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pfintonis
air embolism and picc removal

I know INS standards call for the use of an antiseptic ointment to the site of a picc line upon removal. Our current procedure does not call for this. I am trying to encourage my team to use "evidenced based practice" in implimenting policy change. To this end, standards call for it, everyone seems to be doing it, but I have yet to find a single reported case of air embolsim with picc removal. And as far as an antiseptic ointment, I can't recall ever having an insertion site become infected after removal. WE do make sure the site is below the level of the heart, and pressure held until hemostasis is achieved the gauze and tegaderm dressing until epethelialized. Since the puncture site is in the peripheral veins, there is a possitive pressure not effected by inspiration. Everyone seems to say that because it is a precaution and rist in central line removal that we should do it with piccs as well. Am I missing something here. Does anyone know of any evidence of air embolism and picc removal. thanks for your input..

P.F. RN, CRNI

Clinical resource RN

Venous Access Team

NSMC Salem Hospital

Partners Healthcare

lynncrni
I just finished revising this

I just finished revising this INS standard, so I can reply. First, you are correct that the current standard states to use an antiseptic ointment. That language has been corrected because the anti-infective agent is not what is important. Infection is not the problem.  It is sealing the hole with a petroleum-based ointment that is critical. I could not locate any actual published case studies of air embolism with PICC removal, however I do know that air emboli has occurred with improperly placed PICCs, during tubing changes, etc. I know this because I have been the expert witness on several legal cases involving these situations. While it is not documented with PICC removal, it still remains a theoretical possibility that air can enter the circulation after PICC removal. The skin-to-vein tract remains open and is connected to an intact fibrin sheath. The patient stands up and takes a deep breath with his arm raised and sucks air in. The connection between tract and intact sheath has been documented in another such incident where the patient went outside to smoke after removal of a subclavian inserted CVC. I will agree that the chances are much more likely with subclavian and jugular insertion sites than with PICC insertion sites, however in the name of patient safety, we can never overlook this possibility. Also, a PICC is a type of central venous catheter. It will be far less confusing, create greater patient safety, and ensure compliance through consistent practices if the policies and procedures for all central lines remain the same. So this is my rationale for why this type of seal with a petroleum-based ointment is necessary when removing all CVCs, regardless of the type. 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
standardization of technique is important

It is rare that I ever leave a message in a public forum anymore however when a patient safety question arises I feel the need to comment.  When a facility standardizes for patient safety one must consider getting on an airplane.  Would you like a pilot to go thru an algorithm in their miind of I check the gas only in these situations and not in these or the engine when this happen but not if we use this type of engine.  Accidents happen when one does not perform a task routine to a checklist.  Having a policy that removal of every CVAD regardless of perceived risk is done the same way leads to less safety mishaps.  I agree with a checklist to the removal of a CVAD that is standardized and the same for every type of CVAD.  If you were at INS this year you would have seen the poster with (4) patient mishaps (even death) from removal of a CVC at at very large medical center.  One of the lines was pulled while the patient was sitting upright in the chair.   Pulling a PICC with a patient upright even though I would not recommend this is a low risk of air embolism but pulling a CVC jugular is much higher.  How does the nurse think through the situation that if it is a PICC I do this and if it is a jugular placement I do this.  I agree with the standardization of care and a checklist to patient safety.  Removal should be a standard checklist and all CVAD's that are non tunneled should be subjected to the same removal process.  routine creates a climate of safety.

Kathy Kokotis RN BS MBA

Bard Access Systems

 

WadeBoggs26
Placing ointment on a puncture wound?

 It was brought to my attention that all petrolatum products carry an FDA warning that they are not to be placed on a "puncture" wound, does the INS recommendation override this warning?

