Would you all mind sharing with me your protocol for CVL/PICC removal. Ointment/no ointment?
We use Petroleum gauze to cover insertion site of all CVC removals.
According to the Infusion Nursing Standards of Practice, a petroleum based ointment is necessary to seal the skin-to-vein tract left when a CVAD is removed. This can be Vaseline, povidone-iodine, or neosporin ointment, however the anti-infective properties are not the issue. Sealing the hole is the goal. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
It is interesting that many nurses I converse with believe a folded up piece of gauze covered with a transparent dressing is occlusive. Povidone iodine ointment and neosporin are not available on many units as floor stock but come out of pharmacy with a prescription, Vaseline gause is also not readily available (unless you possible work on a unit that sees chest tube- and I can not speak to that as a current practice either.) So although the INS standards say it is necessary to seal the skin track, I wonder how often it occurs across the country. Experienced/seasoned I V nurses may but what about other?
Just a thought.
Deb McPherson, MSN, RN, VA-BC
Staff Development Specialist
The INS Standard #44 states that the removal of a non-tunnelled CVAD should include cautions to avoid air embolism which we all know is a CMS "Never Event". It continues to say that Digital pressure should be applied until hemostatsis is achieved by using manual compression and/or other adjunct approaches such as hemostatic pads, patches, or powders that are designed to potentiate clot formation. The nurse should apply petroleum-based ointment... to seal the skin catheter track. I agree with Lynn Hadaway that sealing the hole is the issue. Many hospitals are finding that use of Bioseal does all the above in one. It seals the site, it is a hemostatic and applied before the line is removed it removes the potential for AE. Therefore there is no immediate or latent opportunity for AE. Although the literature tends to show that AE is a non-event, it is a Never Event with CMS and once your facility has one, everything changes.
I am a paid consultant for Biolife, makers of BioSeal powder; and a passionate user!
Lauren Blough, RN, BS,CRNI, VA-BC
Vascular Access Clinical Specialist and Consultant
Lauren Blough, RN, BS, CRNI, VA-BC
Clinical Development Manager
Biolife, LLC "Makers of StatSeal"
We apply sterile gauze, then remove after hemostasis, then apply sterile xeroform gauze, sterile gauze, and tegaderm.
My question is what kind of discharge instructions are you providing the patient for the care of the site? I asked the question with no response.
We have them keep the dressing on for at least 12 hrs.
Linda Burns RN CPUI
Vascular Access Team
Children's Health Care of Atlanta
The issue with the new products such as Bioseal is that there are no studies supporting it use for this purpose. The challenge is that clinical studies will be virtually impossible for ethical reasons, however a case report or animal studies is where we have to begin. I am not sure what the xerofoam dressing is and if it actually forms a tight seal or not. Again, there are no studies or case reports on this either. Lynn
We stock single use packets of bacitracin or neosporin ointment in our Pixis as an override (not as a medication just as an ointment). When we remove a PICC or other CVC, we lay the patient supine, remove the catheter, hold pressure with a 4x4 until hemostasis is obtained. Then keeping pressure above the puncture site with one finger, we apply a 2x2 gauze with a dollop of ointment on it to the puncture site and cover it with a small occlusive dressing. The patient is instructed to lay quietly for about 10 minutes then resume normal activities. The dressing should be left on for 24 hours. There is insignificant cost in this method and it is very effective.
Xerofoam gauze would be considered a Petroleum (Based) gauze .....and therefore.....OK
Great, thanks for info, never used that brand. Lynn
More information than you might want....but wanted to jump to help educate everyone (if needed).
XEROFORM™ Petrolatum Gauze. 3% Bismuth Tribromophenate in a special petrolatum blend on fine mesh gauze. Non-adherent. Clings and conforms to all body contours.
Lynn, Do you have the evidence for this standare? We are trying to incorporate this into practice and some are wanting to review evidence.
We are developing a midline policy. Do any other institutions restrict midline placement to a patient that's been afebrile for 48 hours?
I'm not aware of any evidence that supports this practice, and there's actually some issue to consider first. The first is safety. It's not clear exactly why, but all petrolatum containing products are requried by FDA regulations to carry the warning that it should not be applied to punctures. We do know that there has been a case of petrolatum embolism that resulted in death, the petrolatum entered through a central line puncture site.
