If a patient had 2 sets of blood cultures done that came back negative, and two doctors wanted the PICC removed because they felt it was a source of infection as the patient was not showing signs of improvement, would you culture the tip of the PICC upon removal?
No as that would only get to extraluminal side of catheter. You need to obtain at least one of a pair of cultures from the Cath lumen and compare to the one from a peripheral vein. It was appropriate to remove the PICC in this situation Did patient improve after removal? 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
No as that would only get to extraluminal side of catheter. You need to obtain at least one of a pair of cultures from the Cath lumen and compare to the one from a peripheral vein. It was appropriate to remove the PICC in this situation Did patient improve after removal? 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
Yes she did, according to the MD's notes.
Kimberly Masser CRNI
Vascular Access Services
Frederick Memorial Hospital
Frederick, MD 21702
How did the patient receive ongoing antimicrobial therapy after the PICC was removed?
Please pardon my ignorance, I am always so confused about this part: In the absence of a confirmed CLABSI (due to a lack of positive blood cultures) and the presumed lack of any other identifiable source of infection, what is the rationale for removing the line? If there is a line in place and no other identifiable source of infection, is the presumption that the line is the culprit? Is the strategy simply an attempt to get the line out ASAP to escape the 48 hour window and avoid a CLABSI diagnosis? What do you do if the ideal therapy is a long term vesicant antibiotic and you still will need a central line? Do you pull the presumptively infectious PICC and replace it with something else while the patient is not improving (presumably still fevering)? This is the scenario that still confuses me (not hard to do!)
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
The patient was placed on PO meds. If the line is suspected of an infectious process in the patient, a PIV can be placed for several days until another PICC can be placed.
Kimberly Masser CRNI
Vascular Access Services
Frederick Memorial Hospital
Frederick, MD 21702
Confusion is coming from trying to apply surveillance criteria for CLABSI to a clinical diagnostic process for CRBSI. Look at many differences between these 2 types of data. 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
I guess what is confusing to me about the scenario is the conclusion that this must be a CRBSI when cultures never grew out. I know the IDSA Guidelines state to remove a long term catheter in the setting of a CRBSI that is not resolving on susceptible antibiotic therapy, but what is the evidence that this line is the culprit? Is it a diagnosis of exclusion? I had a situation while working inpatient oncology once where a patient with persistent fever on antibiotics had a line pulled and it was later found they had an occult anal fissure. The line was never the problem. If Vancomycin is the treatment of choice, you can't give that orally (for empiric CRBSI treatment) and you wouldn't want to give it peripherally if you could avoid it. I'm glad in this scenario the patient improved after the line was pulled, though.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Cultures only grow out something IF the blood sample capture any organisms. The lack of positive culture could mean that there simply were no organisms flowing thru that peripheral site at that time or not enough blood was sent for culture. The wise choice is to remove the Cath. Also the reason for a Cath sample to compare to the peripheral with time to positivity or colony counts. 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