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georn
Bard Solo PICC

for those out there using this product:  we here are looking at changing to this catheter.  we already use the almighty power picc and the groshon.  now there is a all in one.  single, double, and triple.

would like feed back regarding patient care, cost, and ease of use, and anything else you have to add.

all info greatly appreciated

geo

Cherylanne Perry
We recently switched to the

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

Beth George
Thanks for the information
Thanks for the information on the PICC Solo.  We are going to these shortly at our facility.  We have just began our PICC team recently (August 07) and are still working out the kinks.  I think the Solo will be a great stride in patient safety and the Sherlock system will help out greatly. 

Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL

estevens102206
Thes SOLO Piccs are a great

Thes SOLO Piccs are a great idea, but they are still reverse tapered over two french sizes from tip to hub. I can't justify placing a PICC in a patient this is over a 7 French at the hub. Would you place a triple lumen central line in your patient's arm!!! It is the same size. 

Eric

Eric

Oncology Ambula...
We are still using Bard Per

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

Karen McKeon Williford RN, CRNI

estevens102206
It is a shame that just

It is a shame that just because you get less bleeding from a reverse tapered cathether, that you totally ignore what a 7 French catheter is doing to a patient's arm. If you are not making a skin nick before inserting the dilator, you should not have an abundant amount of bleeding from the site in the first place. The fact that some companies have fooled us with marketing sayings such as ...." the reverse taper plugs the hole"... is embarrassing to me.  

 

Eric

Eric

sesymons
I find this thread
I find this thread interesting because I have had concerns regarding the possibility of increased incidence of thrombus formation with the reverse taper design though only since using the triple lumen catheter.  I have used reverse taper for over 2 years now and have not seen an obvious increase in thrombus. My suspicions tend toward other reasons for thrombus development... along the virchow triangle line. And we look at the size of the vein before deciding on a triple or double. However when I have someone with an elevated INR or decreased platelets, I give thanks for having a reverse taper catheter at hand. Skin nick or not, these patients will bleed without the reverse taper and then we have to deal with the panic calls....not to mention the dislodgements from the wet dressings and the sterility problems from people placing pressure dressings on these sites.
kokotis
Kathy Kokotis Bard Access

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 


 

 

Kathy Kokotis

Bard Access Systems

lynncrni
Hi Kathy, Sounds like you

Hi Kathy,

Sounds like you have had a bad week. I don't wish to start a huge discussion, but the same question could be ask of those companies making reverse taper PICCs. Show the data that it is safe. This came about strictly because of radiologist asking for it and now it has taken on a life of its own because of great sales and marketing efforts. But we should never be in a position to base our practice on sales and marketing messages. We need sound science on this issue. The sizes and lengths of these tapers differ between brands. So I would like to see some manufacturers supporting research to demonstrate that this product design is safe. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Leigh Ann Bowegeddes
I am having a different
I am having a different experience. So far, no one on our team likes the introducer, and I just had one curl back, even after fully inserting the dilator by itself. I was able to easily advance a different brand of introducer. A couple of our team members have had occasions of the Solo not advancing easily to SVC, repeatedly going up the IJ. I just had this experience, and could not get it to go to SVC after multiple attempts, and all the tricks. Finally gave up on it. We have also had occlusions. Time will tell, but so far, not impressed.
Leigh Ann Bowegeddes
Incidentally, notable price
Incidentally, notable price increase over our previous product with custom complete tray, and this tray is not MSBP. We still have to add large drape and sterile gown.
Heather Nichols
  I have to say that I

  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. 

kokotis
Kathy Kokotis Bard Access

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

kokotis
Kathy Kokotis Bard Access

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

kokotis
Kathy Kokotis Bard Access

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 

 