In terms of effectiveness, there is no reason to believe that pertrolatum by itself is in any way capable of sealing a CL insertion site. At room temperature, petrolatum is just a very viscous liquid and has no structural integrity that would help it actually 'plug' a hole, once it comes in contact with the body it has even less ability to do this, since the melting temperature of petrolatum is 37c. As a result, petrolatum's ability to resist deformation accross a puncture when exposed to negative pressure in the puncture is essentially non-existent. A more practical way to understand this would be to take a coffee stirrer, place some petrolatum on the end and inhale slightly through the stirrer, you'll find that at most you'll get a small amount of initial resistance while the petrolatum displaces, followed by the free flow of air. The only way to successfully 'plug' the puncture using petrolatum would be to fill the puncture with enough petrolatum that the adherence to the interior walls of the insertion tract would be sufficient to occlude the tract, which then puts the patient at high risk for embolizing the petrolatum.
Pre-saturated petrolatum gauze is much different in that it does have the potential to actually occlude the insertion site, while significantly limiting the ability of petrolatum to enter the vein.
I think some of the issue comes from a misunderstanding of what is meant by "semi-permeable" dressings. "Semi-permeable" dressings don't allow the free-flow of air, in terms of airflow they are occlussive. The reason why they are termed as "semi" permeable is that they allow for the osmotic transfer of vapor and gasses, not air movement through the membrane.
Please share the resource for this patient with the petroluem embolization. Where is it published or reported? Thanks, Lynn
WadeBoggs Thank You! Our policy has been to remove line, digital pressure, ointment ( usually Povidone-iodine ) folded 4X4 covered with lg. TAD. Your study has me thinking we should immediately advocate for change to vaseline gauze ??? INS should certainly re-visit thier recommendation - where is the EBP ???
Vaseline gauze is a trade name for petroleum based gauze. So this is already stated generically in the standards lynn
My understanding of the INS standard is that it states to use an ointment (such as vaseline), not that only a petrolatum/vaseline impregnated gauze should be used. Functionally speaking, applying an ointment to the puncture and applying an ointment impregnated gauze are two very different things in terms of both potential effectiveness and safety.
I can only find the abstract of the article related to vasoline emboli and it states it potentially occured on CVL insertion, not after removal
. Do we have any other evidence?
The vasoline emboli occurred on insertion, showing vasoline entering the tract to the vein poses a serious risk, I'm not sure that based on this we can assume no risk if it's placed in the puncture at removal vs on insertion. Is there something so fundamentally different about the same tract at insertion vs at removal that we can say there aren't similar risks at either time?
A burden of proof that favors patient safety doesn't seem to support this practice, particularly when there are safer and more effective alternatives readily available. There is an evidence supported suggestion of risk, and no evidence that it is in any way effective, and actually what we know about the phyical properties of petrolatum would suggest it most likely is not.
From what I can tell, the label to not use on puncture wounds has to do with bacterial growth/infection risk. Has anyone seen any increase in infections with this practice?
Wadeboggs, I'm not sure one study from 23 years ago where an emboli somehow occurred on insertion (this is not clear since only the abstract is in English) constitutes a "serious risk" of using vaseline to seal the skin/vein track after removal. This practice that's been in place for quite a long time in some institutions and is an INS standard.
A case from 23 years ago wouldn't mean much of the circumstances related to had changed since then, but I don't think anything regardless pulmonary vascular physiology has changed it that time.
There are times when assessing risk that your only measurement of risk comes from extreme cases, where the occurance of those extreme cases could suggest numerous less severe cases, sort of like with glass shards in IV solutions. In cases where embolism results in immediate death, the cause is detectable by autopsy, small amounts entering venous circulation, which would presumably be more common in occurance, would not be clearly evident as a petrolatum embolus, the adverse effects would not be differentiated from other causes. So the existence of a documented extreme and likely relatively rare occurrance, should at least raise concern that other less severe but still harmful occurrance may be occurring.
We certainly can't quantify it to any accurate degree, but it would be negligent to say there is no risk, and given that we should look to other interventions that have less risk.
Lynn, could you please weigh in on this topic of petroleum OINTMENT following CVL removal. What evidence did INS use to make the standard?
