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MichaelMac
never trim your picc

My new dept. manager has just instructed us to 'never trim your piccs' prior to insertion.  Apparently she met the Arrow rep and walked away with this change in our practice.  The reasons she gave were 1) the smooth, manufactured tip will reduce the incidence of thrombus formation (rough edges from the cut will promote thrombus), and 2) despite the turbulent flow in the SVC, it's safer to have medications exit from the catheter from staggered exit sites (rather than a double lumen being cut flush & having the meds potentially mix on exiting the catheter).

I'd like to make decisions using evidence based practice.  Anyone have any resources to back up or refute these claims?

Thanks,

Michael

lynncrni
These are certainly 2 key

These are certainly 2 key issues that have caused a lot of concern since we began using all CVCs. I will include here what I have always taught about these issues.

RE trimming a PICC to patient specific length. First, I have never cut any catheter. I have always believed that the manufacturers tip was the best. This is especially true of polyurethane tips that are a modeled round tip and I would never want to sacrifice this formation. Silicone catheters are cut in the manufacturing process very similar to what is done at the bedside. However, Janet Pettit, a neonatal nurse practitioner, has done some in vitro studies of cutting and taken pictures with a high powered microscope to demonatrate these rough jagged edges after cutting. There have been no clinical studies of outcomes with cut PICCs vs uncut PICCs, but we know that most are cut and the thrombus rate is fairly significant with PICCs. Here is Janet's article:

1.    Pettit J. Trimming of peripherally inserted central catheter: The end results. Journal of the Association for Vascular Access. 2006;11(4):209-214.
Obviously we do not live in a one-size-fits-all world. So you must weight the risk vs benefits of cutting. Excess amounts on the outside will make it more difficult to maintain the dressing and easier for catheter dislodgment, which also means changes in the tip location. So not an easy decision. It would depend on the pt age, site of insertion, external length needed for securement, patient activity, pt size, etc. I would rather choose a catheter length that would not require cutting but this may not be possible either.

RE the staggered lumen issue. This is a feature that is a marketing position. The spacing between the exit ports is usually between 0.5 to 1 cm. Compare this to the spacing on a hemodialiysis catheter where the spacing is 2 to 2.5 cms apart. There is documentation that ~25% of the blood is recirculated through the dialysis machine more than once even with this amount of staggering. So will staggering of 0.5 to 1 cm on an infusion catheter really make any difference? There is no clinical evidence to support this. There is one in vitro study from ~20 years ago. They set up a model of the circulatory system and then compared staggered vs nonstaggered lumen when infusing TPN through one and Dilantin through another. It did show that precipitate was forming with the nonstaggered lumen. We know that Dilantin is very unstable and incompatible with all other solutions, so this was no surprise. In the ensuing 20 years there have been no other studies, except manufacturer white papers used for marketing purposes. Most brands of all CVCs including PICCs, tunneled, nontunneled, and ports are ***not*** staggered. If this were a tremendous issue, I think we would have seen something else published in the past 20 years. So I do not believe that the staggering issue is so important. Here is the study I am referring to:

1.    Collins J, Lutz R. In vitro study of simultaneous infusion of incompatible drugs in multilumen catheters. Heart & Lung. 1991;20:271-277.
 

Hope this helps, 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

Mats Stromberg
Just my thinking on excess

Just my thinking on excess outside catheter length; it will make it more difficult to maintain the dressing and easier to dislodge the catheter by mistake during dressing change for instance. What would you say Lynn and what would others say or do regarding the shortening of a Groshong PICC that you have pulled say 5 cm after cxr? How long outside catheter length should one accept?

Mats

lynncrni
The single lumen Groshong is

The single lumen Groshong is the only one that I know of where you do trim on the external end. The downside, and in my opinion it is a huge negative, is that you have to assemble the catheter hub at the bedside. I have never liked that idea. Double lumen Groshongs can not be trimmed on either end. I think the external catheter length is a patient specific decision. It depends upon the exact insertion site, the type of catheter stabilization method or device, the patient's activity level, etc. For instance, if you have a Biopatch dressing plus a Statlock, you may actually need a little longer length than if you use some other dressing with sutures. I do agree that having excessive external length is a problem with the dressing. 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

kathykokotis
ports are trimmed

It is rare I ever answer anymore however but since RN's do not place these devices they maynot be aware of how the device is placed

Polyurethane ports which have replaced many of the silicone ports are timmed to size and have longer dwell times than a PICC line.  Polyurethane tunneled lines are also trimmed.  This trimming has taken place since the 1970's and 1980's with not much published to my knowledge.  Any company will send you instructions for use whch tell you if trimming is allowed or not allowed.

Dual lumen ports and tunneled catheters are non staggered and incompatibles are run thru them.  Instructions for use will state wether you can administer incompatibles via a non-staggrered lumen

Kathy Kokotis 

 

 

kathykokotis
ports are trimmed

It is rare I ever answer anymore however but since RN's do not place these devices they maynot be aware of how the device is placed

Polyurethane ports which have replaced many of the silicone ports are timmed to size and have longer dwell times than a PICC line.  Polyurethane tunneled lines are also trimmed.  This trimming has taken place since the 1970's and 1980's with not much published to my knowledge.  Any company will send you instructions for use whch tell you if trimming is allowed or not allowed.

Dual lumen ports and tunneled catheters are non staggered and incompatibles are run thru them.  Instructions for use will state wether you can administer incompatibles via a non-staggrered lumen

Kathy Kokotis 

 

 

Donna Fritz
staggered lumens

Lynn,

I'm surprised by your comment about MOST CVCs that are used do NOT have staggered lumens.  That is not my experience, but I know that brand of catheter used seems to be very geographic.  My experience with non-tunneled caths is primarily DL Hohns and TL Arrows which are both staggered.  In oncology we use many tunneled CVCs and what I've used most is DL Groshong, which is also staggered.  PICCS many times are not staggered--a blunt cut at the end--although Groshong brand PICCs should be staggered (don't use them).  I have rarely used dual lumen ports, but it might depend on whether it was an open ended cath vs. a Groshong cath on the end, as the Groshongs will be staggered.  Just my experience . . . .

lynncrni
You happen to be using the

You happen to be using the only brands that are staggered. But there are numerous other brands of all types of catheters - PICC, nontunneled, tunneled, implanted ports - that are not staggered and have never been staggered. The only published study is a 20+ year old in vittro study supporting the need for staggering. If this were a truly siginificant issue, I think there would have been more negative outcomes and more publications in that ensuing 20 years. This feature has been a marketing issue and not a clinical issue. 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

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