How to get blood return on PICC?

According to numerous clinical guidelines, verifying blood return is a critical step before administering medications through a Peripherally Inserted Central Catheter (PICC). Understanding how to get blood return on PICC is vital for patient safety and ensuring proper catheter function.

Quick Summary

Obtaining blood return from a PICC line requires a systematic approach, starting with non-invasive patient positioning techniques, followed by gentle flushing and assessment for mechanical issues, all performed with strict aseptic technique. Persistent issues may indicate a more significant problem like a thrombotic occlusion or catheter malposition, requiring escalation to a healthcare provider for further investigation and intervention.

Key Points

• Start with the simplest interventions: Before assuming a major issue, have the patient change their arm position, cough, or take a deep breath to move the catheter tip away from the vein wall.

• Check for mechanical problems: Inspect the entire line for kinks or closed clamps, including under the dressing, and consider replacing the needle-free connector.

• Use a gentle, systematic flush technique: Employ a 10 mL syringe or larger and a pull-pause method to aspirate blood; never force a flush if you encounter resistance.

• Recognize signs of more serious issues: A persistent lack of blood return, especially a one-way occlusion (flushes but doesn't aspirate), may indicate a thrombotic occlusion or fibrin sheath.

• Know when to escalate: If basic troubleshooting fails, stop and notify a healthcare provider to investigate further with imaging or administer a thrombolytic agent.

• Prioritize safety: Never administer vesicants or other critical medications without confirming a brisk blood return, as this is a key indicator of correct catheter placement.

Understanding the Importance of Blood Return

Verifying blood return from a PICC line is a fundamental safety measure in modern healthcare. This confirms the catheter's tip is properly positioned within a central vessel, such as the superior vena cava, and that the line is patent (unblocked). An inability to get blood return, while sometimes harmless, can signal a serious issue like a catheter occlusion or tip migration, which could endanger the patient if not addressed promptly. For critical treatments like vesicant chemotherapy, confirming blood return is non-negotiable. Therefore, mastering the troubleshooting techniques for obtaining a blood return is an essential skill for any clinician working with PICC lines.

Step-by-Step Troubleshooting for No Blood Return

When you cannot get a blood return from a PICC line, follow these steps in a systematic order, from least invasive to most. Always maintain a strict aseptic technique throughout the process.

1. Initial Assessment and Patient Repositioning

Before assuming an occlusion, rule out the simplest causes. Check for obvious issues:

• Patient and Arm Position: The catheter tip may be resting against a vein wall, a common cause of positional occlusion.
  • Ask the patient to change their arm position. Try raising, lowering, or bending the arm.
  • Instruct the patient to take a deep breath, cough, or perform the Valsalva maneuver (bearing down). This can shift the catheter tip away from the vessel wall.
• Clamps and Kinks: Ensure all clamps are open and there are no kinks in the line. This includes checking under the dressing where the line exits the body.

2. Flush and Aspirate Technique

If repositioning doesn't work, proceed with a gentle flush and aspiration.

1. Prepare a saline flush: Use a 10 mL syringe (or larger) to draw up saline. Using a smaller syringe can generate excessive pressure, potentially damaging the catheter.
2. Scrub the hub: Vigorously scrub the needle-free connector with an antiseptic wipe for at least 15 seconds, and let it dry completely.
3. Connect and aspirate gently: Attach the syringe and pull back slowly and gently on the plunger to attempt to aspirate blood. A pull-pause technique can be effective, allowing blood to slowly fill the syringe without causing hemolysis.
4. Try a small flush: If aspiration fails, instill a small amount (2-3 mL) of saline and try to aspirate again. If you meet resistance, STOP and do not force the flush.

3. Consider Equipment and Mechanical Issues

If the problem persists, examine the equipment.

• Change the needle-free connector: The connector itself can sometimes become faulty or clogged. Replace it with a new one using aseptic technique.
• Examine for external kinks: Carefully inspect the entire external portion of the line for any kinks, even under the securement device or dressing.

4. Advanced Troubleshooting: Suspecting Deeper Issues

When basic steps fail, more complex issues might be at play.

• Thrombotic Occlusion: A blood clot can form inside the catheter, preventing aspiration. This is one of the most common causes of occlusions. It's often diagnosed by the inability to aspirate but the ability to flush (a one-way occlusion). Treatment typically involves a thrombolytic agent like alteplase, which must be administered by a healthcare professional according to facility protocol.
• Catheter-tip Migration: Over time, the tip of the catheter can shift from its optimal position in the superior vena cava, potentially moving into a smaller vessel or pressing against a vessel wall. Changes in the external length of the catheter can be a sign of migration. A chest x-ray or dye study may be needed to confirm this.
• Fibrin Sheath Formation: A fibrin sheath can build up around the catheter, creating a flap-like effect that allows fluids to be infused but blocks blood from being aspirated. This is another form of one-way occlusion that requires medical intervention.