Thank you, Kristi
The references used are listed in the INS Standards. I strongly believe that an ointment is required to seal the site of all CVADs that have just been removed. Due to ethical reasons, I doubt that we will ever have actual clinical studies on this issue. Would you want to be in the group randomized to not get the ointment dressing? There is no evidence that a semi-permeable transparent membrane dressing is sufficiently "occlusive" to prevent air from moving into the venous circulation. This language was changed from "antiseptic ointment" in the 2006 standards because the goal is not infection prevention and many people were intrepreting the use of "antiseptic" to mean there was an infection risk here. Also many hospitals were requiring triple antibiotic or povidone iodine ointment to be by specific presxription and was not readily available on floor stock any longer. The language was changed to "petroleum-based gauze" to occlude the puncture site. Vaseline is a trade name and will NEVER be found in a document such as this. Vaseline is a petroleum based gauze and the most prevalent product available on nursing units. This is what is used to remove any tube where occlusion is necessary - CVADs, chest tubes, etc. Vaseline gauze will meet this statement in the standard. I am not aware of any plain petroleum ointment in a tube that could allow excessive amounts to be applied. I cannot read German and the evidence used to write the INS Standards is from the English language. Since I cannot read the entire article, I would never use the abstract only as a suitable reference for the standards. Lynn
I hope you don't mind but I copied some portions of your post to make them easier to respond to individually:
" The language was changed to "petroleum-based gauze" to occlude the puncture site."
As far as I'm aware according the copy I have, which as far as I know is current, ointment is still given as an option in the Standard. If ointment is now not to be used in favor of an ointment impregnated gauze, then I'm glad to hear that and you can ignore the rest.
"The references used are listed in the INS Standards. I strongly believe that an ointment is required to seal the site of all CVADs that have just been removed. Due to ethical reasons, I doubt that we will ever have actual clinical studies on this issue. Would you want to be in the group randomized to not get the ointment dressing? "
I've never worked in a facility that advocated the use of ointment, and only one that advocated the use of an impregnated dressing. In two other facilities tegaderm was the policy, and in another duoderm was the policy, so there's really nothing that extreme about studying the use of dressings without the ointment, in fact you could just look retrospectively at patients in the many facilities who don't use the ointment in their policy. (Two facilities specifically prohobited the use of ointments due to concern that it compromised the patency of the occlussive dressing, while offering no reliable occlussion of the site).
"There is no evidence that a semi-permeable transparent membrane dressing is sufficiently "occlusive" to prevent air from moving into the venous circulation."
What evidence is there that ointment is sufficiently occlusive? Unlike petrolatum ointment, which starts out as a semi-liquid and then quickly becomes a liquid at body temp, semi-occlusive dressings have the physical properties that would suggest it can block airflow accross a puncture site. Semi-permable membranes are only permeable to omsmitic gasseous and vapor exchange, they have a well defined level of permeability from which we can calculate the rate of airflow, which is non-existent at the levels we are trying to avoid in the case of a D/C'd central line.
I appreciate reading all of the discussion threads from this site. I usully don't chime in much because I don't place PICCs, but do lots of interventions and problem solving with many devices in pediatrics. I recently learned of an error that I wanted to share. Our organization does stock betadine ointment in the pyxis and so we have been using it as the product to apply with PICC removals. The product is made by APLICARE, I went on line to verify its ingredients and the web site says it is a "water soluabe product" and "it does not block air from reaching the site". Of course, I was shocked! We now have switched to the vaseline gauze. I just want to share this awful experience and encourage those of you using an "ointment" to check thier on line product info.
Linda Tirabassi PhD RN CNS CPNP
Do you have the entire study in English, Mr. Boggs? I'd be interested in reading it. The abstract does not explain in any way how this vaseline entered the bloodstream on INSERTION, not after removal. I still fail to see the relevance, but I'd like to see the study.
When consideration is being given to placing something like an ointment on a CL insertion site, I would hope the question of "what's the worst that could happen?" is asked. Just like air, a liquid has the potential to migrate towards a source of negative pressure, so the question at that point shoud be, "how is petrolatum in a vein tolerated"? The answer according to the study is 'not well'. Whether it got in on insertion or removal is sort of moot, since we know from basic physics that it is possible to find it's way into the vein, the relevant information the study provides is that death can occur, and assumedly other complications short of death that may be more likely and less likely to be recognized as being due to petrolatum.
