage of this biofilm with introduction into the bloodstream is what produces bloodstream infection. Therefore we must do everything possible to reduce or eliminate the introduction of these organisms into the system. Keeping secondary sets attached to the primary administration set is considered to be best practice. The backpriming technique facilitates this practice and eliminates the risk associated with connection and reconnection.

Flushing Dual Lumen Catheters

2010-02-18T10:19:00.002-05:00

For patients with a dual lumen valved catheter, we are teaching the patient and primary caregivers to do their own daily infusions of an antibiotic. Our policy states that the valved catheters can be flushed weekly with normal saline when not-in-use. One lumen is "not-in-use." Do we teach the family to only flush it weekly? Or do we teach them to rotate the use of the lumens?

My first thought is that when only a single antibiotic is required, a dual lumen catheter, with or without an integral valve, is definitely not required. There are studies showing that more lumens increases the risk for catheter-related bloodstream infection. The number of needed lumens must be an important part of the pre-insertion patient assessment for their vascular access needs. If your team is only provided with dual lumen catheter, with or without an integral valve, for use in all patients, this is a serious situation that you should work to correct.

On the other hand, this could be a patient that had multiple therapies prescribed when the catheter was placed and a dual lumen catheter was needed. Now that the patient is going home and continuing their own infusions, the issue of how to manage the extra lumen becomes important. This brings up the question of exchanging the dual lumen catheter for a single lumen catheter prior to discharge.

I am not aware of any published evidence to help with answering these questions, so we must examine the risk associated with each option and choose what is best for each patient. When changes in infusion therapy leaves an unnecessary or extra lumen, some will choose the exchange procedure so that the patient only has to manage one lumen. As stated, single lumen catheters have a lower risk of CRBSI because there are fewer hubs to manage. But there are risks associated with the exchange procedure. I am not aware of studies that have examined the complication risks associated with the exchange procedure and there is concern for infection. The exchange procedure must be performed on the external catheter segment that is not sterile. I would consider factors such as the patient's ability to perform the required flushes and the costs associated with those flushes versus the cost and risk of a catheter exchange. Valved catheters may recommend weekly flushes, however nonvalved catheters must be flushed at least once per day with saline and heparin. Also, is the patient immunocompromised and/or hypercoaguable? These factors could increase the risk of catheter exchange making it less of a possibility. If the patient will be receiving the infusion therapy through a continuous ambulatory infusion pump with the nurse visiting daily to change the cassette, the home care nurse can also flush the extra lumen without any problem.

That still leaves us with the question of how to manage the extra lumen when a single lumen catheter has not been chosen and an exchange is determined to be a greater risk than managing an extra lumen. Again, we must look to the evidence and I am afraid there is not an evidence-based answer to this question. All valved catheters are flushed with saline only and the frequency can be no more than weekly according to some manufacturer's instructions for use. You should always know what is recommended by the manufacturer of the specific catheter in use. Some think that alternating lumens for the antibiotic infusion will reduce the risk of CRBSI because of exposing both lumens to the antibiotic. This concept conflicts with what is known about biofilm. Infusing antibiotics do not penetrate the intraluminal biofilm and would make no difference in the risk of CRBSI. So there truly is no answer for this question and I would say that both practices are acceptable. You can use one lumen dedicated for infusion and only flush the extra lumen weekly with a valved catheter, at least daily with a nonvalved catheter. Or you can alternate the lumens for infusion. We simply do not have any data upon which to decide which is the best method.

Best of all would be to choose the number of lumens based on the patient's infusion needs from the beginning. But as we have discussed prescribed therapy can change. The choice of lumens is based on what is the easiest for the patient and caregiver to perform.

Therapeutic Phlebotomy from a VAD

2010-02-04T10:17:00.004-05:00

The 2006 Infusion Nursing Standards of Practice states, "PICCs, midlines, tunneled catheters, and implanted ports should not be used for therapeutic phlebotomy.” P. S72 What is the reason for this standard and why are nontunneled percutaneous catheters not listed?

The primary reason for not using these catheters for therapeutic phlebotomy is that when this edition of the standards was written there was no published evidence about experience with using them for that purpose. Without evidence, the committee could not make any standards or practice criteria about this practice. Since that time, there may be published evidence now. The actual success rate for this procedure was then and may still be unknown. The standards are in the revisions process now and the committee is taking a hard indepth examination of all published evidence for the entire document.

The concerns for this procedure include the fact that patients in need of therapeutic phlebotomy have very thick, viscous blood flow. This fact coupled with the internal diameter of the catheter in place could reduce the chance of withdrawing the needed volume of blood. It could also shorten the life of the catheter due to attachment of plasma proteins and increasing risk of thrombotic occlusion. The length of these catheters will also add resistance to blood flow, thus increasing the challenge with this procedure. The risk of infection and thrombosis was not known when the current standards were written.

The reason for excluding nontunneled percutaneous central venous catheters was that they are usually not considered for this procedure. Patients requiring this procedure are usually chronic patients, not an acute care patient where the majority of nontunneled percutaneous CVCs are used.

I just did a quick search on PubMed using the search terms "therapeutic phlebotomy" which resulted in over 3000 articles listed. I narrowed the search by using "therapeutic phlebotomy and polycethemia vera". I looked at the titles of 100 articles back to 1998 and none included any indication that the article was about doing the procedure from any type of catheter. For course this simple method is not a complete literature search and some of those articles may contain some information about the procedure. Studies may be published but not indexed on PubMed. But I did not find any articles with the primary purpose of research on using any type of catheter for this procedure. Again another but - I do know that others have successfully done this procedure from implanted ports and tunneled catheters. If the catheter is placed for this purpose, they choose catheters with large internal diameter and use a very large gauge port access needle. The downside to this practice is that the port septum will not last through as many punctures when large gauge needles are used. I also think that the internal diameter of a PICC or midline catheter is far too small to be successful with this procedure.

Sorry I can not be more specific about this topic but we simply need more evidence about clinical outcomes.

Heparin lock for neutral displacement needleless connectors

2010-02-03T10:55:00.004-05:00

We are hard on the trail for definitive and current research/evidence for using/not using heparin flushes with our PICC lines. We are going to one brand of neutral displacement needleless connectors which the manufacturer advertises as being able to eliminate heparin flushes. We need to be directed to the research which supports this, could you help us out?

Please note that I have removed the brand and manufacturer name as I only respond in a generic manner. I do not think you will find any definitive research that you are seeking simply because it has not been done. I also do not believe that it is acceptable to totally eliminate heparin locking solutions from the care of central venous catheters. Saline is used for flushing the catheter and low dose heparin is used for locking the catheter when the infusion is complete. The concentration should be heparin 10 units per mL according to the Flushing Protocol Cards published by INS.

The published evidence that I have found on this issue is not definitive at all. Some say they have the same outcomes with saline locking and heparin locking while others reported more negative outcomes with saline locking. The following is a list of articles I have found:

Stephens L, Haire W, Tarantolo S, et al. Normal saline versus heparin flush for maintaining central venous catheter patency during apheresis collection of peripheral blood stem cells (PBSC). Transfusion Science. 1997;18(2):187-193.

Schilling S, Doellman D, Hutchinson N, Jacobs B. The impact of needleless connector device design on central venous catheter occlusion in children: A prospective controlled trial. Journal of Parenteral and Enteral Nutrition. 2006;30(2):85-90.

Jacobs B, Schilling S, Doellman D, Hutchinson N, Rickey M, Nelson S. Central venous catheters occlusion: A prospective, controlled trial examing the impact of a positive-pressure valve device. Journal of Parenteral and Enteral Nutrition.

Rotello LC, Albrant D, Purcell T, et al. INCIDENCE OF TRIPLE LUMEN CATHETER AND PORT OCCLUSION UTILIZING NORMAL SALINE FLUSHES.Chest. October 1, 2007 2007;132(4):493a-.

Cesaro S, Tridello G, Cavaliere M, et al. Prospective, randomized trial of two different modalities of flushing central venous catheters in pediatric patients with cancer.J Clin Oncol. Apr 20 2009;27(12):2059-2065.

Bowers L, Speroni K, Jones L, Atherton M. Comparison of occlusion rates by flushing solutions for peripherally inserted central catheters with positive pressure luer-activated devices.Journal of Infusion Nursing. 2008;31(1):22-27.

I do not think any of these have studied the neutral displacement devices. Your only hope of evidence right now would be to trial the chosen product and collect outcomes on lumen occlusion and infection from your patients. For a thorough explanation of the design and the differences between the types of needleless connectors, I would refer you to the Jan-Feb issue of the Journal of Infusion Nursing, Volume 33, No 1, page 22-31. This article is not listed on PubMed yet so I can't link you to it.

No blood waste with IV medications!

2010-01-25T19:22:00.003-05:00

When giving an IV medication through a central venous catheter, should the heparin lock solution be withdrawn and discarded along with 3 to 5 mL of blood? This is recommended by some hospitals to get rid of the heparin. Is this necessary? Is there a maximum amount of heparin that can be given in a 24 hour period?

No, there is no need to withdraw 3 to 5 mL of blood and discard it to get rid of the heparin lock solution. This is done with hemodialysis catheters when the dose of heparin used to lock these large lumens can range from 1000 to 5000 units per mL. This can easily result in anticoagulant dose with either the initial locking procedure or if the residual volume was to be flushed into the bloodstream. However, the concentration of heparin lock solution for all central venous catheters should never exceed more than 100 units per mL. This low dose means that you do not need to withdraw and discard any volume of blood.

In fact, withdrawing that amount of blood with each medication dose can easily result in nosocomial blood loss and iatrogenic anemia. This is a well documented problem in critical care patients when blood samples are frequently taken from the catheter for lab tests. So the practice of discarding even a small volume of blood with each dose of medication should be stopped immediately. Blood transfusions are often needed because of iatrogenic anemia and this is a problem that can easily be avoided.

The maximum amount of heparin lock solution in a 24 hour period depends upon the patient and their individual coagulation factors. The current Infusion Nursing Standards of Practice states that the dose of heparin for locking should not alter the patients coagulation factors. This document was written in 2006 and is in the process of being revised now. In 2008, the Infusion Nurses Society released a set of cards with Flushing Protocols for all types of catheters, therapies, and ages. These cards called for the use of heparin lock 10 units per mL for central venous catheters. There is no evidence that the higher concentration of 100 units adds to catheter patency, thus the recommendation to reduce to 10 units per mL. The only time that heparin 100 units per mL is now recommended is for de-accessing implanted ports. These Flushing Cards can be ordered from Infusion Nurses Society

Competency for PICC Removal

2010-01-21T17:45:00.002-05:00

We have identified a core group of 7 nurses for training on PICC removal. Is this enough? Should we train other nurses? What is the number of removal procedures required to maintain competency with this task?

I have just been through the published literature on competency assessment. I know nurses want to be told a "magic number" of procedures that will ensure they remain competent, however that number is just not known for any procedure. I have not found any recommendations on a specific number of times that a procedure should be performed to be considered "competent".

Also, I can not determine if this small group of only 7 nurses will meet the needs of your hospital. That will depend on numerous variables such as how many patients you have, how many PICCs are inserted and removed at your facility, where those nurses will be working and where the patient in need of a PICC removal will be located, plus numerous other issues.

Each hospital must make the decision about the number of supervised procedures required for initial competency with 3 to 5 being the most common. On going competency is determined by outcomes. So you should have a mechanism for tracking what happens to these catheters. How many are discharged with the PICC in place, with removal to be done by home care? How many are removed when there is no longer a clinical need for it such as end of therapy? How many are removed for a complication? Who is assessing for those complications? Who is managing those complications? Who is working to prevent those complications?

While this approach may work for your hospital, it is not one that I have much confidence in working very well. It forces the nurse into a task-oriented technical role. It ignores the other issues that will arise during the life of that PICC. Insertion requires less than 1 hour, but what happens to that catheter during the days, weeks, months or years of its use will have the most impact on the outcome for the patient. This is why the services of infusion nurse specialist are needed.

Tourniquets for PICC Fracture

2010-01-21T17:30:00.002-05:00

In the past I've heard that when a PICC breaks, one should apply a tourniquet to the affected extremity with the PICC to prevent a segment of the catheter from moving into the patient circulation; yet I've also heard this can be dangerous and is not evidence-based. My organization is also considering implementing this as a practice. Any sources to share on that?

All I can share is the rationale for this practice and when I think it is best to use. When the nurse suspects that a PICC has fractured, a tourniquet should be placed high on the extremity. The reason is so that compression from the tourniquet will prevent the fractured PICC from embolizing to the right heart or pulmonary artery. A simple cutdown procedure on the extremity is far less invasive and risky than a large-bore snare device inserted through the femoral vein and advanced to the right heart under fluroroscopy in the hopes that one can snare the fracture catheter and remove it.

This tourniquet should not be tight. You should always be able to feel the radial pulse with application of any tourniquet as you are not trying to cut off the arterial circulation. This tourniquet should not be removed and the patient needs immediate diagnostic and surgical services to locate and remove the catheter fragment from the extremity.

If the nurse is not present when the fracture event is suspected, a tourniquet probably will not do any good. For instance, if the patient is flushing the catheter at home and feels something "snap", the chance of successful application of a tourniquet is very low. By the time the nurse gets to the patient or the patient gets to an ER, the fractured catheter has already embolized.

So it really is a decision based on the specific situation for each patient. If there is anything that can be done such as a tourniquet to hold the PICC in the extremity, that is the goal. Of course, it may be far too late by the time the nurse is present.

Optimum Dwell Time for PICCs?

2010-01-21T17:18:00.002-05:00

Is there a recommended dwell time for PICCs? I know the current INS Standards state the dwell time for PICCs is unknown. Is there anything else on that subject? My workplace is considering mandating changing a PICC when it has been indwelling for 1 year, but I've never heard or read of such an arbitrary practice for any central line. This would apply to PICCs that are functioning well without any clinical issues.

No, there are no studies that have established the optimum time for removal of a PICC that is functioning without any problems. Actually we only have this information for short peripheral catheters, but not for any other type of catheter including PICCs.

To establish this recommended length of dwell, we would need studies that have examined the length of dwell time in a large number of patients compared to when and why those catheters were removed. The common analytical method for this calculation is known as the Kaplan-Meier Product Limit Estimator.

Studies on short peripheral catheters have used this method, however I am not aware of any studies on PICCs or CVCs that have made any attempt to calculate this point in time. This method specifically looks at the failure rates such as the point in time when 50% of catheters have failed from a catheter-related reason such as a complication.

You mentioned the INS standards of practice as the source for this. Actually the first source was and still is the CDC guidelines. Both documents are in the revision process now. I am not sure what the final content will include, however I do not think that any specific time period can be established because we simply do not have the data.

Prefilled syringes for catheter flushing

2010-01-18T14:00:00.002-05:00

I am looking for evidence to support using pre-filled syringes for flushing. I work for a small company that provides infusion education for long term care pharmacies servicing nursing homes. One of our clients wants to step back from using the pre-filled saline and heparin syringes and have the nurses use single dose or multi-dose vials of saline and heparin. The consideration I am sure is the expected cost savings they hope to realize from the use of vials vs pre-filled syringes. I haven't researched this for a long time but feel that it is not good practice, that it sets the nurse up for potential failure, and puts the patients at risk for infection.

You are absolutely correct! Going back to using multidose vials or large bags of saline for obtaining solution for catheter flushing is not good practice. The following organizations now make statements about using a single-dose flushing system:
1. Infusion Nursing Standards of Practice from Infusion Nurses Society
2. Institute for Safe Medication Practices (ISMP)
3. Centers for Disease Control
4. Joint Commission

There have been numerous outbreaks of infection from the incorrect use of multidose vials for catheter flushing. Also use of 250, 500 or 1000 mL bags of saline have been responsible for many outbreaks of infection. I have analyzed these reports and reported on then in past publications. Click here to obtain pdf documents of those articles. This page is a list of past articles in this newsletter. Look for the following:
Vol. 4, No. 2. Flushing vascular access catheters: Risk for infection transmission
Vol. 4, Nov 4. Misuse of prefilled flush syringes: Implications for medication errors and contamination.

These articles contain a long list of references of these infection risks.

You also must consider the costs of nursing time to fill these syringes. Learn the hourly rate of pay for nurses performing catheter flushing procedures. Divide this by 60 minutes to get the rate of pay per minute. The difference in time to prepare a saline or heparin-filled syringe with the required labeling is 1 minute and 11 seconds greater than using a prefilled syringe. If there are many flushes to prepare, this time difference will add up to significant amounts of nursing time that is better spent on other nursing activities. Why should nurses be expected to perform these tasks when it can be done in an automated system for less expense? So prefilled syringe are actually less expensive. And I do not accept the argument that the nurse is in the facility and working so you can not incorporate nursing time in this calculation. We know that nurses actually work unpaid overtime because of strict rules. With the unreasonable loads of work on nurses in many institutions, it makes no financial sense to expect nurses to fill these syringes, especially when their technique can increase the risk of infection.

So in my opinion, prefilled syringes of normal saline and heparin lock solution is the only appropriate method that makes clinical and financial sense to me.

Trimming PICCs

2010-01-04T16:35:00.002-05:00

What is best practice for inserting PICCs in children in regards to cutting the catheter? Is it acceptable, not advised or restricted? We have a nurse practitioner inserting PICCs in children up to 6 months of age who is stating that it is an "INS standard" not to cut the catheter. I cannot reference that anywhere - wonder if it may have been a manufacturer's instruction? Does is dependent upon insertion site? What is your position on this issue?

While the Infusion Nursing Standards of Practice do not use the word "cutting" the catheter, it does imply that this is not best practice. Go to page S39 Standard 38 Catheter Selection, Practice Criteria Section III Peripherally Inserted Central Catheter (PICC). The first statement is, "The length of the selected catheter should allow for appropriate placement without alteration of tip integrity; caution should be used and manufacturer's labeled use(s) and directions should be strictly adhered to when tip alteration is required."

So can you physically cut the catheter at the bedside without altering the integrity of the tip? According to work published by Janet Pettit, all tips have jagged edges or irregular pieces coming off the tip when it has been cut. Here is the complete reference:

Pettit J. Trimming of peripherally inserted central catheter: The end results. Journal of the Association for Vascular Access. 2006;11(4):209-214.

This journal is listed on Ingenta.com and CINAHL.com, but not on Medline or PubMed yet.

This article used high powered microscopes to examine the tips after cutting with various cutting tools. The study clearly showed that there are uneven edges both before and after cutting. It is possible to think that uneven edges could increase the risk of vein thrombosis but there is no clinical data correlating cut catheters to the incidence of vein thrombosis yet.

We do not live in a "one-size-fits-all" world. So when you can choose a catheter length that does not require trimming, that would be the ideal situation. But that specific length is not going to be available for every patient. This risk of cutting must be weighed against the benefit of having a catheter length specific for that patient's needs. Extra external catheter length means that it will be difficult to manage the dressing and could increase the risk of infection if this catheter becomes pulled in or out of the vein. Neither situation is good. So you must choose the approach that presents the least risk for each patient.

Personally I have never liked the idea of cutting catheters at the bedside because I have serious concerns about the integrity of the tip being created. Until we have more clinical data, this issue remains unresolved.

Dopamine extravasation management

2010-01-04T16:05:00.002-05:00

We have had a Dopamine extravasation. The pharmacy says that Regitine has been recalled. Any suggestions on how to treat this?

The brand name, Regitine, is no longer on the market and it was in very short supply for a while many years ago. The original manufacturer was acquired by another company and I do not know the exact reason for their decision, however I do not think it was a true recall of the medication.

While this brand name is no longer available, there are generic equivalants for phentolymine that are available. So this drug is still being used to manage extravasation injuries for many of the vasoconstricting drugs such as dopamine. You can learn more information at
http://pubchem.ncbi.nlm.nih.gov/summary/summary.cgi?cid=5775
This site list several manufacturers.

Happy Holidays to All!

2009-12-21T19:06:00.002-05:00

All of us at Lynn Hadaway Associates, Inc. wish you and your family a very happy, healthy, and safe holiday season.

I know that I am very far behind at answering your clinical questions. My excuse is that I have been buried with work on revision of the Infusion Nursing Standards of Practice. I will plan to take a short break over the holidays and then get back to work with many projects and new products. Our best wishes for you in the coming year and I look forward to more communication with you about your issues and concerns with infusion therapy. Thanks, Lynn

When to Insert a PICC for Endocarditis?

2009-11-22T14:57:00.003-05:00

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.

Dressing Alternatives for Central Venous Catheters

2009-11-22T14:40:00.002-05:00

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.

Multiple attempts for 1 PICC introducer?

2009-11-11T11:15:00.002-05:00

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.

Low dose tPA by infusion

2009-11-11T10:55:00.002-05:00

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.

How Much Heparin for Locking a Catheter?

2009-11-02T13:48:00.002-05:00

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.

Syringe Size for Heparin Locks

2009-10-21T13:11:00.003-04:00

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!

Family Present During PICC Insertion?

2009-10-20T13:18:00.002-04:00

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.

Treatment of Phenytoin Extravasation

2009-10-14T11:07:00.002-04:00

Can you please recommend an authoritative resource that indicates the standard of care related to the application of warm, dry heat, cool or cold compresses to an extremity post phenytoin (Dilantin) extravasation? Unfortunately, I cannot find a clear consensus on this issue and am trying to revise a nursing competency.

There is no such authoritative resource available at this time. I do applaud your efforts to get such a protocol in place because making these decisions when an event has occurred is never the best approach. So your decision-makers must assess the published evidence and make a collaborative decision.

The use of heat in any form will cause local vasodilation, increase the circulation and thus spread the extravasated drug into contact with more tissue. The use of cold would cause vasoconstriction, limit the amount of tissue in contact with the drug, but allow the highest concentration in the affected tissue. Neither are good options so thermal manipulation in either direction may not be the best choice.

