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DeAnna
PICC lin removeal

At our facility when we remove PICC lines the nursing staff is having the patient perform the valvsalva maneuver.  INS standards state that you should place antseptic ointment over the site.  CDC recommends that no antibiotic ointment should be placed at all to prevent fungal infections.  Our currently policy states to use anitseptic ointment and the infection control nurse wants that removed that because of the following: the potential for fungal infection, CDC's recommendation, and she has never heard of anyone having any air embolism from a PICC line or central line being removed.   What are other facilities doing when removing PICC lines? 

rivka livni
there is no need for

there is no need for valvsalva, because the insertion site is a prepheral vein, not a central vein. Supine position is sufficiant, sitting or lyaing is OK, remove slowly not to stimulate the vein into spasm, cover w/ 2x2 hold pressure for 30-60 seconds and apply tape, check if bleeding. If OK we tell pt to remove the tape and gauze when they get home. No special ointments.

As a rule, in most cases, the longer the PICC was in the LESS likely it is to bleed, the "fresher" the PICC is , the more likely to have some site bleeding.

lynncrni
Sorry I must respectfully

Sorry I must respectfully disagree. The national standard - from both infusion and critical care literature - for removal of all central lines is to place an air-occlusive dressing over the puncture site and to use all other interventions to prevent AE. The best method of accomplishing this type of dressing has long been established as a dressing with a petroleum based ointment. This can be an antibiotic or antiseptic ointment. This seals the skin-to-vein tract that is left when all CVC are removed. I would agree that the risk of a venous air embolism from a PICC removal is very low and that it has not been reported in the literature. But I would also state that the risk is **not zero**. It can happen. With air embolism listed as one of the hospital-caused complications that CMS will no longer pay for after Oct 1, 2008, why take the chance that you will be the first to report such an air emboli? If there were a thrombosed/stenosed vein from the puncture site up to the subclavian area, venous AE could occur. I would look for this in a patient with poor hydration and in a sitting position and one with a history of thrombotic issues from the PICC. I am not willing to take this chance. 

To address the infection control nurse who wishes to remove the ointment based on CDC recommendations, I would educate her on the correct interpretations of these guidelines. It is true that ointment placed routinely on an insertion site during regular dressing changes has been shown to not decrease the infection risk and to increase the risk of fungal growth. However, those studies did not include this aspect of catheter removal. If you can not get them to understand this, then compromise on using a Vaseline-based gauze under the dressing. But that site absolutely must be occluded with more than just a dressing alone. Within a few days, I will try to gather a list of references on this issue and put it on my blog. Lynn 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Stephen Harris
I have to agree with Lynn

I have to agree with Lynn and not Rivka.  The longer a PICC is in the more likely an air embolus as the wound track to SVC becomes well established. According to the studies I have read ABX ointment is contraindicated in line maintenence not line removal. As far as AE upon removal why not take more precautions instead of less?

 

Stephen Harris CRNI

rivka livni
So sorry to disagree with

So sorry to disagree with both Lynn and Stephen. What you are saying does not make sense to me.

Stephen,The track created from the skin level insertion site goes only as deep and as far as the intima layer of the vein directly underneath it and goes no further. How is it possible to have a track all the way to the SVC? I don't get it, unless I don't understand what you said, which is possible.

Since it is a PERIPHERAL vein (much smaller diameter then a central vein and much much slower blood flow then central veins) once the catheter is removed and pressure is applied to the site I do not see how an air embolism is physically or even anatomically possible. Isn't the intima immediatly starts the cloting cascade to seal the hole? Where w/ a central vein there is a possiblity of AE due to the fact that the blood flow is so high it could "wash away" the clot forming at the site of the intima thus allowing air to enter the blood stream through the LARGE TRACK created by the CVD. I realy need to understand how can an AE possible from a peripheral vein if you apply pressure and wait for the intima to seal the "hole"?