 

Thanks,

Chris

lynncrni
I did finally find the

I did finally find the statement you are asking about at http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=26810. I don't think that the INS statements "override" this warning statement, however I think we must use some critical thinking here. I think this statement is referring to an accidental puncture wound, where there is most likely to be lots of contaminants introduced. This ointment creates a seal around the site preventing these contaminants from escaping. I can well understand why this statement was made. If there is a purulent exudate coming from any CVAD insertion site, I would want to use an antiseptic ointment instead. For sites without drainage, an antiseptic ointment is not required as treating an infection is not the goal. The fact is that all sites must be adequately sealed to prevent air from entering the skin-to-vein tract and producing an air emboli. This can and does happen and leads to stroke, respiratory arrest and death. It is a very serious problem that must be addressed to protect patients. With the ointment you are preventing air from entering. There should be no contaminants to be trapped as with an accidental puncture wound. I woiuld take this question to your pharmacy and therapeutics committee but they will need to know what is in the literature about air embolism from CVAD removal. So go to the INS standard on this complication, find these articles listed, and educate yourself about all aspects of this complication so this committee can make an informed decision. If you do not wish to use a petroleum ointment, you can always use an antiseptic ointment such as a triple antibiotic one, however these ointments are the only things that will successfully seal this site to reduce the risk of air embolism. 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

WadeBoggs26
 Thanks for the reply Lynn,

 Thanks for the reply Lynn, our P&P is currently working on this along with our NPC and pharmaco-therapeutics committee which is how the question came up.  We do have a copy of the Standard but we didn't see any articles cited related to the standard, can you maybe help point me in the right direction?  Since everything we stock that contains petrolatum says "do not apply to deep or puncture wounds" on the packaging, we looked at our antibiotic ointments but we found the same warning, which we assumed was because they contain petrolatum as well.  We CC'd risk managment in on the conversation due to the FDA warning, their concern was that the FDA warning might be due to risk of the petrolatum entering a vein or artery.  Is there any information about the safety petrolatum in a vein?  Are there any articles/studies that demonstrate the effectiveness of an ointment vs a semipermeable occlusive dressing alone?  If we could show that a film dressing is not sufficient, or even better that it is not sufficient and is more effective when combined with an ointment, it might help make a better case for using ointment as well.

lynncrni
You are asking for the

You are asking for the impossible. There will never be any studies comparing 2 methods for prevention of air embolism after CVAD removal. Think about it - we know that air emboli can and does occur with CVAD removal. So we are going to put some patients in a group with one method and some in another group with another method to see which works best. No IRB would ever approve such a study for ethical reasons. There is no dressing alone that can create a totally occlusive site without this ointment. This has been done for my entire career when removing CVADs so this spans the past 40 years. Yes, I was practicing as an infusion nurse when we first started to placed CVADs and cared for the first PN patient at a large Atlanta hospital in the early 1970's. These ointments have been the standard of care of that long. There has never been any reports of this ointment working its way into a vein or artery. I truly do not think that this warning was written about the situation we are discussing. I think it was written about dirty accidents where a rusty nail punctures a foot or other dirty puncture wounds. Just like the ointment prevents air from entering the vein, the ointment would prevent escape of any comtaminants taken into the wound from the puncturing device and thereby increase the risk of infection. I strongly believe that the risk of catheter-associated venous air embolism is far greater than the risk of applying the ointment. The references you see listed on the INS standards are what is available. We must rely totally on case reports and animal studies for complications such as this. You will also not find any instructions for use or labeled indications on any dressing material about a specific dressing preventing air emboli after CVAD removal. If your hospital chooses not to follow this simple practice, your patients are at great risk for air embolism from any CVAD is removed. If you take this route, you must offset this risk by holding pressure for a longer period, by a larger thicker dressing, by having the patient remain flat for a longer period, by not allowing any activity that would require a deep breath, etc. You would also need to assess the length of catheter dwell time - longer the catheter is indwelling, the stronger the skin-to-vein tract and the greater the fibrin sheath. These tracks can remain open for very long periods of time. The use of these ointments creates the safest method, in my opinion. There has been a case report published of a CVAD removal without such ointment where the patient was allowed to go outside to smoke after removal. AE resulted and they were able to find this column of  air extending into the patients chest on radiographic techniques.  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