We know that phenytoin is a vesicant medication, one that will cause tissue necrosis if it leaks from the vein. If this occurs, immediate surgical treatment to wash the drug from the tissue may be the best option. You can also try immediate local injection of hyaluronidase to encourage reabsorption of the drug. You can find the most recent literature review in Doellman & Hadaway

The best approach is to eliminate the use of IV phenytoin totally to prevent these events from occurring. Generic brands of fosphenytoin are now available that are cheaper and without the same level of risk associated with phenytoin. Many facilities have switched to this approach. If IV phenytoin must continue, it is nursing responsibility to use all interventions to prevent extravasation injury. This must include:
1. use of the smallest gauze catheter in the largest vein possible to allow greater hemodilution of the drug. Many have the mistaken idea that a larger catheter produces less risk, but there has never been any evidence to support this concept.
2. never use a vein in an area of joint flexion including the hand, wrist or antecubital fossa.
3. never use a catheter that is greater than 24 hours old because the risk of mechanical damage is present which is then compounded with chemical damage.
4. constantly monitor the site during the complete injection or infusion of the total dose including aspirating for a blood return every 1 to 2 mL, assessing the quality of a free-flowing gravity infusion, instructing the patient to inform the nurse of any feelings of discomfort at the site.

Breach of Policy, Potential Infection Risk for 1800 Patients

2009-10-07T16:02:00.004-04:00

News media in south Florida are reporting an investigation of the actions of one nurse that may have put more than 1800 patients at risk for bloodborne diseases. The nurse who worked in a cardiac stress test lab was starting I.V. infusions prior to the drug-induced stress tests. Following the test, she was detaching the catheter and short extension set and reusing the remaining IV fluid and attached set on the next patient.

Broward General Hospital questioned the nurse following an anonymous report of her actions. The nurse said she knew the risk of reusing supplies and there is no explanation given for her total disregard of basic nursing procedures. The hospital began testing these patients for evidence of bloodborne diseases, requested a police investigation and suspended the nurse who resigned the next day. More information is available at Sun Sentinel newspaper and a Miami TV station.

This case raises many questions for me. What training had the nursing staff been given about the risk associated with this practice? What was the rationale for this nurse's behavior? Was there some aspect of the hospital culture or system that drove her to think this was acceptable? Why was it allowed to continue for almost 6 years? It will certainly be interesting to follow this case to learn more details. It also highlights the need for extreme vigilance with infection prevention procedures with all IV supplies and equipment.

All supplies can only be used on a single patient and discarded. Single dose containers are also required for something as simple as catheter flushing. If a multiple dose vial must be used, it should be dedicated to a single patient. Also, fluids and tubing should only be opened within one hour of their intended use. So attaching the set and priming for use the next day is an infection risk. The goal is now infection prevention, not just the control or limitation of infection. The only acceptable rate is zero!

Growing Need for Evidence-Consulting Services to Help

2009-10-06T15:14:00.003-04:00

The number of requests for evidence is growing! I know the importance of basing your clinical decisions on the available evidence. I also know this requires time to find that evidence and most nurses do not have the time to invest in the time for searching.

That is where we can help. We can provide these references or the published evidence to directly address your questions, however we can not offer this as a free service. We currently have an article database of 7000+ articles about infusion therapy, vascular access, and all related components. We constantly scan the literature for new evidence as it comes available. So we have the resources to meet your needs.

We can arrange consulting services at many levels such as:

education courses designed to meet the needs of your staff - either online or in a traditional classroom. Click here to see what courses are available.
a project fee based on a detailed understanding of your organization's needs
a small monthly retainer fee for ongoing needs for the specific number of months you need. 5 hours/month of consulting time for $1100 per month; 10 hours/month for $2200. This arrangement is a 20% discount from our hourly rate.

The purpose of this blog is to share information with all who read it. We will continue to address issues on the blog under the following guidelines:

Clinical questions can only be received by email.
Questions will be answered in the order in which they are received.
All answers will be written to address the widest range of interest.
We do not have a rigid schedule for adding new post, but make every attempt to post at least 3 per week. The length of time required to answer your question depends upon scheduled work for our clients, other projects, and travel.
We can not respond to patient-specific, urgent requests on this blog. Those services are available with a retainer agreement.
List of references to address a specific clinical question or issue can not be provided as a free service, but are available with all education courses, and through a retainer or project agreement.

I understand how important the evidence is for making your decisions. We can meet your needs. Just call our office tollfree - 1-866-358-7861 or email me at lynn@hadawayassociates.com to discuss your issues and goals.

Signed Consent for CVC?

2009-09-28T13:42:00.002-04:00

Do you know if critical care areas or ER may insert a CVC as 'part of the care'? I know that a physician can make this decision when the patient is unable to sign a consent form but it would seem to me that all CVC insertions require some form of written consent?

The first place you should turn to is your hospital's risk management department. Many risk managers now have the position that a PICC and other percutaneous CVCs have become such a routine practice that it is covered by the general consent signed on admission. Others still support the use of a separate piece of paper signed by the patient or family for any CVC insertion. There could also be a difference between a percutaneously inserted CVC versus a surgically inserted CVC such as a tunneled cuffed catheter or implanted port.

It is critical to understand that the term "informed consent" is not well understood by all healthcare professionals. So make sure everyone is using this term in the same manner. This is a process that begins with thorough education of the patient, family or significant others. It may end with the operator having the patient sign a piece of paper, however this piece of paper is only one small step in the process. So all CVC insertions would require informed consent - the patients thorough understanding of the what, when, why, and how along with risk, benefits and alternatives. All education provided should be documented along with patient comments and your assessment of their understanding of the information. The need for a signature on a piece of paper is directed by your risk management and any applicable laws in your state.

When to Begin Use of CVC

2009-09-28T13:06:00.003-04:00

Our old policy states that a central venous catheter maybe use for up to 24 hours with a physician's order (pending tip location confirmation) provided "there was blood return". I noted on your blog that you indicate its a 'national standard to avoid the use...till there is adequate confirmation of tip location'. I wondered if you could direct me as to where I could find that written to support changing our policy....I suspect you would say it was not a good policy to leave as it has existed. I know that in practice nurses 'wait' for verification of placement and I certainly support this practice.

Yes, I would agree that this policy must be changed! The authoritative document that guides nursing practice is the Infusion Nursing Standard of Practice from the Infusion Nurses Society, http://www.ins1.org. This document is written for all nurses performing any infusion therapy in any setting. It is one of the most important documents used when writing policies and procedures and also during the legal process of a lawsuit. The contents applies to all nurses, not just the infusion nurse specialist.

In Standard 42 Catheter Placement, on page S42 you will find:
42.4 Central vascular access devices shall have the distal tip dwelling in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium. Those central vascular access devices using the femoral approach shall have the distal tip dwelling
in the thoracic inferior vena cava above the level of thediaphragm.
42.5 Central catheter tip location shall be determined radiographically and documented prior to initiation of the prescribed therapy.

This standard is followed by many nursing and medical references.

It is also important to obtain complete anatomical information from the radiology department about exact tip location. "The catheter is in good position" or "the catheter is ok to use" is not sufficient. The nurse must have knowledge that the tip is correctly positioned. This means the radiology department should be saying something like, "the catheter appears to be in the lower SVC" or "the catheter tip is located 4 cm below the right tracheobronchial angle". They will not ever be able to guarantee that the tip is at the SVC/RA junction based on a chest xray, but they should be providing some language to indicate that the catheter is positioned correctly.

I have seen many times when physicians would say that a catheter was in good position and the IV team would start to use it to discover the next day from the written report that the tip was in the internal jugular vein with the tip pointing toward the head. Aberrant tip locations can mean much higher rates of complications such as thrombosis. Tips located in the IJ can lead to a retrograde perfusion of the intracranial sinuses leading to neurological complications. I remember one patient with this situation who was also prescribed to received IV phenytoin. Of course, the IV team refused to allow further use of this catheter until it was repositioned. And yes, I have had physicians scream at me for holding the line on this but it is a matter of patient safety.

The presence of a brisk blood return is important each and every time the catheter is used, but it will only tell you that the catheter is in a blood vessel. In addition to the IJ, the catheter can be located in the contralateral subclavian vein, or any number of smaller tributary veins joining the axillosubclavian or brachiocephalic veins. And there is the possibility that it can be placed in the artery instead of in the vein. The xray will show all of the locations.

Your policy should reflect the best practice, so it definitely needs to be rewritten. Along with the INS standards, your written policies will be examined during a lawsuit as well. An infusion nurse expert working for the plaintiff or patient would have a great resource to support negligence with your policy as it is currently written.

New technology has been introduced in the US that uses blood flow and ECG information to tell when the catheter is at the cavoatrial junction. This technology has a great chance of replacing the standard chest xray, however the national standard is still a post-procedure chest xray.

Criteria of Central Venous Catheters

2009-09-25T13:46:00.002-04:00

Do you know if any of the national associations, such as INS, AVA, and/or CDC have any criteria for insertion of central lines?

I am not aware of any separate documents with this criteria listed from any organization. You can find the information in the new edition of the INS textbook though. The chapter is #24, Central Venous Access Devices: Access and Insertion by Melody Bullock-Corkhill, BSN, BS, MS, CRNI. The textbook title is Infusion Nursing: An Evidence-Based Approach published by Saunders/Elsevier. Click here to link to it online.

Occluded PICCs in Neonates

2009-09-24T14:56:00.004-04:00

We have had 12 clotted PICCs in the last 3 months in the intensive care nursery. These have been either 1.9 or 2.8 Fr PICCs and each one had heparinized parenteral nutrition infusing, then suddenly the line occluded. Any suggestion on how to solve the issue?

I am assuming these PICCs were all placed in neonates. While I can not provide definite answers with the limited information provided, I can give you some questions to pursue and other information to gather. Catheter occlusion can be from many causes and they fall into 3 categories - thrombotic, drug precipitate and mechanical.

Were they all term infants or were some very small fragile premature infants? Where was the catheter inserted and where was the tip location? Suboptimal tip locations lead to vein thrombosis which can occlude the catheter tip. Also what was the hydration status of these babies? Fluid volume deficits also add to the risk of vein thrombosis. How was the catheter stabilized? Catheter movement leads to vein trauma that produces thrombosis.

How long had these PICCs been in place? How long had they been used for parenteral nutrition infusion? Were they also receiving infusions of fat emulsion? Were these lines also used for piggybacking other medications into the infusing parenteral nutrition solution? Were these infusions all continuous? Were the infusions ever stopped and disconnected for any reasons? If so, how were the lines flushed and locked during this period?

Your first step would be to assess everything that was infusing or injected through these lines in the period leading up to the problem. Look at the complete history of the catheter's performance. Based on this assessment, you may have some information to point you in the direction of the cause. Is it more likely to be thrombotic? If so, is it inside the catheter lumen or inside the vein around the catheter? Did you try any type of thrombolytic agent in the catheter? What was the outcome?

Small internal diameter catheters will have a longer length of catheter affected by blood reflux. The lumen is smaller so the same amount of blood will move farther into the catheter. The same amount of blood will move for a shorter distance on a catheter with a larger lumen. So any blood reflux can create a problem. What is the mechanism of the infusion pump being used? Is there any short delay in the pumping cycle that will allow for reflux? Did the pump have any alarms leading up to the sudden occlusion?

If these lines have other medications piggybacked into the parenteral nutrition infusion, I would suspect lumen occlusion from incompatibility. Fat emulsion can also cause lipid accumulation on the catheter walls.

Was there ever any leakage from the puncture site? Were they easily flushed? What was the quality of the blood return from the catheters before the occlusion? Were these lines removed? If so, could you detect anything inside the lumen?

To solve the mystery, you will need to look at all these factors and I have probably overlooked something.

VAD Insertion In Unstable Patients - Who, What, and When?

2009-09-24T14:23:00.002-04:00

I am writing to ask your help in finding resource(s) to support our desired practice, e.g. having the physician place a central line in patients who are in crisis (e.g., cardiac arrest, active GI bleeding, hemodynamically unstable, etc.). We are finding that often the physician will give an order for a PICC to be placed in these patients instead of placing a line themselves. Is there evidence based practice out there?

The best answer that I can give you is that the services in your hospital must be organized to provide the most appropriate vascular access at the time it is needed. Your examples include some situations where time is critical to the successful resuscitation of the patient. Are you really saying that during a cardiac arrest, a physician will call for a PICC to be inserted? This does not make sense because the infusion nurse specialist is not readily available at the patient's bedside and the procedure can be time consuming. These delays could cause patient harm by seriously delaying the infusion of life-saving drugs. During crises such as this, a short peripheral catheter is the cheapest and fastest, IF the patient's veins are not severely compromised. Often it is impossible to find a peripheral vein and a central venous catheter must be rapidly inserted. Insertion of either a peripheral or central catheter during an emergent situation will not allow time for proper attention to sterile technique. The CDC Guidelines and the Infusion Nursing Standards of Practice state that these catheters MUST be removed as soon as the patient is stable or within 48 hours. These catheters carry a much greater risk of bloodstream infection. By the way, many people want to apply that statement to catheters inserted by the EMS before the patient gets to the hospital, but this is not correct. It applies to all types of catheters inserted in any location under circumstances that prohibit the complete sterile procedure.

In the other situations you mentioned such as bleeding or other causes of hemodynamic instability, a short peripheral catheter may already be in place, however the patient needs indicate a more stable form of vascular access. In those cases, there would be time to insert a PICC under the recommended conditions for sterile technique. The next challenge would be to have a nurse from your team readily available to those patients when the need arises. Your service should be structured so that you can meet the needs of these patients. This is a huge challenge to those teams that are very short-staffed and overloaded with planned or scheduled insertions. But I think you can see that the needs of all patients must be met. PICC insertion offers the least risk of insertion complications and is probably the most appropriate choice for these patients.

The purpose of this blog is to provide input to the questions I receive. While doing that, I am often able to provide links to applicable publications, however I can not conduct a complete literature search to provide an evidence-based answer to clinical questions. That service is available through a contract with your facility. I can not quickly point you to any evidence other than what I quoted above from the CDC and INS. Evidence-based practice is needed to answer these questions and that begins with a thorough literature search. Please let me know if you are interested in contracting for those services.

FDA Acts on Promethazine Risks

2009-09-22T18:35:00.002-04:00

The FDA has finally released notice about a new black box warning for promethazine hydrochloride (Phenergan). Click here to read the full report.

This warning is long overdue. I have reviewed far too many medical records with serious outcomes associated with promethazine given IV. To read my recommendations for the safe administration of this drug, click here.

I know of many hospitals that have written new policies creating a better approach to all antiemetic medications. Regardless of the approach chosen, the IV administration of promethazine should be reduce, if not eliminated totally. If it can not be eliminated, it remains the nurses responsibility to ensure that it is given safely. So please know the serious risks and ways to properly reduce those risks.

Smallest Catheters in the Largest Vein

2009-09-22T17:47:00.003-04:00

I was called to the ER for a "hard start" on a pt. that was going to receive Vancomycin and they weren't sure what her next course would be.....surgical consult, admission, etc. Blood cultures had already been drawn. When I arrived in the ER the nurse said "I need at least a 20, an 18 would be better because I need to give her Vanco." I asked for clarification and indeed Vancomycin was all that was ordered. I explained to the nurse that the best course would be the smallest catheter appropriate in the largest vessel to aid in hemodilution of the vancomycin since it is an irritant to the vein. She disagreed and deferred further questions the the ER DR. He too said that he would prefer an 18 for the Vanco, but would be ok with a 20. He then stated that if all I could get was a 22gauge, then he would order a different antibiotic. I then asked for clarification mentioning the same as above in regards to the hemodilution,etc. He said " I just won't put Vanco. in anything less than a 20." Upon further evaluation, I discovered that this seems to be the way of thinking with all of the ER nurses and DR.s and many of the ICU/PCU nurses as well. What evidence is there is support the concept of the smallest gauge catheter?

First, let me emphasize that you are totally correct - the smallest gauge catheter in the largest vein possible is the correct approach to this situation. I do not know why or where this attitude comes from, however I have heard it before. Those with this position mistakenly think that a larger catheter is required to ensure stability within the vein. This could not be more wrong!

I would direct you to the very first message I posted on this blog Changing Physicians Perceptions of Vancomycin.

Additionally you should look at the literature on phlebitis. Maki published a good study on phlebitis many years ago that identified that large gauge catheters have a greater risk than smaller sizes.

You should expect other healthcare professionals to share their evidence to support a difference of opinion. I doubt they can support this opinion with evidence.

The studies on outcomes with short peripheral catheters leave a lot of questions yet to be answered. And there are numerous factors to be considered, but I would not be bullied to make a choice that I know will put your patient at risk.

I also find it extremely strange that the physician was so willing to change the order for antibiotics if you would not place a large size catheter. That makes no sense to me. Why did he prescribe Vancomycin in the first place? Why the willingness to change? If the patient's diagnosis did not indicate a clear clinical need for Vancomycin, it should not be prescribed. There is a huge amount of evidence about the inappropriate use of Vancomycin.

Using 2 needleless connectors??

2009-09-04T13:45:00.003-04:00

Have you ever heard of putting a positive pressure device (PPD) at the end of a midline or PICC and then attaching an extension tubing with a PPD at the end of the PPD on the midline or PICC? I recently heard rationale that since the extension tubing is changed q 72 hrs, not having to completely open the system when changing the extension tubing reduces the risk of infection/air embolism/bleeding. The PPD on the end of the extension tubing would be changed with the extension tubing q 72 hrs, while the PPD on the end of the midine or PICC would be changed q 7 days. We have been connecting the extension tubing directly hub to hub and I am wondering if this is not the safest practice for our clients.

First, lets get the terminology correct. There are NO needleless connectors of any type that exert any amount of pressure inside the catheter lumen. So these are not positive pressure devices. They are positive displacement devices. They just push blood back into the bloodstream after it has refluxed into the lumen. So no pressure, just displacement.

Reduction of complications by using these connectors as you describe is a myth. There is no evidence to support a reduction in complications. In fact, using two needleless connectors in this manner may increase the risk of infection to your patients. CDC guidelines state that the needleless connector should be changed at the same interval as the IV sets. So leaving a needleless connector on the catheter hub to allow for easier change of IV sets would extend its use and allow for more biofilm (the source of bloodstream infections) to grow. The type of needleless connector does not make any difference here. So you should not do this with any type - positive, neutral or negative displacement device. They all should be changed at the same interval as the IV set.

Catheters used for intermittent infusion should have the extension set and one needleless connector attached. This should be changed every 72 to 96 hours. The IV sets used for infusion through this catheter should be changed every 24 hours because there are no studies that have examined the intermittent use of these sets. Although the CDC guidelines do not address this type of set, it firmly states that the needleless connector should be accessed ONLY with a sterile device. Sterility of the male luer tip on an intermittent IV sets is questionable after the first use, however the Infusion Nursing Standards of Practice allows this set to be used for 24 hours. I am reasonably certain that repeated connection and disconnection of the same set for extended periods would no longer provide a sterile male luer tip to access the needleless connector. No one has ever studied this!

Catheters used for continuous infusion should have the IV set attached directly to the catheter hub without the addition of a needleless connector at all! The set and connector must be changed every 72 to 96 hours. So there could be greater risk to allow the needleless connector to remain in place for longer periods due to the biofilm growth inside. The need to change both pieces together means that the risk of air emboli is present and all precautions to prevent this complications would be needed. This includes putting the patient in a lying position, instructing to perform a Valsalva maneuver if not contraindicated at the exact time of disconnection, or closing a clamp on the catheter itself.

Blood Samples from a Small Lumen PICC?

2009-09-02T12:56:00.002-04:00

We have been drawing blood from adult and infant 3 fr piccs. We are finding recommendations not to drawn blood from anything less than a 4 french during Google searches. What information can you pass on to us on this subject?

My first question is what sources are you finding on your Google searches. Are you searching on Google or Google Scholar? When I do a Google search on this topic, the first things that come up are individual nurses opinions as they have written on discussion forums. The Internet is a great tool, but you must realize that it makes everyone a publisher. So you must carefully evaluate the source of your information. On Google scholar, you will search only the published literature and most of that has gone through a peer-review process, which adds credibility to it.

I have also heard the warning about not drawing blood from a PICC smaller than a 4 French but I know that neonatal nurses often draw blood samples from PICCs as small as 1.9 French. The key is the technique. Flush with a 10 mL saline-filled syringe first to assess patency. Change to a 3 mL syringe. On aspiration, smaller syringes cause less pressure. The syringe size is smaller and usually will not allow enough negative pressure to cause catheter damage. But you must remember that on injection smaller syringe cause increased intraluminal pressure and subsequent catheter damage when there is some form of obstruction in the catheter or vein lumen.

With the 3 mL syringe, use a slow, gentle technique to withdraw the blood. This may mean lots of patience to allow enough time for the blood flow to begin through the small lumen. Once the backflow has been established, you might need to chance to a larger syringe to get enough blood for the specific tests being done.

So with proper technique and patience, it is possible to use small lumen PICCs for blood sampling. I do not think there has ever been a published study on this practice but there are neonatal nurses doing this frequently. I welcome additional comments from nurses who do include this in their practice.

Lidocaine for venipuncture

2009-09-01T17:01:00.002-04:00

Do you know of any national guidelines for the use of Lidocaine and peripheral IV starts. I am looking specifically when it would be recommended- we are looking to develop the standing orders so that physician orders are not necessary. I really am against just having lidocaine available for all of the nurses to use at their discretion (hospital setting) without a doctors order but cannot find anything that really says when it is most appropriate to use.

