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Karen Day
Karen Day's picture
TPN and Central Lines

Hello all,

I had a physician present something to me that I had never heard before.  She wanted me to put in a picc line with as many lumens as possible (she wanted at least 3) so that one lumen could remain "unused" except for flushing in case she wanted to start TPN on this patient.  I told her that I would put a double lumen picc line in for this patient and that until TPN was started, one lumen did not need to remain unused and waiting(dedicated) for TPN.  I did inform her that once TPN was started if she so chose, then one lumen would be dedicated for the TPN infusion at that time.  She also stated she did not want any blood draws to be performed via the catheter as "the blood could provide a rich environment for bacteria and then when TPN was started through that catheter, the chance of a CRBSI was even greater due to the richness of the TPN"  I educated her on the flushing protocols for picc lines and although she seemed to understand, she was still hesitant about not having a pre-dedicated lumen for TPN without having had any blood draws through it either.  I told her if it would make her feel better, she could draw a set of blood cultures via the PICC and Peripherally prior to starting TPN if she wanted.  I guess what really threw me was the fact that due to poor vascular access the patient did qualify for a picc, not a triple lumen as she wanted, but she wasn't even sure that she would even be ordering TPN and I didn't feel the need to leave a lumen unused and waiting on an order that may never happen.  After all, aren't we supposed to use the smallest size catheter possible to provide the access needed.  I hope I explained this so that you can understand.  Does anyone have any suggestions/comments?  Is there something else I should have told her or am I in the wrong.

 

IVRN
You are absolutely right. 
You are absolutely right.  You may want to share with her the Grove study, which discusses the risks of larger french size PICCs leading to higher rates of thrombosis.  That is why we use the smallest size that will do the job. 
Michael Drafz
Michael Drafz Vascular

Michael Drafz

Vascular Access Specialist

Sharp Memorial Hospital San Diego, CA

I agree too, but would add: why not wait to place the line until she knows that the patient needs TPN. (unless of course no other access is available).

Michael Drafz RN, CRNI, VA-BC

Clinical Lead Vascular Access Service

Sharp Metropolitan Medical Campus

San Diego, CA

 

Karen Day
Karen Day's picture
I presented that too, but

I presented that too, but the patient was suffering from acute pancreatitis, dehydration and was a very difficult IV access - so I went ahead and placed a picc for him.

Thanks for the support.

 

Robbin George
Insert a double lumen PICC
Insert a double lumen PICC and when /if you need additional lumen exchange overwire

Robbin George RN VA-BC

lynncrni
I have never seen any

I have never seen any evidence that any parenteral nutrition solution should or must go through a "virgin" line or lumen, yet I have heard others make this same comment. It is not included in ASPEN guidelines. I think your physician does not have a good understanding of biofilm and fibrin deposits. Yes, fibrin will accumulate on the catheter walls from blood sampling and from blood reflux of any kind. Biofilm is caused by the introduction of organisms that attach and begin to grow a biofilm. So this is related to hub manipulation techniques - cleaning, changing tubing/caps, etc. There is some risk of glucose in any solution providing more nutrients for biofilm growth. But I would also have placed a dual lumen and then deal with an exchange if and when the TPN is needed and the number of therapies requires 3 lumens. If you can manage with 2 I would not do this exchange. 

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

karenbement
At the hospital where I
At the hospital where I work, "virgin" lines are requested for TPN even if we just placed the picc the day before if the lumen has been used for something else.  CDC guidelines under Intravascular Catheter related infections  states:  "  Designate one port exclusively for TPN if a multi lumen catheter is used to administer TPN (Cat. II)... I find that a very vague statement.   Comments?

Karen Bement

Carla Hoosier
The more vein space taken
The more vein space taken up, the risk of thrombosis is greater. I think the double lumen is adequate, proper flushing technique is a must prior to starting the TPN.
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