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Marcia Ann DeRuiter
PICC removal

someone brought up the possibility of using sterile petroleum jelly to the site when a PICC is removed instead of and antibiotic ointment.  Mostly because it doesn't require obtaining a Dr. order.  Any concerns about this? 

 

lynncrni
I have used a Vaseline-based

I have used a Vaseline-based gauze for covering the site of a CVC before but never seen sterile prtroleum jelly. I am assuming you are home care and therefore the need for a physician order. In the hospital, povidone-iodine and/or neosporin would be used based on established hospital policy and a patient-specific order would not be required.  

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

www.hadawayassociates.com

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

bartina
Nancy Rose RN IV Team VA

Nancy Rose RN IV Team VA Medical Center Wilmington, DE (800) 461-8262 ext 4830

Would anyone be willing to share a policy or procedure for central line removal?  Currently our doctors (interns and residents) remove central lines except PICCs.

Since the femoral vein is  below heart level, is air embolism a concern after femoral vein line removal? I will search air embolism but would appreciate input from the experts.

Thank you. 

Nancy Rose 

momdogz
We don't routinely use

We don't routinely use vaseline impregnated gauze nor antibiotic ointment for any of our CVC d/c's.  Infectious disease recommends not using antibiotic ointment.  We've used sterile gauze with transparent semi-permeable membrane dressings for years, and have had no problems 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

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

Saharris
Stephen Harris RN, CRNI

Stephen Harris RN, CRNI

The use of ointment is contraindicated for CVC dressing while the CVC is inserted in the patient(can promote fungal growth). I have not seen any research showing this to be a problem on a dressing post removal and occlusive is not the same as covered. We use betadine ointment for all d/ced CVC dressings. I agree that by not using a truly occlusive dressing you risk AE. As an RN who has worked with malpractice attorneys in depositions I can tell you they drool when they hear "We have always done it that way." The question is are you following the standard of care?

 

Stephen Harris RN, CRNI

Chief Nursing Officer

Carolina Vascular Wellness

 

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

mary ann ferrannini
The only time I routinely
The only time I routinely use an ointment is site has symptoms of local infection or if catheter has worked a large hole in the skin. I will often see large holes on the non-tunneled dialysis catheters,and I am concerned about preventing an air embolis. In those cases I will often use some sterile vaseline from sterile vaseline gauze as I cannot always easily find any abx ung in the facility I work for.I personally,would not use a non-sterile gel or KY when discontinuing any CVC.
lynncrni
I am not trying to cause you

I am not trying to cause you all to panic, but those of you not using some form on petroleum-based ointment on the puncture site of ***all*** CVCs are asking for an air embolism. This is not an infection issue. This ointment serves the purpose of sealing off the skin-to-vein tract that is present on virtually all catheters. I have served as the expert in several lawsuits involving air embolism upon catheter removal and this is always one of the important aspects of the removal procedure that is raised. It is the national standard of practice to seal this site with an occlusive dressing, and this ointment is really the only component that can adequately seal the tract. A dressing alone is not sufficient, regardless of whether is is gauze and tape or a TSM dressing. So please add this to your policy. One additional factor is the fact that all air emboli from all causes is on the list of complicating conditions that Medicare will deny payment for after October 1, 2008. So there is every reason to use all methods to prevent their occurrence. The ointment is cheap and can prevent a devastating outcome for your patients and a horrible financial outcome for your facility.  

 

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

www.hadawayassociates.com

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

Robbin George
Standard 49 III (PICC) IV
Standard 49 III (PICC) IV (Nontunneled CC) Practice Criteria Item G does not designate removal of these CVCs as a sterile procedure but a colleague who is preparing for the CRNI exam is confused as to the language that states "Digital pressure should be appled until hemostasis is achieved, then antiseptic ointment and a sterile occlusive dressing should be applied to the access site"--Could someone please qualify the terms STERILE and OCCLUSIVE as used in these statements--We have been using vaselline gauze covered with a 2X2 and tape--Like the previous comment we (the IV RNs) use ointment when removal results in a large "wound"--Hospital policy does not specify ointment as there was concern for allergic reaction--Lynn's comment is very strongly worded and perhaps we all should be evaluating our policy on this matter

Robbin George RN VA-BC

Marsha Hardin
On the issues of ointment vs
On the issues of ointment vs sterile occulsive dressing. Does the petroleum based ointment not prevent the track tissue from adhering to itself?
lynncrni
I don't quite understand

I don't quite understand your question. The ointment provides a barrier to prevent air from being pulled into this skin to vein tract while the skin epithelializes.

