I am a home infusion nurse and a patient has been having increasing skin irritation under dressing site. The doctor who has ordered her therapy is not available for questions and I encouraged patient to contact doctor. He would not see her in office so patient finally emailed him a picture of her irritated skin.
On Monday patient was having such itching and irritation that she called doctor on call and he instructed her to remove her sterile dressing. She contacted me Thursday and informed me that her dressing has been OFF since Monday.
Am I correct in believing this PICC line should be removed due to exposure to air for nearly a week?
The doctor has ordered steriod cream and now wrapped gauze around picc site.
Please let me know if I am mistaken in thinking the pt is at great risk for infection and should get a new line placed.
Many factors would need to be considered. How long has this PICC been in place? How much longer will she need it? What is actually causing this skin irritation and how will it be prevented if you do place another PICC? Was it CHG as the cause or do you think it was the dressig? What are the patients allergies? What are the primary and any secondary diagnoses or comorbidities such as diabetes? What is her response to the steroid cream at the site/?If this PICC has been in place for longer than a week and it is only needed for a few more days, you might just try to manage until it can be removed. After the first week of dwell, the risk of BSI is greater from the intraluminal side but that is on catheters with a dressing maintained. I would not say exposure to the air alone is the risk. It is skin organisms and what else may have been in contact with this area from regular activities of daily living.
If there is a much longer time that it will be needed, it might be better to put in a new one as soon as possible.
But before I did that, I would make every effort to figure out what caused this so you will not repeat the same thing again.
Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Up until 1 1/2 weeks ago there was not a hint of irritation. She is being treated for lymes disease and has had the PICC for over 3 months. Getting Rocephin and the dr wants her to keep it for one more month to get Levaquin. I really think it was a contact dermatitis also. I have been using Chloraprep and allowing it to dry at least 2 minutes. No problems at all untill last two weeks and once the irritation started it went quickly. She has not other co-morbidities and NKDA. I just called her and she said it is much less red and "angry" looking. I did not think it was recommended to have insertion site exposed to air for so long. I worry about PICC migration and infection risk if her skin is showing s/s of breakdown.
Do you have INS standards that you are referring to? If so let me know and I can have some data to share with the Dr. He is not familiar with PICC lines and this is making me nervous.
Thanks again. I really appreciate the responses on the weekend.
What would you recommend if he wants to keep the line for another month?
Would you switch to Hibaclens and then a different dressing, maybe a Primapore Q 3 days?
Sarah
You will need to purchase the 2011 edition of the Infusion Nursing Standards of Practice as this is the document to which you are held accoutable. This does sound like a contact dermatitis which can occur with repeated exposure to things like CHG or the adhesive on the dressing, could be either or both. This insertion site does need to be covered and protected with some type of dressing and it should not be allowed to remain open. What type of catheter stabilization method is being used? I would suggest continuing to use the steroid cream with a gauze dressing held on with Kling or Kerlix, along with some type of stabilization device. Hibaclens is CHG, so that will not work if CHG caused this problem. You can use alcohol alone but that will cause lots of burning on this angry skin. So I would probably go back to povidone iodine and see what happens with that. I also strongly recommend the use of skin protectant barrier solutions for every catheter in every patient. I would never apply a dressing of any kind without this solution. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I appreciate your time. I know that Hibiclens is chlorhexadine, but didn't know since it was so diluted it might work. I will try betadine and alcohol. Again, thank you both for responding.
Sarah
I switched her to a Stat Lock after I stopped using a Sorbaview Shield when it looked so red and irritated. What about using this PICC for another month? Any clinical evidence that this is not a good idea? Again, Lynn, I really appreciate the advice. What about a Biopatch or Silvasorb patch to insertion site? Currently we use them.
Also, when it is healed would you recommend going back to a sterile occlusive dressing?
Sarah
Hello, I have seen this alot, especially with anti-fugal meds. Doctors have suggested gauze dressings and changing the dressing ever three days. I think what you are seeing is a contact dermatitis. What med is the line being utilized for?