Kathy Kokotis

Bard Access Systems

Heather Nichols
  Thank you for your
  Thank you for your congrats Kathy, but I am sure we use Cathflo for more than catheter occlusions, and by "occlusions", I mean SOLID occlusions.  Usually a fibrin tail and/or sheath will contribute to "no blood return", but not a solid occlusion.  We do not count "no blood return" as a solid occlusion as long as the catheter flushes without resistance.  A no blood return, is not always treated with tPA, and if it is, we do a 3 hour infusion.  It can sometimes be fixed without it.  We are not currently tracking the "no blood return" calls since we usually fix them without any drug intervention, but I have asked Brian (computer guroo) to add it to our data collection program, and he is currently working on it.  I apologise if some of the things I have said have pissed you off, but I guess I am really feeling let down by the Solo at this point in time.  Maybe I DID expect the holy grail of PICC's.  Is there anything wrong with that?  I was hoping it would solve all of our current problems, and if it had worked like it was supposed to, it would have.  I cannot help it if we have great stats.  We work hard for it.  We have trialed multiple PICC's over the last 2 years in efforts to get it right. We live by the rule around here that the patient comes first, and we do what is right for the patient.   By the way, when is the last time you put in a PICC?   And you may want to slow down and read what I write a little better, because I said that we HAVE NOT had any problems with reverse taper, and we have been using a reverse taper catheter of one kind or another for the last several years.  If there had been a problem with phlebitis and/or thrombus due to reverse taper, we would have known about it, so I AGREE WITH YOU!!!!! on that one.   What is wrong with you?  We are supposed to be on the same side.  Aren't you a nurse?  I am NOT slamming any company in general, nor any particular product.  I would never have trialed the Solo if I did not believe Bard had good products, so back off!   
Gack
Hi everyone! My thoughts on

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

Brian Gackenbach RN, BSN, CRNI

University of Louisville Hospital

brianga(at)ulh(dot)org

Leigh Ann Bowegeddes
Kathy: In response to your

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

estevens102206
In the Frequently Asked

In the Frequently Asked Questions portion of the SOLO website, the company states that a neutral or positive pressure cap should be used with these SOLO PICCs. Well if that is the case, then why would I pay more for this "valved" catheter?  This seems to be a marketing campaign for a product that has little clincal benefit. 

Eric

Eric

spqr
You point is well taken. If
You point is well taken. If you have to use a positive or a neutral valve with the Solo then what is the real value of the Solo? We have too many Bard RN's in this industry, who are paid to give the Bard party line, while attempting to pass themselves off as independent objective clinicians.
mtpicc
[quote=spqr]You point is

[quote=spqr]You point is well taken. If you have to use a positive or a neutral valve with the Solo then what is the real value of the Solo? We have too many Bard RN's in this industry, who are paid to give the Bard party line, while attempting to pass themselves off as independent objective clinicians. [/quote]

 

Your posts are myopic and one sided.  Do you work for one of the Picc manufacturers?   

Michael Drafz
Michael Drafz Vascular

Michael Drafz

Vascular Access Specialist

Sharp Memorial Hospital San Diego, CA

I have not been on this site for a long time and I am disappointed how unprofessional some of the responses have become.

I thought as RN's we follow certain professional, scientific and ethic guidelines.

As for a new product, we have the professional responsibility to evaluate the product scientifically, everything else is just hot air. The product has barely come out, how can we objectively know how it is performing in the patient?

So I would suggest to stop the guessing and collect data and present it, so we can base our decisions on something.

By the way, I am one of the "Bard RN's" . And let me tell you that Bard is where it is because there are many of us who do not give Bard the "Party line". If I am dissatisfied with their product they will know and I also have stopped using product if I felt that it did not perform as I thought it should. But I will also stand up if they have a product which is good for patients and clinicians.

 

Michael Drafz RN, CRNI, VA-BC

Clinical Lead Vascular Access Service

Sharp Metropolitan Medical Campus

San Diego, CA

 

Heather Nichols
    I think you have a

  

 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. 

Lawrence Rojas
One thing I'm not fond of is

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

Lawrence Rojas RN

Radiology Dept.

Garden Park Medical Center

Gulfport, MS

amymilburn
Eric, We are currently

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.

estevens102206
Amy you should read the

Amy you should read the messages carefully before replying. In my message I stated that on Bard's own website they state that using a positive or neutral end cap will keep the reflux low, but with a negative or split septum cap the catheter might have reflux.  My question was intended to find out why we still would have to use a positive or neutral pressure cap if the PICC is valved. That defeats the whole purpose of having a valved PICC.

