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lucy jones
solo

We have a new bsi committee and I was asked to look into cathflo usage at our facility.  Since we switched to the Bard Solo, our cathflo use DOUBLED (though our line days stayed roughly the same), and our dvts went from 0 to 6. 

Has anyone else noticed this trend with the solo?

 

Heather Nichols
Solo

     Yes, and yes.  Our infection control nurse, who is also our director, stopped our trial early because of the severe increase in the two complications you listed as well as two infections in less than two month.  The previous year we only saw one primary and one seconday infection all year long. 

Barb Nickel
We trialed the Bard Solo in

We trialed the Bard Solo in early 2008.  Our cathflo use escalated quickly.  We discontinued it's use and went back to our valved catheter.    The rep admitted that several facilities were having similar issues at that time.  I know of another facility in our area that discontinued it's use based on a rapid increase in occlusions as well.  barb nickel

Gwen Irwin
Solo

We never switched to the Solo.  Why?  Because there is too much education and practice changes for the staff nurses.

The main reason for occlusions from what I hear is that it takes a different feel and persistance to get the blood return.  Many nurses think that there isn't going to be blood return and stop there.  They don't flush after that.  Therefore, blood is left in the catheter to clot.  Again, from what I hear, this is the reason for more occlusions.

Gwen Irwin

Austin, Texas

Timothy L. Creamer
SOLO

Lucy, are you using the SOLO2 catheters? If not please contact your Territory Manager for guidance. The SOLO2 has optimized valve performance resulting from continual quality improvement enhancements and performs with tighter parameters for aspiration PSI requirements resulting in very consistent outcomes i.e. minimizing occlusions or perceived occlusions. Were the DVT's on patients with occluded catheters?

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

coffeemania
Solo PICC needs to be removed from practice.

The valve on the SOLO is the cuprit to all problems you have encountered. By looking at the device presented to me in March this year, I am not lying, my first impression was "oh no. This is bad engineering." However I did give it a chance. I ordered 20 kits. I received numerous complaints from the nurses. 99% of the complaints were of clotting. So out of the door it went. I just use the regular power picc and put a Maxplus on it. It is simple in many ways. It is easier to educate the staff. It is easier for them to work with. It  works perfectly. Extremely low DVT (1%). Rarely clotted. AND IT IS CHEAPER!!!! So why buy yourself troubles???

Timothy L. Creamer
Power PICC SOLO

Regarding the SOLO valve, the engineering is significant. Seperate valves for aspiration and infusion providing maximal gravity flow rates for a valved catheter. Your trial was in March 2009 so your outcomes with 20 kits is not unrealistic with a large number of end user clinicians. I'm happy you are happy with Power PICC and your outcomes are positive. For facilities investigating a PICC with saline only indication, the SOLO2 is "good engineering" with consistent improved performance.

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

lynncrni
Tim, I am glad you mentioned

Tim, I am glad you mentioned the design of the Solo valve because it gives me an opportunity to repeat a question that has never been answered for me. I think we all agree that contact between the catheter and blood results in the attachment of a protein layer, often called a conditioning layer in the literature. We work hard to make sure that there is no reflux of blood left to reside inside the catheter lumen which can lead to occlusion. As you stated, Solo has separate valves for aspiration and infusion. If you aspirate blood according to the recommendations to assess patency before each use of the catheter, that blood moves through the aspiration valve. Then the following saline flush would go through the infusion valve. Then how does the blood ever get removed from the aspiration valve. I am having a hard time understanding how this could possibly work without the residual blood left in the aspiration valve being flushed out. So can you explain this to us? Thanks, Lynn

