Hi there,
I am fairly new to the PICC inserter world. I am trying to find resources that speak to attempting an over the wire exchange for a blocked single lumen PICC. I have read some anecdotal stories about people seeing clincians 'rotorooting' a blocked PICC with a guide wire in an effort to clear it--this seems dodgey to me.
However, my question is, after the failure of all unblocking attempts (the legitimate kinds!) how safe/reasonable is it to make a gentle attempt at an over the wire exchange? I have concerns about the risks of embolizing the blockage into the blood stream of course. I read through the INS standards that I was given but they don't speak to this kind of thing.
Teach me Oh Be Wan, your my only hope....;)
Nell
I would argue that the INS Standards do include this information. Standard 55 Central Vascular Access Device Exchange. Do you have polciy and procedure to cover what you are asking about? Have you weighed the risk vs benefits for this procedure? Your question involves many aspects of a specific procedure and the standards are not written to answer that level of detail. The references listed are the ones available as of when we finished our literature review in mid-2010. So your literature search can easily begin at that time and go forward. You did not state the cause of this blockage nor the clinical signs and symptoms. Has there been a cathetergram done in radiology to determine what is causing this obstruction? What techniques were tried? If you tried tPA and the obstruction is caused by a drug precipitate, there is no reason to expect that the tPA would resolve the issue. That is just one example. There could be a multitude of other reasons. After knowing what you are actually dealing with, you can then create a plan of care. Without more informaiton about the cause, it might be dangerous to proceed. 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
As usual, Lynn is getting to the root of the issue. Just to add though, you said blocked, which leads me to figure that you can not flush. If it is a line packed with blood, the problem is quite obvious and you would try tpa to clear. If minimal or no blood is observed, I first check for visible mechanical obstruction. Remove any connectors, and check directly from the hub. Make sure the line is not kinked or pinched, take the dressing down if need be. If you still cannot flush. then procede to tpa. If you suspect drug precip because tpa was unsuccessful and the line is clear, I would follow up with a cxr. If the position is satisfactory, lower 1/3 svc, and you still can not flush, then an exchange may be your next option if all other things seem "normal". I personally wouldn't put a wire through a catheter that is occluded and technically Rns are not supposed to insert wires beyond the axillary vein. For a wire exchange, the catheter is pulled back most of the way and the guidewire is inserted just long enough to hold the insertion site.
To exchange a blocked picc, or a picc that has had intralumenal contamination, you can exchange the line without a wire by inserting the break away sheath without the microindroducer over the trimmed picc. They usually slide in to an established site fairly easily. Then you can remove the old one and insert the new one. No wire, no flying particles. If you are unable to advance over the catheter or lose the vein, then a new picc on the other arm will be neccessary.