We have a patient on cyclic TPN with nothing that would cause precipitate. She has a double lumen picc line of which one lumen will not produce a blood return. The other lumen was causing problems which required cathflo sometimes twice a week until we started using neutron caps. It now has not needed cathflo since we started using the neutron caps. The problem is the other lumen. It has been cathflo'd many times with no success. The patient flushes it twice a day and does not now use it for infusion of her TPN. I'm stumped as to what to do. We had her go in for an x-ray to verify placement again and all was good. The RN seeing her describes the lumen collapsing on itself when she draws back but can flush it. Any suggestions?
Cindy Tripi, RN, OCN
Director of Patient Care
Amerita Specialty Infusions
Some formulas of TPN have many components that can lead to precipitate such as calcium. Also is this a 3-in-1 admixture with fat emulsion in the same fluid container? If so, you could easily be dealing with fat lining the catheter lumen, narrowing it and preventing blood return. Does this PICC have staggered or nonstaggered lumen exit sites? If staggered, one lumen could be occluded with fibrin and the other not be. Or one lumen could be positioned against the vein wall and the other be free from the vein wall. What information did you get from radiology - specific information is required and I would not accept them telling me that "all was good". This could be no more than the technique of the person attempting to draw back. What size syringe is she using? On aspiration, larger syringes create greater pressure so smaller syringes with a slow and gentle technique to aspriate may produce a blood return. What type of needleless connector is being used on the lumen without a blood return? You must know whether it is negative, positive or neutral fluid displacement and use the correct flushing and clamping sequence for each. Neutron is neutral so you can disconnect the syringe before or after clamping the catheter. For negative, flush, clamp, then disconnect. For positive, flush, disconnect then clamp. The patient must be taught how to do this for the NC in use. 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
This is a challenging issue that we have come accross as well. If the patient is getting medications and/or TPN and I can not clear with cathflo and have verified tip placement, have used a 1 mL dose of 0.1 Normal Hydrochloric Acid. It can clear any precipitaion along the the internal lumen of the catheter. It often works well in conjunction with cathflo. Our facility has used HCL for over 20 years for precipitaion issues and it has saved many catheters from being replaced.
Theresa Reed
Texas Children's Hospital
Houston, TX