BIPOLAR LEADS:

Bipolar leads are so named because they require a positive pole and a negative pole. Just like a a battery that have positive an begative poles. The positive electrode is the one that actually “sees” the current coming. The lead that sees the current makes the wave. The direction the current is coming from determines if the wave will face upwards of downwards. Sounds like Greek in England? I apologize but I will try to make it as simple as possible.
Lets review that small paragraph:

• That bipolar leads have positive and negative poles = CHECK
• The positive lead is the one that sees the current = CHECK
• The direction the current is coming from determines the direction of wave deflection = CHECK

So which are these bipolar leads that have positive and negative poles with the positive lead seeing the current? There are 3 bipolar leads in a 12 lead EKG: -

• Lead I. Measures the current traveling between the right and left arms. The right arm is negative pole and the left arm is positive pole. So, the lead on the left arm is the one that sees the current travelling from the right arm = CHECK
• Lead II. Measures the current traveling between the right arm and the left leg. The right arm is negative pole and the left leg is positive pole. So, the lead on the left leg sees the current coming from the right arm. = CHECK
• Lead III. Measures the current traveling between the left arm and the left leg. The left arm is the negative pole and the left leg is the positive pole. Likewise, the lead on theleft leg sees the current coming from the left larm. =CHECK

You’ll notice that in the bipolar leads the right arm is always negative and the left leg is always positive. Also note that the left arm can be positive or negative depending on which lead it is a part of. If you join leads I, II, and III at the middle, you get the triaxial diagram

AUGMENTED LEADS:

· aVR. Measures the current traveling toward the right arm. This is a positive electrode. The electrode is on the right arm.
· aVL. Measures the current traveling toward the left arm. This is a positive electrode. The electrode is on the left arm.
· aVF. Measures the current traveling toward the left foot (or leg). This is a positive electrode. The electrode is on the left leg.

These are called augmented leads because they generate such small waveforms on the EKG paper that the EKG machine must augment (increase) the size of the waveforms so they’ll show up on the EKG paper. These leads are also unipolar, meaning they require only one electrode to make the leads. In order for the EKG machine to augment the leads, it uses a midway point between the other two limbs as a negative reference point
Both the bipolar and augmented leads are also called frontal leads because they look at the heart from only the front of the body.

PRECORDIAL (CHEST) LEADS

These leads are located on the chest. They are also unipolar leads, and each one is a positive electrode. The precordial leads see a wraparound view of the heart from the horizontal plane. These leads are named V1, V2, V3, V4, V5, and V6.

 FACTS ABOUT EKG

· An impulse traveling toward (or parallel to) a positive electrode writes a positive complex on the EKG paper.
· An impulse traveling away from a positive electrode writes a negative complex.
· An impulse traveling perpendicularly to the positive electrode writes an isoelectric complex (one that is as much positive as it is negative).
· If there is no impulse at all, there will be no complex¾just a flat line.

NORMAL QRS DEFLECTIONS

How should the QRS complexes in the normal EKG look? Let’s look at the frontal leads:

• Lead I Should be positive.
• Lead II Should be positive.
• Lead III Should be small but mostly positive.
• aVR Should be negative.
• aVL Should be positive.
• aVF Should be positive.

Now that this might need a day or two to digest, I will stop at this point. Next, we will re-visit this same topic with descriptive diagrams to show you how the current travel and the expected EKG wave deflection.

The length of pregnancy is calculated at 280 days from the first day of the LMP. However, there are various factors that will affect the length of pregnancy and the calculation of the EDD: -

Ever heard that the gestation period of a human being is 9 months or 40 weeks? This is a generalization because various factors can affect expected day of delivery.

* The length of the menstrual cycle: Some people have 28, 30 or 33 days cucles. Others even have 25 days cycle whle others are never consistent.
* Conception within three months of discontinuing the contraceptive pills:
* Conception while taking the contraceptive pill
* Conception when an intrauterine device is in situ
* When the last bleed is calculated as a menstrual period when it is an implantation bleed
* In vitro fertilization when the day of conception is known.

When taking details of a woman’s menstrual history, the following questions should be asked:
* At what age when menstruation started
* Regularity of menstrual bleeds
* Frequency of menstrual bleeds
* Length of menstrual bleeds, especially the last one.

Gestational age and calculation of EDD by LMP is calculated according to Naegele’s rule. That is, counting forwards by nine months and adding seven days from the first day of the LMP or by adding a year, counting backwards by three months and adding seven days.

It is important to calculate using the length of the menstrual cycle. The latter calculation is based on a 28-day cycle. For a 33-day cycle, the calculation is to add nine months, then seven days then five days.