I am not aware of any published guidelines that identifies the specific types of patients that can benefit from the use of Lidocaine for peripheral venipuncture. Many would say that all patients should receive attention to procedural pain such as venipuncture. Basing the use of any local anesthetic on a nurse's assessment of the patient may not be the best approach. I have tried to think of objective data to include in this assessment. This may include pediatric patients, a history of vasovagal reactions in the past, and a patient's request for local anesthetic are the primary factors that come to mind. But that means that the majority of patients would not have the benefit of this, thus creating a lower standard of care for most of your patients.

There are other approaches to local anesthesia for venipuncture. For instance you can use bacteriostatic normal saline. The preservative, benzyl alcohol provides local anesthesia. You can learn more about this by clicking on the following articles:

Windle, et.al, 2006

Brown, 2004

Wilson and Martin, 1999

Fein, et.al. 1998

There are also many other technologies for local anesthesia such as inontophoresis, dermal patches, and many others. So you don't have to settle for Lidocaine injection in just a few patients.

PICC Insertion in ED?

2009-08-27T18:00:00.002-04:00

We are having a discussion at work if it is appropriate to place PICC lines in the emergency department. Usually it is an emergent situation and I am concerned about sterile conditions. Do you have an opnion on this subject?

I can understand your concerns about any catheter that is placed during a true emergent situation. In my opinion, a PICC is not the catheter of choice for insertion during any critical or crisis situation. In fact, the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections states:

When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours (22,71,201,202). Category II

This statement would apply to all catheters regardless of whether it was placed beside a wreck on the interstate highway or on a regular nursing unit within the hospital. In these situations, a PICC would require too much time to thread the catheter into the proper tip location and therefore, a subclavian or jugular inserted catheter would provide faster venous access. In these situations, aseptic technique is not the highest priority when the patient's life is in jeopardy. However, those patients may be a candidate for a PICC within that 48 hour period, and the questionable CVC can be removed after a PICC has been placed.

But not every patient in the ED would fall into this category. There could easily be patients in the ED that require venous access and a PICC is the most appropriate choice for them. The patient's needs should direct the care received. This may mean that the infusion nurse specialist make themselves available to go to the ED for PICC insertion.

It is all about meeting patient needs. The patient safety movement and trend toward high reliability organizations emphasize that care should be organized around what the patient needs, not what is most convenient for the providers. This would mean making PICC insertion services available for some situations in the ED, but not necessarily in those critical or crisis situations.

List of Vesicants

2009-08-26T21:04:00.002-04:00

Do you have a whole list of all vesicant medications that is not limited to chemotherapy drugs?

No, I can not tell you where to find such a list. I always strongly recommend the use of a drug book written specifically for IV administration. In my opinion, the best book is Intravenous Medications, written by Gahart and Nazareno, and published annually by Mosby. This book will contain language on each drug monograph about the need to establish absolute patency of the vein and usually mentions the risk of tissue damage.

I would also caution you, however, that all fluids and medications can pose a serious risk to your patient if they leak from the vein. These risks are not just limited to those called "vesicants", defined as a medication that causes tissue death when it leaks out of the vein and into the subcutaneous tissue. All fluids and any medication has the potential to cause tissue damage if there is a sufficient volume that leaks into the subcutaneous tissue. The volume causes compression of nerves, arteries and muscles. The greatest risk may be caused by compression of nerves as this can lead to local neuropathy or complex regional pain syndrome. You must also remember that veins and nerves are located in very close proximity to each other. So it can be easy to cause nerve damage with any fluid or medication. This can leave your patient with a life-long loss of arm or hand function and chronic severe nerve pain.

So you do need to know the vesicant properties of the medications being given, but remember that is not the complete risk! To read more about the most recent issues of managing infiltration and extravasation, read Doellman, Hadaway, et.al. recently published in the Journal of Infusion Nursing.

Blood Return from Catheters, Part 2

2009-08-26T20:39:00.002-04:00

We are currently not finding our way through the blood return issue. Both the INS and ONS are clear on having a blood return, however practice seems to be that with a non-vesicant chemotherapy agent we shall use the vascular access device. Recently the doctors and the clinical nurse specialist are suggesting that a vesicant can also be okay through a life port. What has been your experience and the practice throughout the United States?

I would fight and fight hard against these physicians and clinical nurse specialist. In fact, I would refuse to give any medication, vesicant or non-vesicant, through a central venous catheter that does not yield a free flowing blood return. This must be easily obtained on aspiration, free-flowing, and the color of whole blood. In other words, pink-tinged fluid is not sufficient.

There are numerous causes of lack of blood return including:
1. fibrin tail, partial or complete fibrin sheath. The nurse has no method to determine which is the problem without dye injection through the catheter under fluoroscopy.
2. vein thrombosis at or near the catheter tip.
3. drug precipitate occluding the lumen.
4. numerous mechanical issues such as pinch-off syndrome with subclavian insertion site; left-sided insertions abutting the vein on the right side; malpositioned catheters where the tip has migrated into the ipsilateral jugular vein, contralateral subclavian vein, or any number of smaller vein; catheter dislocation by inadvertant withdrawal or advancement of the catheter due to inadequate catheter securement.

There are far too many problems to take a chance. Vesicant medications leaking into the tissue can produce necrotic ulcers, however a large volume of any non-vesicant medication or fluid can lead to severe tissue damage due to compression of surrounding structures. Nerve damage is a growing issue with all types of vascular access.

The standard of care, defined in the US by what a reasonable and prudent nurse would do in the same or similar situation, is to assess the catheter for functionality **before** it is used for each and every dose of medication. This standard of care is established through many published reports of serious outcomes associated with catheters. These reports are then used to write the national standards of practice, defined as what the nurse must actually do, by the Infusion Nurses Society and the Oncology Nursing Society.

By "life port", I am assuming that you are referring to a brand name for an implanted port. This type of catheter requires an additional level of caution, in my opinion, because it is all out of site. In addition to the above mentioned causes of lack of blood return, there can also be problems with the location of and technique for insertion of the port needle.

So the bottom line is that blood return is one of the factors required to make a complete nursing assessment of the functionality of the catheter before that catheter is used. While its presence or absence can not be regarded as a complete diagnostic tool, it is a major factor that must be assessed among all the others which include:
1. lack of any resistance to flushing
2. absence of any edema, erythema, or change in temperature at or near the catheter's insertion site.
3. absence of all discomfort at or near the insertion site and within the patient's chest, neck, shoulder, or back.

Without this complete assessment, the nurse has not met the standard of care and can easily put the patient at risk for serious complications.

Disconnecting Continuous IV Fluids - Again

2009-08-18T16:53:00.003-04:00

I’ve searched the literature and cannot find anything that addresses the question of whether primary infusions that are disconnected from the patient for varying periods of time (to allow ambulation or showering, for instance) should be considered intermittent infusions and changed every 24 hours or if they can be used for 72 hours to one week. I am hoping that you have an opinion on this that you are willing to share.

I am so glad you asked because I definitely have an opinion about this practice. It is my opinion that this practice has become routine and it is dangerous. Frequently disconnecting any IV administration set that is used for continuous infusion creates several serious problems with patient care.

First, there are no studies that have ever addressed the intermittent use of IV administration sets. The CDC guidelines do not make any difference between intermittent sets and those used for continuous infusion. All the studies have purposefully eliminated sets used for giving intermittent medications and focused exclusively on the set used for continuous infusion. My thoughts are based on principles of infection prevention and what we know from the literature on needleless connectors.

Currently, the prevailing practice is to place a needleless connector on the hub of all peripheral and central catheters regardless of whether that catheter will be used for intermittent or continuous infusion. It is my firm opinion that this is a dangerous practice!! But let me explain.

The presence of these needleless connectors makes it very easy for frequent connection and disconnection of the IV set. There are numerous issues and unanswered questions about these needleless connectors with an increase in catheter related bloodstream infections getting the most attention. While I can not address all of the factors in this format, I strongly believe that if we went back to the original practice of connecting the IV set directly to the catheter hub when continuous infusion is required, we would eliminate the cost of these needleless connectors and the potential risk they may add during continuous infusion. One reason nurses offer for placing these connectors inline for continuous infusion is to facility changing the sets by avoiding the risk of opening the catheter. They state this reduces the risk of air entering the catheter.

CDC guidelines states these connectors must be changed at the same interval as the set. They can not be allowed to remain in place while only the set is changed, therefore the catheter hub must be opened to change both the connector and the set. So nurses must be able to change these devices safely to prevent air emboli.

Frequent disconnection increases the risk of contamination of the catheter hub, a common and well documented outcome of increased catheter hub manipulation that leads to subsequent bloodstream infection.

Interruption of the infusion prevents the patient from reaching therapeutic goals intended by the prescribed fluid and/or medications. What happens to the patient's blood glucose level when an infusion of parenteral nutrition is stopped for 1 hour? How about insulin, potassium, aminophylline, heparin or many other medications given continuously? It is not in the patient's best interest to interrupt these infusions. I do not know of any studies that have assessed this practice, however I believe that it is adding cost because it slows or interrupts the patient's response to prescribed treatment.

What is the hospital policy for ensuring that the set is reconnected correctly? How was this set maintained while disconnected - left open, covered with a sterile cap, loosely covered with something like a foil packet from an alcohol pad, or looped and connected to an injection site on the same tubing? The only acceptable method is to cover the male luer end with a new sterile dead-end cap. Are those made available to nursing staff? What is the maximum time allowable for any infusion to be stopped and still be compliant with physician orders? How is the needleless connector cleaned before reconnection - agent and technique? How do you identify that the set has been maintained closed while disconnected and that the set is being reconnected correctly to the proper site on the correct patient? There is a significant problem with reconnecting IV sets to the other catheters and devices. If you allow this practice, all of these issues should be addressed in policy and procedures.

The bottom line is that this is a risky practice. Continuous infusion should be just that - continuous without interruption. I would want to investigate why nurses think it is acceptable to disrupt the infusion and then work with them to find better method of nursing care.

To directly answer your question, there is no research addressing this, however if the set is disconnected it is categorized as an intermittent infusion. According to the Infusion Nursing Standards of Practice, intermittent sets are changed at 24 hours. This means that cost will be a tremendous issue if you comply with these standards. So it would be better practice - clinically and financially - if continuous sets were not disconnected.

Drapes for Maximal Barriers

2009-08-18T15:35:00.002-04:00

Where does it state that the patient's face must be covered to be compliant with full maximal barriers during insertion of any central venous catheter? Only one manufacturer makes a drape that covers the entire patient. The others make a drape to place over the patient (chin to toe), and include a mask for the patients face and a half drape and the fenestrated drape for the arm. Are we being compliant if we don’t cover the patients face with the drape?

One resource for the explanation of maximal barriers is the Institute for Healthcare Improvement (IHI). Click here to go to their page with definitions and explanations of maximal barriers. My interpretation of their explanation means that this should be a one-piece drape with a fenestration for the insertion procedure covering the patient from head to toe.

A study by Young, et.al., 2007 provided drape dimensions and documented a great reduction in catheter-related bloodstream infection with the larger drape.

It makes sense intuitively to me that a one piece drape would be superior to multiple small towels to cover the same area. Multiple pieces can easily slip and expose unsterile linens or patient's clothing or skin. However a quick literature search does not reveal any studies about one-piece draping systems compared to a system that would use multiple pieces. Standards of practice from the American Operating Room Nurses could make statements about this aspect of drapes, however I do not have these standards available. During a CVC insertion, especially a PICC, patient movement or repositioning may be required. Movement with a one-piece draping system would be easier to maintain than a system using multiple pieces.

Most facilities I know about are using a drape that covers the face. They have developed systems to hold the drape off of the face in patients that may feel claustrophobic with the drape in direct contact with their skin. Drapes would provide a better barrier than covering the patient's mouth and nose with a mask. Many patient's can not tolerate the mask or patients with a tracheotomy or endotracheal tube could not be protected by a mask.

Manufacturers have been working hard to meet this standard by providing large sheet drapes in their kits and it is worth the effort to find one that does cover the patient from head to toe.

Dual Lumen PICCs for All Patients - NOT!!

2009-08-10T10:29:00.003-04:00

We have a Head Nurse on an inpatient Orthopedic ward insisting that it become hospital policy to insert only dual-lumen catheters on patients on his floor. Most consults on his patients are for long-term antibiotic administration. He has stated that because the majority of his patient
population is on PCA's, they require double-lumen PICCs. As a practice, we research the compatibility of the medication in the PCA and the antibiotic ordered in order to determine the number of lumen. He has stated that regardless, he wants double-lumen PICCs.

Your approach is absolutely correct and I would firmly resist the request from the nurse manager. The sources of catheter related infection fall into two categories - extraluminal from insertion technique and dressing management and intraluminal from the various issues associated with hub and tubing management. The greater the number of lumen and hubs to manage, the greater the risk of infection.
Templeton, et.al reported on this very issue and should provide good evidence to support your practice.

The number of lumens chosen should never be an automatic thing based on the desires of management, the request of the patient or physician, or the availability of products. The one and only set of factors that should drive the choice of the number of lumens in all central venous catheters is the number, types, schedules, and compatibility of the various fluids and medications prescribed. Of course, your assessment should include the patient-related factors that could cause a change in the prescribed therapy so that a catheter exchange is not needed at a later time. But to automatically choose a dual lumen catheter for every patient is below the national standard of care. I have actually testified to that in a deposition where the only thing prescribed was 2 antibiotics, one every 24 hours and one every 36 hours. A dual lumen PICC was inserted in a diabetic patient. There was simply nothing to justify a dual lumen catheter in this patient.

So educate this nurse manager and keep up your efforts for best infusion practices based on the evidence.

Education for PICC Insertion

2009-08-04T18:05:00.002-04:00

We have two nurses (who were taught by physicians & initially supervised by physicians) who have been inserting PICCs for the last several years. The hospital would like to educate additional RNs to do this. What would your recommendation be for qualifications for one of these nurses to provide the education & hands-on teaching of the learners? - CRNI?

Well, you might not care very much for my approach to your answer but here goes. When you say "additional RNs to do PICC insertion" what exactly do you mean? Are these RNs part of an infusion therapy or vascular access team? Or are they nurses who work in other clinical areas and the hospital wants to get them trained on PICC insertion?

The team concept is the one and only one that I would support or endorse. Many years ago, I adopted the policy of never giving a PICC course at a hospital that wanted to bring several nurses from numerous areas of the hospital and expect them to become proficient at PICC insertion. It simply can not be done effectively and efficiently.

To learn more about the excessive costs, time, and waste of resources with this approach, I would refer you to the study by Hornsby, et.al. They documented substantial losses with this concept of having any nurse do PICC insertions "in their spare time." Patients suffer because their nurses are distracted from their regular patient care assignments. PICC insertion demands a highly skilled infusion nurse specialist that is dedicated to obtaining and maintaining their knowledge and skills with vascular access. It is not a simple procedure that can or should be done by all nurses - ever.

Now if you are talking about the best method for educating new members of a team, that is different. I would not recommend that nurses who are expected to place PICCs at the bedside be trained by physicians. Who taught the physician how to perform the procedure? Chances are they learned on the job and had no true formal education about the procedure. Radiologist comes closer than any other physician however, the technology and techniques used in the radiology department will be very different from what is used at the bedside. In radiology, fluoroscopy is used along with very long guidewires. Fluoroscopy is not used at the bedside to track where that long guidewire is actually going, therefore the length of the guidewire used at the bedside must be limited and not passed farther than the upper part of the extremity. Many times catheters and wires used in radiology call for the catheter to be driven over the guidewire - another procedure not performed at the bedside. Ultrasound for vein location and catheter tracking technology is used at the bedside but often not in radology.

Currently PICC education comes from 2 sources. All large catheter companies have PICC insertion courses offered to customers through various means. All nurses should complete some type of continuing educational offering about PICC insertion. This could be a traditional classroom course or a self-directed course on a CD or DVD. Company policies about how these courses are provided vary greatly but that is where I would start.

There are local education companies that provides PICC education. They may have self-directed learning methods through purchased DVDs, online resources, or teach a traditional classroom course. This may be the best method when a small number of nurses need this education. One word of caution though - many of these companies use the misleading word "certification." There is not certification in a specific task such as PICC insertion. For more information about this I would encourage you to go to the INS site to learn about the differences between a certificate program and a true certification.

After they have completed the requirements for the chosen educational program, there must be a period of supervised clinical practice. Your hospital must create a policy about what is required to document competency. How many successful insertions are required? How do you define a successful insertion - success with venipuncture or success with complete catheter advancement, etc? I would strongly recommend that this supervision be performed by a nurse specializing in infusion therapy and vascular access and has extensive PICC insertion experience. Most often this will be a nurse with the CRNI credential, but it could also be a nurse with oncology or nutrition support credentials. I would want this preceptor to have strong clinical experience with many PICC insertions along with documentation that they have kept pace with our rapidly changing knowledge in the area of vascular access.

PICC insertion represents an expansion of a nurse's scope of practice. Each nurse who accepts this responsibility must also be held accountable for outcomes. They must have the knowledge and critical thinking skills in addition to the psychomotor skills of the task. Finally they must be willing to accept responsibility for the clinical outcome with PICC insertion. I have reviewed several legal cases of serious complications resulting from PICCs inserted by critical care nurses or nurses from other areas of the hospital. These patients have had devastating outcomes. So this is not a simple task that every nurse should be allowed to do or be expected to do.

Thanks for allowing me to get on my soapbox. I am in the process of creating my presentation for the preconference before the fall INS program. I have always firmly believed in the infusion therapy team concept but I now see mounting evidence that this is the pathway to financial improvement in additional to better clinical outcomes.

Blood Cultures for Diagnosing Catheter Infection

2009-07-30T12:42:00.003-04:00

Where do we stand these days on drawing blood cultures from a central line when doing a fever/infection work up? Do we draw from the line and from a peripheral source or just the peripheral draw? Can you reference any studies on this? We have historically done a draw from the line and from a peripheral source but I have heard rumor that this may not be good practice from an infection control perspective......What's your advice?

I think the issues you have raised are more about the new definitions than about reducing the risk of infecting the catheter from the blood sampling procedure. So first I would ask, are you trying to diagnose a confirmed catheter-related bloodstream infection or a central line associated bloodstream infection? I know those names sound like they would be the same thing, but there are different criteria for each.

Catheter-related bloodstream infection is defined in the CDC Guidelines for Prevention of Intravascular Catheter Related Infections. This definition includes at least one positive blood culture from a peripheral vein, clinical evidence of infection such as fever or chills, and no apparent source of BSI except the catheter. You should also have a culture of a catheter segment (which means sacrificing the catheter before the diagnosis is made) with the same organism from the peripheral blood culture OR simultaneous quantitative blood cultures from a peripheral site and from the catheter. There are 2 methods for confirming that the catheter is the source - the culture results from the catheter sample produce a colony count ≥ 5 times the colony count from the peripheral sample OR the catheter-drawn sample becomes positive 2 hours before the peripheral sample. The technique used depends upon the capabilities of your facility's laboratory.

Central line associated bloodstream infection is less definitive. The patient must have a positive blood culture, clinical signs and symptoms, and a central venous catheter for more than 48 hours before the onset of symptoms.

These definitions and lots more information and specific criteria can be easily found at the CDC website. At the site, type in either or both of the terms CR-BSI or CLABSI to obtain lots of information.

First, I would work with my infection control and prevention specialist to clarify the definition being used. Then determine what you are wanting to accomplish - a diagnosis of CRBSI with possible treatment to salvage the catheter or a diagnosis of CLABSI which may be more preferred for surveillance purposes.

My preference would be to have a definitive diagnosis so that treatment without catheter removal may be possible. Mermel, et.al. has written another set of guidelines on the management of catheter-related infections. This paper was released from the Infectious Disease Society of America in 2001 and has now been updated. You can download a free copy by clicking the authors name.

PICCs and Other Vascular Devices

2009-07-15T16:07:00.003-04:00

Is it permissible to insert a PICC in the same arm where there is radial arterial line and an MD wrote the order for us to insert PICC in the same arm where there is pacer? Right now, we said no to both of them. Maybe you can send me literature to support our responses.

I am assuming that you are referring to two different patients - both had orders for a PICC and one also had a radial arterial line and one had a pacemaker on the same arm as the PICC.

First, I would ask why did both devices need to be placed on the same arm? Was both of these patients restricted to using only one arm for some valid clinical reason? If so, what was that reason? As the nurse inserting the PICC, you must do a proper evaluation of the risk and benefits for the decisions you will make about a PICC insertion procedure. You are placing the catheter, not the physician. A physician's order can never relieve you of the accountability of the outcome.

So your question about "is it permissible" can not be answered. This totally depends upon the risk factors for each patient. How long has the radial artery catheter been in place? For how much longer will it be needed? What is being done through the radial artery catheter - pressure reading, drawing blood gases or both? What is your assessment of the neurocirculatory system in that patient? For the patient with the pacemaker, how long has it been in place? What type of pacemaker is it?

We have an online continuing education course that examines all the issues with pacemakers and central venous catheters. I would encourage you to take that course for more detailed answers and to obtain a thorough list of references.

I can not send actual references because that is a violation of copyright laws, but the reference list in the course will direct you to the evidence you need for making sound clinical decisions.

Coagulation Studies from a Catheter?

2009-07-15T15:45:00.003-04:00

Why should blood samples for coagulation studies **not** be drawn from a catheter?. I remember reading this somewhere but can't seem to locate quick information on it. Is it not preferable because of the heparin that might be in a line or the idea that drawing through a catheter will skew the results due to the pulling action that has to occur?

The studies have all involved the question of drawing the blood sample from a catheter that has been exposed to heparin. This will definitely skew the lab values, regardless of how much blood is withdrawn and discarded. Here is a list of a few studies.

