I have been wondering why the 2011 INS standards included PICCs in the CVAD section on removing non-tunneled CVADs? Do PICCs and centrally placed VADs have the same risk for air embolism when being removed? The 2011 Standards call for the valsalva maneuver to be performed with CVAD removals which I believe includes PICCs. When a PICC is removed, at some point during the removal it basically becomes a midline in length until removed, but the valsalva is not indicated for a midline removal.
Can anyone help me understand the difference in using the valsalve for PICCs and not midlines? The team I am on has never done this for PICC removals and no incidents of air embolism ever noted. A Physician assistant in our IR department stated they do not perform this either. Also, at the 2015 AVA conference in Dallas, which I attended, I asked a presenter who is a physician and places and removes PICCs, if he does this. His response was no, also that I have an active what ever that means. Please help me understand this. Our hospital is changing our PICC removal process solely because it is in the 2011 INS standards. Will the 2016 INS standards continue this practice for PICCs? Thanks for any clarification provided.
Forum topic
Sat, 12/12/2015 - 00:33
#1
Valsava and PICC removal
A PICC is indeed a CVAD and the same standards of care apply to all CVADs. The risk of VAE with PICC removal is minimal but it does exists. The issue is the exit site at or above the level of the heart. With PICC insertion in the upper arm, the exit site can certainly be at or even slightly above the level of the heart, increasing the risk of VAE. Then there is the issue of an intact fibrin sheath which can extend into the central venous vessels inside the thorax. This can remain intact the entire length of the PICC. The skin to vein tract is attached to the fibrin sheath, allowing a good conduit for air to enter the central venous bloodstream. Finally, the standard of care for all CVADs should be the same, to decrease confusion among staff nurses who are managing all CVADs. As you know the new INS Standards will be released in January 2016. VAE is included and the information has been revised based on the evidence we found, although I don't remember the exact wording on that standard. I do think there is still an emphasis on preventing VAE with PICC removal in much the same manner as before. VAE also occurs during the dwell time when tubing and connectors are changed and that risk is also the same with a PICC and other CVADs. I have seen published case studies of VAE from a PICC with inappropriate set change techniques, yet another reason to have the same standard for a PICC and other CVADs. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
This is a perfect example of print meeting practice. As Lynn wrote, everything written on this topic will say YES. According to blah blah blah you should have the person valsalva during removal of a PICC. However, in practice very few do this. Why?..it's because in writing you will error on the conservative side. They have to. Legally, if something happened they would be liable so think about it, they have to. The practical side of this is that most Vascular Access nurses that remove PICC's , and have been doing so for ever, will say NO. You don't need to Valsalva to remove. As you found out when you asked the physicians.
Now, does that mean what Lynn says could NEVER happen?...NO....but a plane engine could fall from the sky and land on your car killing you instantly, but I bet you still drive.
I don't like the argument of creating standardization in the Standards of Practice as a means of reducing errors. This is a strategy aimed at making nurses think less. If the main argument for valsalva during PICC removal is that we valsalva during all other CVAD removal, I think you are compromising the integrity of Standards of Practice. Standards of Practice should be evidence-based. They should not be based on strategies to dumb-down nursing practice in the hopes of creating safer practice. There is plenty of variation in CVAD care, i.e., different concentrations of heparin for different lines, different types of acceptable dressings, different flushing frequencies, etc. I'm also not impressed with isolated case reports as sufficient evidence for justifying a national practice standard. I believe practice standards should be based on more rigorous science. On the other hand, valsalva is free and the cost to apply a petroleum-based ointment to the exit site under an occlusive dressing to prevent VAE is minimal, so why not? Maybe the wording of the practice standard should be changed to say, "Consideration should be given to..."?
I think there is some merit in the observations of long-time practitioners who find these sorts of standards, but have never practiced in that manner. I'm not saying the way long-timers have been doing it is necessarily the right way, but it should trigger a harder look at the issue. Just my thoughts.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Keith,
I'm totally lost here. We throw around EBP and Standards of Practice. Do you have hard evidence that the Vascular Access community is NOT using EBP or working in accordance with the SOP?...I have been to 5 major institutions that have Vascular Access teams and we all pretty much do everything the same way. I think we all practice based on what your calling SOP. I need specifics..please tell me of teams that are just inserting lines with no regard to what the standards are and making up rules as they go along. I think that kind of discussion "dumbs down " nurses. I've been on this site for quite awhile and it seems like it has degraded to a practice lecture from a few that have a command of the craft. So for us, I thank you for pointed out the importance of EBP...but supply us with examples of non compliance with the standards.