5. When to Escalate to a Healthcare Provider

If you have tried the basic troubleshooting steps without success, it is crucial to stop and escalate the issue. Administering certain medications, especially vesicants, without confirmed blood return is extremely dangerous. A provider may order a diagnostic study, such as a cathetergram, to investigate the cause and determine the appropriate intervention.

Comparison of Common PICC Issues and Solutions

Issue	Cause	Troubleshooting Steps	Escalation Required?	Outcome
Positional Occlusion	Catheter tip resting against vein wall due to patient movement or position.	Reposition patient's arm, have patient cough or breathe deeply.	No, usually resolves with patient repositioning.	Blood return obtained, line function restored.
Mechanical Obstruction	External kink in the tubing or a faulty needle-free connector.	Check for kinks, replace needle-free connector using aseptic technique.	No, typically user-fixable with proper technique.	Blood return obtained, line function restored.
Thrombotic Occlusion	Blood clot inside the catheter lumen. Often a one-way occlusion (flushes but doesn't aspirate).	Gentle saline flush attempt, then escalate. Do not force flush against resistance.	Yes. Requires order for thrombolytic agent (e.g., alteplase) administration.	Patency restored after thrombolysis or line replacement.
Catheter-tip Migration	Tip of the catheter has moved from its intended central vein location.	Escalate immediately. May be confirmed by changes in external length.	Yes. Requires imaging (x-ray, dye study) to confirm tip location.	Catheter repositioned or replaced.
Persistent Withdrawal Occlusion	Fibrin sheath has formed, creating a one-way valve effect.	Escalate to provider. Confirmed by flushing easily but inability to aspirate.	Yes. May require thrombolytic therapy or catheter replacement.	Patency restored after treatment or line replacement.

The Role of Preventative Care in Maintaining Patency

Prevention is key to avoiding issues with blood return. Regular, turbulent flushing using the push-pause method helps keep the catheter's internal lumen clean and free of build-up. Additionally, performing a positive pressure flush upon disconnecting the syringe helps prevent blood reflux into the catheter, which can cause an occlusion. Adhering to a proper flushing schedule and using the correct technique is the best defense against a non-functional PICC line. Consult reliable sources, such as guidelines from the Infusion Nurses Society (INS) for best practices: https://www.ins1.org/.

Conclusion

While a lack of blood return from a PICC line can be concerning, a systematic approach to troubleshooting can resolve most issues. By starting with simple, non-invasive techniques like patient repositioning and moving to more advanced methods, clinicians can effectively manage these complications. Remember to prioritize patient safety by never forcing a flush and escalating to a healthcare provider if a clear blood return cannot be established, especially before administering critical medications. Proper education and adherence to institutional protocols are vital for safe and effective PICC line management.

Frequently Asked Questions

What is the very first thing I should do if I can't get blood return from a PICC line?

The first step is to check for positional issues. Have the patient reposition their arm, cough, or take a deep breath. This can often move the catheter tip away from the vein wall and restore blood return.

Why is it important to use a 10 mL syringe or larger when flushing a PICC line?

Using a syringe smaller than 10 mL can generate excessive pressure, which could potentially damage or rupture the catheter. Larger syringes produce less pressure, making them safer for flushing PICC lines.

What does it mean if I can flush the PICC line but can't aspirate blood?

This is known as a 'one-way occlusion' or Persistent Withdrawal Occlusion (PWO). It often indicates a thrombotic occlusion or a fibrin sheath has formed, creating a flap that allows fluid to flow in but not out.

When should I escalate a 'no blood return' issue to a healthcare provider?

You should escalate the issue if repositioning and gentle flushing techniques have failed to restore a blood return. It is especially critical to escalate if you suspect a thrombotic occlusion or need to administer a vesicant medication.

Can I still use a PICC line that has no blood return for infusions?

It depends on the medication and institutional policy. While some non-vesicant medications may be permitted after confirming patency through a dye study, it is generally recommended to resolve the issue first. Never administer vesicants without a confirmed blood return.

How does a positive pressure flush prevent loss of blood return?

A positive pressure flush involves maintaining pressure on the syringe plunger as you disconnect from the catheter. This prevents blood reflux back into the catheter tip, which can lead to a thrombotic occlusion.

What is the Valsalva maneuver, and how does it help?

The Valsalva maneuver involves a person attempting to exhale against a closed airway, which temporarily increases intrathoracic pressure. This can help move the catheter tip off the vein wall and potentially restore blood return.