1. Hinds P, Quargnenti A, Gattuso J, Srivastava D. Comparing the results of coagulation tests on blood drawn by venipuncture and through heparinized tunneled venous access devices in pediatric patients with cancer. Oncology Nursing Forum. 2002;29(3).

2. Mayo DJ, Dimond EP, Kramer W, McDonald KH. Discard volumes necessary for clinically useful coagulation studies from heparinized Hickman catheters. Oncology Nursing Forum. 1996;23(4):671-675.

3. McLaren G, Hanna C, Mills L, Bourdeau J, Cowin R. Comparison of sampling methods for obtaining accurate coagulation values in hemodialysis patients with heparinized central venous catheters. Nephrol Nurs J. Dec 2001;28(6):632-636.

4. Pinto K. Accuracy of coagulation values obtained fron a heparinized central venous catheter. Oncology Nursing Forum. 1994;21(3):573-575.

After review of these articles and any others that you might find, your hospital should establish a firm policy and procedure about this practice. These will provide the basis for the evidence needed to make strong practice decisions.

Flushing Frequency

2009-07-15T15:22:00.002-04:00

We are currently flushing our temporary non-tunnelled CVCs according to manufacturers recommendations. Unused lumens are also flushed at least every 12 h. What are your thoughts on this?
Despite using positive pressure caps we still experience a significant number of complete withdrawal occlusions. Some centers in our health authority have decreased flushing to once weekly but do not keep meaningful stats to compare their occlusion rate before switching to once weekly flush, so they don’t really know if the incidence has increased.
Also do you know of any research that talks about acceptable rates for occlusion?

By catheter flushing, I am referring to the use of 0.9% sodium chloride, preservative-free in a single dose container. The frequency of flushing all catheters is driven by what is being given through that catheter. All catheters, regardless of size or location (in other words, both peripheral and central) must be flushed before each use as part of the complete assessment of catheter patency. This includes assessing for resistance, aspirating for a blood return, assessing site condition, and investigating any patient complaints that occur during this assessment.

All catheters must be flushed after each use to ensure that all infused medication is flushed from the catheter lumen and to prevent contact between 2 medications that could be incompatible with each other, thus producing a precipitate inside the lumen.

The frequency of flushing a lumen or a catheter that is not being used is controversial and there are no studies that have demonstrated the most effective frequency. In a hospital setting, the frequency is usually every 8 or 12 hours, but in ambulatory infusion or home care this could be every 24 hours or maybe even every other day.

The key to catheter patency is to use a flushing and clamping technique that is recommended for the specific brand of needleless connector being used. A negative displacement connector requires a positive flushing technique, but a positive displacement connector should not be flushed with a positive flushing technique. A neutral displacement connector is not dependent upon flushing technique.

I am not surprised at all that the positive displacement connectors are still producing a significant number of occlusions. Are you using saline to flush and to lock your catheters? I just finished a literature review that will be published soon. I am not convinced that saline for locking a catheter is the right answer. I still think that an anticoagulant is required. At present, heparin is the only anticoagulant we have for this purpose. I know there are lots of reasons to eliminate the use of heparin for locking catheters, but we do not have a successful alternative yet.

I am not familiar with a standard or guideline that sets an acceptable rate for any complication. The goal should always be zero. We have seen this with infection. We previously thought that benchmarking against the CDC data was acceptable, but now the emphasis is on total prevention. Studies have shown that hospitals can achieve and maintain a zero rate of catheter related bloodstream infection. We do not have similar data for occlusion but I do not think there is an "acceptable" rate established.

Saline for Locking Central Venous Catheters - Not a Good Idea!

2009-07-02T10:39:00.002-04:00

I have always been skeptical of using saline alone for flushing and locking central venous catheters, but until now the evidence has been very limited. While searching the literature for a new manuscript about heparin, I found a new article that provides more information.

Cesaro, et.al conducted a randomized trial in children with cancer and newly inserted tunneled, cuffed catheters. They compared one cohort with heparin flushing and a "standard cap" (their term) to saline only flushing with a positive displacement needleless connector. There were 203 patients and more than 75,000 catheter days. The experimental cohort has twice the rate of occlusion and almost triple the rate of bacteremia.

There has been a small study of a similar type in patients with PICCs. Bowers, et.al found a 6% occlusion rate with saline only flushing and a positive displacement needleless connector. This rate was not statistically significant, possible because the study had only 102 patients. The authors went on to quantify the cost of declotting 6% of their PICCs annually and reported that even this small number was too costly.

Evidence is growing that saline alone is not sufficient for locking any central venous catheter. I know there are numerous issues with heparin and we need alternatives, but there is no alternative locking solution that has been cleared for market by the US FDA at this time. So we keep waiting and using heparin or obtain one of the alternative solutions from a local compounding pharmacy. Neither are good options, but those are the only choices currently. I would encourage everyone to obtain and read these recent articles and apply them to your evidence-based practice. Click on the highlighted authors name above to get to the reference information and abstract.

Using a PICC before the Xray Results

2009-07-01T13:42:00.003-04:00

We are a 5 member PICC Team and do a large number of insertions per month. The question I have is about using a PICC before the x-ray has been read. A few of us feel that the PICC is the best peripheral IV you will ever have. Some tell our staff that they can use the PICC as a peripheral IV but not as a central line until the x-ray has been read. As long as you have a good blood return why can't you use this line for peripheral fluids?

No catheter inserted to be a central venous catheter should ever be used for any infusion until the actual tip location has been confirmed. The reason is very simple - you do not actually know where the catheter tip is located until you have the results of a chest xray. The catheter tip could be angled toward the head in the internal jugular vein or in the contralateral subclavian vein. In those cases, the infusion is flowing against the blood flow. Retrograde infusion into the intracranial venous sinuses can lead to neurological complications. Also the tip can be impinging on the vein wall, increasing the risk of thrombosis which is compounded by the infusion. Infusion of any fluid or medication could be into any number of smaller tributary veins which would increase the risk of thrombosis. So, a flush with normal saline and locking with heparin is all that should go through any central venous catheter until the tip location is actually known.

You may be concerned about the length of time that is required to receive the information about the tip location from radiology. There are 2 things that can change this situation.

The PICC Team can take on the responsibility of assessing the chest xray for tip location, avoiding the wait for a radiologist to read the film. This has been considered within the scope of nursing practice in many areas of quite some time and it continues to grow today. You will need to have the knowledge and skill to assess the chest xray. Please notice that I did not say that the nurse is "reading the xray" as this is only within the medical scope of practice. We offer an online continuing education course in assessing chest xrays for catheter tip location. Learn more by clicking here.

The other change is to use new technology that will identify the tip location immediately during the insertion procedure. There are several types of catheter tip locating devices currently available. Also, you can use the ultrasound probe to rule out jugular placement immediately after insertion. Another approach currently involves the use of ECG to determine changes in the P wave to know when the catheter tip is at the level of the SA node, which is at the top of the right atrium. A new technology from Vasonova is very promising. To learn about this, click here. Other promising technology on the horizon will use an infrared light device to detect the catheter's tip location. While changes in technology seem very promising, the current standard of practice is to obtain a post-procedure chest xray. Use of this new technology will probably change this standard, but that has not happened yet.

Your concept of a PICC being the best peripheral IV is erroneous. Although you have made the veinpuncture into a peripheral vein, the catheter is advanced into the thorax where it can and does go into a number of alternative locations. These locations have been well-documented to lead to catheter complications such as thrombosis, vessel erosion, and many other issues. I would also be very concerned about having the primary care staff nurses known when you could or could not use this catheter for central venous infusion with your approach as there is no consistency among your PICC team. The current national standard of care is to avoid using any central venous catheter until you have adequate confirmation of the tip location. This will provide the safest approach for your patients.

Parenteral Nutrition in Neonates- Peripheral or Central Catheter?

2009-07-01T13:10:00.002-04:00

I've been to the National Association of Neonatal Nurses and others and cannot find a standard for my question. I'm looking for protocols regarding infusing total parenteral nutrition (TPN) and fat emulsion through a short peripheral catheter in a neonate.

You have a great reason to be concerned about this practice. First, we have traditionally divided parenteral nutrition into "total" or TPN and "peripheral" or PPN. Those classifications have now virtually gone by the wayside. The guidelines and standards of practice from the American Society of Parenteral and Enteral Nutrition use the term "parenteral nutrition". ASPEN recommends that a central venous catheter be used due to the high osmolarity of most PN formulations. Click here to access the ASPEN documents.

The Infusion Nursing Standards of Practice states that the maximum osmolarity that should be infused through a peripheral vein is 600 mOsm per liter. All parenteral nutrition formulaes are above this level. Pharmacy literature uses maximum concentration of 900 mOsm per liter. Some formulas with very low concentrations of dextrose may fall below this level. The Infusion Nursing Standards are reviewed by pediatric and neonatal experts, so inclusion of the lower level indicates these experts acceptance of the maximum of 600 mOsm.

The new textbook, Infusion Nursing- An Evidence-Based Approach, includes a chapter on infusion therapy in children and was co-authored by two pediatric and neonatal nursing experts. They state that 10% dextrose is the largest concentration that should be infused through a peripheral vein and recommend that concentrations greater than 10% be infused through a peripheral vein.

Both 10% and 20% IV fat emulsion products are isotonic and can be infused via peripheral veins. Infusion with the other PN components can decrease the irritation caused by the hypertonicity of the PN solution. However, the dextrose content should not exceed 10% and the total osmolarity should not exceed 600 mOsm per liter, although some may extend this to 900 mOsm per liter. The number and condition of veins in most neonates are quite limited, therefore the risk of peripheral thrombophlebitis must be weighed against the risk of inserting a central venous catheter.

These 3 resources would establish the national standard of practice.

Time Interval for Repeat Chest Xrays

2009-06-17T13:38:00.004-04:00

Do you know of any research articles written that investigate the occurrence of PICC tip malpositioning after a PICC is inserted and initially confirmed?
We are trying to make evidence-based practice changes with regards to INS standard 42; practice criteria N., “If the patient is receiving long-term or chronic therapies, repeat radiographic study should be performed to confirm catheter tip location, according to organizational policies and procedures”. Our hospital is trying to determine what an acceptable time period should be to perform periodical chest films to re-confirm tip location in patients receiving long-term therapy.

The tip of any central venous catheter, including PICCs, can migrate. This is well documented to occur with migration from the original superior vena cava-right atrial junction to the internal jugular vein, the contralateral subclavian vein, and into the right atrium. Conventional thought has related the risk of this problem to changes in intrathoracic venous pressure and arm movement. More recently, a poster at the 2009 INS conference provided details of animal studies showing that aggressive, rapid, or forceful techniques for flushing catheters can also lead to tip migration.

The challenge is that the problem occurs sporadically and spontaneously. There is no pattern and therefore, no available recommendations for the frequency for repeat chest radiographs to assess tip location. A patient with pneumonia and severe coughing may have the catheter tip noted on a routine chest xray to be in the internal jugular vein but a repeat xray within a short period of time shows it to be in the SVC-RA junction.

So there is no way to create an evidence-based time interval for a repeat chest xray. Your policies and procedures should address the signs and symptoms of tip migration that would provide clinical indications for a repeat chest xray. This would include, but not be limited to, lack of a blood return, difficulty with flushing or infusing, complaints of hearing a running stream or gurgling sound, strange pain or discomfort in the neck, back, shoulder, or chest, cardiac arrhythmias, or changes in respiratory or cardiac status. Retrograde perfusion of infused medications into the intracrainal venous sinuses has also lead to neurological conditions. I wish it were as easy as a specific time to recommend a repeat chest xray, but this is a decision based on clinical evidence. So this requires infusion nurse specialist with indepth knowledge of the patient and catheter and potential outcome.

Prefilled Syringes and Expelling the Air

2009-06-15T18:31:00.002-04:00

I'm hoping you can advise us on removing the air from our pre-filled flush syringes. We have new staff who have been doing this differently than our policy calls for and I want to make sure we are doing everything we can to protect our patients as well as make their infusion at home as easy as possible. My question is: Does pulling back on the pre-filled syringe to the break the seal before expelling the air increase the patient's risk of infection?

Prefilled syringes for catheter flushing are packaged in 2 different ways - aseptic filling and terminal sterilization. Aseptically filled syringes are virtually the same as batch filling in your hospital pharmacy. A syringe is filled with sterile fluid under aseptic conditions such as a laminar air flow work bench and capped. The filled syringe is then packaged without additional sterilization. Terminally sterile syringes are filled, capped, sterilized and then placed in a clear overwrap package. Both processes result in a product that is sterile within the fluid pathway and the male luer tip of the syringe, although a terminally sterile product has a higher level of sterility. It is important to note that terminally sterile products should not be confused with a completely sterile product that can be added to a sterile field. These syringes are filled, capped, packaged in a strong overwrap and then sterilized, resulting in a product that is sterile on all surfaces.

I am not sure if you are using an aseptically filled or terminally sterile prefilled syringe. All will have a plastic overwrap that serves as a dust cover. So the space in the distal syringe barrel outside the fluid area will be clean but not necessarily sterile. You will need to expel the air before use and this should be done by pushing forward on the plunger rod rather than pulling back.

There is another issue - after attachment to the catheter hub, the plunger rod must be pulled back to aspirate for a brisk blood return from all catheters. This is a national standard from the Infusion Nurses Society and the Oncology Nursing Society. After you have pushed forward to expel the air, there should be a small space to allow you to aspirate to check for a blood return from the catheter.

For a terminally sterile prefilled syringe, this action should not add to the risk of catheter-related bloodstream infection. These syringes have been sterilized after filling. The type of plastic overwrap is intended to prevent dust and other particles from coming into contact with the syringe barrel. While the distal barrel is not labeled as "sterile", there has not been a reported outbreak of infection associated with these syringes.

For aseptically filled syringes, the risk could be greater because there is no sterilization process after filling the syringe. There have been outbreaks of infection reported with aspetically filled syringes, although not directly attributed to any contamination of the distal syringe barrel.

To read additional information about the misuse of prefilled syringes, click here and then go to Volume 4, No 4. Scroll through the issue to the second story - Misuse of prefilled flush syringes
Implications for medication errors and contamination.

Ultrasound for Short Peripheral Catheters by Primary Care Nurses

2009-06-09T17:40:00.002-04:00

I am a PICC insertion nurse working through Interventional Radiology. My hospital currently does not have a vascular access team for the placement of Peripheral IV's. The Nurses in the ICU and trauma units as well as the med-surg floors place their own IV's. The Trauma portion of the Hospital has purchased Site-Rites to allow the physicians to place central lines. I was approached by a nurse who has questions about the placement of Peripheral IV with the use of these ultrasounds due to the fact of their goals to reduce the use of short term central lines. I am concerned with this practice. I would like your views on this subject. My question to you is there information on this specific technique? Is this a practice that should be discouraged or perhaps at least approached delicately.

There are several published studies supporting the use of ultrasound for placing short peripheral IV catheters in specialty areas such as ED. These studies report a greater success rate with venous cannulation, making the nurse and patient more satisfied - initially. The downside is that we do not have data on the clinical outcome with these US-inserted catheters. US requires one of two techniques to insert a short peripheral catheter. The static approach uses the US to locate the vein and mark the spot. The probe is then set aside and the venipuncture proceeds as it normally would. This uses an expensive piece of equipment for a very limited purpose. The other method is called the dynamic method where the nurse continues to hold the US probe while making the venipuncture. This utilizes the benefits of the US, however it requires dramatic changes in technique or a second person. We need one hand to hold skin traction during venipuncture and catheter advancement and one hand to hold the catheter. This does not leave a hand to hold the probe. So either a second person is involved or the skin traction is sacrified. This is where the lack of clinical data on catheter outcomes is a problem. Do this catheters produce a greater amount of phlebitis or infiltrations?

Another issue is the length of time those catheters will actually dwell and again there is no data. Even if the primary care nurses are successful with getting the catheter in, it might only last for a few hours before it fails. Then the procedure must be repeated, driving up the costs of care. To avoid this situation, there must be a comprehensive approach to all vascular access assessment and proactively choosing the correct device that has the greatest likelihood of reaching end of therapy with the minimal number of devices used. Turning staff nurses loose with an US machine will never achieve this goal.

US is also designed to locate veins that are deep in the tissue, usually between 10 to 20 mm. The superficial veins used for short peripheral catheters lie in more superficial tissue usually between 3 to 9 mm. So US may be more beneficial for bariatric patients or those with severe obsesity where the superficial veins are deeper in the tissue.

The other issue is the huge learning curve with US. It usually requires ~50 insertions to become comfortable with using US for a PICC insertion. I am not aware of how many attempts it would take to reach this goal for a short peripheral catheter insertion.

There is no doubt that the use of US is a benefit in the hands of the correct professional but I would not favor trying to get all primary care nurses skillful with its use.

There is a newer and better technology for this purpose - infrared light devices. I gave a presentation on this at the INS conference this year and will soon be putting this up as an online CE course. More on that later. So to answer your question, I would approach the use of US in this situation with serious caution.

Masks for Changing Needleless Connectors??

2009-06-09T17:20:00.002-04:00

I work in Vascular Access at a large teaching facility. They have instituted a new policy requiring a mask and sterile gloves for all cap changes. What gives with this? It doesn't make sense.

If correct technique is used then why would you contaminate sterile gloves by removing the old caps or even exposing an open catheter to air while you remove dirty gloves (after removing the old caps) and don sterile ones?

You raise some valid points but first, let me see if I understand what you are asking. Your facility now requires that the change of a needleless connector on the hub of all vascular access devices be changed while you are wearing a mask and sterile gloves. You did not provide the exact procedure that your facility has implemented for this, so I can not make any judgments about that.

I can understand the driving force behind this new recommendation - no reimbursement for hospital acquired bloodstream infection. Your question included the phrase "If correct technique is used" and there is a lot of details in that simple qualifier. We know that correct technique in cleaning needleless connectors has not been properly identified through research. This would include what agent to use for cleaning, how long should it be cleaned, what scrubbing techniques, and length of drying time. There are no real answers to any of these issues yet. We also know that these connectors can become heavily contaminated and do grow biofilm, the primary cause of catheter-related bloodstream infection (CRBSI).

We also know that air embolism is on this same list of outcomes that will no longer be reimbursed. Therefore you must use appropriate technique to clamp the catheter when changing any administration set or needleless connector. You can NEVER leave a catheter open while you change gloves and I don't think this is what your facility had in mind.

I do not completely understand the requirement for sterile gloves as these needleless connectors and catheters hubs are definitely not sterile. Maybe the prevailing thought was that regular exam gloves may be contaminated and they did not want to take this chance. Since this is a teaching hospital, I would imagine that your patient acuity is very high and therefore has more risk factors for infection. I can easily see the benefits of a mask while doing any catheter care, however I am not aware of any research that has identified masks during dressing or connector changes as an appropriate method to prevent CRBSI.

I would recommend that you track down the people who originated this policy and ask more questions. You need to know more about the thoughts that went into these recommendations. I would be very interested in what those thoughts are. So please share them when you located the people responsible.

Drawing Blood Samples from a PICC

2009-06-05T12:34:00.003-04:00

I am a member of a PICC team in a community hospital and I would like to get your opinion about drawing blood from the PICC line. Are we allowed to do that on a routine basis or unless specifically ordered by MD? Is it an INS standard to draw blood cultures from PICC lines? Will the result be accurate?

Infusion Nursing Standards of Practice, #66, Phlebotomy on page S71-S72 addresses this question. The decision to use any central venous catheter (CVC), including PICCs, for blood sampling should be made by each facility and put into a policy and procedure. This standard has separate sections for phlebotomy from a direct venipuncture, from a vascular access device, and therapeutic phlebotomy.

The catheter's instructions for use does include obtaining blood samples as an indication for the catheter. There are several factors that your facility should address in their policy including the need for a physician's order to use the catheter, what personnel can use a catheter for this procedure (e.g. only RN, LPN, or lab technician), and how competency with the procedure will be assessed and documented.

Concerns about the routine use of all central venous catheters for obtaining blood samples includes but is not limited to obtaining a good sample that will produce valid lab data and the increased manipulation of the catheter's hub for this procedure and the subsequent risk of bloodstream infection from that manipulation. Your facility must assess the published information and make a policy based on what is best for your patients.

Regarding obtaining blood samples for culture from a CVC, including PICCs, this should also be covered in your policy. Is the physician trying to rule out the catheter as a possible cause of the bloodstream infection? If so, obtaining a sample from the catheter and from a peripheral venipuncture is definitely indicated. If the blood culture is for some other reason and the catheter is not suspected as the cause, then a set of peripheral blood cultures might be sufficient. This is a procedural question and requires guidance from the facility's policy and procedure, and physician based on the reason for the culture. This is not something that can be definitively addressed in the Infusion Nursing Standards of Practice.

As always, your policy should be based on evidence. I know this requires your time to locate. This is part of the consulting services I provide to all healthcare facilities. But that level of detail would require more time and details than what I can include in this format. Please let me know if you would like more information about these consulting services.

PICCs and Extension Sets

2009-05-13T19:44:00.003-04:00

We are using BARD Groshong PICCs (not power) and have always added an extension set at the time of insertion, treating it as part of the catheter (not changing the ext). Of course, if the extension is removed for some reason, then we change it weekly with the dressing changes. There is now discussion as to whether or not this is considered best practice, also whether or not it is now necessary to put an extension set on a valved PICC.

Is it considered safe to send a person home with a Solo-PICC with the valve n the hub end and are you advocating that these have Heparin flushes not just saline after use?

