When rounding on our PICC lines today I came across a PICC line without a cap on the end of the red port and blood visible in the lumen.  The nurse states that it must have happened 2.5hours ago after the patient recieved blood.  The open ended lumen was lying on the sheets in the patient's bed. The patient is on isolation for MRSA and his diagnosis is pneumonia.  My question is, should the PICC line come out and be cultured and replaced? And is there an amount of time that can go by when you can keep the PICC, clean the end and withdraw off of it before flushing to keep it?

I would think that at this

I would think that at this point, that patient needs to have a port placed!  We have had to go to that on some uncooperative nursing home patients after MULTIPLE PICCs being placed.  Solves the problem - it's under clothing and if they do pull, it just needs to be reaccessed.

Wendy Erickson RN
Eau Claire WI

PICC without injection cap I

PICC without injection cap

I got a call from the ER who needed a PICC line "fixed". On arrival this patient had a DL PICC. A little bit of history-Patient is a NH resident who was confused and combative-pt was discharged after our initial placement 2 weeks ago to a NH and came back 6 days later to have PICC replaced after patient pulled the PICC out. Now she is back because both lumens of DL PICC placed 6d ago are totally clotted. On my arrival I find that the purple lumen is without an injection cap. I thought this through carefully, what the consequences might be if I went either way. For the life of me, I could not with a clear conscious declot the line/replace the cap and send her on her way. I replaced the catheter.  Two hours later I get a call from the ER asking me to come back because the patient pulled out her new line before she could even leave the ER! So I guess it would have been removed one way or the other! :) But I slept well that night because of my decision. Cindy Hunchusky,RN, CRNI

PICC without cap

I had this happen to the Mother of a Nursing administrator and she was the one that called it to my attention. Talk about embarrassing moments!

We withdrew blood, scrubed the hubwith alcohol, flushed and placed a new cap on it. Luckily the patient did not end up with a problem.

PICC Found Without Cap

I too have found PICCs without caps in the more than 20 yrs of placing Pediatric PICCs.

As Lynn has stated, not an ideal situation.

After weighing risks and benefits of keeping the line, I have cleansed the hub carefully, attached a syringe, aspirated and discared 1 to 2 mls of blood, then attached a new cap and flushed. The MDs were notified and careful monitoring for CRBSI was followed. I can not recall a CRBSI occurring, but that could just be poor memory of this aging PICC RN.

Moira

 

Moira McErlean

I do not know of any evidence

I do not know of any evidence to provide answers to your questions. I would be also worried about air embolism but you did state that the line was filled with blood so probably clotted. Were you able to flush the line at all? Culturing the distal tip after removal would not provide any information about what was growing on the intraluminal surfaces. So immediate removal will not provide any benefit in my opinion. How long had the PICC been in before you found it this way? If more than a few days, chances are there is already biofilm growing on the inside of the lumen anyway. So I would probably clean the hub, attach a new needleless connector, document what you found and watch the patient carefully for any signs of CRBSI. I would also alert his physicians to what you found so they will be watching for signs of BSI as well. Not ideal, but probably the best of a bad situation. Eager to know thoughts of others, 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