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

Timothy L. Creamer
SOLO Valve Blood Clearance

Lynn, happy to explain your questions regarding blood clearance within the Power PICC SOLO separate aspiration and infusion valves following patency assessment before catheter use. In my clinical practice I take advantage of the purple but transparent extension legs to visualize blood return preventing blood aspirate through the valves and into syringe/needleless connector. For your question though, let us use the scenario of drawing labs from a Power PICC SOLO. The unique oval design of the hub housing the valves creates turbulence when flushed. The push pause method of flushing adds to this turbulent effect on both sides of the valve, essentially “scrubbing” the surfaces of the valves and interior of housing preventing fibrin build up. The slit valve material is very thin, and therefore the turbulent motion of the flush solution reaches both sides of the valve keeping it clean and free of build up. Your question is valid and one vigorously tested in the development phase. Power PICC, Power PICC SOLO, and another proximal valve PICC were tested for residual hemoglobin following blood aspiration then flushed with saline. The Power PICC SOLO demonstrated the least amount of hemoglobin in the hub (including valves) of the three. An animated visual demonstration of the flush effect is available for viewing at www.powerpiccsolo.com, the flush video under Product Information demonstrates the turbulent effect of the oval hub design, this happens on both sides of the valves.

Hope this helps.

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

lynncrni
Thanks for the explanation

Thanks for the explanation however you will have to accept my skepticism over this explanation. First, I do not now and never have accepted the theory that the turbulent flushing method will remove anything from the catheter. There is absolutely no science to support this concept. There is some evidence in the biofilm literature that the shear force (which is increased with turbulence) will cause a stronger biofilm. The harder the organism hits the plastic, the greater the amount of adhesion to the catheter. So it is conceivable that this flushing technique will increase the biofilm problem. Also, once the shear force of turbulence exceeds the strength of the biofilm, breakage occurs. Breakage means that the biofilm floats freely into the bloodstream to cause a BSI. In the absence of evidence that this technique actually does some good, I will not teach or in any way endorse its use. So I would suggest that Bard Access conduct a study and publish it. By the way this flushing technique is not now and never has been included in the INS standards of practice because there is no evidence to support its use. I don't mean to be contrary but I just don't find your explanation to be sufficient. Sorry, Lynn

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

Timothy L. Creamer
"Then how does the blood ever

"Then how does the blood ever get removed from the aspiration valve. I am having a hard time understanding how this could possibly work without the residual blood left in the aspiration valve being flushed out. So can you explain this to us? Thanks, Lynn"

The explanation answered your direct question. The oval design of the hub produces a swirling effect of the flush solution even with a gentle forward flush motion, I only mentioned that a push pause flush would enhance that effect within the oval hub housing. Residual blood is removed from the slit valves on both sides with flushing due to the oval design of the hub. If you flushed a Power PICC SOLO according to your teaching method the effect would  be the same. Call it swirling or turbulent, the oval shape promotes this effect within the valve housing. The turbulent effect of intentional push pause flushing is different than that resulting from a unique hub design.  I recognize and appreciate your passion regarding "push pause" flushing technique and lack of evidence base studies, however biofilm adhesion, biofilm breakage, or shear force effects on the catheter were not included in your question. I don't find you to be contrary at all, just your response is poorly related to the original question. Sorry, Tim

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

lynncrni
Well, I guess I am not

Well, I guess I am not adequately communicating my question because I do not find the answer in your reply. I remain concerned about the valves used for aspiration. Your reply discussed the turbulence that removes blood from the valve housing. But what actually removes blood and its proteins from the valve itself. I realize these are openings in a silicone disc, but blood components can still adhere to the valve opening. I do not see how this swirling motion above and below the valve will actually flush these blood components from what is trapped between the valve leaflets or sides. Lynn

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

Michelle Todd CRNI
Solo Valve

Tim, I still can't find where you have answered Lynn's question about the aspiration valve and the infusion valve. I had the same question of the rep when I trialed the Solo and I did not get a good answer then either. 

Calebkent
Solo PICC

To answers Lucy's question:

I have used the PowerPICC solo exclusivly for over a year and in that time we have seen a reduction in our CathFlo usage. I am confident that your increase in occlusions is due to the PICCs not being flushed as frequently. After our conversion, we saw an increase in CathFlo usage but with continued education on flushing frequency we saw our CathFlo usage settle to rate rate below our rate when we were using the PowerPICC. The key to the SOLO is frequent saline flushes.