The reason for adding an extension set to the hub of a PICC is to make it easier to get to the needleless connector for attaching syringes and medication tubing. This is especially beneficial when the patient is self-administering medications at home. A long extension set allows the needleless connector to reach the hand. The patient can hold this connector making it easier to attach the syringe and administration set. For patients in the hospital, a short extension will move the connector away from the insertion site, making it easier for nurses to adequately clean the connector and attach the syringes and sets. When using catheters with a sufficient extension leg or "pigtail" build onto the catheter, this extension set may not be required while hospitalized, but it will still be needed when patients are self-administering medications.

Regarding the Solo PICC from Bard Access Systems, I have not had any first hand clinical experience with this catheter. However, I have heard numerous discussions among colleagues with excessive frequency of catheter lumen occlusion. Because of the valve, the instructions for use call for saline only flushing. There is no explanation as to the reason for the lumen occlusion rates with this catheter, so I am not sure if the use of heparin would or would not improve the outcomes.

Catheter Dressing and Bleeding

2009-05-13T19:33:00.002-04:00

We routinely use a Biopatch and occlusive dressing for PICCs and implanted ports and change the dressing every 7 days unless soiled, dirty or loose. What if there is a constant oozing or bleeding that requires a daily dressing change- would you recommend a gauze dressing for less trauma to the site or continue to use an occlusive dressing to decrease risk of contamination?

First, I would use a hemostatic dressing material (e.g. Gelfoam, Surgicel) to stop the bleeding. If this does not work, I would want some other diagnostic test to determine why it is bleeding. I have seen bleeding with the old method of PICC insertion but bleeding with the modified seldinger technique is minimal, if at all. I have never seen bleeding from an implanted port site. So I would question why you have a significant problem with site bleeding.

I would not say that a transparent dressing reduces the risk of contamination over the use of a gauze and tape dressing. According to the CDC guidelines, both dressing types are acceptable. So I would use the type of dressing that is most comfortable for the patient. The bleeding will increase the risk of local site infection, so I would use the hemostatic material under a gauze dressing until the bleeding has stopped, even it if meant not using the Biopatch for a while.

And, as always, you must use one of the skin protectant solutions, especially when changing dressings more frequently.

Turbulent Flushing Technique

2009-05-13T19:12:00.002-04:00

I am in the process of reviewing our policies/procedures about flushing all central venous catheters. We have advocated the use of "turbulent method" or stop/start flushing method. I
have checked the Infusion Nurses Society Policies & Procedures, 3rd ed and they say "slowly
inject flush solution." Other resources state use vigorous flushing. Manufacturers do not use "turbulent" in their literature but teach it.

I can understand that the potential for releasing bacteria into the bloodstream is a concern but does it outweigh the risk of ineffective flushing which in term may lead to occlusions, thrombosis, loss of device, and delays in treatment.

Very good questions but a serious lack of data to provide answers! I have not and still do not teach or support the concept of this turbulent flushing technique because there has never been one data point published anywhere about its outcomes. The only pieces that have ever been published are opinions which base their ideas on the theory of fluid flow.

The fundamental flaw in the thinking is that we can keep catheter walls free of accumulating fibrin and biofilm that leads to complications of occlusion and infection. There is no evidence to support this. There is some evidence that vigorous or turbulent flushing techniques produce biofilms with a greater strength. When your flushing technique produces a shear force that is greater than the strength of the biofilm, breakage occurs. Biofilm breaking off means that clumps or clusters float into the bloodstream and can easily produce infection.

Vigorous flushing could be beneficial immediately following blood aspiration into the catheter lumen. In this situation, there has not been time for serum proteins to attach to the catheter walls with subsequent formation of fibrin. When blood has refluxed into the catheter lumen and allowed to reside for any length of time, it is highly questionable as to the effect of the flushing technique on the attached fibrin.

So I do not believe that the turbulent flushing technique offers the level of benefit that has been ascribed to it. And it has the potential to increase the breakage of biofilm, which will be present inside virtually all catheters. In the absence of any outcome data, I believe that the risk of bloodstream infection is a greater risk than lumen occlusion.

To prevent lumen occlusion, I think you would be better off to pay more attention to correct flushing and clamping technique for the specific needleless connecter you are using, a flush syringe that is designed to overcome syringe-induced reflux, and immediate disconnection of intermittent medications rather than allowing them to remain attached after the fluid has infused.

Disconnecting Continuous IV Fluids

2009-05-13T17:22:00.002-04:00

It is the practice of some nurses to start each PIV with a saline lock and then attach the continuous IV fluids to the saline lock. They will then disconnect the fluids for a short period so the patient can bathe or ambulate. As an infection control issue, is this any different than intermittent medications through the PIV ? Would they then need to change the tubing q 24 hours?

I am so glad you asked this question as this has become my soapbox! There are several issues involved in this practice, so let me break them down.

First, I strongly believe that all short peripheral IV catheters require a short extension set. This adds numerous benefits. It separates the "business end" from the actual catheter. When a needleless connector is directly attached to the peripheral catheter, there will be excessive catheter movement inside the vein leading to higher rates of phlebitis and increasing the risk of infiltration or extravasation. These complications produce serious, often life altering outcomes for your patient. Having the needleless connector on the distal end of the extension set makes it much easier to get to this connection surface, adequately clean it, and prevent excessive catheter motion in the vein. This extension set separates the nurses hands from the source of the blood, reducing exposure and provides a slide clamp to control flow in both directions.

Second, a needleless connector should only be attached to the distal end of the extension set when the therapy is reduced to only intermittent medications. If there are continuous fluids prescribed, a needleless connector is not indicated. The presence of this needleless connector adds another luer lock connection that can come loose or become contaminated. It also adds unnecessary costs. And, as you have described, it makes it far too easy to frequently disconnect the fluids. This disconnection increases tubing manipulation which is a known factor that increases the risk of catheter related bloodstream infection. I would hasten to add that this is based on basic principles of infection control and has not been examined in well designed research. A short peripheral catheter will only dwell for a few days, so there will be a much greater risk of infection associated with hub manipulation in central venous catheters.

Third, when the continuous fluid is disconnected, the nurse is altering the patient's ability to reach therapeutic goals. I would remind your staff that these fluids and medications were prescribed for a reason. You must consider that fluid and electrolyte balance, at the very least, will be affected. If there are other medications in the primary fluid, the patient's lab values will be seriously impacted. I am thinking about insulin, heparin, and aminophyline, but I am sure there are others. The pole, pump, fluid container and administration set should all be positioned so that the patient takes this entire set-up with them to ambulate in the hall. For a quick shower, I have had patients shower when the catheter must be rotated at the 72 or 96 hour interval. Take out the catheter and send the patient to the shower while the nurse is setting up the new fluid container and administration set. Then after the shower, insert a new catheter. If the catheter rotation is not needed, the site should be protected and the entire set up taken with the patient to the shower with the tubing long enough to allow the pole to be outside of the shower stall.

I would also ask if the physicians know of this practice and that the patient is not receiving the fluid as they prescribed it. Additionally how are they maintaining this administration set while it is disconnected. Are they provided with sterile caps to cover the male luer end? Do you have a policy for this practice to address the safe handling and reconnection of the set? And, yes, this practice will drive up cost because these sets should be considered intermittent sets and changed every 24 hours. There is absolutely no data that I have ever found on the use of sets for intermittent purposes. All studies have excluded intermittent use and only included sets used on a continuous basis without disconnection. Based on this lack of data, the standard of practice is to change intermittent sets at 24 hours rather than allowing a longer use.

So the bottom line is that no catheter - peripheral or central - requires a needleless connector when the infusion is a continuous basis. For a peripheral catheter, the presence of an extension set is best practice and the needleless connector can easily be added when the continuous infusion is stopped and the patient still needs to have intermittent medication. One problem is when the hospital only provides short extension sets with a fixed needleless connector. So you must think about all of these issues when considering this issue.

PICC and Exercise

2009-04-28T15:03:00.002-04:00

We are in the process of updating our patient education information about PICCs and would like to include exercise especially for cancer patients.We have previously advised no repetitive motion and limited lifting to a 10 lbs maximum. I would appreciate any info that you may have.

This is one of those questions that is based in our knowledge of anatomy and physiology and infusion nurses' experience. Unfortunately, I am not aware of any published studies that have examined this specific issue.

I would strongly advise that your patients with a PICC be taught to avoid strenuous, repetitive activities including those that involve lifting heavy objects. The reason is the normal muscle pump action, also known as the venous pump action. Normal muscle contraction exerts pressure on veins to compress them. Upper venous valves open, distal valves close, and blood is forced back to the heart.

When a PICC is located in the upper extremity, excessive, strenuous, repetitive muscle contraction can compress the catheter along with the normal venous compression. This brings the vein wall into more frequent contact with the catheter, increasing the endothelial damage and thrombosis development. This is not an acceptable risk in cancer patients who are already at risk for thrombosis due to their hypercoaguable state.

Venous and catheter compression causes other issues. It can lead to catheter dislodgement, especially if the catheter is not properly stabilized with a manufactured catheter stabilization device. Tape and sutures are not adequate and do not provide outcomes as good as a manufactured stabilization device.

Also, catheter compression can force the locking fluid out of the internal catheter lumen, much like pinching a straw. When the compression is relieved, blood can be pulled back into the catheter lumen, increasing the risk of a clotted catheter.

I can appreciate the need for exercise, however it should be tailored so that it does not involve strenuous, excessive, or repetitive movements of the arm with the PICC. So walking, biking, and any aerobic activity could be encouraged but weight lifting should be discouraged.

Patients should be encouraged to use the arm in a normal manner though. Holding it still with no normal activity could encourage venous stasis and also risk a clot formation. This is basically the same principle for not placing any catheter in a paralyzed extremity. The paralysis is preventing the normal muscle or venous pump action, leading to venous stasis and the risk for thrombosis.

PICC Dressings - When to Change?

2009-04-28T14:44:00.002-04:00

Our staff is asking if it is permissible, on a case by case basis, to change out the PICC insertion dressing 8-12 hrs post insertion vs. the customary 24 hrs. I can find no answer in my INS P&P / practice material addressing this question. It seems to me that, if hemostasis has been achieved, and there is no unusual swelling, bruising or pain, then it would be ok to do. The motivation behind this, of course, is cost. Our home infusion staff are looking at changing out the dressing at p.m. start of care for the patient who had a PICC placed in the a.m. This would sometimes enable us to avoid another nursing visit the next day. This is only for those patients who are able to achieve independence with therapy following the initial visit and require only routine follow-up (the minimum is a weekly visit).

By the way, I’m finding a number of acute care facilities are dressing PICC sites immediately after insertion with the Biopatch. They are claiming that use of the Biopatch post insertion enables them to defer next dressing change for 7 days. I don’t buy it. Have you heard of this?
What do you think of these practice?

These are very good questions and serve as examples of how practice changes based on new products and new evidence. First, the need to change a PICC dressing within the first 24 hours after insertion is based on the old method of insertion that resulted in a large vein puncture and a small catheter left in this large site. Bleeding after insertion was common. Now, we are using ultrasound and the modified seldinger technique (MST) for insertion and bleeding is not a significant problem. So you must first assess the insertion method and the typical amount of bleeding, if any, in the hours following PICC insertion. If the site is clean, there is no need to change the dressing at all. If the site has bloody drainage, it should be changed. So your home care nurses can change the dressing at their initial vist if there is bleeding only.

Regarding immediate application of Biopatch and then not changing the dressing for 7 days, yes! This is being done and is supported by new evidence. Click here to read a recent study that addresses this very issue.

Steps in Skin Antisepsis During Dressing Changes

2009-04-28T14:03:00.003-04:00

We are working on our central line dressing policy and will be using Biopatch® and Sorbaview® dressing. What should be the cleansing procedure? Some policies I have seen say to use 3 alcohol swabs in circular motion followed by a friction rub with chloroprep and then when the area is tacky apply the Biopatch followed by the Sorbaview dressing. Others do not use alcohol at all, but use three chloroprep swab one after each other using friction rub. What is the best way to do it?

The idea of using 3 swabs of any solution applied in a circular pattern is outdated. In fact, I know of several professionals that have tried to locate the studies to support this practice and none have been found. So this practice looks like it was based on theory and expert opinion but has no science to support its use.

There are 2 resources to consider to arrive at the answer to your question. First is the CDC Guidelines for Prevention of Intravascular Catheter-related Infections. The following statement is given a Category 1A recommendation, "Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes." The key is clean skin. So if there is excessive skin oils, bleeding, sweat, tape residue, and/or any other form of matter, you should clean this before applying the skin antiseptic. Before we place a catheter, the site may need to be washed with soap and water, however this is not possible when doing a dressing change around an existing catheter. At this point the best method for removing the oils, sweat, blood, etc. is to use alcohol swabs. But there are no recommendations for using 3. So use the number sufficient to render the skin clean. This step could also be performed with sterile saline but alcohol swabs are more convenient and readily available. If the skin is not dirty, this step is not necessary. In fact, alcohol will remove normal skin oils and cause excessive skin dryness in some patients. After the skin is clean, then you apply the chlorhexidine gluconate following the instructions of use from the specific product being used. If using Chloraprep®, click here to locate the chosen product and obtain their instructions for use. These instructions state to use a back and forth scrubbing motion for 30 seconds and allow it to dry for 30 seconds. The back and forth motion allows the solution to reach organisms in the lower layers of the epidermis. The other product is Chlorascrub® but I can not locate their instructions for use at the website. You should contact the manufacturer to learn their specific recommendations.

Three chlorhexidine swabs are not necessary. Choose a swab product that has the amount of solution required to clean the area under the dressing. This volume of solution is sufficient to thoroughly clean the area.

Make sure that all solutions are thoroughly dry before applying the dressing. Allowing to dry until it is "tacky" may not be sufficient.

One other thing - you should be using some type of skin protectant solution also. If used from the beginning, these solutions protect the skin, prevent irritation, and cause the dressing to remain adherent for a much longer period. I would never apply a dressing to any patient without using some type of skin protectant solution.

Calculating Intraluminal Catheter Volume

2009-04-24T15:43:00.002-04:00

How can we calculate the intraluminal volume for a central venous catheter? Our challenge has been the proper amount for declotting of CVCs in pediatric patients.

You are correct - this is a challenge and may not be possible. A mathematical formula can be found in this article:
Lawson M, Vertenstein MJ. Methods for determning the internal volume of central venous catheters. Journal of Intravenous Nursing. 1993;16(3):148-155.

Your challenge will be knowing the exact length of the catheter. The instructions for use for all catheters contain information about the internal volume of each catheter. This varies by the size of the catheter lumen and length. When the catheter is cut to a patient-specific length, you must know that length to use this published formula. Without that length, you can go by the volume provided by the catheter manufacturer for the entire catheter length at the time of manufacture.

Radiographic Technologist and PICC Insertion

2009-04-24T15:29:00.002-04:00

What are the requirements for Diagnostic Imaging staff to place PICC's? I know that RN's in Interventional Radiology start them but what about techs etc.?

Here is the statement from the American Society of Radiologic Technologist:

Placement and Removal of Peripherally Inserted Central Catheter (PICC)
The ASRT recognizes that placement and removal of peripherally inserted central catheter is within the scope of practice for radiologic technologist with appropriate clinical and didactic education where state statutes and/or institutional policy permits.
Adopted by the House of Delegates, Resolution 03-3.01, 2003
Reviewed February 2005

Click here to go to their website. Then download the ASRT Position Statements to get the entire document.

It is important to notice that there are 2 caveats in their statement. This practice may be addressed by state statutes or rules governing the scope of practice for this group but this will vary between states. There must be institutional policy to permit this group to perform this task. Joint Commission requires that all personnel have documented competency before performing the task independently. So these technologist must have an established process for continuing education and supervised clinical practice just like an RN would.

Jugular vs subclavian sites

2009-04-24T15:13:00.003-04:00

What is the optimal site selection for temporary central venous catheter insertion sites in patients without renal failure? Is the right internal jugular recommended over the subclavian approach?

Your question brings up many things to be considered. Are your concerns based on the lowest infection risk or prevention of all complications? This reference provides some information:
Marschall J, Mermel LA, Classen D, et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology. 2008;29(s1):S22-S30.

It states that there are nonrandomized studies showing a lower risk of infection with a subclavian site as compared to the jugular site, however the risk and benefits of each site must be considered on an individual patient basis. Jugular sites for percutaneous catheters create tremendous challenges with proper catheter stabilization and adequate dressing. On men, the growth of a beard is always a problem and long hair on women creates problems with this site. For tunneled, cuffed catheters and implanted ports, the jugular site is always preferred but there is no catheter exiting from the skin at the jugular site with these catheters. On the other hand, the subclavian site is associated with pneumothorax, brachial nerve plexus injuries, and pinch-off syndrome for all types of catheters. So this is a patient-specific decision.

Change Frequency for Needleless Connectors

2009-04-24T15:02:00.004-04:00

Is there literature out there to define best practice for a) the frequency of routine change of External Positive Pressure Device (i.e., recommendations to change from Q 7 days to 72 hrs) and b) the necessity to change EPPV following blood draws?

By EPPV, I am assuming that you mean a needleless connector with positive displacement. You need to look to 2 resources for your answer. First is the CDC guidelines which state that all needleless connectors should be changed at the same interval as your IV administration sets. If your policy is 72 hours, then all needleless connectors should be changed at 72 hours. This has been the recommendation since this document was published in 2002, so it is not new.

The other resource is the manufacturer's instructions for use. While the CDC considers infection risk, the manufacturer is also assessing mechanical failure. They test these devices to a certain point and then write their instructions based on that testing.

Regarding your question about changing the needleless connector after blood draws, please scroll or search for the post of April 10 on Blood Sampling and Needleless Connectors.

Infusion Therapy and Organizational Learning- What Does Your Facility Know?

2009-04-24T14:17:00.002-04:00

Your questions continue to come in via email. While I appreciate the material to use for continuing my blog, I am struck by the simple fact that many of your facilities do not have adequate knowledge of infusion therapy. Many are questions that seem very basic to me as an experienced infusion nurse specialist. Many are asking for published evidence to support my information. But all of it points to the fact that most facilities, especially our nation's hospitals, have not invested in the processes of knowledge management for infusion therapy.

What do I mean by this term? I can hear the questions popping into your mind as you read this. Knowledge management and organizational learning go hand in hand. Wikipedia defines this as "a range of practices used in an organization to identify, create, represent, distribute and enable adoption of insights and experiences. Such insights and experiences comprise knowledge, either embodied in individuals or embedded in organizational processes or practice."

Now lets apply this concept to infusion therapy. Infusion therapy is one of the most invasive procedures performed in a healthcare setting with great frequency. It encompasses all ages groups, all service lines, all types of patients, and extreme numbers of medications, solutions, technology, and other treatment modalities. It involves the sciences of anatomy and physiology, mathematics, physics, geometry, biology, microbiology, chemistry, and mechanical engineering, although I am probably forgetting some. It requires collaboration between nursing, pharmacy, medicine, dietary, laboratory, biomedical engineering, risk management, infection prevention, and performance improvement. When you think of the breadth and depth of knowledge required for safe delivery of infusion therapy, it is astounding to me that most facilities do not invest heavily in this service.

When hospitals disband IV teams, valuable knowledge, skills and experience usually walks out the door with the nurses as they leave for another job. The knowledge and skills of those IV nurses, gained over many years of caring for the patient populations at that facility, are taken to other facilities. That investment is allowed to depart from the facility and there is no one to replace it easily.

Infusion therapy and the delivery of these services requires serious attention to the management of this knowledge so that the processes and practices within that organization produce the best outcomes. This will be cost effective. Poor outcomes involve serious complications that dramatically increases cost. Yet, most hospitals do not see the need to invest in this specialty. I would hasten to add that we have not done a good job at creating the "business case" of our services either. What is the financial return on investment from an IV team? Most do not have this data. Your CFO does not understand low phlebitis rates, numbers of medication errors, bloodstream infection rates, or any other quality measure you use. We must take it a step further and convert this to the actual dollars saved by doing what we do. What financial return does the facility enjoy by investing in a full service infusion therapy team? Answers to this question will place our worth in the proper perspective.

Most administrators expect all nurses to perform at the highest levels immediately upon employment. Yet there is no standardized curriculum, methods of teaching, or supervised clinical experience during our years in nursing school. Physicians face the same problem with this specialty in medical school. Without these standardized processes, what can we expect but chaos, negative patient outcomes, life-threatening or life-altering complications, and increased costs.

I will continue to respond to questions via my blog but most questions require more than just a simple, short answer. Responses on my blog will only go so far. I do not have the inside knowledge of your patient populations, the culture of your facility, the types of therapies being prescribed, and the written policies and procedures. Your questions are based in this lack of knowledge management and organizational learning about infusion therapy and the delivery of this service. I know the economic crisis is impacting hospitals just like other industries. It may seem odd that I am trying to sell consulting services in these tough times. But that is exactly what most hospitals need. If there is not a knowledgeable, experienced infusion nurse specialist in your facility, you need the contracted services of this specialist. I am waiting to hear from you!

Eliminating Heparin Lock Solutions

2009-04-15T19:44:00.003-04:00

If you are using a central venous catheter (CVC) without an integral valve and opt not to use heparin lock solution, how frequent should you flush this line with saline, and how much? Is there evidenced based practice for this to base a change for our facility?

As you stated, catheters with integral valves such as Groshong from Bard Access or PASV from Navilyst have instructions for use stating that saline only is sufficient for flushing these catheters. Heparin is not contraindicated and it can be used, however the valve makes it unnecessary.

When you do not have a valved CVC, you can eliminate the heparin ONLY when you have a needleless connector added to the catheter with the saline only instructions for use. Some of the positive displacement and neutral displacement needleless connectors have instructions for saline only and some do not. So check there written material closely.