Beyond that, it's an ineffective way of achieving the goal of occlussion. So, out of all the options, we chose the least effective and most dangerous option as our primary option.
The consideration is death from a venous air embolism. But it may be worse to have a massive CVA from a venous air embolism that moves to the brain. This happens for numerous reasons including patent foreamen ovale, right to left shunting in the pulmonary vasculature, and air rising against the blood flow from CVADs especially when they are high in the SVC. Yes, CVAs do happen from air emboi. I have worked on several legal cases where the patient was left with no ability to care for themselves and spent the rest of their days in a skilled nursing facility due to the lack of correct CVAD removal. This does include, among other factors, proper occlusion of the skin tract. There is a case study of a patient that was allowed to go outside to smoke shortly after his CVAD was removed. He had an air emboi and they were able to document air in the intact fibrin sheath extending from the skin tract. An intact tract, standing or sitting up, breathing deeply is a virtual guarantee for air embolism.
One abstract in English based on a single German publication is not sufficient evidence to change a standard. At best 1 case study alone reporting this problem would represent a Level V, the lowest level of evidence from the INS scale. But the entire publication is not available in Engllish. What is written in this abstract is very limited and raises several questions. There are many critical care articles supporting use of any type of petroleum based gauze to occlude the skin tract from removal of CVADs. In 40+ years of infusion nursing practice, I have always used a petroleum based gauze on these sites.
You are responsible for making decisions based on evidence. This decision should be made by the appropriate committee(s) at your hospital and then all staff should follow that procedure. One final thought (and this will be my last post on this thread as I think we have beaten it to death), air emoblism is now on the list of hospital acquired conditions for which hospitals will not receive any payment for the treatment of this complicating condition. This began from CMS on October 1, 2008 and is now the rules for many insurance companies. So just think of your hospital paying for the care of a 50-something patient who requires nursing home care for the rest of their life. Lynn
I was referring to petrolatum embolism, which is what we seem willing to trade an air embolism for. To clarify, the question is why the INS chose to support a practice that is not only less likely to prevent an air embolism than other readily available products, but is also more likely to create other adverse events. In other words, ointment is not air occlussive, and can follow negative pressure into a vein, which is not well tolerated. There are other interventions which are more likely to actually occlude airflow, and don't present the risk of introducing a non-excretable foreign substance into venous circulation.
I also ran to get my Standards to review. It does say OINTMENT. I have been a proud CRNI for many years and our Team always uses the STANDARDS in the formulation of our Policies & Procedures. So I am just trying to be sure that if I bring this up as an urgent change I feel should be instituted ASAP and taught to our nurses, I want to be certain of what our organization is advocating for" best practice ". Was the intention that there was going to be a wording change and it was overlooked? Nevertheless, it seems from some other posters that gauze (petroleum-based impregnated ) has been used successfully.That is what I will bring forward to Nursing Administration.
I would never rush to get a policy changed based solely on one case study abstract that is 20 years old and has not been duplicated in any other literature. This abstract raised more questions for me than it answered and we have not seen the entire article translating into English. The INS standards committee has begun work on the next version but the process of revising this document takes several years. Lynn
Please don't think this is obsessive, but you mentioned in 40 plus years of practice that you have always used a petroleum based GAUZE. INS Standards 2006 & 2011 say OINTMENT. So shouldn't I advocate for a change now if you know the wording is going to be revised and that you personally use the gauze, NOT the ointment. I really don't care that much about the case study, just that our Administration relies on us to be knowledgeable about current best practice and as CRNI's that we follow Standards. Thanks, PW
So, Lynn, are you still standing behing the use of a petroleum based OINTMENT for this purpose? We are in the process of changing our practice to meet this standard.
Yes I absolutely do support a petroleum ointment in or on a gauze dressing for removal of all CVADs. Lynn
What are nurses instructing the patient to do at discharge? Keep air occlusive dressing on for 24 hours? Then what? If the site isn't healed, are you sending an air occlusive dressing (petroleum gel, gauze, Tegaderm) home with the patient so they can redress?