As for the DVTs we have not seen an increase since our conversion. The DVTs we have experienced have been also exlusively with the larger 6F catheter in critical care patients. I would evaluate the size of the vessel and your catheter size before blaming the PICC for the DVT rate.

 

Good Luck.

Caleb Kent, RN, BSN, CRNI

julwagner
We had the same issue with

We had the same issue with the SOLO. Our thrombolytic therapy increased substantially. We completely went away from the SOLO and are using the basic power PICC now. I know they have "revised" the SOLO but I'm not inclined to even try it at this point.

Gwen Irwin
solo

I can't imagine any reason for increased DVTs related to the type of catheter.  I believe that vein size is more important related to the catheter size to impact the DVT increase.  Does anyone understand why a brand of catheter would increase DVTs?

Gwen

Austin, Texas

momdogz
No - I don't think it's related.

In addition to amount catheter is filling vein, location of insertion site, whether catheter securement is used - there other patient specific reasons that increase risk for DVT, phlebitis/thrombophlebitis.  

Mari

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

Michelle Todd CRNI
DVT risk, partial occlusion

Yes. It has long been known that the type of material a catheter is made of will influence the rate of DVT. The first IV catheters were made of a very stiff material. The new generation material is vialon which is able to soften in the body and curve in veins without kinking so readily. There is less scraping on the vessel wall as well and less complications. With regard to PICC lines, it is the same thing. There are silicone catheters and there are polyurethane catheters. In the polyurethane category, the different materials from different companies are also different. Some are very stiff and some soften once inside the body. If you need a power PICC for your patient, you are going to need the stiffer polyurethane catheter.  Silicone, such as a Groshong PICC, is very delicate. It can not tolerate CT scan and it also has a 20% breakage rate with typical use. I teach all of our nurses to secure the hubs of a Groshong, thus protecting them from breakage. Anything tubing that is connected to a Groshong should also be taped. Our beakage rate has been near zero when the line hubs are secured. I find that Bards Solo and Power PICC catheter material is a softer type of material than some power PICCs, but their silicone Groshong catheters are far softer and thus easier on the vessel intima. This answers your specific question about type of catheter, but it still does not account for the full cause of DVT. The Vicrow's triad has already been discussed and then there are things like, the use of heat for at least 10 min prior to a PICC placement. The use of heat, even on large veins, lessens the chance of venospasm upon passing the PICC. Less venospasm means less rubbing on the vein intima as the PICC passes through. And indeed the introducer makes a difference. I have had much better success with the microintroducer made by Kane Medical. We used this in the last hospital I worked at and I use it currently as well. Although I use Bard PICC lines, I order them without the microintroducer and buy it separate. It comes out being the same price. And to the other person asking about the microintroducers, My rep Daniel     [email protected]   would probably be happy to show you why you are having difficulty with the transition on the microzEZ. I used to have them ripple up on me due to the thin transion being a little too thin. This caused terrible trauma to the vein until I figured it out each time and got a new introducer out. I feel that I cause less trauma with the Kane introducer. In the past year that I have been using it, I haven't even seen a DVT. The one other thing I do is that if there is a venospasm upon passing the PICC I will order a heating pad at 105 degrees as continuously as tolerated for 24 hours. If no symptoms of pain develop, then the heat is removed. The way I understand it, Bard has improved the Solo valve by narrowing the pressure range at which it will open and close. Before this change, it would seem that the line had a partial occlusion when actually the valve was not opening at the pressure being used. Apparently, Groshong had a similar problem when we first stated using it and they we able to make change to what we know now. I, too, felt that the Solo was clotting was too easy and I am glad they have resolved some of these issues. I also found that the line would have issues from the first hour due to the wire being inside the valve. I could not leave the wire in for CXR which is sometimes very useful on a bariatric patient. As the wire was removed, it would drag out with it a long stringy clot and as soon as the wire was removed there was blood back up in the cath. The rep told me I needed to flush it well right after wire removal and then again 15 minutes later after the valve "rests". I can't help but presume that this is where the thrombus starts and then we have to treat it within days with TPA. I have had less clotting with the Bard regular power PICC even without the use of Heparin.