If you are not using a valved catheter and not using a needleless connector with saline only instructions, then I would recommend that you continue to use heparin lock solution. There are several studies on needleless connectors and occlusion rates. Even with the needleless connectors with saline only instructions, the occlusion rates can still be between 10 to 12%. One small, randomized trial using the same positive displacement needleless connector had one cohort with saline only and one cohort with saline followed by heparin lock solution. The rate of occlusion in the saline only group was 6%. This was not statistically significant, however performing the declotting procedure on 6% of their PICCs annually was determined to be too costly.

Here are a few studies you should look at for their methods and rates of occlusion:
1. Bowers L, Speroni K, Jones L, Atherton M. Comparison of occlusion rates by flushing solutions for peripherally inserted central catheters with positive pressure luer-activated devices. Journal of Infusion Nursing. 2008;31(1):22-27.

2. Jacobs B, Schilling S, Doellman D, Hutchinson N, Rickey M, Nelson S. Central venous catheters occlusion: A prospective, controlled trial examing the impact of a positive-pressure valve device. Journal of Parenteral and Enteral Nutrition. 2004;28(2):113-118.

3. Schilling S, Doellman D, Hutchinson N, Jacobs B. The impact of needleless connector device design on central venous catheter occlusion in children: A prospective controlled trial. Journal of Parenteral and Enteral Nutrition. 2006;30(2):85-90.

You should also obtain the Flushing Protocol cards from the Infusion Nurses Society at www.ins1.org. Elimination of the saline completely is only recommended for short peripheral catheters.

Blood Sampling for Culture from a PICC

2009-04-15T19:05:00.003-04:00

If a patient has an order for blood cultures times 2, we prefer to have one sample drawn from the PICC. If blood cannot be aspirated, even after flushing with saline, do you use Cath-flo? If you instill it into the PICC for 30 mins, withdraw and get a blood return, do you use the sample containing the Cath-flo for the culture? And, if it takes 2 rounds of Cath-flo, followed by saline flushes after a total of 1hour, to get a blood return, is that specimen going to be valid? When I was researching this on the internet, I only found that Cath-flo should not be used on any line that is suspected of being infected for fear of a septic emboli, so I wasn’t sure if that meant it should never be used for obtaining blood cultures. I am hoping you can shed some light on this subject for us!

These are great questions, however I can not provide any concrete, evidence-based answers for you. But lets explore what we do know.

First, do your infectious disease physicians and infection prevention professionals agree with drawing a blood sample from the catheter? To diagnose central line associated bloodstream infection (CLABSI), this catheter sample is not required. Even for a laboratory confirmed CLABSI, a sample from the catheter is not required. The downside to this approach is that the catheter is not ruled in or out as the source of the infection and could overestimate the catheter as the cause.

If you are trying to diagnose catheter-related bloodstream infection (CRBSI), a sample is drawn from the catheter and compared to a sample from a peripheral vein. From your description, I can only assume that your goal is to diagnose CRBSI which will guide the decision to remove the catheter.

When you aspirate blood, you are trying to gather planktonic organisms from the intraluminal biofilm. The tPA will destroy the fibrin and loosen some of the biofilm that is integrated with the fibrin layer. Genentech instructions state to aspirate the contents from the catheter before flushing after the tPA instillation period. This aspiration prevents flushing the biofilm into the bloodstream. The planktonic biofilm is what leads to bloodstream infection.

There is usually no need to draw a discard volume of blood when obtaining a sample for culture from a central venous catheter. But I have never heard discussions or read anything about combining the use of tPA with the practice of obtaining this blood sample. The process of performing the tPA instillation could increase hub contamination simply because of the additional manipulation. I don't think that the presence of the tPA would alter the outcome of the culture, other than the possible contamination from manipulation. But the tPA probably will release a greater amount of biofilm. Since virtually all catheters will have a layer of biofilm, then my reasoning would be that virtually all of your samples would be positive for some type of organism.

I am not aware of any studies on this issue, nor if Genentech has any statements about this. I would recommend that you contact the clinical support staff at the company to seek more information about this. You should also thoroughly discuss this issue with your infectious disease physicians and infection prevention staff. You might need to do some data collection to arrive at the best practice, but I think it all comes down to what you are trying to accomplish with these cultures. The outcome is more critical if your goal is to always rule out the catheter as the source and therefore prevent it from being removed. So no real answers but lots to think about and pursue with your colleagues.

I welcome the thoughts of others on this issue from your practice or professional opinion.

A Safe Amount of Air in an IV Line?

2009-04-13T17:57:00.003-04:00

Is there a reference (or an "authority") somewhere that says definitively how much air is safe to allow to get into an IV line? It is almost impossible to draw up and administer a medication without a tiny bubble in a syringe. I can almost (but now quite) remember reading 3 or 4 ml of air are essentially harmless, and that it takes a lot more than that to be dangerous. Do you know where I could find that information?

No, you will not find this information in the published literature that I have ever seen. The amount of air that would have catastrophic results varies from patient to patient and depends upon the rate of entry, patient's position, type and size of catheter, patient's blood pressure, and the presence of an undiagnosed patent foramen ovale. So one patient may be able to tolerate much more than others.

We have always focused on the catastrophic outcomes of air embolism. This is usually thought to be respiratory compromise, however there is a growing number of cases of cerebral air embolism producing major cerebrovascular accidents. This can produce such severe outcomes that the patient requires complete nursing care for the remainder of their lives.

Now there is a growing body of knowledge that small amounts of air in the form of microbubbles are not benign. Please see the post from July 2008 about a new report of damage from these microbubbles. To read this post, click here.

I would also challenge the concept that small air bubbles can not be adequately removed from a syringe. From more than 25 years of clinical practice, my experience is very different. The air can and should be removed from a syringe. Those small champagne-type bubbles in the IV administration set are much more difficult. In my opinion, we should re-examine the use of inline final filtration to remove these air bubbles and reduce the risk associated with them. The problem with this is that the damage from these microbubbles are cumulative over time and not a catastrophic event.

Rates for Infiltration

2009-04-13T17:25:00.002-04:00

We have known that our IV infiltration rate should not be more than 15 % but I cannot find the evidence for that. I do not see it in the INS standards either. Can you please tell me where we can site that rate?

I am not sure where you got this piece of information, but there has never been any published number that is an "acceptable" rate for infiltration. So, you will not be able to find this in any published literature that I have ever seen.

Benchmarking against the rates of other facilities has been an acceptable way to judge the quality of care being provided, however this concept is changing. Years ago, most hospitals thought that if their rate of catheter-related bloodstream infection is equal to or better than the rates published by the CDC, the quality was considered to be good. Now, the goal is a zero (0%) of CRBSI because there are published guidelines and evidence demonstrating that this complication is preventable.

Infiltration has long been considered one of those complications that is an acceptable outcome of infusion therapy. I firmly believe that this complication should fall into the goal of zero also. By using the INS standards of practice, it is my opinion that this complication can be prevented. At best it can be recognized very quickly and serious negative outcomes can be prevented. The applicable standards include site selection, catheter selection, use of an armboard, catheter stabilization, and medication administration. There is also a standard to grade infiltration and distinct definitions of infiltration and extravasation.

One other problem is that there is very little information published about the actual rates of infiltration and extravasation. While the INS uses these words differently, there is a lack of standard use for these words. This skews the limited published data that we have. I have only been able to find rates for extravasation (leakage of vesicant medications) published for cancer chemotherapy drugs, CT contrast agents injected under pressure, and rates for implanted ports. The majority of these published numbers are far less than 15%. One older study reports extravasation rates of 11% in children and 22% in adults, but this is not the same as infiltration (leakage of nonvesicants). High pressure injection for CT contrast has produced published rates between 0.1 to 0.9%, far less than 15%.

So my opinion is that there is no basis for the 15% rate, and that this rate is far too high for both infiltration and extravasation. The goal should be zero. To learn more, we offer a comprehensive online continuing education course on this topic. To learn more about this course, click here.

Antecubital Fossa IV Sites

2009-04-13T16:14:00.003-04:00

Do you have any pictures or documentation on the adverse effects of antecubital IV starts?

I just did a brief literature search trying to find some published information about outcomes associated with using the veins of the antecubital fossa for insertion of IV catheters, however there is very little published. From my observations, it does seem that there is a total lack of skill to find veins in the forearm. If a vein can not be found in the hand, wrist or antecubital fossa, the nurse gives up. This speaks to the lack of formal education and attention to the development of the skills of palpation and/or the increasing number of patients with difficult venous access.

The national standard is based on our knowledge of anatomy and clinical expertise of experts. The standards state that areas of joint flexion should be avoided, and if this is not possible, the joint should be stabilized by using an arm board. As you can imagine, using an arm board on an extremity with a site in the antecubital fossa could be uncomfortable for patients. Without this arm board, arm movement can increase the risk of the catheter eroding through the vessel wall producing infiltration, extravasation, and thrombophlebitis. These complications definitely prevent the use of other venous sites distal to this area on the same extremity. Infusion through a distal site will exacerbate the complication because the fluids and medications being infused with flow through the area of complication, increasing the problem. This point has definitely been an issue in numerous legal cases.

There are 3 veins in the antecubital fossa - basilic, cephalic, and median cubital. In addition to the issue of joint flexion and the possible resulting complications, there are nerves close to all these veins and the brachial artery very close to basilic vein. Damage to the nerves and artery can add to the list of complications. Accidental arterial injection of most drugs can lead to serious injury. I have served as the expert on several cases resulting in arm amputation because of unrecognized arterial venipuncture in the antecubital fossa.

Sorry but I am not at liberty to share pictures through avenues other than continuing education courses. I don't own the pictures but have permission to use them. The copyright permission is not transferrable.

The increasing use of ultrasound for venipuncture can guide the nurse to avoid large nerves and arteries. So, the bottom line is that antecubital fossa veins should only be used for venipuncture and insertion of a peripheral catheter when other sites have failed and there is guidance from some type of visualization technology such as ultrasound.

Skin Antiseptics in Neonates

2009-04-10T11:35:00.002-04:00

We are starting pediatric PICC insertions, and have discovered controversy for the INS recommendation for IV skin preparation in infants less than 2 months of age. Do you have information on this or someone who I might contact to get current practice?

Janet Pettit, a neonatal nurse pracitioner and vascular access specialist provides the answer to this question.

There remains a controversy over use of chlorhexidine gluconate (CHG) in those patients less than 2 months of age, though I believe about 50% of the NICUs that I visit have switched and probably 70% in CA. We tend to focus on the product labeling and forget that 80%+ of devices, medications and such used in this population are off label. There are still 2 camps - the aqueous CHG users and the alcohol based CHG (majority). The aqueous version (soapy scrub) needs to be removed from the skin (dressings won't stick if it's present). This was adopted in the latest version of the AWHONN Skin Care Guidelines as it was unclear what effect CHG may have on the skin and this is the practice with povidone iodine (PI) . I've been told by the manufacturers of CHG that removal from the skin may be difficult to achieve and would negate the ongoing effect. There are reports in the literature of skin erythema and damage with both types of CHG. We don't remove from the skin in our practice and haven't seen skin reactions with this practice. The problems we've seen is around the umbilicus of those infants < 1000 grams (about 28 weeks gestation). We see erythema, which appears as soon as the CHG is applied to the skin and skin breakdown. We continue to use PI with these infants for approximately 2 weeks then switch to CHG. I have found that the majority of alcohol based CHG users do something similar in limiting use.

Here is the statement from the California Perinatal Quality Care Collaborative:

There are no data that show any antiseptic agent to be superior to chlorhexidine gluconate (CHG) for skin antisepsis. Many CHG containing products exist on the market in both aqueous and alcoholic formulations and in a variety of strengths, contributing to the complexity
of “best” newborn skin antisepsis. Taking into consideration the issues of efficacy and the potential of local irritation and systemic absorption, CHG or PI are the skin disinfectants recommended by PQIP as outlined below.
Chlorhexidine Gluconate (CHG) Alcoholic-based:
• Apply over 30 seconds using side to side motion
• Allow to dry over 30 seconds
Chlorhexidine Gluconate (CHG) Aqueous:
• Apply over 30 seconds
• Remove with sterile water or saline following the procedure
(aqueous CHG will not dry due to its soapy consistency)
(Malathi et al 1993, Lund et al 2001).
Povidone iodine (PI):
• Apply over 30 seconds and allow to dry
• Remove with sterile water or saline following the procedure

“After topical applications of chlorhexidine, some percutaneous absorption occurs, particularly in preterm newborns, but only at trace levels.” Studies to date have used a variety of concentrations for multiple interventions. Tens of thousands of neonates have received
chlorhexidine for umbilical cord care, bathing and maternal vaginal lavage prior to birth without reported adverse effects. (Mullany, 2006).

Povidone iodine containing solutions are commonly used for skin antisepsis prior to invasive procedures. Current practice is to remove the solution at the conclusion of the procedure. Caution should be exercised with use, particularly in very immature and sick infants who require
repeated applications over large areas. (Linder, 1997).

Four of 36 (11%) infants < 1000 grams exposed to 2% aqueous chlorhexidine developed severe skin irritation (all had erythema and one progressed to breakdown with exudates). The study used 2% chlorhexidine for all central & arterial catheters and PIVs for infants <1000 grams and<14 days and 1% chlorhexidine in ethanol for all other IVs. (Anderson 2005)

Eight studies investigated in this meta analysis involving a total of 4143 catheters met the inclusion criteria. All studies were conducted in a hospital setting, (ICUs or hospital wards) and various catheter types were used. The summary risk ratio for catheter-related bloodstream
infection was 0.49 (95% CI, 0.28 to 0.88) in patients whose catheter sites were disinfected with chlorhexidine gluconate instead of povidone iodine.

Among patients with a central vascular catheter, chlorhexidine gluconate reduced the risk for catheter-related bloodstream infection by 49% (risk ratio, 0.51 [CI, 0.27 to 0.97)]). Subset analyses of aqueous and nonaqueous solutions showed similar effect sizes, but only the subset
analysis of the 5 studies that used alcoholic solution produced a statistically significant reduction in CRBSI. The lack of significant difference may be a result of inadequate statistical power.
(Chaiyakunapruk 2002) (Class I)

0.5% chlorhexidine gluconate in 70% isopropyl alcohol is more efficacious than 10% povidone iodine for the prevention of peripheral intravenous catheter colonization in neonates. (Garland 1995)

PQIP COMMENT: Alcohol applied topically may damage some
polyurethane catheters when applied at the time of a dressing change.
Check with the catheter manufacturer’s recommendations for
compatibility.

Many thanks to Janet for this information!!

Small Drug Doses and Syringe Size

2009-04-10T10:57:00.003-04:00

Is it acceptable to use a small syringe to inject small amount of some drugs into a central venous catheter? Some drugs doses are less than 1 mL such as 0.25 or 0.5 mL. Is there a risk of catheter damage if these drugs are given from a 1 mL or 3 mL syringe? We have concerns about transferring this small amount to a larger syringe but are also concerned about the psi from these small syringes.

This is an important question and one that I can get on my soapbox about. Yes, it is perfectly acceptable and preferred in my opinion, to use the syringe size that is appropriate for the drug volume!! I would always use a 3 mL syringe for these doses and NEVER transfer to a larger syringe because the risk is too great.

Catheter damage will ONLY occur when the force applied to the syringe plunger meets resistance along the fluid pathway. So if they catheter is open and patent, the intraluminal pressure will not rise, therefore there is no catheter damage possible. This resistance can be detected by using a saline-filled 10 mL syringe to assess patency before the dose. This same syringe is also used to flush the line, and aspirate for blood return. This is a crucial step that can not be overlooked.

I would avoid using a 1 mL syringe as it is possible to reach very high pressures with those syringes because the opening in the syringe tip is so small.

I am very concerned about the idea of transferring drugs from a small syringe to a larger syringe. There is a great risk of altering the dosage that you have carefully measured in the small syringe. There are risk of contamination. Plus it requires additional nursing time and it is not necessary. Just make sure that there is no resistance to the flush before you use the 3 mL syringe and there should be no problems.

On the opposite end, a 10 mL syringe can cause catheter damage if there is resistance and a strong hand is forcing the plunger. So the key factors should be 1) never forcefully inject with any syringe size, 2) assess patency before each dose with a 10 mL syringe, 3) use the syringe that is appropriate for the drug dose.

Blood sampling and needleless connectors

2009-04-10T10:30:00.002-04:00

What is the current thought on changing or not changing needleless connectors after lab draws or blood transfusion? Manufacturer guidelines apparently state there is no need to change the cap. Staff education here finds that to be something that is not very safe. Do you have any thoughts, articles to support either way?

This is a frequent question and one that does not have much evidence to answer it. At this point, the only thing we have to rely upon is the manufacturer instructions regarding this issue, however I would expect to see some form of data to support those instructions. Many manufacturers have conducted testing about the amount of blood that can reside within their needleless connector. Look carefully at the technique being described and the volume of saline used to flush the connector. Then make a judgment about how this compares to the technique being used at your facility.

The current statement in the INS standards of practice is, "If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set." There are several problems with this statement. First, many needleless connectors are not clear, preventing the nurse from seeing any residual blood remaining inside. Second, the change of the administration set with residual blood is easy, however the change of the catheter is not easy or practical for most patients.

We know that residual blood can create a wonderful medium for the growth of organisms. Add this to the fact that these connectors may not be adequately cleaned before each and every connection OR the fact that some may be difficult, if not impossible, to adequately clean. Now there is a great situation for the growth of biofilm that can cause a bloodstream infection.

I also have questions about the practice of changing these connectors after each blood sampling or blood transfusion. We are aspirating for a brisk blood return as one component of our assessment of catheter patency. No studies have been done to recommend that XX amount of blood is required but most of the time this blood will enter the attached syringe. This means that it has passed through the needleless connector. Is there a difference between this blood in the needleless connector and blood sampling or transfusion?

It is painfully obvious that there are many unanswered questions. In these situations we have to rely only upon our professional expertise to guide us. If the needleless connector is clear and you can visibly see that there is no blood remaining, is the risk of opening the line to change this connector greater or lesser than leaving it in place? If the needleless connector is not clear, there is no way to see what is happening inside. What are the differences between designs of these devices? If it is clear and there is no visible blood, my opinion would probably be to change them at the established interval of 72 or 96 hours.

The most important factor is to carefully monitor rates of CRBSI. You should also look at the point in the dwell when these infections are occurring. If the patients present with signs and symptoms within the first week of dwell, this is most often attributed to the skin as the source of infection. If the signs and symptoms occur after the first week, the catheter hub is the course of the infection. This would guide your interventions to improve your outcomes.

Management of Catheter Related Thrombosis

2009-04-10T10:02:00.002-04:00

I work for a home infusion company that provides infusion services to 2 separate hospitals in the area. They both do very different treatments for this problem. In a patient with a PICC who complains of pain and swelling in the axillary region, the nurse calls the doctor and says that an x-ray is needed to check for thrombosis formation.

One hospital gets the x-ray and if a thrombosis is present calls in the vascular team. They pull the PICC, start the patient on Lovenox and place a new PICC in the other arm. The other hospital leaves the PICC in and gives them Arixtra and does nothing else.

What is your recommendation for this patient (pull the line or leave it)? What test would you recommend a x-ray or Doppler study? What treatment should be given?

There are no published guidelines about the management of any catheter-related thrombosis. So the management depends upon the approach chosen by the physicians at each hospital. The limited informtion that is available supports the uses of diagnostic ultrasound as the best method of diagnosing this problem. A regular chest xray will not reveal these thromboses. A dye injection through the catheter under fluoroscopy will show vein thrombosis, however this is an invasive procedure that can increase the risk of vein damage and thrombosis itself. The ultrasound is non-invasive and produces more reliable results.

Regarding what to do with the catheter, recent discussions and presentations at AVA supports the idea of allowing the catheter to remain in place. Removal and reinsertion at another site will only put the patient at risk for the same problem at the new site.

Published forms of treatment involves catheter-directed thrombolysis done in radiology or systemic anticoagulation with some form of heparin. There are no recommendations about the "best" approach. Arixtra (fondaparinux sodium) is used in conjunction with warfarin to treat DVT in hospitalized patients. Are these patients transferred back to home care with this treatment? Are they also on warfarin? There are numerous drug and herb interactions with this drug. I would like to hear from other nurses in home care about whether they are seeing patients on Arixtra in the home. Please add your comments to this post.

Masks for CVC Care

2009-04-06T11:43:00.002-04:00

What are you thoughts on masking the patient during a cap change for central lines (PICC)? for a dressing change? For the nurse during cap change? Is there evidence to support?

This is an area where I have never seen any research or any published information. The concept of maximum barriers includes wearing a mask but this has only been applied to catheter insertion. Other components of maximum barriers for catheter insertion include sterile gloves, sterile gown, and large sheet drape for insertion of all central venous catheters (CVC) including PICCs.

My clinical experience supports the use of masks on the nurse and patient during a dressing change on any CVC. This was based on our personal and professional opinions because we were doing this long before anyone coined the phrase "maximal barrier precautions". However we did not use masks during the change of any administration sets or needleless connectors.

The human mouth and nose are heavily colonized with streptococci, staphylococci (including MRSA in some people), diphtheroids, gram negative cocci, and candida. As we know, many of these organisms are the leading cause of catheter-related bloodstream infection.

When discussing the pathogenesis of CRBSI, the emphasis has always been on the skin (both patient and caregiver), the catheter hub and all connection surfaces, the infusate, and seeding from other sites of infection. The first two areas - the skin and catheter hub - have received the greatest attention in our efforts to prevent CRBSI. In my opinion, it would be easy to have oral organisms come into contact with and contaminate the catheter insertion site and/or the sterile components of the administration sets and other components we attach to the catheter. But I can not find any published evidence linking these oral organisms to CRBSI. So it may be a good idea but nothing to support its use yet. In that case, the biggest stumbling block could be the additional costs of using mask plus the nursing time required to put them on for every procedure. Should we incur these costs before we have the science to reveal the need? That would be a question that each facility must answer.

