We are starting to see more partial and full occlusions now that our volume of picc lines is going up.  We have the Groshong picc line, and at first had alot of difficulty with occlusions and started using the CLC2000 and noted improvement.  Now this last 2 months I have noticed we are using activase about 2-4 patients  during a weeks time . ( We only have about 10 patients in house with picc lines on average)  I have been stressing to all the staff about the importance of flushing before and after infusions as well as in a timely manner.  Any suggestions??  

  We used to use the

  We used to use the Groshong.  We used it for several years, but no matter what type of cap we placed on it, it always had an occlusion problem.  We switched to the Boston Sci. Vaxcel PASV, and we rarely see a full occlusion any more.  We had only one or two last year.  What we see most is lack of blood return due to fibrin tails or sheaths, but not many of those either.  We recently started using a power injectable picc only for those that need it with a CLC2000 on it.  We have occlusions with that picc.  You just can't beat PASV for lack of occlusions and low maintenence.

 

The CLC2000 is not

The CLC2000 is not contraindicated for groshong catheters. The positive displacement that the CLC creates only opens the groshong valve just as you would create with a syringe infusing and closes as soon as there is neutral pressure. The difference is that is is a passive.

I thought using the CLC2000

I thought using the CLC2000 with a Groshong "valved" PICC was contraindicated as it might disrupt the proper closing of the groshongs built in valve. Has the manufacturer been contacted for help with this?

Sorry for the delay in

Sorry for the delay in responding. I had problems connecting to the site for a couple of weeks and have not caught up yet.

 Traditional syringes induce reflux into the catheter lumen because of compression of the rubber gasket on the plunger rod. When you empty the syringe, compress this gasket, and then release it to disconnect the syringe, the syringe reflux occurs because this gasket expands. Then there is disconnection reflux if using a negative displacement device. The answer is either use a syringe designed to prevent this reflux or do not inject the entire amount of saline in the syringe so that this compression does not occur. BD and Tyco Kendall now make redesigned syringes to prevent this. Lynn 

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

By the way are they

By the way are they clamping?

Tell them not to clamp the lines

Kathy Kokotis

Bard Access Systems

Our facility has been using

Our facility has been using the Ultrasite caps for nearly 4 years now. We saw a dramatic drop in the use of TPA for occluded lines as a result. When we had spikes in TPA usage after the change to positive pressure caps, we found that nurses were using a flush bag system and simply shutting the pump off after an antibiotic infusion leaving it connected to the patient until the next dose. Another spike in TPA use was attributed to using a 6 inch extension set with a needleless Y site that was not positive pressure that would reflux upon disconnection of the syringe from the ultrasite cap connected to the end of the ext. set.  Look at staff turnover- do you have an education program as part of your staff orientation that addresses proper flush technique for use with positive pressure cap systems versus positive pressure flush technique with non-positive pressure caps?

Leah

Lynn, Can you explain

Lynn,

Can you explain syringe induced reflux.  We use a 10cc prefilled saline and a positive displacement valve.  My understanding is that as the syringe twists on or off a small amt of saline is released at distal tip of PICC.

Thanks so much

Diane

Celia Brown

A PICC line is for blood

A PICC line is for blood draws

Use a 20cc flush for after blood draws

Occlusions are the result of poor care just like the new articles are showing that catheter related infection are the result of poor care and can be eliminated.  Did anyone read the Wall Street Journal article last month stating that fact about CR-

BSI's?

Kathy Kokotis

Bard Access Systems

We use all open ended PICC

We use all open ended PICC lines ane rarely have any occlussions. I'd say maybe 3 a month if that. I came from a place that used Groshongs and positive pressure devices and they had multiple occlussions. Maybe 2-3 daily

 

Try this little demo for

Try this little demo for your nurses to reinforce the importance of good flushing. Place an IV catheter on the end of your present positive pressure valve and flush. When the syringe is disconnected, the valve "does it's thing" and expells saline out the end of the catheter. Next, leur loc a syringe of saline onto the IV catheter and valve. Watch the tip of the IV catheter. There will be saline come back the tip of the IV catheter. In a real patient, that is not saline coming back, but blood coming back into the tip of the catheter.  EVERY time you access your line, blood  refluxes into the tip of the line. This will make a believer out of nurses when they see this happen. Good flusing is most important for PICC maintenance.

