Forum topic

We recently switched to the Solo and all of our IV team love them. Its great to be able to cut the PICC to size and utilize the tapered end, especially for our patients with elevated INR's. We also have begun to master the sherlock, and our success rates at cavaoatrial junction placement have increased. As far as cost is concerned, we found that the Solo does not cost more than what we were using prior to the switch. The insertion kit is well equiped with the echogenic needle, 7cm introducer and the nitinol wire.The only thing we have to say about the kits is that the drapes are  not as large as we prefer to maximize full barrier precautions. We only have the 5fr double lumen available to us for now and are looking forward to the 4fr single coming out.

Definetly look into these catheters!

Cherylanne

We are still using Bard Per Q Cath but hoping to convert to SOLO. Our present PICC has a reverse taper and we are not seeing site problems. We ARE seeing very little bleeding post insertion allowing us to place Biopatch at the same time. Then we know our PICCs remain undisturbed until the weekly dressing change.

Karen

Kathy Kokotis

Bard Access Systems

Reverse taper

Blame the IR doc's if you have a problem with the idea as they invented it and Cook Medical produced it!!!!  I have yet to see a randomized, prospective, blinded study or any other study for that matter that says a reverse taper causes a higher rate of thrombosis.  Show me the proof.  For all the companies making reverse tapers:  Bard, Boston/Avisata, Angiodynamics, Cook, MedComp, Churchill OEM, Jet Medical, please enlighten us with your complaints on increased thrombosis posted to the FDA Maude data base.  Oh!  There are none?

For all of you not making reverse tapers:  Arrow, BD, Vygon, VCath I understand for neonates it is no needed.  Oh you are not all peds or neonate products? 

Show me the proof as at this point I am tired of hearing this story as at least 80% of PICC lines sold have a reverse taper

You finally have on on the rant.

Kathy 

  I have to say that I agree with Lynn on this one.  Leigh Ann and I had this discussion while painting my kitchen this weekend.  Guess we were REALLY bored!  All of the catheters from different manufacturerers do have different size and lenght of tapers, and there have been no studies done for, or against, the use of them.  Now, the Solo has a very long (and large) tapered end.  My team has been using them for the last three weeks, and I have to say, that I am NOT impressed.  We have placed about 35 or so.  There are certian educational questions I have asked Bard, only to be told that the answer is confidential.  We were also told that the Inter-Link cap that we have used on out Boston PASV catheter for the last 3 years with no problem probably shouldn't be used on the Solo without an extension that has a clip on it?  If I wanted a catheter that cliped, I would not be using a valved catheter.  We have seen 4 occlusions, three infections (not proven to be catheter related yet), and several defective equipment problems in the three weeks that we have been using the Solo.  We had 3 infections all year last year out of over 2000 PICC's placed, and we only had 9 occlusions during the same time period. 

   We are going to place 100 catheters total during our trial.  I will reserve judgement till then.  There is always a learning curve with new products, but with the increased cost of the Solo, I would not expect to have to add things to it to be able to use it.  We have been using a reverse taper catheter for about 5 years now and have not seen any increase in thrombus of phlebitis because of it.  So I cannot say that the reverse taper is a problem.  We will see. 

Kathy Kokotis

Bard Access Systems

This is my only comment to the reverse taper on PICC lines.  There are some abstracts/posters believe it or not out there.  Unfortunaltely most of the data is from antecubital placements.

So who did these studies on PICC outcomes "Deb Richardson" MD Anderson.  Back in 1993 MD Anderson and forward on only used Cook Medical PICC lines with reverse tapers on oncology patients to the tune of 3,500 a year in 1993.  I think we would all agree this is a high risk population for thrombosis.  MD Anderson switched to another reverse tape catheter in 2005 because they wanted reverse taper and 6 F DL and 5 Fr SL.  BIG SIZE for ONCOLOGY!!!!

You would be surprised to find that MD Anderson would only place a 6 french silicone DL and 5 F silicone SL reverse taper back in 1993.   I know this because no other manufacturer was elgible for this business back than.  I know this hospital kept very good data so maybe they are the ones to publish on thormbosis and PICC lines and reverse taper.  In fact they can compare lower arm to upper arm as they went with ultrasound in 2004-2005 time period. 

