What causes the serous discharge sometimes seen from PICC insert sites?
How are people managing this discharge to prevent skin breakdown, maintaining dressing?
We are an acute care teaching facility with Vascular Access Team inserting at least 150 PICCs monthly.
Thanks
Interesting that you bring this up.
We had a patient a few weeks ago that had clear light yellow drainage from the site that required gauze dressing and the resulting frequent dressing changes. They evaluated the arm with ultrasound and it was normal. Our only guess was that it was "lymph" fluid. We don't know that, so it will be interesting to hear from others. Is it possible that it was lymph fluid?
We insert between 360-400 per month and have seen this maybe 2 times.
Gwen Irwin
How is lymph fluid identified?
Clinitest strips test positive for glucose.
Were you able to keep the PICC until treatment completed? Did the leaking stop on its own and how long did it take?
It used to be just the patients with low proteins who would leak out of their site or any other puncture wound ie the xylocaine puncture site but now are finding that patients with normal protein counts also leak--is their a relationship with how high on the arm PICC is placed as almost seems that the higher up it is the greater the incidence but like you--we don't see too many people with this problem (maybe a dozen in my experience over the last 15 years).
What we do find is that these patients are labor intensive with frequent dressing changes and our concern for risk of infection, skin breakdown, dislodgement of line. The patients are not routinely evaluated with ultrasound but those who have had ultrasound have been negative.
Patrice Wilken RN
Vascular Access Team
Winnipeg
I would question the possibility of a small hole in the catheter at the exit site and the serous fluid possible being the flush solution or IV solution? Just a thought.
Valorie Dunn RN BSN CRNI
Valorie Dunn,BSN, RN, CRNI, PLNC
I also thought it could be a hole but when PICCS are removed and flushed no hole has been apparant. Guess it could be a fibrin sheath with fluid doing retrograde exit through insert site. Have you had any patients with this discharge? Sometimes it can be enough to cause skin breakdown and increased potential for infection with the frequent dressing changes. What has your experience been?
Patrice Wilken RN
Vascular Access Team
Winnipeg
We had one pt that experienced this as well. I cosulted with the PICC RN and the only thing he could think of was that this pt was having some "strange" reaction to the PICC materila. The thought of a pin hole did not occur to me until much later so I vever thought about checking it afterr it was pulled. I am curious to see what others experiences have been with this. Thanks
Valorie Dunn,BSN, RN, CRNI, PLNC
On occasion we wil see a pt. who is diuresing and will have fluid leaking from around the picc line. We use a product called Bioseal CVC. It is a brown powder used to dehydrate the fluid and form a seal around the insertion site to prevent the need for 48 hour gauze dressing changes. After you have ruled out a leak from catheter fracture, try using Bioseal CVC. The website is www.biosealcvc.com . Our facility uses it on insertion of every picc line for hemostasis and microbial barrier until the weekly dressing change is due.
Susan
to have and use it the next time we have serous/lymph discharge from a PICC insertion? We have had 2 or 3 episodes and in one we had to pull the line, because it went on for over a week and skin breakdown was coming and the patient just couldn't stand the constant dressing changes. Are there any dangers from "blocking" the discharge this way? Would a suture or two do the same job?
Mats in Stockholm
I would have serious reservations about such a practice. If you are not sure what the drainage actually is and what is causing it, there could be some additional problems if it is obstructed by the sealant agents. We just don't have enough experience with these products yet, but hopefully will see more research published soon. 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
What we've done the couple of times we've seen this is to wait for it to stop doing daily dressing changes. Once, as I stated, it didn't stop, but I have seen it stop after a few days and the patient could keep the PICC. I think the beginning of skin breakdown or patient decision would be my indications for removing the line. Anyone agree/disagree?
Mats
We also try saving the line with frequent dressing changes--and have even tried the thin hydrocolloid dressings as a skin barrier under the PICC to protect skin from maceration. But ultimately we begin planning for alternative access as soon as this leaking is noted as more often than not, we can't save it.
Just wish I knew what predisposes the site to leak and how to identify what the fluid is. Any suggestions?
Patrice Wilken RN
Vascular Access Team
Winnipeg
Have you seen an increased rate of infection with the Bioseal? I would hesitate to use any sealant on the insertion site of a PICC as I feel it may do more harm than good. Is there any reliable research on these products as yet? I have only had one patient to leak serous drainage from the insertion site and it stopped withing 72 hours. I just performed frequent dressing changes as the patient was adamant about not wanting to lose the PICC which was functioning perfectly. We did take a close look at it when it was removed and there were no leaks or ruptures that we could see. We did use a different dressing for the frequent dressing changes that was thinner and we have found to be less irritating to the skin but also occlusive.