We use an open-ended PICC

We use an open-ended PICC but saw a great increase in clotted catheters when we changed our policy (against my wishes) to "If a patient has a PICC line, blood samples will be obtained from the PICC".  I know many of you have this policy, but I feel that it can shorten the life of the catheter and increases the number of clotted lines.  My feeling is that the patient needs to be educated about the use of the line and should understand that if we do use it for blood draws, that there is a risk of losing the line.  I have absolutely no problem using the PICC if the patient has no other site for peripheral venipuncture, is needle-phobic, or requests we use the PICC.  But someone who has good vessels for draws and has ALWAYS had blood drawn from the arm, should continue to have ti drawn that way.  We put together a teaching sheet with this information for the patient to consider and many patients opt for NOT using the PICC.  I continue to gather data and hope to change the policy so that it is not a blanket statement.

Wendy Erickson RN
Eau Claire WI

 Be sure the nurses know

 Be sure the nurses know that turning off the infusion pump does not produce the same effect as disconnecting the tubing from the line.  I discovered one Groshong PICC line which was connected to a turned off pump, and had blood all the way up into the distal end of the infusion set. 

 

Jerry Bartholomew RN, BSN, CRNI

VA Medical Center, Spokane, WA

Jerry Bartholomew RN, MSN, CRNI

VA Medical Center, Spokane, WA

We use groshong picc

We use groshong picc lines.  We do not have a high incident of occlusions.  I think we had 2 over the last 6 months.  We seem to have more trouble with understanding how to flush the PICC lines properly and care of the line.  Even though we have not had occlusions we have had a few infections which we feel is related to lack of knowledge regarding the lines.  We are having several inservices in the beginning of 2007 for catheter related infections and on PICC lines themselves....care use and maintenance. 

We had a different

We had a different experience. We averaged about 2 occlusions per day with the Groshong, even with the addition of positive displacement valves. Our numbers were the same with open-ended catheters, with the PPV. We had much better outcomes with the Vaxcel with PASV. We use NS flushes only, with the BD Posiflush, which I think does help.

We use Groshong PICC lines

We use Groshong PICC lines and the CLC 2000 valve.  We flush with 20cc NACL every 8 hours and after using the PICC line flush with 20cc NACL . We have never had an occluded PICC line.  I hate to write that, fear of jinxing myself.  I realize the 20cc NACL flush q 8 hours is overkill but we do not have any problems with occlusions. 

Gina Ward R.N.,

Gina Ward R.N., C.P.A.N.

 

Lynn,   I dont seem to have that article in the journals I have.  Are you able to forward me a copy?  Thanks  Gina

email gina.ward@hcahealthcare.com 

 

Have you looked at the BD

Have you looked at the BD PosiFlush prefilled syringe and compared it to the prefilled syringe you currently use?   It might be, as Lynn described above, syringe plunger reflux.  Once I saw it, it made all the sense in the world to me.  With nearly a 1,000 nurses at our hospital, it will be impossible to instruct them to consistently flush, hold the plunger, and then disconnect, and then clamp. 

It's been a real "ah-hah" moment with all the nurses I've shown this to.

 

Have you thought about

Have you thought about looking at the Vacel with PASV by Boston Scientific? My understanding is that it will greatly reduce your complete occlusion as well as withdrawal occlusion. It would be worth checking in to.

I have 30-40 inpatients with

I have 30-40 inpatients with picc lines and around 1-2 occlusions a month. I increased the flushing before and after and specially after blood draws. Education was the key in my hospital. Nurses need the right tools and education and than the start to handle the picc line right.

Andre

Read the recent article in

Read the recent article in JIN on the Technology of Catheter Flushing. It is not about one single aspect of the system, what type of needleless device or catheter being used. The entire system must be considered as one unit. Changing one piece will not address the entire problem. You may be seeing syringe induced reflux. A positive displacement device only addressed the disconnection reflux. Lynn

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