Encourage them to publish their data.  Since they used reverse tapers for 14 years at least in oncology they must have one heck of a data base on this topic.  They can even compare two manufacurer's, upper arm to lower arm, etc.  They also now use smaller poly catheters so they can even look at materials and catheter size.

Bottom line MD Anderson has been using reverse taper PICC lines since the early 90's in large french sizes starting with Cook Medical placed by RN's at the bedside in the antecubital vessel without even ultrasound.

Considering to date there are few manufacturer's producing a non reverse taper PICC line I guess those producing the non reverse taper would find they have a good sales story if indeed they can prove that the reverse taper causes a higher rate of thrombosis.  If I were one of those companies and I believed this theory I would do the study to get the competitive edge. 

Kathy 

Kathy Kokotis

Bard Access Systems

Interlink and valved PICC lines.  Interlink is a negative pressure device just like steel needles were back in the day.  When using a steel needle one would use positive pressure flush and/or extension set with slide clamp to reduce reflux.  

Negative pressure devices can be used on any catheter but one must do positive pressure flush.  I would not suggest one needs to change needle-less systems to use a catheter.  The key is to use that system properly and safely.  Interlink can be used on a valved and non-valved catheter.

Back to occlusions.  I doubt that a valve or non valved catheter will eliminate and may not in fact reduce occlusions ( even a needle-less system for that matter).  All the valve effects is the inside of the lumen of the catheter.

According to Dr. Haire the majority of occlusions are from the surrounding outside area of the catheter.  No valve or needle-less system will work on fibirn tails, sleeves, mural thormbosis, etc.  Good luck on thinking that PowerPICC Solo will eliminate clotting.  I doubt one sees additional clotting  but the purpose of a valve is for patient safety i.e. air embolism. bleedout, and getting rid of the 92 year old drug that was never approved by the FDA called Heparin.  Saline is safer.  CathFlo from Genentech is to address those occlusions.  That is why the 2 mg dose is so important to get to the fibrin tails.

There is no hooly grail to eliminate catheter occlusions.  Should one find one please let me know.  I can make a killing on that one.  Valves do not eliminate occlusions.  Triad of Virchow:  bedrest, pregnancy, dehydration, vomiting, coughing, and I can do on an on cause catheters to occlude. There is a holy grail to break down occlusions CATHFLO

Kathy

Kathy Kokotis

Bard Access Systems

You know what I do find Heather and Leigh Ann is that you have stumbled on a way to reduce occlusions to almost nothing for PICC lines and have virtually eliminated fibrin tails, mural thrombosis, and fibrin sleeves for PICC lines

You had 9 treatable occlusions last year in 2,000 PICC lines so that is an occlusion rate of .45% or less than one percent for PICC linme.  We all want to know how you did it with the ouside fibrin tails being a factor.  Please enlighten us all as your Pharmacy only purchased 9 vials of CathFlo all year and spent less than $1,000 on CathFlo or aliquotted TPA.  WOW!!!  Your certainly are a poster child for reducing occlusions.  You could eliminate the need for CathFlo altogether!!!!  You should write a paper on the reduction of occlusion in and outside of the catheter. 

You pharmacist must be real happy with budget expenses since the average occlusion rate published for PICC lines is 10-25%.  You saved alot of money.

Kathy 

Hi everyone!

