Jeffery Fizer RN, BSN
We have been using the Bard SOLO PICC for a few months now. We started using them first in our BMT unit, where the nurses are most aware and sensitive to any change in product. We have placed about 20 double and triple lumens and there have been no reported complaints. I asked the question the other day and the overall reply was "we love them, they're great." This unit also draws almost all of their labs from the PICCs!
We have started to use them on all of our oncology or immunocompromised patients because of the decreased catheter manipulation. We have also started to include the home infusion patients for the decreased flushing which may also meet the needs of medicare patients who don't have coverage for home but could go to an infusion center for care.
We have probably placed a total of 50 SOLO PICCs and still no reported complaints. We are using them with the microclave connector.
Karen McKeon Williford RN, CRNI
It's good to hear that you're having success with the microclave with Solo. One of the implementation steps of a major quality project we've done is to reduce the number of needleless connectors in our facility from 7 to one (large teaching facility, inpt/outpt)....we've researched and examined connectors quite thoroughly, trialed the Microclave, and will be bringing them into the facility to monitor with quality indicators for up to a year.
And we're bringing Solo in next month.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
We began using the Bard Solo PICC several months ago. We haven't seen an increase in our occlusions. We are using a positive displacement cap on all our PICC. We are also using positive displacement on all CVL's and a positive displacement extension set on our PIV's. We have not had an increase in BSI and have had fewer PIV restarts and no more occlusions with our CVL's (PICC lines included) than before we switched to the Solo or positive displacement. When we began placing PICC's the floor nurses (who weren't educated regarding the subject) would put a dead end type cap on the PICC's and would forget to clamp the line, ect. We had far more occlusions during that time than we do now.
Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
There seems to be a wide variety of experience with the Bard Solo PICC. As I understand the design of the valves inside the hub - there is one larger valve that opens on infusion and 2 smaller valves that open on aspiration. Perhaps Paul Blackburn or Kathy Kokotis could help us understand the design of these valves. My question is - if one valve is for infusion and another set of 2 valves are for aspiration, how should the flushing be done to ensure that blood is properly flushed from the 2 valves used for aspiration? It seems that this is the key to the challenges many of you have seen.
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
Beth do you not find it redundant to be using a positive pressure cap with a "valved catheter?" What is the point of the valved catheter?? Why would you pay the increased cost of the SOLO if you are doing OK with the positive pressure cap on your other lines?
When we first developed our team here (Sept 2007 & yes, I am really green and new) there was a big educational issue regarding PICC's in general. The only caps we had in stock here were the Clave blue "dead end" type caps. Nurses were changing caps on the PICC's and using these caps, not clamping the PICCs and boom...occlusions. When we first decided to change to the Solo PICC we were told that no special cap was needed. We were surprised later when we found that positive displacement caps were recommended.
Beth, I agree with you 100% on this issue. I was not questioning your practice, just questioning why the manufacturer presents us with a "valved" catheter and then tells us to put on a positive pressure cap (which on its own makes a catheter "valved"). When we trialed the SOLO I was expecting to not have to use the positive pressure caps since the catheter was valved. To my surprise we ended up having the higher cost of the SOLO and then added back in the cost of the positive pressue caps. Made no sense to me so we quit using the SOLO and went to the Arrow pressure inj PICCs and just kept our CLC 2000 caps. It allowed us to stay saline only and reduce our costs.
There is no inline valve that can create positive pressure. This is why these add on positive pressure valves are being recommended. The negative and "neutral" add on valves create suction upon disconnection, which is strong enough to open the valve in the Solo and cause reflux. One positive pressure valve that will cause zero reflux at connection, and gives positive pressure at disconnection is the Max Plus. The negative pressure that happens when connecting to the Max Plus is not strong enough to open the aspiration valve in the solo, thus fluid will not back up into the catheter. This makes it totally neutral upon connection, and positive on disconnection. Since there is no clamp on the solo, positive flush technique will not be effective with a negative or "neutral" valve because the last step will always be to disconnect the syringe, which will draw blood back into the line. Please don't believe me without trying this and seeing it for yourself. Use some colored fluid and look closely at the catheter tip when connecting and disconnecting. -Clean the Hub
Clean the Hub,
I did the test that you recommended and about 60% of the time I had reflux upon connection. I have a clear PICC (not a Solo) and used red food coloring. Sometimes the reflux was 8cm, sometimes 4cm, occasionally none. Could you explain this to me? I am assuming that it is because I am using a true nonvalved open ended line instead of the Solo? Thanks.
Cheryl Kelley RN BSN, VA-BC
Reflux on connection does happen as you have found, but I am not convinced that reflux at this point has much clinical significance. When we connect to the catheter, it is immediately followed by a flush or infusion. So this reflux is immediately removed from the catheter lumen. Even a small amount of time may cause protein to adhere and eventually fibrin to build up, but this takes a long time to be seen as a problem. Reflux on disconnection will sit inside the catheter lumen causing an immediately occlusion from a clot if the proper flushing technique has not been used.