Jack
Jack, I was basically repeating what you said, but I was apparently much less clear. I was suggesting that in this instance, the standards say to valsalva during PICC removal, but as (I think) you observed, this is a procedural step that many facilities (if not most) skip because it doesn't make a lot of sense. Lynn suggested that steps like these are based on two purposes: (1) to attempt to standardize processes to minimize confusion, and (2) because of case studies that suggested VAE is still possible even with PICC removal because of the presence of a continuous fibrin sheath that remained patent after catheter withdrawal. I was just stating my concerns about basing practice standards on isolated case studies (I don't think the science is strong enough to base practice recommendations), and standardizing practices with an arbitrary grouping of devices such as CVADs in an attempt to reduce errors and confusion. In this case I think the standardization strategy is an attempt to dumb-down nursing practice because it attempts to free nurses from critically thinking about the care of different types of devices with different requirements for care and different considerations for complications.
My final thought was an acknowledgment of the merits of the opposing view: since valsalva is free and petroleum-based ointments with occlusive dressings are cheap, why not take the added measure to all but ensure a VAE does not occur, even with a PICC?
I am not calling anything SOP. When I referred to Standards of Practice, I was specifically referring to the INS Standards of Practice last published in 2011. The purpose of my comment was only to engage in a discussion about how certain practice steps are selected for inclusion in the Standards, because I have never fully understood why valsalva was a procedural step recommended by INS during the removal of PICCs.
I am not trying to lecture anybody. I don't think anybody is making things up as they go along. I think most facilities value the Standards of Practice, with a few interesting exceptions. It is possible that the use of valsalva might be one of those?
In summary, I think there is a low cost, minimal value added by including valsalva as a means to prevent VAE during PICC removal, I am expressing my concern over how certain things get included in Standardss and others do not. For example, why is there still no INS guidance on flushing technique ("turbulent" vs "push-pause" vs continuous flush vs etc.), when so many other Standards and guidelines include it? The answer is that there is little-to-no science to draw conclusions for recommendations, but things like the valsalva are included with a similar amount of science.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Your right, you were agreeing with me...I was just in such disbelief that agreeing with me was possible, I didn't see it...so thanks for your comments, and yes I agree with you in your analysis. But be cautious with agreeing too much young Jedi...you may be accused of going to "the dark side"...(just a shout out to all you Star Wars fans......lol)
Jack
I would encourage each of you to read the front matter in the 2011 standards to acquaint yourself with the level of evidence scale used by INS. That grading tool has been slightly refined in the 2016 standards and there will be an explanation of our process to write this document. There is nothing in your comments that the Standards committee has not thought about and thoroughly discussed. Our data analysis was led by a PhD prepared nurse scientiist and all other committee members have a minimum of a masters degree. So that means lots of experience with evidence based practice. Case studies would be ranked as a level V. In our scale there is a new type of ranking level I A/P. In our specialty there are many aspects that must rely upon anatomy and physiology and venous air embolism is a great example of this. There is no possible way to ethically conduct studies on humans about the prevention and management of venous air embolism, therefore anatomy and physiology is the basis for our statements when i A/P is used. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I feel like I was just sent to the corner and told to think about what I've done! I didn't mean to offend those on the Standards Committee. I certainly don't want to bore this discussion board with points the Standards committee has already dealt with (not that that EVER happens here!). I think Discussion Boards like this exist to exchange ideas about how to interpret information. My insufficiently educated mind does not understand why someone would lump all ethically untestable issues relating to anatomy and physiology into a new category I A/P. I think instead, the approach should be to not comment on the practice due to a lack of rigorous evidence. I hope my ignorance does not offend anyone. I do not agree with the decision to include valsalva as a prevention measures when removing peripheral lines of any kind. I think many people agree with this statement, and the sheer number who disagree should (and has) prompt discussion about the merit of the evidence used to determine that standard.