My thoughts on the Solo PICC? Well...as Heather indicated, we are still early in our trial, but so far I have not had any problems myself with the catheter. I too don't care for the very long introducer sheath, nor the length of the reverse taper. I find that I end up with about 1/2 the length of the introducer exposed and then upwards to 7 or more cm's of the catheter (due to the reverse taper and the catheter not going any further into the sheath) hanging outside the patients arm. This means that I must peel and remove the sheath with at least 10 cm's of my catheter exposed. Not always an easy task to get that length of catheter into a vein w/o the assistance of the introducer...but thus far...been doable. More important to me though is not the occasional extra effort to get that last 10 cm's in, but is the fact that I am inserting 10 cm's through the skin as opposed to through an introducer. We all know that bacteria can reside many layers deep in our skin and even though we vigorously prep the skin...I still just don't like the notion of inserting that long of a section of catheter...dragging through the openning in the skin the whole way, finally coming to rest in the blood stream. Now...I'm probably being WAY over concerned about the risk, but still to me...it's just not "best" practice if it can be avoided...thats all. Not saying that either that this is a deal breaker for me...it is just my observations and me voicing my impressions thus far. Outside of that...I've no concerns...I've not had a single problem with insertion/tip position and seems like I get better blood return...for what that is worth :)

As far as our data goes here at U of L. Perhaps Heather was quoting from memory. I am the data manager here, and can tell you exactly what our rates are. For all of 2007...we had 3,850 catheter days for our primary PICC (PASV). Of these, we had 17 confirmed calls where we actually had an occluded picc that required tpa (Cath-flo) to clear. Our rate is 4.416 per 1000 catheter days. To clarify, these are total occlusions only. At the present time, we don't track calls that we receive for assisting in withdrawal only occlusions...perhaps I'll add that though.

Still, well too early for me to comment of the effectiveness of the valve on reducing occlusions. I can only say that historically here...using the exact same metrics and data collections, prior to our adoption of the PASV catheter our occlusion rates fluctuate from 25 to 35 per 1000 catheter days. After PASV...its been on average, below 10...our highest month was probably just at 10...averaging out as I reported earlier to 4.416/1000 catheter days. The only change was the catheter...we previously used BD L-Cath...for what that's worth. So, even though I don't have a randomized/blind study...yada, yada...my data and experiences tell me that at least one externally valved catheter apparently does reduce occlusions.

To the original poster....hope this information has been helpful.

Brian

Brian Gackenbach RN, BSN, CRNI

University of Louisville Hospital

brianga(at)ulh(dot)org

Kathy:

In response to your comments about the valve... If the valve isn't intended to reduce clotting, we don't need it. Blood loss and air embolus is something I can avoid without a valve. The reason the Groshong valve did not work for us is exactly what you mention - changes in intrathoracic pressure related to coughing, vomiting, movement, etc. We had the same occlusion outcomes with Groshong that we had with a plain open-ended catheter. We had a dramatic decrease in occlusions with PASV because the valve has a pressure gradient difference. In other words, it takes significantly less pressure to infuse than to aspirate. (You can find this point noted in the patent paperwork, I am certain.) The valve is specifically created to hold against blood backup with changes in intrathoracic pressure. The inability to do this made Groshong and all the positive displacement valves we tried ineffective against intralumenal occlusions. The Interlink cap has not increased our occlusion rates, because the PASV valve closes as soon as we stop flushing, and the removal of the access adaptor from the Interlink cap doesn't create enough negative pressure to reopen the valve. When we switched to PASV we deleted the use of positive displacement valves, which we had been using with our open catheter and with the Groshong. This helped to reduce our costs, without adversely affecting our outcomes.

I have heard nothing yet as to whether the Solo valve has a pressure gradient difference, but if you are telling us it is only intended to eliminate heparin and avoid air embolism and bleedout, we need to significantly lower our expectations of the Solo PICC. We eliminated heparin years ago, incidentally.

I agree that all catheters will develop fibrin on the outside, and this fibrin will sometimes lead to occlusion. Usually it just leads to withdrawal occlusion, which we dissolve with the tPA infusion. There are no studies that conclude whether or not our few occlusions are the result of fibrin, though I know that some of them are the result of the nurse forgetting to flush the line after drawing blood, as I have dealt with those and heard the confession with my own ears.

In Affectionate Disagreement,

Leigh Ann

 I think you have a point there Eric.  And Leigh Ann, Brian and I asked Bard the question about the pressure differences in the valve on the Solo, and we were told that they could not give us that information.  It was confidintial. 

