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valoriedunn
PROPER PICC FLUSH TECHNIQUE

Our nurses are having a debate over the proper technique for central line flushing. 99% of our piccs are power injectable.  Some say push pause while others are for brisk continuous push.  Any feedback is appreciated.

lynncrni
Neither is actually the best

Neither is actually the best in my opinion. All catheters should be flushed with a slow, gentle, constant flushing technique. There is absolutely no evidence showing that the so-called push-pause technique does any good and it could increase the chances of biofilm breakage, theorectically. No actual studies to show that either, just published information about biofilm, tensile strength and its breakage.

The rapid, forceful continuous flush has been shown in one small animal study to produce a jet effect which can cause the catheter tip to whip around inside the vein causing tip migration and endothelial damage.

So the method we have used for many years is still the best in my opinion. Steady, gentle, never forceful against any amount of resistance.If there is any resistance stop immediately and investigate the cause with diagnostic tests.

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

valoriedunn
Thanks Lynn!  That is how I

Thanks Lynn!  That is how I teach my patients.  The nurse who places PICCs think it needs to be more turulent.  I thought push pause was "old school" so to speak.

Valorie Dunn,BSN, RN, CRNI, PLNC

Mats Stromberg
Push-pause creates more turbulence?

But surely it is reasonable to assume that push-pause creates more turbulence in the catheter system than does flushing with a steady pace without the pausing, and thus clears the catheter better? Even if there is no hard evidence of this. With a constant speed, will not the fluid  travel fastest in the middle of the lumen and not at the cathteter wall, where we need it. Why should push-pause cause biofilm breakage if no forceful flushing is used?

Lynn, in your article of 2000 in Nursing you state: "Using a push-pause technique while flushing solution into the catheter creates turbulence inside the catheter lumen and helps remove blood from the catheter.” Is this no longer your view or am I missing something?

Thanks, Mats

lynncrni
You have quoted that article

You have quoted that article correctly but that is a 10 year old article and this concept of turbulent flush was just getting started. Since then, there has been no data, none, zero, nothing published that shows any outcome data with this technique. This so-called turbulent flushing method is based on the theory of fluid flow. It assumes that whatever is adhered to the walls of the catheter can be moved out by this technique. There are numerous issues with this idea, in my opinion. First, there is no evidence that this technique prevents or reduces the fibrin that firmly attaches to the catheter walls. Then there is the issue of biofilm. In 2000 we did not have the same level of knowledge about biofilm that we do today. The literature on biofilm now discusses the tensile strength of the biofilm and the breakage of the biofilm. High flow rates cause the organism to be rapidly forced against the catheter wall, causing biofilm with a greater tensile strength. In other words, stronger biofilm. Is this a good thing or not? When the shear force of any fluid flow exceeds the tensile strength of the biofilm, it breaks off, floats into the bloodstream and produces BSI. So there are so many unaswered questions and a serious lack of outcome data. I have strong reservations about its use and do not teach its use until we know if the outcome is positive. Also, this technique is **not** endorsed in the Infusion Nursing Standards of Practice due to the absence of outcome data. 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

Mats Stromberg
Outside or inside?

Thanks Lynn,

No, I do not know of any research supporting push-pause or any other flushing technique, I am just trying to reason around the issue:

What I want to do is to clear the inside catheter wall from residue; to get rid of blood or drugs or lipids or whatever that I just may have "placed there" by administering something or by taking a blood sample or checking for blood return. Is not the biofilm on the outside of the catheter? On both sides? With push-pause technique I do absolutely not mean flushing with a greater force, I only mean making those short pauses. Could that produce enough disturbance on a biofilm (on the outside of the catheter) to break it and thus risk causing a BSI? Or is it a biofilm on the inside of the catheter that we do not want to risk disturbing?

Thanks

Mats

vascular
Doubtful...

 

While you are correct that there are no data to support the use of push-pause technique compared to your slow and continuous flushing, I believe that this practice will just promote the growth of biofilm and thrombus formation within the lumen of the catheter. 

If the push-pause technique is consistently used, the theories from 10 years ago will continue to be sound and WOULD prevent any buildup to begin with.  IF for some reason there is small buildup of this biofilm and breaks off, the body is an amazing thing... there are mechanisms in place to combat these invaders early on. 

However, if you keep the biofilm within the catheter (where the body cannot do something about it) and let it brew and continue to grow because of the slow and steady flush... eventually a big enough clump CAN and WILL break away and really cause the body some serious damage even sepsis. 

I teach prevention and the best way I have seen so far is the push-pause technique.

These days, evidence based practice is the "PC" way of doing things and the Buzz word people are throwing around, but this ignores a lot of the theory based practices that may actually work and I very much disagree with that.  Just because nobody has the spare time or the means to explore this idea, doesn't mean it is wrong and obsolete.

 

lynncrni
Yes, biofilm is well

Yes, biofilm is well documented to in both places. Catheters that have dwelled for less than a week have more biofilm on the outer walls while catheters in place for more than a week have more biofilm on the intraluminal walls. You could remove whole blood that you have just aspirated into the lumen before it is allowed to deposit fibrin products onto the walls. But the concept of this turbulent technique "cleaning" the catheter walls or removing all of the attached material is just not possible. Once blood has refluxed into the lumen and is allowed to reside there, the fibrin becomes firmly attached and this technique is probably not going to remove it. We just have no idea because there has never been any studies. The disturbance to the biofilm totally depends upon the tensile strength of the biofilm. If organisms are introduced during this turbulent technque, the resultant biofilm will have greater tensile strength. The fact is that we simply do not have any idea what outcomes we are actually producing with this technique - positive or negative. There have been plenty of theories and myths applied but there is no outcome data. 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

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