Enjoy and share with a friend

In the second part of 12 lead EKG interpretation, we will look at simple heart arrhythmias that can be detected by 12 lead EKG or just a primary lead EKG strip. By basic I mean those rhythms that you can look at only one primary lead (usually lead 2) and tell what it is. There are other EKG abnormalities that needs you to look at more than one lead, the position of the heart (also called axis), specific segments, amplitude and voltage of the leads. But don’t let this make you run away from 12 lead EKG interpretation because it is quintessential you understand it. If reading this can make you save only 1 life, then it is all worth understanding 12 lead EKG interpretations. Needless to say, more lessons are coming about: -

1. Understanding 12 ECG/EKG lead placement
2. Understanding the circulation of the heart and which arteries when blocked caused AMI
3. Understanding which leads on EKG are positive, negative or neutral in polarity.
4. Understanding the normal axis of the heart and what deviation from normal axis mean (Have you ever seen some numbers at the top of EKG graph and you wonder what they mean? Just understanding those numbers points you to the problem area and when you look at specific waves, you are just confirming. This is a key to successful 12 lead EKG interpretation

The following are the common arrhythmias of the heart that you probably already know about. They are straight forward to diagnose and most of them has no emergent attention command

1. Sinus Bradycardia:AKA Sinus Brady is a regular heart rhythm with less than 60 beats per minute. It should be noted that sinus bradycardia has regular beats. There must be P waves before every QRS at a ratio of 1:1, meaning per every 1 P wave, there is 1 QRS complex. The distance between P wave and the beginning of QRS complex (PR interval) must be between 0.12-0.20 seconds. Each small box in EKG measures 0.04 seconds, meaning a normal PR interval has 3-5 small boxes.  Got it? Are you sure? Soon we will find out because if you see a rhythm of 45 and call it sinus bradycardia before measuring PR interval, you could be misdiagnosing with junctional rhythms.
2. Sinus tachycardia:AKA Sinus Tach is a regular rhythm with more than 100 beats is a minute but less than 150 beats. Why less than 150? If a rhythm has more than 150 beats, it is not possible to see the P-Wave as the beats succession is so rapid. This is what is called supraventricular tachycardia and recently renamed as narrow complex tachycardia. We will look into this soon. Sinus tachycardia must have a normal P-Wave before each QRS complex and PR interval must be the same. The distance from one R wave (top of QRS) to the other must be the same (R-R). If R-R wave is not regular, you might be looking at atrial fibrillation AKA A-Fib. Are you feeling like you might have misdiagnosed sinus Tachycardia already? Most likely not but keep reading
3. Sinus Arrhythmia: What? Never heard of that! Sinus arrhythmia is an irregular heart rhythm usually seen in ICU or telemetry patients on continuous monitoring. The heart rate is variable depending on inspiration or expiration. With inspiration, the heart rate increases and with expiration, the heart rate decreases. All other parameters are normal like 1:1 ratio of P-wave and QRS complex, PR interval of 0.12-0.20 and QRS complex less than 0.10 seconds.
4. Premature Atrial Complex (PAC):This is yet another rarely heart arrhythmia that is benign in nature. You never call a rhythm PAC but rather mention the underlying rhythm with PAC. Example, Sinus rhythm with PAC or Sinus Bradycardia with PAC’s. So what is it? There is an ectopic beat once in a while. The ectopic beat originates from atrial heart cells firing before they are supposed to. Except the ectopic beats, all other beats are normal with normal measurements. Patients may complain of feeling as if the heart stopped for a beat, something also reported in A-Fib
5. Atrial Flutter: The so called saw tooth wave form is one of the easiest for many of us to diagnose. The atrial beats (firing) could be as many as 230-350 times in a minute but ventricular conduction may be normal (60-100 beats). These saw tooth like waves are called U-Waves. Aha! U-Waves. QRS is normal in morphology and measurements. Of course, there are no P-Waves as they have been replaced by U-waves.
6. Atrial Fibrillation: A-fib is a silent killer FYI due to clots formation in the right atria. Nothing about A-Fib is regular. The rhythm is irregular meaning that there are variable R-R wave distances between each beat. The baseline may look like a wavy line with irregular U-Waves. It is an irregular irregularity in simpler terms. There are no P-waves but U waves. QRS is upright and normal in measurements (<0.1 second).
7. Supra Ventricular Tachycardia (SVT) also called narrow complex tachycardia (NCT).This is a super fast sinus tachy is simpler terms. The heart is so fast, between 150-250 beats a minute. Do you know how it is treated? Ever heard of adenosine?
   