I would want to also examine the data about the occurrence of CRBSI in my hospital. At what point in the catheter's dwell time are the signs and symptoms appearing? If within the first week after insertion, the general consensus is that the skin is the primary source of the organisms. If after the first week, the general consensus is that the catheter hub is the source. These concepts are derived from the amount of biofilm on the internal and external catheter walls. Then I would work toward changing nursing practices aimed at the most prevalent causes. If within the first week, all skin antiseptic agents, practices, and techniques must be addressed both before, during and after catheter insertion. After the first week of dwell, I would focus on all issues of hub management such as appropriate changing of IV sets and connectors, thorough cleaning of all connection surfaces and catheter hub threads, reducing the number of times the catheter is used for blood sampling, and the hand hygiene during all these procedures.

Persistent problems after all of these efforts might indicate that masks are the next step. If you choose to go this route, I would encourage you to share your outcomes through a publication. We definitely need evidence-based answers to these questions.

Preparing IV Administration Sets for Later Use??

2009-04-01T10:51:00.002-04:00

I am wondering if you have any information regarding the practice of getting tubing ready for later use. For example; if a department is putting together the different tubing parts to save time. My question is how long is that tubing still considered safe to use? I have found a department within my hospital that is arguing with me that it is okay to get the tubing ready in advance and store it that way for up to weeks at a time.

My first response to the staff in this department would be to ask them for their references to support this practice. They should produce published studies supporting their practice.

I do not have an confidence in their ability to show you these documents. I have never seen any studies supporting this practice. Another place to check would be the recommendations from the set manufacturer. I have looked at a package from one brand of IV sets and found nothing on their printed label stating that the set must be used within any given period of time. These labels are written with the idea that the product will be used immediately after opening. I would anticipate the response from the manufacturers to be something like "there has been no testing so they will not be able to make any statements about this practice."

Let's think of the things that could happen with this practice. You did not state what department wants to do this, but I am guessing that it is a busy outpatient or ambulatory surgery center. A large number of patients come in early in the morning and must be rapidly processed. This appears to be one way they can save time. But it is actually putting patients at risk for the use of contaminated tubing, and subsequent site or bloodstream infection.

The only sterile parts of an IV set is the fluid pathway and the ends covered by the plastic caps. These caps can become dislodged in packaging and shipping, meaning that the entire set must be discarded. The package only acts as a dust cover and is not considered a sterile package. The package on my desk now states "Do not use if tip protectors are not in place."

How are they storing these assembled sets? What is the chance that these tips will fall off, thus exposing the sterile protected part of the tubing? What if the tip cap falls on the floor and someone picks it up and places it back on the set? Then another person comes along and uses that set not knowing that it is now contaminated. If these caps can come off inside the package, I am certain that they can fall off after they are assembled.

I have also heard that ambulatory clinics want to hold tubing and fluid containers for use on the same patient on consecutive days. This is also dangerous practice. This is an intermittent use of that set and there have been no studies to date on how frequently these sets should be changed. The Infusion Nursing Standards of Practice states that intermittent sets shall be changed at 24 hours. This standard would negate this practice of multiple uses of the same tubing on consecutive days. How are they protecting this tubing and fluid container between patient visits? How will they assure that the proper tubing and container is reconnected to the correct patient? The risk are too great in this situation also.

All administration sets should be used as soon as they are opened and managed with careful attention to aseptic technique during use. The practice of opening and leaving them for even a day is not supported by any evidence that I am aware of. But again, I would expect them to provide the supporting evidence for their desired practice to you. Without such evidence, this practice must be stopped.

I would also investigate why they are having to assemble so many pieces of tubing for each patient. Sets are now available with so many different configurations, lengths, and components, it seems unreasonable that they would not be able to find a complete set that meets their needs without the need for assembly.

Nexiva and Catheter Stabilization

2009-03-30T12:49:00.003-04:00

I read in your blog that the FDA defines a stabilization device as a device with an adhesive backing. The Nexiva® from BD does not have an adhesive backing, but is being called a stabilization device. It makes me uncomfortable just placing a transparent dressing over it and calling it stabilized.

The Nexiva peripheral IV catheter from BD Medical has a larger flat surface than any other peripheral IV catheter on the market. This offers the advantage of better stabilization, however, the catheter does not meet the FDA definition nor the INS definition as a catheter stabilization device.

I strongly agree that a transparent dressing is not adequate as a catheter stabilization device. Regardless of the catheter's hub design, there must be some method used to provide catheter stabilization. The current list of these devices includes sterile tape, surgical strips, and manufactured catheter stabilization devices. I am not aware of any outcome studies on the Nexiva. So we do not have any evidence about how it performs in clinical practice. The large flat surface provides great benefit, but we do not know the most common complications and the incidence rates associated with Nexiva. On the other hand, the studies with a manufactured catheter stabilization device have been done with one product (Statlock, Bard Medical). These studies were conducted before Nexiva was available. So we definitely need outcome data to make the best clinical decisions.

Flushing Split Septum Needleless Connectors

2009-03-30T12:39:00.002-04:00

I'm having a hard time finding any INS endorsement on the split septum valves. Is it OK to draw labs through the cap and leave it for 96 hours? The standard says to change the cap if blood cells may be left behind, With this technology , I'm told that not that many cells are left behind. I would still like to see something from INS .

Professional organizations such as the Infusion Nurses Society do not endorse products. So you will not find any information from INS supporting one product over another. So I am not sure what other information you wish to see from a professional organization. Can you be more specific about that?

Information about the flushing that is required to adequately remove blood from any needleless connector comes from the manufacturer of that connector. Also, the manufacturer will make recommendations about the length of time each connector can or should be used or the frequency of changing to a new connector. Split septum devices are not "valves" because they do not have any internal mechanisms. They are an open fluid pathway, which could allow for easier removal of blood cells by flushing. There are no moving parts to provide any obstruction to flushing blood out.

I don't know what you mean by "not many cells are left behind". How many is too many? How many is sufficient? These questions can not be answered. If you have removed all visible blood from the needleless connector, that is the best that one can accomplish with flushing technique.

Clamping A Central Venous Catheter

2009-03-30T11:53:00.002-04:00

At our annual Patient Safety Days, there was a huge discussion among some of our PICC nurses and a newly employed nurse. The issue was about clamping PICCs. I came to the conclusion that there is a lot of confusion over clamping or not clamping the new Purple PICCs. One nurse said that they are under negative pressure so they do not have to be clamped. The PICC nurse said that all the PICC nurses have been instructed to fill out Unusual Occurrence reports if they go in a patients room and find the catheters are not clamped. Do they need to be clamped or do they not need to be clamped?

Your PICC nurses are correct - most hospitals have written policies that all central venous catheters (CVC), including PICCs, should be clamped when not in use. The reason is that the catheter would be an open lumen subject to allowing air to enter the venous system if the administration set or needleless connector were to come loose. Air emboli is on the list of "never events" - events that can be prevented and your hospital will no longer be reimbursed for treating this complication. So it is imperative to prevent air emboli from a patient safety standpoint as well as a financial standpoint.

A "purple PICC" is one brand of PICC that can withstand the high pressure needed for injection of contrast agents for a CT scan. This is just one feature of the catheter and many other brands can withstand this high pressure but are not purple. You will need to know if the specific brand of PICC you are using has an integral valve. This could be a valve on the internal catheter tip or a valve built into the catheter hub. These valves offer some protection against venous air emboli, however there is never a guarantee that the valve will always prevent air from being pulled into the catheter. For instance, a valve near the internal catheter tip will lie in the bloodstream and be subjected to fibrin/thrombus development. This material can prevent the valve from closing properly and this would allow air to enter the catheter and the bloodstream.

The idea expressed by the nurse about the catheter being "under negative pressure" is false. The pressure associated with any catheter comes from infusion or injection. The pressure at the fluid container or syringe is greater than the venous pressure, therefore fluid flows into the bloodstream. When the catheter is not in use, it is closed with a needleless connector and there is no pressure being generated, either negative or positive.

I think the confusion is coming from the needleless connectors being used. Some create negative displacement, meaning that blood will reflux into the catheter lumen upon disconnection of the set or syringe. Some will create positive displacement, indicating that a small amount of fluid is held in reserve until the set or syringe is disconnected. Upon disconnection, this reserved fluid moves out to the catheter tip to positively displace the refluxed blood or move it out of the catheter lumen. Some are neutral displacement meaning that there is virtually no blood reflux on connection or disconnection from the device.

Confusion about the clamping practices comes from the flushing technique needed for these different needleless connectors. A negative displacement connector requires a positive pressure flushing technique. You can do this by flushing inward as you withdraw the blunt cannula or by closing the clamp on the catheter or extension leg after you have flushed the solution into the lumen. For a positive displacement connector, these techniques can not be used as the clamping before disconnection will negate the positive displacement of the device. For a positive displacement needleless connector, flush the catheter, disconnect the syringe and then close the clamp. For a neutral displacement connector, the clamping sequence can be done before or after syringe disconnection.

Clamping all catheter lumens is a necessary safety mechanism, however the point when the clamp is applied depends upon the type of needleless connector on the catheter.

The statement about completion of an unusual occurrence report sounds like your hospital has a written policy stating that all catheters require clamping. If this is the case, all nurses must be properly educated about the procedures and the devices being used. It also sounds like there is a lot of misinformation among your staff about the issues of pressure.

So, yes, clamping is necessary as a safety mechanism. But the flushing-clamping sequence for all catheters depends upon the type of needleless connector being used.

PICC Certification? No such thing

2009-03-30T11:02:00.003-04:00

Could you please comment on the "PICC certification"? Some education companies are advertising these "certifications" as being credentialed by American Nurses Credential Center (ANCC)? Why have you not provided a similar "certification" ?

I have always maintained the opinion that the word "certification" in nursing should signify that the nurse has meet the established criteria to master a body of knowledge within a given specialty practice. This could be infusion nursing, infection prevention, critical care, or emergency nursing to name just a few of the dozens of nursing certifications programs available. These requirements usually include a specific number of hours of clinical practice and successful passage of a national certification examination. A nursing certification program is credentialed by the American Board of Nursing Specialties, a not-for-profit organization "to create uniformity in nursing certification and to increase public awareness of the value of quality certification to health care." You can read much more information about nursing certification at www.nursingcertification.org. There is an extensive bibliography list on nursing certification. After reading this information, my conclusion is that there is no certification offered in a task such as PICC insertion or ultrasound use. These are task that require documented competency. There is no national certification program in any given tasks.

An education company will usually provide continuing education credits (e.g., contact hours) for any educational program successfully completed by the nurse. The education company can be an accredited provider of contact hours from the AACN, a state nurses association, or a state board of nursing. This means that the education company has met the estabilished requirements to award contact hours for that program. This includes having a list of behavorial learning objectives with matching content outline, adequate time allotted, appropriate teaching strategies, and a qualified instructor. It does not mean that the accrediting organization has made any judgment about the subject matter, appropriateness of the content, or assessment of the clinical competency of the nurse. So upon completion of an education program, your certificate of completion may indicate that the education company is an accredited provider from one of the various organizations, however this should not be construed to mean any sort of endorsement for the program from the accrediting organization.

I think the drive to obtain Magnet Status in many hospitals is driving the desire by many nurses to obtain some type of "certification." My advise would be to spend your money wisely on a true certification program from a national professional nursing organization. For PICC insertion, you will need to have documented competency of your skill with this task and this responsibility rests with your employer. There is no national certification program in the task of PICC insertion.

My company does not use the word "certification" in conjunction with any of our educational programs. We often provide competency assessment tools to be used by the employer to document competency with a given tasks. We also provide a certificate of completion when the nurse meets the critieria for each course. A certificate of completion is not a certification. The education process is not a certification. I will continue to adhere to the appropriate use of "certification" as defined and described by the American Board of Nursing Specialities. All nurses should educate themselves about the proper use of this term and make sure that the program you choose is one that will meet your needs.

Aquapheresis and Catheters

2009-03-18T10:49:00.002-04:00

Our hospital wants to start an Aquapheresis program and the cardiologist want us to place Piccs for that purpose. I am having trouble finding any professional info on what is the best line to use. Is it possible to place a picc or that purpose and would it actually work?

The best source of information is the website of the manufacturer of the system - CHF Solutions. I do not have a first hand clinical experience with this procedure, however I did find the following on their website:

CHF 6Fr. Dual lumen peripheral ELC, or

CHF 5Fr. Single lumen peripheral ELC and 18G IV, or
7-8Fr. Dual lumen Central catheter

By ELC, I am assuming they mean extended length catheter. You will need a dual lumen catheter or a single lumen catheter and a large gauze peripheral catheter. Although this does not specify that a PICC can be used, it does state that a dual lumen central venous catheter can be used. There are triple lumen PICCs available in a 7 French size.

One challenge with using their ELC is that the tip will reside in the midclavicular location - a vein location that is known for increasing the risk of vein thrombosis. So you would need to use this catheter ONLY for this procedure and ensure that it is not used for infusion of any fluids of medications.

There are several questions that I can think of about using a PICC for this procedure. The actual lumen size on a 7 Fr PICC may not be large enough to accommodate the needed flow rates. These large size PICCs require the modified seldinger insertion technique, so you must be skillful with that method of insertion. And the length of the PICC could also present a problem with adequate flow rates because length adds resistance to fluid flow.

There will be a presentation about this at the fall meeting of the Association for Vascular Access and I will have more information then. In the meantime, you should contact CHF Solutions and ask these questions of their clinical staff. There website also has a good lists of published articles on this issue.

Accidental Arterial Infusion

2009-03-18T10:19:00.002-04:00

Do you have any good examples of damage done from infusion of medications or inappropriate fluids into an arterial line?

I am not quite sure about what type of examples you are looking for - published articles or my experiences. Fortunately, I have never had a first hand experience with giving a drug inadvertantly into an artery. However, I have served as the expert on several lawsuits where this has happened and have heard discussions of many other cases.

Short peripheral catheters can be placed into an artery when the nurse is not carefully palpating for a pulse in the area of the planned venipuncture. Also, veins and arteries can lie close together. When the catheter is not properly stabilized, preferably with a manufactured catheter stabilization device, the movement of the catheter can erode through the vein and into a nearby artery. If the catheter is placed in an area of joint flexion, an arm board must be used to support the joint. It is not sufficient to tell a patient to hold their hand still. Normal use of the hand can cause erosion through the vessel leading to damage of subcutaneous tissue or arteries lying closeby. A common site for accidental arterial placement of a short peripheral catheter is the antecubital fossa and thus a primary reason that these sites should be avoided for a peripheral catheter.

Usually you would think that the blood will appear in a pulsatile manner and be bright red. There is some information in the drug literature that some drugs alter the color of the blood. For instance, when you aspirate for a blood return directly into the syringe filled with promethazine, the blood will be dark red, regardless of whether it is arterial or venous blood. Aspiration should be into a saline-filled syringe to rule out arterial placement. The nurse should rely upon other characteristics such as the quality of the gravity drip rate. The pressure from a bag placed about 3-4 feet above the patient will not be sufficient to overcome arterial pressure and therefore will not flow properly. Infusion pumps may produce occlusion alarms if the alarm setting is on low, however I would prefer to observe the quality of the drip rate by gravity.

There have also been cases where a PICC has been placed in an artery without being recognized. When there is any question about the position of the catheter on xray, the safest practice is to obtain a blood sample from the PICC and run blood gases on it or to transduce the line for pressure.

Arterial infusions can lead to amputation or complete loss of function in that extremity. Go to the Institute for Safe Medication Practices and do a search using "promethazine" and you will find information about the outcomes of arterial injections of this drug. One lawsuit involving amputation after promethazine injection was just settled by the Supreme Court a few weeks ago. Also doing a Google search will produce numerous postings about promethazine and the associated problems with IV injection.

CVC Removal and Preventing Air Embolil

2009-03-18T09:59:00.002-04:00

I am hoping you may be able to help me find some recent articles regarding subclavian catheter removal (and the nursing implications to prevent air emboli). I have an article from The Journal of Intravenous Nursing but it's from 1991! I want this article for an online CEU opportunity for nontunneled catheter removal. l can find articles that incorporate this information; however, include too much "other" information.

The nursing literature does not have many recent published articles about venous air emboli and central venous catheters, however the older articles are still valid information.

I am not sure what you mean by "other" information. Many articles will address complications of CVCs and include air emboli. Or they will address all types of emboli in one article including thrombus, air and catheter emboli. Or they will address all of the times during the life of a CVC when air emboli can occur such as during insertion or accidental disconnection.

The Infusion Nursing Standards of Practice addresses all aspects of catheter removal in Standard 51.

I have served as the expert on several lawsuits involving air emboli associated with CVC removal. The primary issues are:
1. the patient should be lying flat if they can tolerate that position. The exit site should be at or below the level of the heart. With a PICC, the flat position may not be required to achieve this relationship between exit site and the heart but subclavian and jugular sites will require being flat to prevent air from being pulled in.
2. placement of an air occlusive dressing on the site after hemostasis. This will mean using a gauze dressing with an ointment on it. You can use either a triple antibiotic or antiseptic ointment, but a petroleum based ointment is required to seal off the skin-to-vein tract that will be left after the catheter is removed. This dressing should remain in place for at least 24 hours to ensure that this tract has closed.
3. the length of time for a patient to remain flat is not supported by anything but expert opinion. This time varies from 10 to 30 to 60 minutes.

I would recommend that you go to PubMed and enter the terms "venous air emboli and catheter". This will produce a list of more than 500 references. You can read the abstracts for most of those and determine what is useful for your project.

Statements About CVC Tip Location

2009-03-16T16:22:00.002-04:00

I have listened to Lynn and others about central venous catheter (CVC) tip location and how the FDA and other organizations state that the tip must be in the vena cava. Can you give me some direction about finding these two guidelines?

First, the information from the FDA is found in two places. Look at the package insert for any CVC and you will find statements from the manufacturers about the recommended tip location. This package insert is placed inside the package of each and every type and brand of catheter sold in the United States. These inserts are written in accordance with guidance documents written for manufacturers by the FDA. If you do not have access to these package inserts, you can look on the manufacturers website or contact the manufacturer to obtain these instructions for the specific catheter being used. The second source from the FDA is a set of videotapes created about 15 years ago and mailed free of charge to all hospitals in the US. You can find information about ordering those tapes by clicking here.

From the radiology literature you can find the following articles. I have listed the primary authors and linked their names to either the online abstract in PubMed.

Quality Improvement Guidelines for Central Venous Access, Lewis, et.al., 2003

Central venous catheter tip position: A continuing controversy, TM Vesely, 2003

Finally, an additional list of references can be found in the PICC Tip Location paper released by AVA several years ago. Click here and then scroll down to the position paper titled Tip Location.

Dedicated Lumens for Blood Sampling??

2009-03-11T14:08:00.002-04:00

I am searching for information concerning the dedication of lines for lab work from multi-lumen catheters. Some of my nurses teach our home infusion patients who are receiving twice daily antibiotic infusions to alternate lumens and others to dedicate one lumen for the infusion and save the other for lab draws. I cannot find information in the INS standards, nor in other areas. Our home infusion company does not take a stand on this issue.

This is a tough question because there are no studies on the issues you have raised. I have actually seen both methods in practice, however I am not aware of any studies that provide answers about which is the best practice.

The idea of having a dedicated lumen for drawing blood samples came from the original manufacturer of multiple lumen catheters. When using a catheter with staggered lumen exit sites (the points where the fluid exits the catheter into the vein), the recommendation was to draw the sample from the one that is most distal to the catheter tip. This would be the longest external catheter extension leg. This would mean that you are drawing blood from above the points where fluid may be flowing into the vein from the other lumens.

Coagulation lab results are altered by the presence of heparin in the catheter lumen. So you would not want to use a heparinized lumen to obtain these samples as this can have a negative impact on the patient's treatment. For most lab values such as blood counts or electrolyte levels, studies may show a statistical difference for samples taken from catheters when compared to samples taken from a peripheral vein. However a statistical difference in a clinical study does not always mean that there would be a difference in treatment. For instance, there could be a statitical difference when assessing potassium level, however that difference would not alter the need for infusing a higher dose of potassium to your patient.

I can not think of a rationale for alternating lumens for blood sampling. So I am not sure why some nurses want to do this. I would love to hear from those of you that do this about why you think this is necessary.

Finally I would caution you that using a catheter for blood sampling increases the hub manipulation and therefore the risk of contamination which can lead to bloodstream infection. I have heard that some hospitals are now prohibiting the routine use of central venous catheters for blood sampling on all patients. So you should be including this in your risk assessment for each patient. Is it possible and possibly less risky to draw the blood sample from a peripheral vein? That depends on the patient and the condition and availability of peripheral veins.

Promethazine Questions About Infusion Procedures

2009-03-11T13:32:00.003-04:00

I am continuing to deal with IV promethazine issues in a large urgent care clinic where I work. What is the current standard on the use of promethazine IV? Specifically, I am asking about promethazine in an bag of IV fluid infusing wide open for dehydration? So my question is not directed to promethazine given IV push.

You are on the right track to pursue more information about this critical issue. In my opinion, all intravenous doses of promethazine should be avoided due to the high risk associated with this drug. Click here to read a news report written by a physician. This site provides information about dilution of this drug. I have not found any references that recommend dilution in a liter of fluids and would never recommend this method of infusion. It is only recommended to be diluted in a small volume of fluid (e.g. 50 to 250 mLs) and to always piggyback it or inject it through plain fluids that are infusing properly. The purpose of this dilution is not to alter the low pH (between 4 to 5.5) but rather to slow down the infusion of the drug and consequently allow time to recognize any fluid escaping into the subcutaneous tissue. The nurse would then have time to intervene and stop the infusion before the entire dose leaked into the subcutaneous tissue, known as extravasation. Please remember that the Infusion Nursing Standards of Practice state that any drug with a pH less than 5 is not recommended for administration through a peripheral. So most preparations of this drug will cause vein irritation due to its low pH. Add to this the risk of extravasation injury and the risk far outweighs the benefits when there are other antiemetic drugs available.