 

 

 

Chris Cavanaugh
Virchow's Triad

When looking at causes of DVTs, it is well documented that thrombosis is a complication of PICC lines.  This is related to the three points of Virchow's Triad.  1) Hypercoagulablity--certain patients will be more prone to thrombosis than others, especially ones with diagnosis that increase coagulablity, such as cancer, pregnancy, and others.

2) Injury--The larger the hole into the vein, the greater the injury, therefore the increased risk of thrombosis.  That is one of the reasons a smaller catheter size is recommended by the INS guidelines.  In addition, the number of times the vein is accessed increases injury.  This is why first stick success rates are so important, few sticks decrease risk of thrombosis.  The stiffer the introducer/dialator the increased risk of scraping the intima of the vein, causing injury.  This also applies to the stiffness of the catheter itself.  Stiffer catheters can cause intimal damage especially when they are advanced, when they go through stenosis, tortuous viens or around corners.  Another thing to consider that could cause injury to the intima is the catheter tip, especially if trimmed uneavenly or at an angle or if the catheter  has a blunt edge.  The multiple passes of the tip back and forth could lead to vein injury as well, increaseing risk of DVT.

3) Stasis--this is the other area that size of the catheter impacts.  The larger the size of the catheter at any point, the more room it takes up in the veins, and the more stasis of blood can occur in that area.  This will also contribute to thrombosis.

Each of these factors will impact the risk of DVT in your patient, the more risk factors, the higher the likelyhood of DVT.   Also remember that many DVTs are asymptomatic, so just because you have not seen a patient with swelling in the PICC arm does not mean the thrombosis is not there. 

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

lynncrni
Intraluminal vs intravenous

This discussion was originally focused on intraluminal catheter occlusion, not catheter-related vein thrombosis. Totally different causes, prevention and treatment. Lynn

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
Except where the original poster mentioned that their DVT's went

from 0-6.  Agreed - different issues.

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

lucy jones
Solo

I would really like to thank everyone for their willingness to respond to my questions.  I appreciate the vitality of this blog!

I also appreciate how delicate some of you have tried to be when hinting that it's my technique that's causing dvts...

I wonder if anyone thinks my increase in dvt rate has anything to do with the MicroEZ microintroducer?  I've noticed that some of the dilators are now displaying a large "bump" and no longer have a smooth transition between inner and outer cannula.  

Lucy, RN

nancymoureau
solo

I'm curious if other PICC brands have this same problem or if the other brands require the extra efforts described by Michelle Todd. We used to use heat with the Landmark catheter because phlebitis was such a problem. Heat increases the vein diameter from dilation, so maybe our catheters are too large. Consideration for vein size is another factor frequently overlooked. Now that we are using duals and triples with greater frequency there will be increases in thrombosis if the catheter size exceeds 33% of the vein diameter. While this percentage is still evolving with evidence basis it is a good number for comparison, especially if there are other risk factors for clotting such as smoking, obesity, Diabetes, cancer, etc etc. 

Nancy

 

 

Nancy L. Moureau, BSN, CRNI

PICC Excellence, Inc

706-377-3360 direct line

888-714-1952 toll free

706-614-8021 cell

[email protected]

www.piccexcellence.com

 

National PICC Certification has arrived. Validate your experience and knowledge through the Certification process leading to CPUI Certified PICC Ultrasound Inserter. For more information see www.piccexcellence.com

 

Nancy L. Moureau, BSN, CRNI, CPUI, VA-BC

PICC Excellence, Inc

 

kathykokotis
landmark

I personally sold the landmark catheter which had a huge rate of phlebitis.  It was an over the needle design and not thru an introducer so it caused tremendous vessel irritation upon threading and resultant phlebitis.  I would doubt that todays thru the introducer techniques would cause as much of a traumatic insertion as Landmark.  Red heads with small veins and dehydrated or anxious patients suffered the worst cases to the point of mast cell type disruption mimicking an allergic response.  I would not use Landmark as an example today on catheter size and thrombosis as the design alone likely caused problems.  That menthod of introduction led to issues of its own resulting in complete withdrawal from the marketplace.