8. Junctional Rhythms:There are 3 types of junctional rhythms namely Junctional escape(40-60 beats a minute, less than normal), accelerated junctional rhythm (61-99 beats, normal heart beats a minute) and junctional tachycardia (100-140 beats a minute). How do you know if it is a junctional rhythm?
   1. The heart rate is regular, meaning R-R is regular
   2. The P-wave is inverted instead of facing upright OR
   3. There is no P-Wave in front of every QRS complex
   4. The PR interval is larger than 1.20 seconds
9. Ventricular Tachycardia:V-Tach (Code blue) is a life threatening emergency rhythm that must be intervened immediately or sudden death will occur. This monster is between 100-250 beats a minute with no P-waves. There is no QRS complex, meaning that the heart is NOT perfusing itself or other organs and cardiopulmonary resuscitation (CPR) is warranted. The waves in this rhythm are through to be bizarre looking QRS complexes. If you see this rhythm (monitor alarms will scream at you even before you see it if you have your alarms set and armed), immediately call for help, assess ABC’s and start CPR. Remember, this is a NON PERFUSINGrhythm and CPR is warranted unless the patient is awake and alert. Guess what, the patient cannot be awake and alert if they are in true V-Tach. If the monitor shows V-Tach and you see them moving, it could be a false rhythm caused by insecure leads or movement. If it is a true V-Tach, they will be unresponsive and you must start CPR NOW! Do you hear me? It is also a shockable rhythm per ACLS algorithms.
10. Ventricular Fibrillation: Call Code blue and start CPR ASAP. Just like V-Tach, V-Fib is a NON-PERFUSING Rhythm. You cannot see any P-Waves, no heart rate, no QRS complex, just a wavy line.

In one of the future articles, I will talk about other rhythms that you may never see easily but can tell you that a life threatening emergency is likely. Example, Torsades de Pointes, which may be seen during long resuscitation due to low magnesium or calcium level. It can also be caused by Haldol IV-Push. (Always give haldol as I.M. and never as IV although you might say… we do this all the time and even doctors order it as I.V. Consider yourself warned!

In the next article, we will look at heart blocks, how to recognize them easily by just checking key areas and then we will go back to interpreting 12 Lead EKG. After heart blocks, we will look at how 12 Lead EKG leads are placed, what they mean, what side of the heart are they are looking at, and what lead correspond to what side of the heart. We will also look at the axes of the heart because understanding axes can accelerate your 12 lead EKG interpretation.

Discussion:

By replying here with comments, describe in as many words as you can: -

1. A life threatening emergency you have ever taken part in. Tell us what happened and what was done to save the patient. Did the patient survive? Do not mention names or locations.
2. Have you ever been in a code blue and how did it go? Did you participate? CPR? How did that go?
3. There are other rhythms that are not mentioned here. Can you identify any?

Do you know what to look for to determine if Mrs. Troponin 12-lead ECG is abnormal? Could you recognize signs that she’s having a myocardial infarction (MI)? How about heart blocks, all of them?

If you can independently interpret a 12-lead ECG, you can anticipate and prepare for the emergency care your patient may need. In this article, I’ll cover the basics of 12-lead ECG interpretation,focusing on a normal ECG. Once we are clear with the normal EKG, we will look at abnormal EKG and how to interpret.

To understand the normal EKG, you must understand the heart contractile process, the electrical pace makers, and electrical pathways all the way to the ventricles. Since my goal is EKG and not cardiac anatomy, I will only focus on what is happening at what point. Maybe we can re-visit cardiac anatomy in future.

The contraction of the heart begins at sinoatrial node (SA node) located on the right atria (also called the natural pace maker). The SA node fires between 60-100, hence the normal heart rate of a human being. All contractions must start from SA-Node for us to call a rhythm as a Normal Sinus Rhythm (NSR). On EKG, the firing of sinoatrial node is indicated by P-Wave on EKG. Got it? After the SA-Node fires, the electrical impulses travels down to atrial-ventricular node (AV-Node) located between the atria and the ventricles, hence the name— atrial-ventricular node (AV-Node). This causes the atria to contract (depolarization indicated by the P-Wave on ECG).

AV-Node has an intrinsic pace between 40-60, meaning if SA-Node failed to fire, the AV node can initiate contractions at a rate between 40-60 beats a minute. Such beats are called Junctional, because they are from AV-Junction and not from SA-Node. To recognize these beats: -

1. The heart rate is between 40-60
2. There is no P-Wave before every QRS complex OR
3. The P-Wave is inverted.

The time the impulse take to travel from SA node to AV node in EKG is indicated by P-R interval (0.12-0.2 seconds). The AV node holds the impulse briefly allowing the ventricles to fill with blood.

