Recently we have had two patients ooze serous drainage requiring daily dressing changes.  Neither of these patients had any edema present and we use the BIOPATCH (which plumps right up). 

I have been asked by our CNO to research and see if this is being experienced by anyone else because a complaint was made by a physician who has experience using non-tapered PICCs and has not seen this happen.

I looked at both of these patients and did not see a large opening, edema, any reason as to why this occurred.

 

Has anyone experienced this? 

Lisa Y., RN, BSN University

Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy

 

I have never seen this serous drainage until last week.  Not with a tapered power PICC, but with a Groshong.  The drainage was obviously not "leakage" of IV fluid.  There was no question that it was lymph.  At any rate......no thrombus......PICC replaced in other arm.

Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy

Hi Cheryl, everything you

Hi Cheryl, everything you listed that nurses are using the ultrasound for is exactly what I do to evaluate and qualify patients for a PICC and the insertion procedure. Maybe I read too much into your post, I was unable to attend the AVA conference and the ultrasound competency class. Did they review assessing patients with symptoms of a possible UEDVT involving a previously placed PICC? I personally do not and have not used ultrasound to assess a catheter involved vein already symptomatic. I always refer to the physician the need for doppler ultrasound to rule out thrombosis. Nursing knowledge and expertise are not wasted, I guess I am focused on the symptomatic presentation. If in your experience serous drainage has always been indicative of DVT (and you still have your first born, LOL) then why get involved with your own ultrasound assessment? Methods of early assessment are significantly important and maybe some clinicians are performing serial ultrasound vessel assessment on asymptomatic patients with PICC's. We have not at our facility. I do look forward to attending an ultrasound competency class, as offered at AVA, and expanding my skills. Thanks for the comments.

Timothy L. Creamer, RN

Regional Medical Center Bayonet Point

Clinical Educator, Bard Access Systems  

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Tim, Are your thoughts

Tim,

Are your thoughts that we should not be using ultrasound to assess the vessel after the insertion, but only during the insertion?

I am thinking out loud here, bear with me!  LOL  A nurse who uses US for PICC insertion does not just use it to "find a vein and stick."  At least they shouldn't use it just for that.  In all reality, nurses are using US not just to guide the needle, but to also:

  • To locate the veins
  • To locate the artery
  • The median nerve
  • Compressibility of the vein
  • Blood flow or absence of blood flow in the vessel
  • Location of valves
  • Size of the vessel
  • Proximity of the vein in relationship to the nerve and atery
  • Determining catheter vessel ratio

With this said, it seems like such a waste of nursing knowledge and expertise as well as lack of a great method of early assessment of complications by omitting this tool.  I am open for thoughts.

I know that using this assessment for diagnostic purposes should not be performed.  But surely visulaizing lack of blood flow around a catheter would fall under "vessel assessment" and thus warrant further FORMAL testing, for diagnostic purposes.

Lastly, the post conferece at AVA was a great opportunity for nurses to advance their skill set in ultrasonography as it pertains to PICC's.  If anyone missed it at the AVA confrence, it was great and well attended by approximatley 150 nurses.

Thanks all.

CK

Cheryl Kelley RN BSN, VA-BC
Independent Vascular Access Consultant

This may seem to be a weird

This may seem to be a weird response to all that have responded, but I have had experiences that had continued serous drainage that were not related to thrombus.  My findings were after a 24 hour dressing change on patients.

The direction of the PICC itself was not in alignment with the direction of the vein.  In other words, the nurse that did the dressing change had the PICC in a position that was straight down the arm from the site.  As we know, from inserting PICCs not all veins are straight in relation to the arm. 

Doing a dressing change that maintained the angle of the vein immediately resolved the serous drainage.

Hope this makes sense.

Gwen Irwin

Austin, Texas

Why Should Ultrasound

Why Should Ultrasound Guidance of Vascular Access be exempted?

·         Vascular access nurses use ultrasound to guide the placement of a central venous catheter. Vascular access nurses are specially trained and licensed by the state where they practice; they do not need to be certified sonographers because they use ultrasound in such a narrow, targeted way. 

 

This is an excerpt from a link found on this forum regarding S.1042 the CARE Bill by Kathy McHugh AVA CEO.

I feel it important to remain in compliance with using ultrasound in such a narrow, targeted way.

 

Timothy L. Creamer, RN

Regional Medical Center Bayonet Point

Clinical Educator, Bard Access Systems

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Classic symptom of

Classic symptom of thrombosis is leakage of fluid from the insertion site.  In my previous practice in a hospital setting, I always joked around and said that I'd bet my first-born that there was a thrombus in the extremity when I saw fluid leaking from the insertion site.  (I still have my first-born!  LOL)

Put your ultrasound on the insertion site and scan up the extemity.  You will be able to see the catheter and visualize that there is still good blood flow around the catheter.  It's pretty easy to do.  As you track along the catheter up to the axillary area, you can visualize blood flow in the same manner that you did when you assessed the vessel for the PICC insertion, gently compressing, looking for compressibility in the vein.  If you see none, you may want to notify the physician and obtain a formal doppler.

Good luck!

Cheryl Kelley RN BSN, VA-BC
Independent Vascular Access Consultant

One patient did have a

One patient did have a thrombus and this patient had the PICC placed by an IR physician.  They no longer want to use this catheter because of the taper and thrombus with serous drainage as they have not seen this with another non-tapered PICC.  The other patient had his PICC placed by an IV nurse and removed today as his therapy was complete.  He had no c/o pain or discomfort only constant oozing.  An ultrasound to r/o thrombus was not performed.

To reply to a previous post.  The IR physician put the catheter to zero.  The IV nurse typically tries for zero as well.  The patient with no complaints only serous drainage had 3cm external. 

Can someone explain how a thrombus can contribute to continous serous drainage from the insertion site.

 

We have seen this leakage

We have seen this leakage occur once, maybe twice in the past six years. Our IR docs thought that it was possibly lymph fluid and that we had punctured a lymph vessel while gaining access to the vein. The one patient that I remember had her PICC pulled boy Home Infusion and then came to the hospital for a new access. My understanding is that the only solution is to pull and replace the line if this happens.

Karen McKeon RN CRNI

Karen McKeon Williford RN, CRNI

I agree with Lynn, rule out

I agree with Lynn, rule out a vein thrombus. Our facility places only reverse taper catheters and your reported situation has not been observed without the other variables you mentioned. However, I am curious about: are the catheters inserted to tamponade or do you routinely leave some exposed catheter and how much? My personal practice technique is to correlate vein depth, diameter, Fr size, and reverse taper when determining catheter length. A shallow vessel that is adequate for a 5fr catheter (33 or 50% rule) will require a calculated amount of external catheter  in order to take advantage of the reverse taper in the subcutaneous tract and not put the patient at risk by significantly occluding the vessel at insertion site.

My response only focuses on reverse taper, other variables could be considered. You are welcome to contact me for any additional questions or comparisons by email

Timothy.Creamer@hcahealthcare.com

Timothy L. Creamer, RN

PICC Team Leader Regional Medical Center Bayonet Point

Clinical Educator, Bard Access Systems

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

I would want to get an

I would want to get an ultrasound to rule out vein thrombosis. The reverse taper is placing the largest segment of catheter in the smallest diameter of vein. We do not have any published data on outcomes specific to the reverse taper design, although most brands do have this design. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861