One thing I'm not fond of is the included end cap. I can't see how that would be a good idea for patients whether in the home or hospital setting that get infusions/pushes of meds on a timed basis as opposed to continuously. The caps will be lost, dropped, or left sitting around while the med is being given, then what placed back on?? Come on, how is that good from an infection control stand point? or are we supposed to find, purchase and replace these caps everytime a med is given? WOW what's the cost of that?

At the very least the positive pressure caps should be in the kit like the groshongs or regular power picc kits have 

Lawrence Rojas RN

Radiology Dept. PICC guy

Garden Park Medical Center

Gulfport, MS

Eric,

We are currently heprin free at our hospital.  You can not relay on a nurse on the floor to always put a positive pressure cap on that PICC.  The other problem we have is the clamping sequence.  If the nurse clamps at the wrong time it totally negates the purpose of that positive pressure cap.  This happens all the time.  In addition, many of our home health agencies do not even keep positive pressure caps.  As you can imagine, this is an issue.   I see the benefit in a valved PICC even if it does cost a little more.  If it will help reduce the confusion, then it is worth it to take a look at this product.  By the way, when has new technology ever been cheaper. 

Amy M.

Eric,

I am not sure why you have to be so rude.  I was referring to an earlier thread that you posted on the Solo picc.  See below.  I am a new PICC nurse to this listserv, and did not realize I replied on the wrong one.  Amy

Kevin,

If you are currently using a valve on the end of your power PICCs then you have a valved PICC. I am finding it hard to pay the additional cost of the SOLO when I already have a valved PICC. Also if something goes wrong with my current valves I can change the valve. If something goes wrong with the SOLO valve, you will have to exchange the entire PICC.  

Eric

Kathy Kokotis

Bard Access Systems

I suggest we all get the definition of occlusion down and standardize that definition.

If one does not know it have the Genentech rep provide education

The reason why we are not treating catheters that are dysfunctional is that we have so many defintions for occlusion.  There is a definition!

The definition of an occluded catheter for all to understand is not complete lack of the ability to infuse and withdraw.  If one can infuse but not withdraw you have a dysfunctional catheter that should be treated.

Lack of blood return is a OCCLUSION.  Lack of 3 cc of free flowing blood is an OCCLUSION.  I did not make up this definition.  You will find it in the IFU's for CathFlo.  Any catheter that does not give blood return must and SHOULD be treated.  CR-BSI and catheter occlusion are hand in hand.  Blood is a nutritional source for bacteria. 

If one adopts the true defintion those fibrin tails that form are occlusions.  They should be treated.  One should not infuse thru a PICC line with no blood return.  You should find out why there is no blood return.

Heather we are on the same page as RN's but not in our definiton of occlusions.  This is not an attack on anyone.  This is a demonstation that we have alot to learn about catheter related occlusions.

Lastly Leigh-Ann there is no catheter on the market that will elinminate occlusions.  If you are looking for the holy grail it does not exist.  Patients clot for so many reasons.  There are studies demonstrating that 70% of thrombosis are undiagnosed and those studies are with PICC lines, short term acute care lines, ports, hickmans.  Yes I believe that EVERY patient who gets a VAD has a thormbosed vessel that is not symptomatic.  Especially peripheral IV's.  What is the point here.  We would be treating the entire hospital population if we start scanning post insertion or in some cases pre-insertion for that matter for catheter related thrombosis (peripheral IV's especially).  Yes peripheral IV's cause vessel thrombosis.  It is that peripheral that stops infusing or gets hard.  What did one think that was????  Yes a PE could occur from that as well.  If there is so much concern over catheter related thrombosis why are patients not dying from PE's right and left.  The way everyone talks about it they should be.

Kathy 

Kathy

All current valved catheter manufacturers discourage the use of negative pressure needleless access devices with their catheters.  I have recently spoken to Boston Scientific about their proximally valved PICC.  Indeed, they too provide dead end caps in their kits, and discourage the use of negative pressure needleless injection caps.  This recommendation is nothing new, and allows the clinician to add whichever needleless access device they choose. 