HINT: To understand abnormal EKG, you must remember the time each process takes. There is no way around this. You also need to know that a QRS complex must be preceded by an upright P-Wave and a PR interval lasting between 0.12-0.2 seconds and not longer. A P-wave must always face upwards in a normal EKG, not downwards. We’ll talk more about this when talking about abnormal ECG.

EKG waves explained

Back to the AtrioVentricular node where we said it delays the impulse and gives time to let the ventricles fill with blood after atrial contraction. Assuming that you know your cardiac anatomy, the impulse travels from AV-Node through bundles of His and down to Purkinje fibers. There is left and right bundles, something you also need to know to understand bundle branch blocks (BBB) coming soon.

The bundle branches are high speed conduction fibers and connects with Purkinje fibers.The moment the impulse leaves the AV node, ventricular contraction begins. Since these are high speed fibers, the ventricular contraction takes 0.06-0.1 seconds indicated by QRS complex. Got it?

HINT: If there is an issue with either right or left bundle of His, the QRS contraction takes longer than 0.1 second, indicated by a wide QRS. Any time you are looking at a 12 lead EKG and QRS is greater than 0.1, you automatically know there is a bundle branch block. We will talk more about how you tell if it is right or left from an EKG.

Normal EKG

Back to QRS complex, which we said it indicates ventricular contraction and relaxation. Before I start confusing you with why QRS has downwards and upwards deflections, before I start explaining why R wave is taller than the rest, let us finish all parts of a normal EKG. I will explain the leads position, their polarity, what side of the heart they look at and the direction the current is traveling before going to abnormal EKG. Deal?

The QRS is followed by a T wave. Between the T wave and the end of QRS (S-section) is the S-T segment. This is a very important section of an EKG because it indicates the oxygenation of the myocardium and potassium levels. Peaked T wave indicates high potassium level. When myocardial cells are injured,the ST segment often is elevated above the baseline. So ST segment elevations are a key indicator of MI. Depressed ST segment may indicate old myocardial infarction.Myocardial ischemia (temporary and reversible) often results in an ST segment below the baseline of the ECG tracing.

HINT: You must know the baseline of an EKG tracing and notice the height of each wave. You also should know what parts of EKG can show you life threatening events are imminent.— ST segment. In the next article, I will go through the leads and which leads you should look at to detect MI.

Discussion:

1. Assuming that Mrs Troponin was having MI, and as a good nurse, you remembered MONA. What is the rationale of using Morphine?
2. How well do you understand bundle branch blocks?
3. How many abnormal Rhythms do you know? List them on comments section of this article and we will discuss them later.

1/3(SBP-DBP)+DBP = MAP
Explanation.
Systole is the time when the ventricles are contracting and diastole is the relaxation time. In normal condition, the systole phase takes about half the time the diastole takes. In other words, diastole takes twice as longer as systole.
This explains why we cannot just add systolic blood pressure and diastolic blood pressure and divide it with 2. The time each takes is different. In-stead, if we divided the time in equal parts, we would have 3 equal parts, where the systole takes 1/3 and diastole takes 2/3 of total time.

To test if this is true, we can multiply systolic BP by 1/3 and diastolic BP by 2/3 and add the results together to come up with the mean arterial pressure.

Lets use real example using the known formula of 1/3(SBP-DBP)+DBP = MAP and control theoretical explanation and see if we will come up with the same results.
Lets say a patient BP = 120/60. Pulse pressure (SBP-DBP) would be 120-60 = 60.
Mean Arterial Formula: 1/3(SBP-DBP)+DBP = MAP
1/3 X 60 = 20
Add the result above to DBP (60)
20+60 = 80
Lets now use the theoretical way of testing if the formula above gives a true picture of how the heart works in normal conditions.
Our sample BP is 120/60

We will multiple SBP X 1/3 AND DBP X 2/3 and then add the total. We should get the same results as above
1/3×120 = 40 + 2/3×60 = 40. 40+40 = 80

Happy? Leave your comments/complements

PICC lines are also safe for patients to take home and administer medications intravenously. Home care for PICC lines can be tricky and likely to develop complications such as infection, dislodging or blockage.

PICC line is centrally placed into the big veins of the body, specifically the subclavian vein. This make PICC line a great asset that can be used for months if maintained properly.

Here are some few tips on how to care for a PICC line at home.