This Discussion Board has become so volatile. It truly is not about exchanging ideas. I'm afraid to say anything on here anymore. I would never talk to my coworkers in this tone and I would never expect my professors to be so defensive about a controversial topic. I will be finished with my Masters in Education in 3 weeks (Hallelujah!). This is not how you educate people.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
I have an engineering background. From that training, I like to know how things happen and why. Sometimes when I do not know how something happens it is hard for me to just accept a standard whether INS, CDC or some other credible source. I appreciate your comments Lynn on how the INS standards are created. I never knew this. I can search the internet to find out how it happens, but sometimes you do not know what source to trust. I am not saying any standard is good or bad, but I would like to understand, in this case, how an air embolism would occur in the removal of a PICC. I am sorry that some of comments may have taken on an assumed tone from the topic of my posting. Sometimes questioning why we do something, even if a standard of care, leads to better standards of care. With that in mind, can anyone refer me to credible source that would help me understand the process of the formation of an air embolism with a PICC removal? Just trying to understand the science behind why we as Vascular Access Nurses do what we do. Thanks.
David Dempsey MS, RN
Well David...You can see why nurses are so misunderstood....lol. To answer your question: you probably won't find anything that tells you HOW exactly that happens. Because it doesn't happen enough. But this is what we do as nurses and really what nurse educators do...they say "you can't do that...why?...because we just never do that"...If I had a dime for everytime a fellow nurse told me I can't do something, because....." well I'd be in Hawaii right now. In 25 years here's what Ive learned. Nurses will not say the 3 hardest words: I DON'T KNOW. Instead they will rely on hearsay...Now before I get hateful replys ..NOT all nurses. But enough that you'll take notice.
But the most disturbing trend and what I think will severly damage the crediblility of the bedside nurse, is the "master syndrome". Nurses that no longer practice at the bedside...but are truly the guiding light of all practice. You'll read it quite often on this site. They step away from patient care and then "teach" us drones that remain at the bedside. So, you'll here "experience is not that important"...angers the hell out of me. The truth is experience is everything!!...it's important to know the trends and study results that are being done in this field....but it never trumps experience. Why you ask (by the way keep asking why, I have been for 20 years). Let's use a football analogy. The coaches will go over scripted plays all week..run them, run them ..until you have down pat. The problem is when the quarterback calls the scripted play they always seem to be adjusting based on the defense..So the "scripted" play needs to be modified on the spot. So that's what experience will do...All the "teachers" can tell you the script , but when you get to the bedside every human being is different..every scenario is different you must be able to adapt and adjust. This is what we argue about. Lynn, says she doesn't come here to argue. I bet you don't...how could you my evidence is real life situations. Your evidence is discussed at a conference and regarding some study. I can't tell you how many patients have asked me..."are you good at this".."how many have you done"...never once have they said " What are the academia's saying about this?. So I make it my job to promote experience. I've been on both sides. But it is patient care your talking about.
What is the most disappointing thing about it....Why hasn't Lynn reached out to the most experienced people in this field and get FIRST HAND information on what works and what doesn't. I say I'm the BEST Vascular Access nurse in the country. How do you prove me wrong?....how can you say NO your not. ( I don't really think I am) but you have to wonder how do we know. Our "experts" are folks that couldn't put in a PICC to save their life...Why, in nursing, do we do that??? Totally discredit the practioner.
So David, you need a PICC line....who do YOU want to put it in, the nurse that has done it for 12 years and 10,000 insertions?....or someone who has looked at all the studies ansd writes a blog. My guess?....I guess I should get dressed. Please guys, don't let us lose what's important. Listen to the quarterbacks they know far more than you think. And for the academias...keep up the good work keeping us informed on the latest....But remember you chose to remove yourself from the bedside, don't try to make us believe by doing that you have been ..anointed. You gave up the most important educational opportunity in our field....PRACTICE!
Jack
Thank you Jack for your comments. So as to sum this up for me, there is no research available rightly because no IRB would approve a study for this. So the source is theoretical in nature for PICCs and based on experience with non-PICC CVADs because air embolism has occurred in practice. So to keep our patients safe and for our practice to maintain safe standards, we extrapolated this to PICCs since they are CVADs. If that is correct, then this what I have been looking for and I can accept that. Thank you all for helping me with that.
Jack, I agree, some people are afraid to say, "I do not know" and that is a problem. If you fudge an answer, you loose credibility. I am glad that I did not know, so that practitioners, such as those that have responded to this post, and have more insight/experience than I can help me learn and understand so I can answer questions reasonably intelligently.
Thank you again to all.