 We all know that the success of the catheter is made up of many things, including design, material, insertion technique, and probably most importantly, the care the catheter receives following insertion.  Post insertion care can often times be the most difficult part of ensuring the longevity of the catheter.  As we all know, clinicians have been taught to use a positive pressure, push pause technique when flushing a PICC following drug infusion.  This same technique should also be used for routine maintenance of the catheter when the catheter is not in use.  When consistently employed, this technique preserves the life of the catheter and will decrease the incidence of occlusion.  Bottom line, there are very few needleless injection caps on the market that won't work with the PowerPICC SOLO*, if the catheter is properly maintained.  Bard will continue to warn against the use of negative pressure caps with the PowerPICC SOLO* as we do with all of Bard's PICCs, whether or not they are open ended or valved.  Clinicians are seeing great outcomes with the PowerPICC SOLO* when used properly. 

Ms. Hadaway,

I agree that there is still considerable confusion regarding needleless access devices. I wanted to inform you that positive flushing does not counteract the mechanism used in positive pressure devices. There is no evidence supporting this "counteraction," and if you try it yourself will see that a positive bolus of saline is still projected upon  the disconnection of a flush syringe, even when using the positive flush technique in these devices. 

Also, I was under the impression that implamentation of the push-pause flushing technique is a way to create turbulence in the lumen and help remove blood from the catheter. Doesn't eliminating as much residual blood as you can from the catheter help to decrease the chance for blood to build up and cause an occlusion?

Brian Colby

Lynn,

 Thank you for clarifying this regarding positive flushing. I did not take into account that the positive flush method you mentioned involved clamping the line before disconnect, and positive displacement valves require clamping after the flush syringe is disconnected. As long as the positive displacement devices are not clamped first, positive flushing can still be utilized in these products, but is not necessary. I understand now. Thanks!

 Brian Colby

I've been placing the Solos for a month or so now since one of the hospitals I service changed over.  The one thing I have noticed, which I am sure is due to the valve in the hub, is that the blood return is much more sluggish, and it takes more negative pressure to overcome that. There is a definite different feel to it, and it feels like the line is looped or curled when it isn't.  I know the purpose, but I can't say I like it much.  Ease of flushing and aspiration is a very helpful tool in assessing the line isn't curled back, looped, or up the neck. I like seeing the blood free flowing back.  I know my line is free of kinks, curls, loops, and not in the azygous! (Usually...nothing is 100%!) I know some of you, maybe most of you, use the Navigator. I don't see the need for it, as I always check the neck with the ultrasound, and I have extremely few problems with jugular placement.   I may just have to get used to the different feel, but I am not wild about it.  I also wish there were usable caps included in the tray.  The ones included are worthless.  Seems a waste to me, other than having something to put on the ends because you forget to drop them on your field because you are used to having them!  Anyone else have the same issues?  Thanks.

 We are trialing the devices at this hospital.  We have an evaluation form that is being completed by  the RN inserting the dievice, a form to be completed by the RN's using the device and I am attempting to track the outcomes of this device.  I am following up on thrombus rates, clotting, malposition and Phelbitisis rates.

The RN's inserting the Solo PICC have provided very favorable reviews.  I have had a limited responce with the review forms from the RN's using the Solo PICC. This is often a normal responce, you don't hear any review unless it is a negative one.  In general when we go to the ICU's the staff is requesting the Solo PICC.  I have not completed the evaluation for the complications.  We are reviewing the out comes of 60 of the Solo PICC's.  I need to have evidence based data before I go to the product standards Comm. to request any change from current device use.

DITTO everything said by Halle Utter re SOLO--We have placed about 300 of these catheters and despite the slow responsing blood return and having to drop caps on the field we LOVE the integral valve because it has eliminated the clamp which was a source of aggrevation and frustration for us--We were constantly having to reinforce the clamping sequence with the positive displacement CLC and finally gave up and began   cutting the clamp off to avoid catheter complications for our in house patients--Now our concern is for the patients we send home with these SOLO PICCs hoping outside agencies and facilities properly idenify this catheter and are acutely aware that they must avoid using a Negative cap