Has anyone come across any research in regard to drawing blood from PICC's and Central Lines? Does it increase the risk of infection within the catheter? We've been taught to check for a blood return every shift. How is this any different? We have a few physicians who will not allow the nurses to draw blood from their central lines. I feel if the blood draws are done properly with adequete flushing afterward, how is it increasing the risk of infection? We have other physicians who write standing orders that it's fine for staff to draw blood from PICC's/Central lines.
Any insight would be greatly appreciated!
Thank you,
Ann (PICC nurse)
Midland, MI
Hub manipulation increases the risk of contamination and therefore the risk of CRBSI. Drawing a blood sample from any CVC increases hub manipulation. There are no studies that have specifically examined the rates of CRBSI with and without blood sampling from the catheter. If these are available, I have not found them yet. So if any knows of them, please share the reference. How do you define "done properly"? How do you guarantee that each nurse will never contaminate this system with the multiple connections required? I don't think you can ensure that this will always happen. Decreasing hub manipulation is the overall goal for all catheters to reduce the risk of BSI.
Checking for a blood return is not thought to add the same level of risk as blood sampling because you are aspirating and flushing with the same syringe and not disconnecting multiple times. The risk of infusing without a blood return is thought to be far greater than the risk of BSI associated with aspirating for a blood return. No blood return could mean you are injecting into any number of smaller veins, the chest or mediastinum, or retrograde into a fibrin sheath. The risk of infiltration/extravasation could be far worse than treating an infection. 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
My question is about the blood draw process. Is there any evidence based research on using the syringe versus using a vacutainer directly for the blood draw? Am I thinking correctly if I think the vacutainer offers less hub manipulation?
Cindy
To my knowledge there is no research assessing this question. In my opinion, there is about the same risk and manipulation is not less with the vacutainer. You must attach a saline-filled syringe and flush, then attach the vacutainer, the attach the final syringe to flush again. If you can obtain the entire volume with one syringe, the number of connections is the same as the vacutainer. If you needed multiple syringes, instead of one vacutainer holder connection, the syringe method would be more manipulation. But no research comparing these 2 methods and their associated infection risk. I also think it would be very difficult, if not impossible, to isolate this procedure as the only factor contributing to BSI in a study. So I would not anticipate seeing such as study any time soon. 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 something that might be better discussed on the telephone if all your questions are not answered with this email discussion. There certainly is evidence that drawing blood into catheters may create an increased risk of occlusion and infection, but nothing to directly link blood draws. A couple of issues are represented with this topic 1) blood is drawn into the catheter initially with placement and with patency verification, 2) With any blood draw it is necessary to completely clear the catheter of blood, 3) Drawing blood peripherally is preferred especially for certain tests such as drug levels. The issue of lab draws is controversial and leans toward avoidance of complications. You are correct, it is possible to draw labs from PICCs/CVC successfully. The real question is should we, or does it increase the risk more than it benefits the patient? Many institutions have decided not to draw blood from PICCs..preference issue, but one that has many pros. The pros of this type of policy is that theoretically you will decrease your occlusion rate, potentially lower infection rate, also may result in less blows or breakage due to flushing against resistance (esp with a Groshong). As you said if you are already checking for blood return qshift it is virtually the same. The other pro is that most labs are more accurately drawn from peripheral veins, you mentioned drug levels, what about inaccuracies with CBCs due to heparin and saline in the line (yes I understand about waste blood but residual flush is still present), also Glucose levels, chemistries are also skewed when drawn from a PICC, PT and PTTs also are affected by flush solutions...so...the best choice is always to draw labs from a peripheral vein, if you cannot then consider drawing from the line then consistently draw from the PICC/CVC. There have been an occasional articles in the Journal of Intravenous Nursing on lab draws from CVCs etc, you may want to do a quick search in your medical library and read their take on the issue, or email me. Sophie Harnage at Sutter Health Medical Center in Roseville CA has reached zero infections through a multilevel process and still draws blood through PICCs or CVLs, see attached. I recommend going to the step of flushing with 10ml of saline after any blood draw first (flush til clear), rechecking your other preventative measures like your needleless connector. Also making sure the whole hospital is using the same connector. I hope this is all helpful, feel free to ask anytime.
Warm regards,
Nancy
Nancy L. Moureau, BSN, RN, CRNI, CPUI
PICC Excellence, Inc
706-377-3360 office
706-614-8021 cell
www.piccexcellence.com
[email protected]
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
here is the scenario
If you do not draw labs from a PICC/acute CVC/port etc. but you draw from a peripheral stick. Phlebotomy comes up and puts on non sterile gloves, preps with alcohol for a few seconds and re-palpates the site and lo and behold no bacteria ever enter the bloodstream from this blood draw done 2 - 3 times daily. I forgot peripheral sticks never cause infections as you never see it or know it was the cause. Oh but wait you never have to report it either as it is not a central line. The patient satisfaction of being a pin cushion must feel real good.
Care and Maintenance is the issue. I am a firm believer in friction scrub, cap changes or hub to hub draw, and 10-20 ml flush
Kathy