David Dempsey MS, RN
I once saw an instance that was likely associated to inappropriate removal technique of a PICC line. My current facility's policy requires valsalva for all CVAD removals, so we do it. Unfortunately we do not see many midlines come through the facility and we do not place them, but after the incident I witnessed in the past personally I would also consider using caution and having the patient valsalva if possible for those as well.
Danielle McClain RN, BSN
There is a credibility issue that I would hope would be concerning to any group making professional practice recommendations.
To begin with, while the tip position of PICCs and CVADs inserted into a central vein is the same, there is most definitely a difference between the isnertion sites, that what defines a PICC, and to consult a recommendation specific to the insertion site that does not recognize that difference is concerning in terms of whether or not it deserves to be deemed credible.
In terms of the anatamy and physiology, the biggest factor is venous pressure relative to atmospheric pressure at a central vein puncture site vs a peripheral vein puncture site, as well as the liklihood of a continous open conduit to the heart.
A credible discussion of a PICC insertion site would have to recognize that at the moment the line is discontinued it is fundamentally no different than a discontinued peripheral IV site, and that a VAE with a PICC discontinution as well as a PIV has never been reported. The only potential difference, which is would need to be clarified as being very theoretical, is the potential for a continuous fibrin sheath, which even theoretically is really only possible in PICCs with unusually long dwell times. For that exception it would be reasonable to include an appropriately limited recommendation; "consideration should be given to PICCs with extended dwell times for the possibility of a continuous, full length fibrin sheath...."
Wow
Wade you have come a long way since playing 3rd base......lol
I happen to know of two patients who were supposedly to have gotten air embolus with removal of their PICC line, one a child and one adult, In the support groups I am with
Both recovered but were left shaken with the feeling and the tipping down and lying on their side. the sudden chest pain etc and collapse indicated that they truly did have one. Both were USA residents.
So guess its never say never, but try to prevent the 'never' ever
OK...now this is good!!....But a couple of questions?....you wrote "suppostedly"..does that mean yes I have first hand information or I heard that this happened?...I have to tell you in all fairness. I have never heard of this happening. In 12 years and 5 years home infusion, never heard this happen. Are you saying this happened twice in the same hospital?...Do you know what the probability of that is?...Secondly, someone at that hospital needs to write about this. If this really happened, I'm I'm taking you for your word, we in the Vascular Access community need to read and possible change what we do. BeeDee trust me, if I'd heard of someone getting an embolism , I mean first hand, I would Valsalva everytime.
I don't want to offend you at all.....but this is an interesting topic that has been discussed outside of this site...I for one, would like to know more.
Jack
I know of 2 litigation cases where patients in the hospital died very quickly after PICC was removed improperly and only covered with a band aid :(
Valorie Dunn,BSN, RN, CRNI, PLNC
Yes Jack I have to write 'supposedly', you see after 40 yrs as a nurse I am now a patient. but I know I cannot say it happened as I 1. wasnt there, [ just 24hrs air travel away] 2. the patients that is the victims, were told little. 3. they reported what happened to them but were never given any clinical data. Just told a bit of air travelled up and made them faint, Their sore chests from the resus done.
What is seen and written on support groups and yes this also is a support group, is not then related/reported to the medical books or sadly the clinical records of the patient often, if the nurse/doctor/institution can get away with it
That comment is first hand, Ive read my notes I know what clinicial things happened to me or didnt yet read amazing data, that seems to be very different.
I was responding to this thread where it was stated "Ive never known of one happening" I responded with yes it has. but using supposedly to explain I could not confirm
You cannot offend me, I no longer am a nurse. Maybe if you ever need to be a patient on Home TPN, have an intestinal complaint or a 4x organ transplant you will get to meet others who have 'suffered' incidents that are never recorded.
I hope that helps you now understand the word supposedly.
BeeDee
Let's start with, I'm sorry your a patient. Truly I am. I am familiar with home infusion patients as I was a home infusion nurse for 4 years and a Director of a home infusion department for a large VNA. No, I have never seen nor heard of an air embolism. I want to start this year fresh. Maybe I get very "passionate" regarding these topics and I guess I shouldn't. My approach comes from a long history of being a man...lol. I have always appreciated knowing things from a standpoint of expert knowledge. I'm a tactile learner, also sometimes to my fault. So I mean no disrespect. But if you have been doing one type of procedure for a very long time. And you have been part of teams that also do these very specific procedures. After more than a decade and thousands upon thousands of situations have been witnessed. And you have never heard of nor been involved in a mishap like the one we are discussing, then it becomes hard to look at it as a REAL potential. Now, forgive me, I'm not saying impossible for it to happen, but I am saying much more unlikely than warrants major discussion. Again, not saying impossible, but when in medicine your always dealing in probabilities. The probability number is incredibly low. But as in anything else we do in medicine, nursing....you assess risk benefit. To have everyone change to include Valsalve during PICC removal for a .004% chance?....you see what I mean?....someone will hit the powerball...but the chance that YOU hit it?...well you can see where I'm going.