laurenb
air embolism and PICC removal

I find this discussion very interesting. As the CMS list Air Embolism as a Never Event it does behoove all of us to look very critically at our PRACTICE not just policy. Policies can be perfect but rounding to see what actually happens at the bedside is critical. To that point, at our facility we had great policy, but still had an air embolism event with a Jugular line, and not related to the nurses technique but because the patient did not follow directions and took a large deep breath immediately after the line was removed and spoke to the nurse: CAn I help hold the dressing?  Wow, who would imagine!  A huge AE event ensued. After much investigation and research we found that following what had been done at another institution would be our solution as well, use BioSeal to seal the sites of all our NON-PICC percutaneous cvc's at removal. It works wonderfully, the nurses and the patients love it and the scarring is minimal compared to the standardard removal method. Apply the powder to the site, with light pressure, remove the line from under the powder and then apply firmer pressure for 2 mins. cover with a transparent dressing (PIV size). Because of the hemostatic properties there is no bleeding, oozing and because of the antimicrobial properties of the iron content, you are covered there as well. We have been doing this for 17months. We do not use it for PICC as the literature does not support it and ONLY our PICC team removes the PICCs and we use site below atrium and a standard drsg to the sites.

 

Lauren Blough, RN, BS, CRNI, VA-BC
Clinical Development Manager
Biolife, LLC "Makers of StatSeal"

WadeBoggs26
 Thanks again Lynn, I should

 Thanks again Lynn, I should clarify I wasn't necessarily expecting RCT's on the subject, but I thought there might be some documented cases of failures of occlusive dressings without ointment, so I appreciate the reference to the case report of patient who had an AE while out to smoke to help build the case that an occlusive dressing alone is not sufficient.

  I went back through the INS Standards reference at my facility, our version was downloaded and then printed off so I think we might be missing part of it.  I couldn't find any footnoting, just a list of articles and studies at the end of the section.  There only appeared to be one that referred to post-removal dressing site care but it was about an AE with gauze dressing only.  I also have been having trouble finding how the INS grades their recommendations and how that particular standard is graded?  I hadn't realized this recommendation was at the level of a Standard of Care, I'll point that out, Thank you.

Chris

WadeBoggs26
 I brought your arguments to

 I brought your arguments to the discussion on this and I have to say it didn't go well.  Maybe we use different definitions, but in my part of the country at least "Standard of Care" implies a certain level of established practice.  As it turns out, the recommendation to use ointment not only did not reach a sufficient level of common agreement in the P&P's and Nursing Practice Resources we surveyed, it wasn't even found in a majority of these.  Using an occlusive dressing could certainly be argued to be a Standard of Care, but not the use of an ointment.  

The case report of the guy who went out to smoke and experienced an AE as it turns out was not due to the lack of an ointment as you implied, but rather that there was no occlusive dressing at all.  Saying that it was due to the lack of an ointment when there was no occlusive dressing is like saying that someone who jumps out of a plane with no parachute and no helmet died because they didn't have a helmet, when the lack of a parachute most likely also played a role. 

I'm fine with bringing theory based recommendations from the INS to our P&P council, but it needs to labelled as such.  Not all practice recommendations are equal and implying that they are only weakens EBP as a whole.  

Recommendations that are essentially 'guess based' need to take into account the level of theory and or evidence that supports as well as opposing factors.  Our research council came up with numerous studies that showed petrolatum does not block pores when applied to skin, so there is a valid question of if it is capable of blocking a much larger hole.  There is also the concern of incompatibility of many antibiotic ointments with some dressings.  Also, there's the question of whether or not an occlusive dressing will remain equally patent with a lubricant underneath it compared to without.  None of these issues prove that ointment shouldn't be used, but they put the strength of the recommendation into context, which is a primary responsibility of those advancing best practice recommendations.