Even with this dilution, I would never feel comfortable hanging promethazine and leaving the patient during this infusion time. I would strongly recommend that the nurse remain with the patient so that a true assessment of the infusion and the site can occur during the entire infusion time. This includes attention to the quality of the drip rate, frequent aspiration for a brisk blood return, constant attention to the site condition for any signs of swelling, and listening to the patient for any complaints of any discomfort. Proper assessment and documentation of these factors are the only way to decrease the risk to your patient. If you notice a problem, you can stop the infusion before the entire dose has been delivered. If you leave the patient, you will not notice when the problem began and will not be present to intervene appropriately.

The following are more links to critical information you should share with the policy makers in your facility
Action Needed to Prevent Serious Tissue Injury with IV Promethazine

The Dangers of Intravenous Promethazine Administration

Dressing Placement and Securing Catheters

2009-03-07T12:39:00.003-05:00

I have a question about securing IV sites. Is there a benefit to applying the transparent membrane dressing all the way over the hub of the connecting tubing whether it be an extension set or a regular IV tubing. This is not the method I have always used and am receiving some opposing viewpoints.

First, I must change your impression of a transparent membrane dressing. A dressing of any kind should not be considered as a means for stabilizing a catheter. I would refer you to the Infusion Nursing Standards of Practice, #43 Catheter Stabilization. Practice Criteria B states, "Products used to stabilize the catheter should include manufactured catheter stabilization devices, sterile tapes and surgical strips. Whenever feasible, using a manufactured catheter stabilization device is preferred."

This edition of the standards removed dressings from the list of stabilization devices because there is no evidence that they actually maintain the catheter stability. So whether you cover the connection between the catheter hub and tubing is irrelevant to maintaining catheter stability. Personally, I do not like to have that junction covered by any dressing material. There are times when you will need to conveniently get to that junction. If it is not covered by the dressing, your task of reaching that connection will be much easier. This would include events such as needing to aspirate all fluid from the catheter if you suspect an infiltration or extravasation or needing to remove all tubing that contains blood if you suspect a transfusion reaction.

The dressing is a critical component of the IV site. It protects the puncture site and surrounding skin, but it should not be regarded as a means to stabilize or secure the catheter.

Catheter Flush Solutions from a Bag of Normal Saline

2009-03-07T12:26:00.002-05:00

I was trying to find a resource for an issue that came up with staff who were drawing solution out of a large volume IV bag to use as a central line flush - and although I know it is unacceptable practice for several reasons, could not find any information to support the "not doing it". Can you help direct me to any resource/reference?

I was so hopeful that this issue was a thing of the past, but I guess not. There is great risk of infection transmission from using a bag of normal saline as the source for normal saline for catheter flushing. The same is true for using a multidose vial.

Several years ago, I published a review of all of these reports. You can download this article by clicking here and then selecting Vol. 4. No. 2 Flushing vascular access catheters: Risk for infection transmission. This will allow you to download the complete article including a long list of references. I sincerely hope you can get this practice changed.

US Supreme Court issues decision in Phenergan case

2009-03-04T17:23:00.002-05:00

ABC News has a story today about the Supreme Court's decision in the case against Wyeth about their failure to warn about the hazards of IV administration of Phenergan (promethazine). Click here to read the full story.

This continues to be a dangerous drug for IV administration. It requires the same level of expert skill as any other vesicant cancer chemotherapy agent, yet most nurses do not realize what is actually needed to safely administer this drug IV. My original blog entry about this drug appeared in June 2007. I am reposting it again to refresh your memory about what is required to safely administer this drug.

Site selection is critical. Make sure you have a peripheral catheter that has recently been inserted. Avoid areas of joint flexion such as the hand, wrist or antecubital fossa as they are more prone to serious injuries if extravasation does occur. If you have no choice and must use a vein in an area of joint flexion, the joint must be supported on a handboard to reduce the risk of the catheter eroding through the vein wall from normal movement of the joint. Choose a large vein in the mid-forearm. The site should be relatively new, preferably less than 24 hours old to minimize any chance of drug leaking from an older site. Catheter size should be the smallest gauge possible in the largest vein possible.

Catheter stabilization will also minimize vein damage after insertion. Phlebitis and infiltration are documented to be reduced when a manufactured catheter stabilization device is used (e.g., Statlock® from Bard Medical, Inc.) Also document your method of stabilization such as the brand name of the device used or sterile tape, etc.

According to manufacturer's literature and Intravenous Medications, published by Mosby, promethazine should only be injected through infusing fluids. Assess the patency of the catheter and vein by the quality of the flow rate. If it is a brisk flow rate and you can obtain a good blood return upon aspiration, it is usually safe to administer the drug. I would recommend using a 10 mL syringe filled with normal saline to aspirate and flush the catheter and vein while palpating for any edema during this manual flush. This step should be done even if you have just inserted the catheter.

Blood aspiration into a saline filled syringe will help you assess the quality and color of the blood return. Blood aspiration into the syringe filled with promethazine can result in a darkened color of the blood, information also found in the drug literature. If the catheter has inadvertently been placed into or eroded into a nearby artery, the darkened color can be misleading. You may think you have aspirated venous blood when actually it is arterial blood.

Never administer promethazine through a catheter that is locked with saline or heparin and does not have fluids infusing. The infusing fluid will serve to dilute the drug, however dilution with at least 9 mL of normal saline may prevent the injection of the complete dose if extravasation is occurring. While injecting, aspirate for a brisk blood return at least every 2 or 3 mL. Stop the injection if blood cannot be aspirated.

Pain or burning should never be considered a normal reaction to the IV administration of promethazine. If your patient complains of the slightest discomfort, stop your injection immediately. Many healthcare providers are under the mistaken impression that it is "normal" for this drug to be painful when given by the IV route. If the catheter has been properly placed, the vein and catheter are appropriate sizes, and the method of injection is correct, there should be no discomfort.

If you have reason to suspect that a portion or all of the dose has extravasated into the subcutaneous tissue, take immediate action. Disconnect the IV administration set from the catheter hub and aspirate any fluid from the catheter to ensure that all drug dose from the catheter lumen is removed. This technique could also aspirate some of the drug from the subcutaneous tissue. No reports have recommended either heat or cold treatment for promethazine extravasation. Also, there are no reports of using any injected or topical antidotes for promethazine extravasation. Contact the physician immediately because a surgical procedure can be performed to wash the drug out of the tissue and minimize the tissue damage. Do a complete neurovascular assessment of the extremity including color, capillary refill, sensation, etc.

Document the exact steps you took to assess the site, the exact anatomical location of the catheter, the fluids infusing, the quality of the blood return, and any patient comments or complaints.

A picture is worth a 1000 words and this is true with all extravasation and infiltration injuries. So photograph the site and place a copy of the picture in the patient records. Provide the patient and/or family with instructions on how to monitor and care for the site.
Taking these simple precautions will go a long way to prevent extravasation and to minimize the risk of serious problems with the extremity.

For more information, go to the Institute for Safe Medication Practices and do a search using "promethazine" to learn more about the outcomes with promethazine extravasation and the steps you can take to provide safer patient care. Numerous resources are available.

I am also interested in your experiences with IV administration of promethazine. So please share your comments in this thread.

Ultrasound Techniques for Peripheral Catheter Insertion

2009-02-27T09:38:00.002-05:00

I'm told by a clinical nurse specialist of one of the leading Vascular Access Systems that peripheral IV's are being put in with ultrasound by simply putting a non-sterile glove over the probe, a piece of transparent dressing or nothing. Once you have cleansed the site, you cannot go back over it with your finger, why would you be able to place a non-sterile probe over the cleansed site? I would think the only way to perform this procedure would be with the use of the sterile probe covers. What is your expert advise?

Your clinical nurse specialist may be correct that some are placing peripheral IV catheters (PIV) using ultrasound without using the sterile probe covers, but that does not mean that this is acceptable practice. How can one get a transparent membrane dressing to adequately cover the probe with the presense of the coupling gel? My first thought about the use of a clean examination glove is that the extra fingers on the glove will get in the way of the venipuncture procedure plus the glove will not fit the probe.

But first, you would need to ask about the specific procedure being used. US for PIV insertion can be performed in 2 ways. The US can be used to locate the vein and mark the site, then the probe and gel are removed to perform the venipuncture in the usual way. This technique may not require a probe cover, but would require cleaning the probe after use. The dynamic method uses the probe to visualize the vein during the complete venipuncture procedure. This means that the probe is left in contact with the skin during the entire venipuncture.

You raised an excellent point about skin antisepsis. After the step of skin antisepsis, the site should not be palpated again. This recommendations carries the highest ranking from the CDC. Therefore, why should anyone think that it is acceptable to use an US probe without a cover to touch the prepped site when the dynamic method is being used? How is the probe cleaned between each patient? Who is responsible for cleaning it? What about exposing the probe to blood? Does the cleaning procedure guarantee that the probe will be thoroughly disinfected to eliminate the risk of blood exposure to the next patient? What is the safety of tracking the coupling gel into the vein?

I am most familiar with the use of these probe covers for placement of a PIV with the dynamic technique. I would agree that a PIV insertion is not a sterile procedure, however we are placing a foreign object into the bloodstream. It has always been considered a clean, no-touch procedure. So why are we taking such chances with our patients? Perhaps I am overly cautious, but I have recently seen an increase in the number of legal cases involving serious infections associated with the insertion of a PIV, even sepsis resulting in death! This is not the simple benign procedure that we like to think. It can and has costs patients their lives.

Ultrasound technology can add to patient safety by helping to locate veins where they are too deep to be seen or palpated. There could be an increased risk of serious infections by eliminating the probe cover when the dynamic US technique is used. I am not aware of any studies that have been done on this issue but the use of a probe cover for this technique is common sense in my opinion.

Which Comes First - Biofilm or Thrombus?

2009-02-22T14:44:00.003-05:00

I teach CVAD management to nursing students and RN's. One question I can not seem to get a clear answer about is regarding a fibrin clot in or on a CVAD and the potential complication of CRBSI's. Biofilm from my understanding is about 25% bacteria and 75% slime. It is sticky therefore red blood cells, proteins, etc stick to it causing a thrombus. I teach that it is necessary to always ensure catheter patency before using the line by flushing and aspirating a blood return. If the line is clotted or sluggish most of the time it is due to a clot, therefore it needs to be treated with tPA. The clot can not be ignored because it is a wonderful medium for the bacteria to grow putting the pt at risk for a CRBSI. So my question to you - is my thinking correct? Do you know of any data to support this thought?

Your thinking is correct. Biofilm formation occurs because microorganisms are introduced with catheter insertion or with hub manipulation. These organisms produce a glue-like substance causing them to adhere to the catheter wall where they go on to produce the slimy matrix that traps plasma proteins, etc. So you will have a combination of a biofilm/fibrin coating various catheter surfaces. Red blood cells can also become trapped producing a complete thrombus.

To learn more about biofilm read the article by Donlan or Ryder.

For any catheter that will not yield a brisk blood return, the national standard of care is to investigate the cause (chest xray and/or contrast injection) and treat it before the catheter is used. Your question seems to indicate that the thrombus formation leads to an increased risk of bloodstream infection. This very question was debated in a point-counterpoint presentation last year at the annual conference of the Association for Vascular Access. The question of which comes first has not truly been answered yet. Anytime we use a catheter, we have a great risk of introducing additional organisms that produce additional biofilm. So there will always be a risk of bloodstream infection regardless of whether there is a thrombus present or not. Treating with a thrombolytic agent is the treatment of choice when there is no blood return or there is resistance to flow through the catheter.

Fibrin formation can easily be on the outside of the catheter and around the catheter tip. A complete thrombus can easily be inside the vein at or near the catheter tip, producing a similar clinical picture of resistance to flow and no blood return. For these problems, instillation of a thrombolytic agent may not reach this clot, indicating the need for a low dose infusion of a thrombolytic agent. These intraluminal fibrin and thrombus problems can become colonized and greatly increase the risk of a bloodstream infection.

I would strongly recommend that you put a huge emphasis on teaching your students to scrub the needleless connector with an alcohol pad for at least 15 seconds each and every time it is accessed. Also clean the catheter hub and locking threads with each tubing and connector change. This simple fact is not consistently taught to nursing students, leaving them with the impression that it is an ineffective and unnecessary step. This simple step does reduce the formation of biofilm because it reduces the amount of organisms that are sent into the catheter's lumen. Also teach them that all syringes and tubing used to access the needleless connector must be sterile. When there is any question about the integrity of intermittent administration sets (e.g., found with the tip uncovered or looped an attached to an injection port on the same tubing, or blood inside them) that set must be discarded and replaced with a new one. Intermittent tubing should also be changed every 24 hours according to the Infusion Nursing Standards of Practice.

Malpositioned PICCs

2009-02-22T14:20:00.002-05:00

I work with a group of 4 PICC nurses. Our practice has been to advance PICCs to get the tip into the SVC up to 6 hours after placement. I admit this did not happen often. But it came to my attention that INS standards say do not advance PICCs. I have tried to find evidence on this issue and the nurses I work with think it is OK to do it sometimes. I came across an article you wrote in 1993, that talked about advancing. Times have changed and what are your thoughts now.

You are absolutely correct - times, equipment, and practices have changed a lot since our article in 1993. That article was a retrospective review of outcomes from our PICCs. We reported our practice at that time - to leave the stylet wire inside the catheter, encase the external catheter in sterile 4X4 gauze pads, then wrap the extremity with a sterile towel, or rolled gauze bandage. We obtained a stat chest xray and the PICC nurse made the initial assessment of tip location, then finished the procedure based on where the tip was actually located. If we needed to advance additional catheter length, the external segement had been encased in the sterile gauze and had not been in contact with the skin at all. This is the only way I can think of to safely advance any catheter segment at any time during the insertion or dwell.

The skin can never be made sterile regardless of how well your antiseptic agent works or how great you apply it. You will always leave about 20% of the organisms in the lower layers of the epidermis. We are constantly shedding skin cells, causing these live organisms to constantly move toward the skin surface. Once the external catheter has been in contact with the skin, stabilized and dressed, there is no established time period when it is considered safe to advance this external segment into the vein.

Currently, technology has decreased the need for this practice. With ultrasound, you can scan the jugular veins and rule out placement in that region before you break your sterile field. With the systems that help to locate catheter tips (Navigator or Sherlock), you can have a very good idea of the general location of your catheter tip before breaking the sterile field. Neither of these technologies has lead to a change in the national standard of care - to get a chest xray for proper placement on all CVCs - but they do provide useful preliminary data. Another technology is the use of ECGs to identify catheter tip location (Pacerview). This requires a connection to the ECG machine and being able to determine a change in the P wave indicating that the catheter has passed the sinoatrial node.

These technologies have greatly increased the incidence of getting the catheter in far enough on the first insertion, reducing the chance of having a catheter that is not in deep enough. Most of the time, a jugular placement can be changed with power flushing - attaching a 20 mL syringe filled with saline, placing the patient in a semi-Fowlers position and flushing. This usually brings the tip down to the SVC. For catheters that are in too far, all you need to do is simple retract a predetermined length of catheter. Neither of these malpositions require advancing any of the external segment.

My final thought is that may be you need to examine your measurement techniques before placement to see if you can improve the number of catheters that fall short of the intended location. But I would never advance any external catheter segment after it has been in contact with the skin for even a few minutes.

Vessel Diameter and Catheter Size

2009-02-18T14:53:00.003-05:00

Are there any references related to the vessel size needed for placement of a triple lumen PICC?

This is a very good question because several studies have shown that larger catheter sizes produce higher rates of vein thrombosis. This follows the tried and true standard for all infusion therapy - choose the smallest size catheter capable of delivering the prescribed therapy.

Prior to the use of ultrasound, we had no method for measuring vein lumen diameter. Now the ultrasound machines can provide an accurate measurement.

The French size of all catheters is equal to the outer catheter diameter measured in millimeters multiplied by 3. So a 6 French catheter would have an outer diameter of 2 mm. The average basilic vein is approximately 8 mm in diameter. Several experts now recommend that the catheter not consume more than 30% to 50% of the vein diameter. So measuring the vein diameter and comparing this to the catheter's outer diameter will provide very useful information.

You can also go to the AVA website - www.avainfo.org - to look for the audiotapes of a presentation given by Dr. Tom Nifong on vein thrombosis at the meeting in Savannah in Sept 2008. Dr. Nifong is a pathologist that has performed lots of math calculations on how much the catheter size decreases the blood flow within the vein. He has not published this yet, but is in the process of submitting it.

When to Say NO to Using a CVC

2009-02-18T10:51:00.002-05:00

We have a patient with an implanted port and the catheter tip is in the innominate (brachiocephalic) vein. There is no blood return but the surgeon and the oncologist insists that it is ok to use for vesicant medications as well as Taxol and Herceptin. Based on AVA and INS statements, our nurses do not want to use this catheter for the chemotherapy. What would you recommend?

My reply to all of these physicians would be a polite but firm NO! As you noted there are 2 significant problems with this catheter - its tip location and the lack of blood return. In my opinion, those factors are probably related. An instillation or infusion of low dose alteplase could temporarily produce a blood return. But this will not alter the incorrect tip location.

You also have the chemotherapy guidelines from the Oncology Nursing Society to support your position in addition to INS and AVA. I applaud your nurses efforts for acting as a patient advocate in this situation. Infusion of any fluid or medications through a malpositioned catheter increases the risk of vein thrombosis. Thrombosis and fibrin increases the risk of infiltration/extravasation injuries.

I would also gather all of the statements from these organizations, along with studies and reports of these outcomes and take them to your risk manager and quality improvement manager. You need a hospital wide policy on these situations. Continue to take a firm stand against practices that are dangerous for your patient.

Repeat Chest Xrays After PICC Insertion

2009-02-18T10:35:00.003-05:00

When a chest xray shows that the PICC line is in the right atrium and needs to be pulled back, how much of an adjustment should warrant a repeat chest xray?

Many people would say that all repositioning efforts for a PICC requires a repeat chest xray. For the situation you described, lets look at anatomy. When retracting a PICC from the right atrium, the closest vein that could lead to an aberrant tip location would be the azygous vein. This vein drains the spinal column and joins the superior vena cava on the posterior side at the level of the second intercostal space. Catheter tips could flip backward into this vein and this is the reason that some experts recommend getting a lateral chest xray for all PICCs.

On the surface, it would seem that retracting 2 or 3 cms would be acceptable without a repeat chest xray. But you never really know where that tip was actually located. To protect yourself in the event there is a serious complication that leads to a lawsuit, you would really need to have a repeat chest xray after each repositioning or adjustment of the PICC. There are no guidelines or standards on this issue, so your facility must establish what your internal policy will be. If others have established such a policy for their practice, please let us know by adding a comment to this post.

Catheter Dislodgement

2009-02-18T10:01:00.002-05:00

It is not uncommon for a PICC to be displaced by 2-3 cm or more during dressing change or when the patient accidentally dislodges the catheter with activity. How much displacement is required to warrant a repeat chest xray to confirm tip location?

It should never be a common or frequent problem to dislodge a PICC during dressing changes or with any patient activity. There are methods to adequately stabilize a PICC to prevent this dislodgement from occurring. The older methods of using sterile tape, wound closure strips or sutures do not produce the best outcomes. Tape in any form was never designed to stabilize a catheter and does not adhere to the plastic of the catheter. A transparent dressing is not considered to be a catheter stabilization device because there is no evidence that is prevents catheter dislodgement.

A manufactured catheter stabilization device is now the preferred method for stabilizing all types of peripheral and central venous catheters, according to the Infusion Nursing Standards of Practice from the Infusion Nurses Society. There are numerous brands available now, however the published research has been conducted with Statlock. Frey and Schears report on this issue and compared the use of these new devices to the traditional methods. There is a strong trend toward better catheter outcomes with a catheter stabilization device.

The superior vena cava is about 7 centimeters in length. If the catheter is properly placed at the junction of the SVC and right atrium, you would only have no more than 3 to 4 cm length to dislodge before the catheter tip is no longer in the lower half of the SVC. Catheters placed high in the SVC have a greater risk of tip migration - where the tip flips upward into the jugular vein or into the contralateral subclavian vein. Vein thrombosis would be greater with these aberrant tip locations. Also, when the patient complains of hearing a gurgling sound or running stream, this means the catheter has flipped to the jugular vein. All of these situations would indicate the need to repeat the chest xray for tip location and make the best decision about what to do with the PICC. For dislodgement, this will usually mean an exchange overwire or removal and insertion of a new catheter. For tip migration, you can attempt to power flush the catheter and move it back down to the SVC or obtain assistance from radiology.

You also need to educate the patient about proper activities with the PICC. Strenous physical activities requiring heavy lifting or repetitive use of the arm could mean that a PICC is not the best catheter for this patient. The patient should be educated about doing normal activities of daily living but this is not the time to continue a weight lifting program or to go back to work doing lots of physical activity with the upper extremities.

Preventing Catheter-related Thrombosis

2009-02-13T10:50:00.003-05:00

The lastest news is about warfarin and catheter-related thrombosis. A recent study published in The Lancet compared the use of no warfarin, dose-adjusted warfarin, and fixed-dose warfarin in almost 1600 patients with cancer and central venous catheters. There were virtually no differences between each group and the authors recommend considering other methods. You can read the abstract by clicking here, but the entire article is only available for purchase online. Or you can go to a medical library to find the issue.