Eric

Eric

amymilburn
Eric, I am not sure why you

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

kokotis
Kathy Kokotis Bard Access

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

 

 

 

 

Kathy Kokotis

Bard Access Systems

Kevin Travis Flint
It's great to see so many IV

It's great to see so many IV nurses interested in bringing high quality products into their facilities, the tone or level of banter may be a bit distracting to some of us so I hope we don't overlook that we want what's the most comfortable & safetest for our patients.  It might be that the SOLO is too new to offer a real evidenced based opinion but we will never know this unless we support each other in our trials as professionals and patient advocates.

 This may sound sappy but I tend to trust proven method over subliminal product bashing,

Kevin

amymilburn
Thank you Kevin.  I am new
Thank you Kevin.  I am new to this listserv, and I agree with you.  I certainly hope that it is not always like this.  We are all going to have different preferences in products.  I have learned that you just have to try different products and see what works best for your patient's and facility.  What works for me may not work for you.  Thanks, Amy
Paul L. Blackburn
All current valved catheter

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. 

 

lynncrni
Hi Paul, I just have to

Hi Paul,

I just have to point out some problems in your message. There is not one data point of evidence supporting the use of the so-called "push-pause" flushing technique. This is based completely on theory of fluid flow. We can not say that this technique will "preserve the life of the catheter and will decrease the incidence of occlusion." 

Also, the positive pressure flushing technique can not be used with a positive displacement needleless device. Positive and positive will counteract each other. Or this flushing technique will prevent the positive fluid displacement mechanism from working.

Confusion still reigns about needleless connectors and the required flushing techniques! Lynn 

 

 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

sesymons
back to concerning this
back to concerning this product:  I am waiting for the new needle before i go there.  Why oh why would you keep the old needle when so many have complained about it. Heard it was going to be a new needle but its not there yet. Horay however for the nitinol wire.
afruitloop
Thank you Paul for stressing

Thank you Paul for stressing that the care of the line post insertion is a very important factor in longevity of catheter life.  No matter the design of the catheter, that being valved or non valved--care, maintenance, flushing technique, clamping sequence, etc all contribute to the success of the device.  Wouldn't it be great if we didn't feel like we had to advance to costly catheter upgrades or add-on devices to assure that the lines worked effectively until the end of the therapy.  Perhaps we should go back to "basic education" as one of the most important upgrades to our infusion therapy.

I'm kinda laughing out loud when I say this, but in all reality no matter how many alterations and advances to products and devices, I can find a way to screw it up! I might not be the only one out there either. LOL  Take care, all.

Cheryl Kelley RN BSN, VA-BC

bc134
Ms. Hadaway, I agree that

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

lynncrni
I have published on this

I have published on this numerous times and will address this again here. The positive pressure flushing techniques will prevent the positive displacement mechanisms for working correctly as they are designed. For a luer-activated valve, the positive flushing technique would be to flush the line, maintain the hold on the syringe plunger while you close a clamp on the extension set or catheter, then disconnect. This closed clamp absolutely will prevent the positive displacement needleless valve from sending the fluid out to the catheter tip to displace the blood that was drawn into the lumen. 

The push-pause flushing technique has absolutely no scientific research to support it. All recommendations for this technique are based on theory only. I will agree that this is valid theory but we do not actually know the real world outcomes with this technique. I might be effective when flushing is done immediately and whole blood is quickly flushed out of the lumen. If the refluxed blood is allowed to sit for a while, there will be protein products that firmly attach to the catheter wall. We have not idea about whether this technique has any affect at all on this.

 We also know that biofilm will be present on virtually all catheters. Biofilm forms at very rapid rates of flow. So this technique will not prevent biofilm from developing. There is also the question in my mind about whether this technique could dislodge biofilm, causing it to become free-flowing into the bloodstream and produce a bloodstream infection. These are all totally unanswered questions. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Shawn H.
Lynn, Can you please clarify

Lynn,

Can you please clarify a couple of things?  You state that "positive pressure flushing techniquest will prevent the positive displacement mechnisms from working correctly as they are designed". Other than the actual positive displacement not occuring from the positive displacement connector upon disconnect (if the line is clamped per the positive presssure flushing technique), are you referring to something else in particular that makes the product not work properly? 

You also state that "This closed clamp absolutely will prevent the positive displacement needleless valve from sending the fluid out to the catheter tip to displace the blood that was drawn into the lumen".  How did the blood get drawin into the catheter lumen in the first place. I am a little confused since your email indicates that a positive flushing technique is performed AND the line is clamped while maintaining the hold on the syringe plunger with the positive displacement device.