So, you met the lottery winner...I haven't but your right, when I do?...then yes I'm sure I'll pay closer attention.
Jack
I had a patient with problems related to air embolism from PICC removal. We learn and share in professional meetings and literature. This is the way to improve practice. Lynn Hadaway, Nancy Moreau, Kathy Kokotis, Dr. Provonost, Marcia Ryder, so many more started at the bottom and have proven themselves with experience and knowledge. They don't always agree with each other, it's the tension that propels us to reach forward. And we DO! We rely on proven experts and use evidence based practice vs anecdotal "I have so much experience I know it all"practice. Why not valsalva? Air Embolism is a never event!
Here we go again,
I DO insert. And have for years.
That's nice Jill, you find many of my practices dangerous?...like what for instance, please just name me one aspect of my practice that is dangerous?....Frankly you skip my posts because you have to. You can't refute what I say. it's ok...I understand your a nurse and we know how us nurses can't stand to be wrong. Oh and one more thing:....What precautions do you take when you make all your patients Valsalva during removal of a PICC. I'm sure you are aware of the dangers of sudden cardiac arrest during Valsalva. It is well documented...but you knew that...so what precautions do you take?
You fear for the safety of my patients?....really? I don't quite know how to answer that.
I'm tempted to delete this entire thread, but I've decided to leave it up to show why the faq says to respect each other's opinions. Quite frankly, I don't really know who's right on this one. I see merits on either side. What I also see is downright rudeness by several of you. Please be respectful of each other. Thanks to everyone for their patience!
Sarah
Sarah Kuykendall, RN - retired
Former Web Manager, www.iv-therapy.net
My apologies Sarah, I will curb my tone. However, can we agree on a rule. At no time should a nurse use the words "I fear for the safety of your patients and facility". That should never be written on a blog such as this. To accuse someone of jeapordizing patient safety is both unprofessional and cannot be tolerated. I would never utter those words unless I knew for a fact that safety was an issue. Jill does not know me nor does she have inside knowledge of my practice.
Jack
Hi all. I am the one that started this by wanting to understand the evidence behind or at least how the valsalva maneuver helps in the removal with PICC removals. I kinda feel bad that this has spun out of control to some degree. I think anonymity on this site allows some to write their opinion with out being known whether or not it adds any value to my original posting. We can disagree and question our standards legitimately. If we do not ask questions, how can we develop and evolve our practice? Disagreeing is fine, but we all have to be professional with our comments.
David Dempsey MS, RN
One more question. Since the valsalva maneuver is contraindicated in certain diagnosis or medical conditions, and since other institutions use this when removing PICCs, does anyone have a good source of diagnosis or medical conditions when it is contraindicated? The CNSs in my hospital are going forward with the change, but no one has mentioned when this is contraindicated. Nurses need to be aware of these patients so that we do not harm to them. I could recreate the wheel, but would rather not. Does INS have any source that would address this? It is either in the 2011 INS standards or the Mosby skills that my institution uses lists some contraindications dealing with head injuries.
Thanks.
David Dempsey MS, RN
The 2016 INS Standards of Practice will address these restrictions and provide references. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Ok, Thanks Lynn!
David Dempsey MS, RN
Finally received my copy and in the process of reading the whole publication. I did skip ahead a little to read the suggestions on the topic that was so heated on this site. They do say that with removal of CVAD the patient should use Valsalva or at least placed in Trendelenburg. I totally agree with that statement and I believe that is being done in every institute. It is a standard of practice. If it is NOT being done then someone is doing the wrong thing. However, CVAD's in this reference are not PICC's. I know that because they actually mention PICC lines seperately. I quote: " While documentation of air embolism during PICC removal has not been found, the exit site could be at the same level as the patient's heart, increasing the risk of air entering through an intact skin to vein tract and fibrin shealth. "
So, can we finally agree to put this to rest. I think the statement by INS covered all bases.
Jack