You are correct. In an open ended catheter, non valved cetheter, the reflux occurs. In the Bard Solo catheter with the MaxPlus, there will be no reflux upon connection. This makes the system neutral upon connection, and positive upon disconnection. Try it with a Solo PICC. Then try with a "neutral" valve. You will see the fluid suck back up and disapprear into the catheter when you disconnect.
Bard Access Systems
I find all of this discussion very interesting
First off all catheters are tubes like plumbing pipes. If I were to open up a tube I indeed get reflux if I want to close off that tube that is open I must clamp while flushing thereby preventing reflux to hold pressure in the line. Under certain circumstances that pressure may not hold since patient variables like N/V do change pressures. I am wrong please correct me
A valved tube like the Groshong (distal), PasV (proximal), and Solo (proximal) are tubes with valves. Nowhere in any of the literature does it say you do not have to do a positive pressure flush. The only thing it does not require is a clamp. So if one does not use a positive pressure flush than one has reflux in the tip and occlusion. The lack of the need for a clamp was really based on not needing to prevrent air emobolism if I am not mistaken besides reflux.
I am not talking about needleless systems which range accross the board - just catheters
When needleless systems first entered the market such as the clave the Groshong users had to add extension sets with clamps to ensure positive pressure flush and reduce occlusions of the inter-lumen. I remember this as it was difficult while un-screwing the cap to keep positive pressure so we added extension sets with clamps. There was no heparin to allow one to have positive pressure flushing mistakes or bad technique.
The addition of positive displacement caps alleviated the need on catheters like the Groshong, PadV, and Solo to need extensions sets with clamps in order to achieve positive displacement of fluids at the tip of the catheter and reduce reflux causing occlusion on the inside of the lumen only. This does nothing for fibrin tails, sleeves, or sheaths on the outside. So if one thinks they are going to have no occlusions by proper flushing by staff you are wrong. Go back to school and study A&P and the Triad of Virchow.
So do you have to use a positive displacement cap on clampless catheters accross the board. NO! however you need an extension set and clamp and positive pressure flushing.
Once again my name is Kathy Kokotis and i am biased I work for Bard Access Systems so there is no question or secrets here.
Kathy, I have one correction. PASV catheters with the integral valve in the catheter hub works by pressure. Once the pressure is relieved, the valve automatically closes and prevents reflux. So a positive pressure flushing technique is not required. That is why the information includes the crack pressure on the valve. Once the fluid in the tubing runs down to about 8 to 10 inches above the valve, the pressure is relieved and the valve automatically closes - no positive displacement techniques are needed.
The same action happens with the new LifeShield TKO Anti-reflux add-on device. It holds the column of fluid when the infusion pressure is relieved.
With either of these devices, it will close and prevent reflux. With all other add-on valves the pathway remains open until the nurse or patient disconnects from the catheter hub. It is the disconnection that causes the positive displacement.
These devices also have a crack pressure set for aspiration. Spikes in intrathoracic pressure from coughing, vomiting, etc are no enough to open the valve. Only syringe aspiration.
The Solo should work the same way, although I have not seen any published information about crack pressures on that valve.
For all of these valves that function by pressure, positive pressure flushing techniques are not required. PASV has always stated that clamping between the patient and the catheter hub can prevent the valve from properly functioning but clamping external to the valve is acceptable.
I found it very intersting to read all the information, questions and answers in this forum. We haven't tried yet to use the Bard solo, but tried the Invision caps by Rymed, our occlusion rate dropped drastically.
If we have to use the Bard solo, it would be good so no need of heparin flushing, like the Groshong.
Question, if we have to use an extension set with a clamp to add in order to create a positive pressure while flushing the lines, then would it be more added gadgets and costs for patients? Our patients are home with their lines and are taught own self care including the cvc dressing, caps change, heparin flushes.
I just completed a trial of the Solo in our ICU and we are going to the Power PICC Solo thru out our hospital. We did not find any significant increase in occullsions. We use the CLC 2000 end cap and teach to flush with a push pause flushing technique.
I don't have the article in front of me but recently read there will always be some occulsoins because pt will start building a fibren sheath, just some faster than others.
As we change over thru out I will let you know if we see any issues.
Rhonda Wojtas, RN,BSN, VA-BC
Clamp while flushing - before disconnecting one would clamp to hold the fluid columns/ I would not completely administrer all saline but leave in 0.5 cc and clamp. Bottoming out the syringe involves reflux. Does that clear it up
I am confused. The Solo is a saline flush valved catheter. It has no clamp. And if you are using a postive pressure end cap you do not clamp before disconnecting.
Rhonda Wojtas, RN PICC Team
I think somehow there was a confusion. There is no clamp on the solo. It is heparin free and valved. The question was how do you do a positive pressure flush while clamping and that question was in regards to positive pressure flush in the line of questions along the many posts here. I was not referring to Solo.