 We are also talking about PICC catheters that are 4, 5 FR not the 7,8,and 9 FR of CVD, not to mention the Cordis which I believe is 12 FR.

I am so embarassed if I am so wrong on this. May be some one should do a study, applying pressure w/ valvsalva on 50% of PICC removals then apply air occlusive dressing and compare it to simple pressure and apply 2x2 on 50% of PICC removals and see if there are any air embolism on the simple removals.

We have discontinued at least 4,000 PICCs over the the past 5 years using 2x2 and not once did we have AE. I know of at least 3 major hospitals around here that do not use air ooclusive dressings to remove PICCs.

I would love to get responses on this and learn something new.

Stephen Harris
Let me relate a personal

Let me relate a personal experience that might help.  A  double lumen midline was put in a patient as a temporary device till a PICC could be put in.  Radiology staff inadvertantly ripped off the hub transferring the patient on a slide board back to the bed. I was in the department and they immediatley called me to assist. The patients arm was being held and as I arrived I  could see that air was being drawn down into the clear part of the midline tubing. My assumption is that if left unattended this pt. would have developed an air embolism.  The wound track  left by a long term picc could possibly be a tube that air is drawn into. Likely, no. Possible, yes. If we are talking about best practice I think an occlusive dressing is best practice. I would not want to participate in a study to see if a quicker way to dress a wound that leaves a possibility, however slight, of a potentially life threatening event versus one without that possibility. Why not do the safest thing?

Stephen Harris CRNI

 

  

lynncrni
The pathophysiology for

The pathophysiology for developing an air emboli depends upon several factors, but I have never read anything about blood flow volume and washing away the clot being included. Once any catheter is removed there is a skin-to-vein tract that remains and can remain for many hours after the catheter is gone. If this catheter had a problem with vein thrombosis, this could act as the conduit or "tube" into the venous system. Remember that old thrombi are a stable formation with smooth muscle and collagen and also that the vast majority of catheter related thrombosis is clinically silent. If there is no air-occlusive dressing and the patient stands up and takes a deep breath, the chance of an air embolism goes up. Many things would all have to come together to make this happen from a PICC insertion site, so it is possible but not likely.

For air emboli to occur, there must be a pressure gradient. Intrathoracic venous pressure is lower than atmospheric pressure. It is this pressure difference that pulls air in through any opening. The subclavian and IJ sites are closer to the thoracic but these venipuncture sites alone are still outside the influence of the intrathoracic pressure. The difference with those sites is that they are above the level of the heart and the conduit into the vein requires a much shorter formation of fibrin/thrombus, increasing the risk of air embolism after removal. A PICC insertion site will be at or below the level of the heart, but if the patient raises his arm, that changes to above the heart, thus increasing the risk of air emboli. If there is no air-occlusive dressing, and the tract is still open, and the stablized thrombus is still present from the puncture site into the thoracic cavity, then everything lines up to increase the risk of air embolism from this old PICC site. So it is possible, but less likely than with subclavian or IJ sites. Hope this makes sense. Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

rivka livni
Thanks Lynn, it makes

Thanks Lynn, it makes sense.

Like you say, the likelyhood of it happening with a PICC is practically nil.

I was a surgical ICU nurse for 25 years in a number of hospitals in 2 different countries (before PICC) and have never seen or heard using occlusive dressings on any venous lines removals, only on Chest tubes. I am not sure I will start now, but you made a point.

Stephen, you are talking about the hub or catheter being open to air while still inserted in the pt's arm, if I understand you correctly. In that case, well ofcourse.....Here we are talking about the safe procedure for PICC REMOVALS.

My goodness DeAnna Francisco got more then she bargained for...

 

Stephen Harris
If you read my post again,

If you read my post again, the wound track left(as in the removal of the PICC) could act as a tube that air could be drawn into. I understand you were talking about PICC removals and I was trying to relay the point that a opening into a vein is an opening regardless if it is a actual line or a established woundtrack.

 

Stephen Harris CRNI 

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