Theresa Strunk, RN, CRNI
Could you and representatives from other facilities who use bioseal at every insertion address the issue that Lynn H. brings up regarding the potential for the Bioseal to block fluid from escaping. I understand that is one of the main goals of Bioseal but does it sometimes result in inability to assess for ruptured lines and/ or lead to fluid (known or unknown source) to build up in the tissue near the site or increased infilltrations? Also, was the product introduced gradually to various pt populations or was it decided to utilize it on every insertion accross the board?
FORHIM
We use it on all patients, peds to geriatric, on insertion. At first we were hesitant due to the added cost but after trialing on every picc during our evaluation and seeing the elimination of unscheduled dressing changes, it ended up being cheaper. While it seals the site and stops bleeding and general oozing, its not glue, so fluid back-up has not been an issue for us. Not a pretty product (unless brown is your favorite color) but the sites look great.
Could it be a rupture catheter, close to the insertion site? Because we have such a high DVT rate with a reverse taper 6Fr Tripple lumen PICC, we switch to 5fr Tripple PICC. However, since we started using them beginning of the year, we had two incidents of IV fluid/medication leaking out at the site. They were leaking badly at the site. In one of them pt was having Diprivan drip and it leaked right out at the site. We replaced it then pulled the old out to investigate. Sure enough we found a rupture site close to the hub. We thought that because the engineers wanted to accommodate 3 lumens in a small 5fr catheter, they had to make the catheter wall super thin, leading to higher risk for rupture. We have a plan to start reporting to the manufacture and risk management if it occurs again.
Have you also considered reporting to MedWatch, the FDA site for problem problems such as this? 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 would wonder why use the hydrocolloid dressing. Doesn't it keep the site moist, since that is the nature of hydrocolloid dressings? If that is what you do, how often do you change the hydrocolloid dressing? What has been your success rate with that? Is there any increase in BSI rates related to hydrocolloid dressings?
Gwen Irwin
Austin, Texas
Recently we inserted a PICC in a patient that lasted 6 days with no problems at all. On day 6 she was moved to Rehab and began physical therapy. When she began moving around and being active, her PICC appeared to be leaking clear fluid at the site. At that time I went to inspect it. After applying a fresh, dry dressing, I observed the site while flushing each port twice and did not detect a leak. Then I observed the site during the 30 minute IV antibiotic infusion and no leaking was noted. Two hours later the patient's nurse called to tell me that the PICC was found to be leaking when she came back from physical therapy. Indeed it was wet. We decided to change the PICC out. When we did, I examined the old PICC thoroughly and found no leaking anywhere. The next day the patient's nurse called and stated the new PICC was leaking as well. At this point I knew something different was up.
I went to the lab and got some urine sticks and i tested the fluid under the dressing. It was positive for protein and glucose and the Ph was 7.5. There is no glucose or protein in the patient's antibiotic, and the Ph of the antibiotic was 5. I concluded that the PICC was not leaking, but the patient was "seeping" her own fluid. After discussing the situation with the radiologist who placed the PICC, we explained that he did disect through the bicept to place the PICC. We decided that the fluid was her own serous/muscle fluid weeping through the picc entry point through the skin. Of course, a PICC line dressing cannot be wet, no matter what is making it wet.
In this situation, we decided to leave the perfectly functional PICC intact and have the nurses schedule daily dressing changes after her therapy. For about 3 days this was a big hassle for the Rehab nurses, but the patient already had one PICC changeout and very much desired to keep the PICC in her left artm and not move to her right. Also, she could've possibly had the same situation in her right arm. After the 3rd day, she stopped seeping the fluid and her dressings were remaining dry.
Her skin took a little bit of a beating (irritated) what with all those extra dressing changes, but the site is improving every day, now that the daily dressing changes have stopped. We're glad we figured it out and saved the line. I hope this helps someone else from unneccessarily d/c'ing a perfectly good PICC. It just took a little patience and a watchful eye.
Leah RN
I wonder why there are so many responses here referring to the PICC insertion site as a drain? PICC's are for infusions and according to the CDC the site should be kept dry.
Lauren Blough, RN, BS, CRNI
Lauren Blough, RN, BS, CRNI, VA-BC
Clinical Development Manager
Biolife, LLC "Makers of StatSeal"
I am in favor of utilizing the bioseal to prevent any drainage at the site to keep it dry per standards. But I am aware that sometimes fluid escaping at the site can be evidence of a more serious problem along the path of the line within the patient (ie a hole/ rupture/ etc) that requires a line to need removal. So my question is in regards to weather the bioseal can result in delayed diagnosis of this problem?
FORHIM
Anytime there has been another problem as you describe, the BioSeal has easily given way. For instance a ruptured PICC from a physician forcing with a small syringe, which did just recently happen. The manual flushing the VAS nurse did to evaluate the leak easily overcame the seal. In the 4 years that we have used the product at a rate of about 1200 per month, we have never had a problem related to 'sealing fluid in' .
Lauren Blough, RN, BS, CRNI, VA-BC
Clinical Development Manager
Biolife, LLC "Makers of StatSeal"