We are haing difficulties getting a blood return from our PICC lines in patients who ar ereceiving vancomycin.  We flush with 10ml NS followed by 5ml heparin 10 units per ml and use an antireflux injection cap.    I did cathflo on last Wednesday and when the nurse went to get labs Monday night he could not get a blood return.  Any tips, ideas would be very appreciated.

Valorie Dunn, RN, BSN, CRNI

Infusion Therapy Coordinator

St Elizabeth Regional Health

ilovenorthface

In the market, you always can find some different and unique vans sneakers and they are north face fleece sought after by many young people who are called as trend-spotters. As we known, the skate north face jackets shoes are not wholesale nfl jerseys only the shoes, they are filled with the street culture, the trend of heritage which can inspire people to seek natural memory and this is the main spiritual content for columbia jackets a brand. And the version of vans sk8 hi shoes attracts my attention. The popularity of the shoes north face outlet look followed suit, becoming a favorite amongst skaters, musicians, artists, and counter culture types alike. Today womens north face jackets they remain in north face backpacks their original form, a perennial classic, built like they always have with sturdy canvas uppers, and waffle rubber soles. This style is perfect and wonderful. However, they still develop new fashionable shoes for people and make everyone realize their dream of trendy brands.

We have had good success

We have had good success using 2 mg in 50 ml saline over 2 hours.  It was hard enough getting that protocol through our P and T group........off label use, I'm afraid.  I'm not sure what they would have said if we had asked for 10 mg!  Meanwhile, we seem to be doing OK.

Alma Kooistra CRNI

And did you see this in a

And did you see this in a written form from this sales representative? That is the only way you should accept such high level clinical information. This is true for the fibrin/thrmobus located directly at the catheter tip, however the fibrin is located well above the catheter tip. So the overspill from alteplase instillation will not reach the portion located along the external catheter walls. After a period of time, this fibrin/thrombus will regrow, causing the lumen occlusion again. To thoroughly treat the entire fibrin sheath along the entire catheter length, you will need to infuse a low dose of alteplase - one protocol is 10 mg in 50 mL infused over 2-3 hours through each lumen. 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

Alteplase

I was informed by the manufacture that the way Alteplase works is by desolving the clot. However, it adheres to the clot eating away even as the clot forms "outside" on the exterior catheter wall. So, as it dwells, it will eventually be drawn to the clot even as it clings to the catheter outside the lumen.

I would not expect a

I would not expect a physician to have this knowledge. These are situations when it becomes necessary to find a way to educate the physician about the risk. If that is not possible, and I have seem times when the physician would not listen or agree with anything a nurse had to say, then you need well written policies to back you up. 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

Vanco and Precipitates

Last month we had a simular situation (our PICC's are valved).  Floor RN C/O negative BR, PICC line "cathflowed" and positive BR obtained. 4 hours later Floor RN again C/O negitive BR only this time she reports seeing some "white foamy stuff" in the scant amount of blood, that she was able to aspirate in the syringe. First thing I asked is what's going through the line and when? Vanco q12 & zosyn q6 and you gussed it on a 6-12 schedule so one bag directly follows the other. These two either form a white turbitity followed precipatae or immediate precipatate.

The real kicker to the story is an M.D. relesed the Pt. home knowing there was no blood return from the line. His rationale when questioned; the pt. was not going to need blood drawn at home. So as long as the PICC was infusing it's fine

Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.

All of the steps you

All of the steps you mentioned are intended to reduce occlusion inside the catheter lumen. But there are also fibrin/thrombus problems that easily develop inside the vein around the catheter tip. Even alteplase instillation will not totally reach the fibrin sheath that is covering the catheter which could be the entire length of the catheter. Your alteplase instillation only reached what was immediately at the catheter tip, then it propogated to recover the catheter tip. This is simply the way our human bodies are made. The catheter is a foreign object and the fibrin sheath is walling off this foreign object. You can try a low dose alteplase infusion of usually 10 mg in 50 mL infused over 3 hours through each cath lumen. You should also pay close attention to where the tip is located. If it is not in the SVC/RA junction it is more likely to have problems with tip migration which can easily produce thrombus. Has the catheter become dislodged any amount? This also changes tip location. 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