Kathy

Margieh
Margieh's picture
Cut catheters

Does anyone know if there are any formal studies related to a higher incidence of thrombus predisposing pt's to infection with cut catheters opposed to catheters wilth a nice beveled tip? I am called frequently to replace cut catheters in a time frame of ten- fourteen days after placement.  

Margie Hood RN

kathykokotis
Margeih

There is only one study I know of.  It is not prospective, randomized however it was published in JVAD by Janet Petit if I am not mistaken and it looked at catheters cut with different types of approches.  There was not a resultant difference in symptomatic thrombosis.  Can anyone cite this study reference for margieh.  As far as thrombosis and cut catheters.  Ports and tunneled catheters have been trimmed for years and there is no study to show a difference in these devices and thrombosis.  Thrombosis (symptomatic) is often seen in the first two weeks of dwell.  That is a very well published time frame in the literature for occurrence

Kathy Kokotis

Bard Access

Timothy L. Creamer
SOLO Valve Blood Clearance

Michelle,

This is the answer I provided regarding blood clearance with saline flushing of the SOLO valve(s).

"..I checked with the engineers for your question regarding blood clearance on the closed slit valves with saline flushing. The valves are contained in a very thin material dividing the oval hub, when the catheter is flushed that material flexes forward slightly with infusion and the aspiration valve slits slightly "hinge" open allowing the swirling saline to contact those edges that otherwise would be closed."

The swirling effect of the saline flush happens on both sides of the vlaves due to the oval design of the hub.

I am very involved in active clinical practice every weekend inserting PICC's, personal experience with the Micro EZ introducer dilator was a significant improvement over the older generic type. I have not had one malfunction due to the bullet nose design at the transition of introducer to dilator, a shorter lie on the dilator, and small radius tip. The skin nick I make is very conservative. I too experienced the issues you described however with the non Bard generic micro introducer.

Hope this helps. If you have additional questions regarding the SOLO valve and blood clearance please feel free to contact me at [email protected].

 

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer
Kathy,Here is the article


Kathy,

Here is the article reference.

Pettit, J. (2006). Trimming of peripherally inserted central catheters: The end result. Journal of  Association of Vascular Access, 11(4), 209-214.

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

nelliepic
SOLO

My facility introduced the Bard SOLO in Jan of this year.  Initially we had a lot of problems with occlusions and we were ready to throw it out.  We did a lot of educating with the nurses and I asked Bard to give us all the necessary help in order to get the education done.  Bard did listen to the complaints and worked on the SOLO and changed the valve.  We are now seeing a significant decrease in our occlusions and DVTs.  We chose the SOLO so that we could get away from the use of heparin.  My opinion is that any time you introduce a new product education is key to optimal function.  I see most of the DVTs in our high risk population so there are a lot of variables when you are factoring your DVT rates.   I would encourage you to look at each one individually.

Denelle Pepin-Donat RN, CRNI

Richland, WA

PICC RN

Kadlec Regional Medical Center

Denelle Oliveros RN, CRNI
Nurse Manager
University Option Care
Columbus, Ohio

jivil
Solo PICC

We are an LTACH and some of our patients require PICC insertion here.  The PICC team (providers) put in the Solo PICC exclusively.  Our nursing staff report a number of challenges with PICC lines in general, but it seems that the issues specific to these lines are related to blood drawing and flushing issues.  Are any of you currently using these and are you seeing issues with them?  Thank you  Jean

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