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

www.hadawayassociates.com

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

Halle Utter
I have never seen petroleum
I have never seen petroleum gauze used with PICC removal, because although the PICC is a central line, the venipuncture site is in the peripheral circulation. This is a bit different from a subclavian puncture site in the chest.  I have never seen nor heard of an air emboli post PICC removal.  Has anyone ever seen one?  I am simply curious.  If that truly is the standard of practice for dressing post PICC removal I will change my practice.  In homecare, I seriously doubt nurses are routinely applying vaseline gauze post PICC removal.  What are you homecare nurses doing?  Do you apply vaseline gauze?   I have never heard of a documented case of air emboli following PICC removal, and would like to read about it if someone has information.  

Hallene E Utter, RN, BSN Intravenous Care, INC

mary ann ferrannini
 I Know that you can get an
 I Know that you can get an air embolus from any IV device, although the risk from a peripheral access site is extremely low (ie PICC or PIV). In my original post I stated I use an ung if the VAD has worked a large hole in the skin,and usually this CVC that has been inserted in the chest. We do not routinely use an ung or sterile vaseline gauze when we discontinue a PICC either,but perhaps we should. What exactly is the risk?
lynncrni
As I have stated in previous

As I have stated in previous messages, the risk of venous air embolism from removing a PICC is low, but it is **not** zero risk. I am also not aware of this event being published as a case study, but that can not be taken for proof that it has never happened. If all the risk-producing hazards line up correctly, then it is quite possible for it to occur with PICC removal - fibrin sheath, skin to vein tract, patient position, deep breath, hypovolemic, etc.

INS SOP #49 Catheter Removal, #III PICC, Practice Criteria G states digital pressure followed by antiseptic ointment and sterile occlusive dressing. This is the national standard and the revision committee made sure that this was put in for PICCs because there is a risk. 

I do not understand the resistance to this simple procedure. Treating a patient for venous air embolism is not cheap and this hospital-acquired condition will not be reimbursed by Medicare and many insurance companies after Oct 1, 2008. So why take this unnecessary chance? 

 

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

www.hadawayassociates.com

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

Halle Utter
I am not resistant, just

I am not resistant, just trying to understand the rationale since the site is in the peripheral circulation.  Technically, should we not be doing the same thing for a PIV removal or a venipuncture?  Or is a PICC more of a risk due to increased dwell time (resulting in a larger more defined "hole" in skin) and longer line, therefore possibly larger longer fibrin sheath?  

Hallene E Utter, RN, BSN Intravenous Care, INC

lynncrni
First reason would be I have

First reason would be I have never seen any information about the problem of fibrin sheaths on a PIV, but I would guess that it does happen to some extent. The difference is that this sheath would be about the length of the 1 inch PIV, not the length of the PICC that would reach into the central circulation.

 The other reason would be that the PIV does not leave that skin to vein tract because of the much shorter dwell time. 

I have found lots of information recently about a new risk associated with microbubbles. Previously we have never thought these to be a problem, but that concept is changing. I found this information while revising the A&P chapter for the INS textbook. There are several articles about CT head scans that have found air emboli in the brain when the patient only had a PIV. Also the pathophysiology of what small bubbles does to the venous endothelium. Next week I am planning to begin writing my blog again and this is the first issue I will be discussing.

Have a good holiday everyone.  

 

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

www.hadawayassociates.com

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

mary ann ferrannini
Thank you Lynn I will
Thank you Lynn I will immediately change my practice and suggest an immediate policy change. It is in our current policy,but it is optional and not mandatory and we will need to change that. Thank you again    Mary
momdogz
Lynn - thanks for your

Lynn - thanks for your comments. Can you post some of the articles about microbubbles here or on your blog so that we can use them in references in our policies? 

 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

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

Halle Utter
Ditto thanks to Lynn.  I'm

Ditto thanks to Lynn.  I'm sure everyone on this listserve is as grateful and appreciative of your expertise as I am.  Your are a wonderful asset to our profession.

Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

Halle Utter
Ditto thanks to Lynn.  I'm

Ditto thanks to Lynn.  I'm sure everyone on this listserve is as grateful and appreciative of your expertise as I am.  Your are a wonderful asset to our profession.

Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

lynncrni
Thanks, I will try to get

Thanks, I will try to get this micorbubble info on my blog today.  

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

www.hadawayassociates.com

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

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