I've always been a big supporter of promoting EBP and have lobbied for use of Cochrane, JBL, and others so I've always given the INS the benefit of the doubt even though I've found some of their practices to be a little dubious.  For instance, "that's how I've always done it" isn't really a proper EBP rationale base, and is essentially the antithesis of EBM.  Grading evidence is essentially mandatory for anyone wanting to be taken seriously in the world of EBP.  Proper source citing is also something the INS could work on, it's typically not considered acceptable to just have a list of sources at the end of the chapter without any footnoting.  It's sometimes acceptable to footnote at the end of a paragraph, but typically it should be done after each statement of fact, this is the standard any High School English student must abide by, I'm not sure why the INS can't live up to the same standard.

lynncrni
Are you certain that you have

Are you certain that you have the 2011 version of the Infusion Nursing Standards of Practice? It sounds like you are still referring to the 2006 dcoument as this did have the reference list at the end. In 2011 each practice criteria statement has the specific references and each statement is ranked. I do not profess to be an expert on EPB but our committee did have a doctorally prepared nurse with much experiene in this area to guide us.

Regarding the use of ointments for catheter removal, I did communicate with a scientist from one of the TSM dressing manufacturers. These dressings do allow for the exchange of air molecules but can also be considered as "occlusive". He also strongly agreed with me that there would not be a study on this if it is left up to the manufacturers as they are unwilling to accept the associated risk. So if your organization wishes to conduct a study on some other alternative for creating an occlusive dressing that would prevent VAE with CVAD removal, I say go for it! Just don't expect any funding from any of the TSM manufacturers.

On another note, I have been the expert in several legal cases involving VAE with CVAD removal and several courts have accepted this standard of an ointment-based dressing as being the standard. Finally standard of care is defined as what any reasonable and prudent nurse would do in the same or similar situation. Standards of practice establishes the actions and interventions that any nurse should take. These are common defintiions in the published lit.

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

laurenb
 If you look at the INS

 If you look at the INS standards 2011 page S58, Standard 44-III.F. you will see that it says: Non-tunneled Central Vascular Access Devices (CVADs)* (*includes PICC): Caution should be used in the removal of a non-tunneled CVAD, including precautions to prevent air embolism. Digital pressure should be applied until hemostats is achieved by using manual compression and/or other adjunct approaches such as hemostatic pads, patches, powders that are designed to potentiate clot formation. The nurse should apply petroleum based ointment and a sterile dressing tot he access site to seal the skin to vein tract and decrease the risk of air embolism. etc.  I think this will answer your question.

Lauren Blough, RN, BS, CRNI, VA-BC

Clinical Specialist

Florida Hospital

Lauren Blough, RN, BS, CRNI, VA-BC
Clinical Development Manager
Biolife, LLC "Makers of StatSeal"

WadeBoggs26
    I did check and yes, the

    I did check and yes, the recommendation appears in the 2011 version without a grade of the evidence or proper APA footnoting.  

    I'm still not clear as to how this reaches the level of Standard Care.  I asked our Legal Nurse Consultant and she wasn't really sure where you were coming from either.  Standards of Care (synonymous with Standards of Practice legally speaking) are those practices for which there is "common agreement", where not following the Standard qualifies as negligence.  There are many things in our daily practice for which there is not enough agreement in practice to establish a Standard.  For instance, it wouldn't be difficult to establish in court that swabbing an access port prior to use is a Standard of Care, although the amount of time you swab is more difficult to establish a Standard of Care for since there is less overwhelming agreement as you get more specific. There is no specific level of agreement defined to establish a legal Standard of Care, but in general it's much more than currently exists with the use of ointment on PICC line sites where use of an ointment is in the minority based on our review.

You seem to be suggesting that the INS standards are the only basis used in courts for establishing standards of care, which would essentially make the INS recommendations law, which I don't beleive is the case.  Standards of Care are typically established in courts using multiple sources, including INS recommendations.

If that is case and legally speaking facilities must follow INS standards 100%, then would you suggest that Nurses who's facility policies differ somewhat from INS recommendations ignore their facility policies and follow the INS recommendations to cover themeselves legally?  

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