If you're performing the positive pressure flushing technique as you've described even with a positive displacement valve and you've clamped the line while maintaining a hold on the flush syringe plunger, you shouldn't see any blood in the catheter tip. So at this point even if the positive displacement device couldn't expel fluid upon disconnection due to the clamp, it really wouldn't matter since there is no blood in the catheter tip due to the manual positive pressure flush.

As far as the dislodging of biofilm, wouldn't tPA that's frequently being adminstered in catheters also act to remove the biofilm from the catheter walls as the tPA is breaking up the clots in catheters?  Are there any studies you know of that talks about this?

Shawn

lynncrni
Shawn, There are numerous

Shawn,

There are numerous factors that produce blood reflux into the catheter lumen and these have been described in many publications. Syringe design, needleless connectors, changes in intraluminal venous pressure, muscular action in the arm with a PICC, and empty fluid containers cause blood to reflux into the lumen. We can not expect the needleless connector's positive displacement mechanism to overcome all of these factors.

In your first question, I am referring to the clamped lumen between the needleless connector and the catheter, nothing else.

Second question - see my first paragraph and all the other articles I have published on this which you can find on my website.

Biofilm and fibrin/thrombus are 2 different things. Both are found in catheter lumens. tPA does not remove biofilm. There is the question of tPA use lysing a clot and imbedded in that clot are organisms. When the clot is gone, these organisms are released to be flushed into the bloodstream. But tPA use has no affect on the biofilm which is firmly and permanently attached to virtually all catheter walls. The only way right now to get rid of the biofilm is to make sure that you are not introducing any organisms whatsoever into the lumen. We are far from meeting that goal in actual clinical practice!!  

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
interesting website about

interesting website about biofilm - M. Ryder, the primary on the bacterial transfer study through needleless connectors, worked with folks from this organization.

Probably more about biofilm than you want to know here.

 http://www.erc.montana.edu/

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

bc134
Lynn,  Thank you for

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

Halle Utter
A  facility where I place
A  facility where I place PICCs (contract) just changed to the Solo.  I read the information and couldn't find any reference to positive, neutral, or negative needleless caps.  There were no caps in the tray.  This facility uses the Baxter Clearlink, which has big negative reflux with disconnect.  Is it acceptable to use these caps with the Solo?  I would like to know where it discusses this in the catheter information so I can give good information regarding what type of cap(s) are best with this catheter.  The routine orders at this facility include Heparin, but they are considering going with saline only.  Where is there reliable information regarding cap choice with this catheter?  Thanks.

Hallene E Utter, RN, BSN Intravenous Care, INC

Robbin George
I sure hope a BARD official
I sure hope a BARD official answers the previous Question because we were told from the very beginning that Negative was a BIG No No--Please Clarify

Robbin George RN VA-BC

lynncrni
Before I make any comments,

Before I make any comments, let me state that I mean no disrespect to sales representatives. You do a great job when you stick to sales issues and information. The problem is that these reps frequently do not state product information in the same way it was originally taught to them. Or they blatantly exaggerate product information to get what they want from you - product sales! So you have to expect to see everything they are stating in writing from the company and not rely on verbal information.

Also, I want to make a comment about the numerous messages being posted on this forum by sales representatives. Many times these posts are sales messages and they interfere with the exchange of clinical information, especially when 2 sales reps from competing companies banter about a certain product feature. This has gotten worse recently, in my opinion and is distracting from the clinical discussions. Sorry if I am the only one who thinks this, I apologize for this message. But I have started to look at who is writing the message before I read it. Thanks for allowing me to voice my concern. Lynn 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Halle Utter
I've been placing the Solos

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.

Hallene E Utter, RN, BSN Intravenous Care, INC

lcole
 We are trialing the

 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.

Kelly Smith
lcole-Are you interested in

lcole-Are you interested in sharing data?  We have completed insertion of our trial of 50 SOLO's, and are continuing to track them for similar data as your study.Let me know if you would like to compare info.

Kelly Smith

PICC Nurse

Boone Hospital Center

Columbia, Missouri

Robbin George
DITTO everything said by

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   

Robbin George RN VA-BC

lcole
Kelly Smith, Boone Hospital

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