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Laurie McCulloch
Action plan for PICC's in the community: Unable to get blood returns

I'd like some guidance or 'experience sharing' for what to do if a PICC in the community (HOME CARE) does not give blood returns?

I am in total agreement with practice standards that all CVC's should give blood returns prior to the administration of drugs and solutions. I am in agreement that all CVCs that do not provide brisk returns should be investigated. The Home IV patients pose a different challenge than our acute care patients. Currently, when nurses are unable to get blood returns they have a protocol that includes calling nurses in the Acute care setting. These nurses are skilled in line assessment and the use of Cath-Flo. They have expertise based on their high volume of PICCs where as the Home and Community Nurses in more rural areas often do not.

The issue is a lack of resources in our smaller communities. We would like to prepare decision making guideline for the Community nurses: what to do when they are unable to get blood returns. This would include assessment and tips but utimately support their decision to restart the infusion or cap the line and delay treatment (not my favorite choice!) The time of the greatest challenge is when our resources are at their lowest (ie.on a Friday afternoon or a weekend!) I do appreciate that the risk is the same anytime!!! However, the reality of addressing it during these times causes undo hardship to our patients.

In Home and Community clients on pumps have continuous flow infusions (mainly Antibiotics) and only have the line checked for blood returns by a Community nurse with a tubing change every 4 days. If this day arrives on a Friday or a weekend and they are unable to get blood returns what should they do?

Does anyone have a protocol, experiences or advice regarding how best to address this issue with Home IV patients?


Laurie McCulloch, Nurse Clinician IV Therapy VIHA

Ann Williams RN CRNI
Hi Laurie, Without knowing

Hi Laurie,

Without knowing your setup, I will tell you what we do.  I am with a home infusion company.  We also have Home Care and Hospice.  There are times that we utilize other nursing agencies for various reasons.  All that being said, all the nurses that work under our umbrella (Deaconess Home Services) have been trained by me on assessment and treatment of both total occlusions and partial occlusions.  I must say I think these nurses have a better understanding than the hospital nurses do. 

So, in our case, the nurse seeing the patient and finding the PWO, will automatically call for an order for Cathflo and then contact us on the IV side for the product.

I am not sure if education and training would be the answer to your problem, but it does seem to work for us.  Hope this helps.

Daphne Broadhurst
Excellent question

Excellent question Laurie. Your dilemma is felt across the Canadian home healthcare field. Ideally, withdrawal occlusion would be treated in the community at point of care. However, until we can get provinicial funding for Alteplase outside the acute care setting, our clients wait until they can be treated in the acute care setting. If you feel administration of Cathflo in the home/community setting is appropriate, please advocate for provincial funding with the Roche rep. Until then...

In the weekend antibiotic scenario you described, a risk analysis could guide our decision. Is the risk of extravasation/infiltration due to a fibrin sheath (likely causing the withdrawal occlusion) greater than the risk of the client missing prescribed therapy for an existing condition? I would love to know if there are any available stats on the actual incidence infiltration/ extravasation due to PICC-related fibrin sheaths. If anyone is aware of these, please post the references? I've never witnessed a similar event, but you just have to look at this site's gallery (extravasation of tpn) to know that it can happen. Is this risk significant enough to warrant a client missing prescribed therapy, particularly if there are no present signs of infiltration/extravasation/venous thrombosis? It would be helpful to have these stats to guide the decision making process with our clients in determining whether the infusion should be stopped for the weekend, a peripheral infusion started (but let's play devil's advocate & if it's vancomycin which risk is more likely- extravasation at a peripheral IV site or a PICC with suspected fibrin sheath?), or continue with the infusion. Quite often, these clients have depleted venous access. Is a trip to ER for initiation of a peripheral IV the best option?

Once the nurse has ruled out mechanical occlusion (i.e.,repositioning the arm, coughing , ensuring proper syringe aspiration technique [trying a 3 mL syringe for aspiration]...), an attempt to reach the attending MD should be made (which more often than not is unsuccessful).  A discussion of the above alternatives & their risks & benefits ensues with the client/caregiver. The nurse should assess the client to rule out signs of the above complications. If a decision is made (with informed client consent) to proceed with the central infusion, the client must be taught to observe for and report signs and symptoms of these complications. Documentation of this decision-making process is imperative. If the client has a received a PICC teaching booklet, hopefully these signs will be included in the booklet, or the nurse could write them in the notes section.

Follow up on Mon. am is imperative to facilitate getting the client in for assessment by the vascular access team.

I'll be anxious to see what others recommend, as it is a confounding issue. It would be very valuable to hear from the legal consultants to know if the nurse would be liable for proceeding with therapy without blood return, having followed the above steps.

Daphne Broadhurst RN
Desjardins Pharmacy
Ottawa, Canada

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

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