1. Make sure the clear occlusive dressing is intact all the time. Covering the PICC line with occlusive dressing when taking a shower is recommended.
2. Avoid heavy using of the arm that has a PICC line to avoid complications such as dislodging and kinking.
3. PICC line dressing must be changed every 72 hours under sterile technique is no Biopatch was used and every 7 days if a biopatch was used.
4. Flush each PICC line port with 10cc normal saline without mixing the syringe. This is a good way to prevent cross contamination of PICC line ports.
5. Always use alcohol prep to clean PICC line head/ports before and after use. Alcohol prep helps to prevent introducing bacteria into your body.
6. You must flush PICC line with atleast 10cc of normal saline after administering medications. This prevents mixing of incompatible medications that may precipitate and clog the PICC line.
7. Never administer any medication on PICC line without consulting your physician.
8. PICC line ports should be changed with every dressing change, Microclave male adaptors are recommended for use as PICC line access ports.

Advantages of using microclave male adaptors on PICC lines

1. Microclave male adaptors prevent PICC line leakages
2. The minimize/eliminate use of needles, thus making them safer for patient and staff use.
3. They minimize introduction of bacteria into the blood stream
4. Makes it easy to make a connection or disconnection without compromising sterility
5. They can be changed regularly with dressing changes and as needed.

How to flush a PICC line

1. Wash your hands with soap and warm water for at least 15 seconds and dry with clean towel.
2. Wear gloves for protection incase of accidental PICC line retrograde leakage.
3. Clean the tip of the microclave port with alcohol pad and wait for it to dry.
4. Using the luer, screw in a 10cc syringe filled with normal saline. Do not use less than 5cc syringe to prevent bursting out the tip of the PICC line, which can cause ischemic conditions like stroke, pulmonary embolism or heart attack.
5. Use turbulence flush technique. In turbulence PICC line/central line flush technique, you flush intermittently with the full 10 cc of normal syringe.
6. Never leave blood showing on PICC line tube.

1. If you are planning on having a baby, be healthy before you get pregnant and take folic acid to prevent birth defects of the brain and spine.
2. Tell your doctor if you have high blood pressure, diabetes or any other illness.If you think you may be pregnant, see a medical provider immediately. Early prenatal care could prevent having the baby too soon. Learn the signs of pre-term delivery – dads, family and friends need to know too.
3. If possible, breastfeed your baby. Breastfeeding during the first year may prevent the baby from getting sick and may reduce the risk of infant death. Research has shown that breast fed babies have very few cases of sudden infant death syndrome (SIDS)
4. Make the baby’s sleep environment safe. Babies should sleep on their back. Do not use soft bedding, don’t smoke around the baby and don’t let the baby get too warm. Avoid sharing the bed with an infant as this can facilitate SIDS. The true causes of SIDS are not clearly known but heat and possible suffocation/asphyxia has been blamed for infant deaths.
5. Use a car seat that is the right size for the age and weight of the baby. Make sure it is properly installed. If unsure how to secure a car seat, your local fire department can help you learn how to do it for free.
6. Never shake a baby. Crying is a baby’s way of communicating but if the crying is too much to handle, call someone to help or place the baby in a safe place and leave the room until you are calm. Shaking the baby can break bones, cause spinal cord injuries with permanent injuries and disability. Shaking a baby is illegal in USA punishable with jail time and fine and the baby taken away by child protection services.

• Do skin checks in the morning and the last thing at night. Look for redness, dark areas, cracks, bruises, and blisters. Note any white spots or areas. The skin may turn white before it reddens. Watch for red, tender, or swollen areas on the skin. Pay special attention to any areas that stay red after the pressure has been relieved. The goal is to find and correct problems before skin breakdown occurs.

• Feel for lumps, soft areas, or unusual warmth (use the back of the hand). Do not massage a reddened area.

• Clean when incontinent (wetting or soiling the bed) as soon as possible. Use a soft cloth or sponge to reduce injury to skin.

•  Minimize moisture from urine or stool, perspiration, or wound drainage. Use pads or briefs that absorb urine and have a quick drying surface that keeps moisture away from the skin.

• When bathing or showering, use warm (not hot) water and a mild soap.

• To prevent dry skin, use creams, ointments, or oils on the skin. Don’t use alcohol or other drying agents on the skin.

• Avoid cold or dry air.

Change positions often

• Limit pressure over bony parts by changing positions.

• If in bed, change position at least every 2 hours.

• If in a wheelchair, change position every 15 to 60 minutes.

• Be careful not to scrape sensitive areas when changing positions. Bed sheets or lifters can be used to help lift the body. A thin layer of cornstarch on the skin may help reduce damage from friction.

• Avoid lying directly on the hip bone when lying on your side. Also, choose positions that spread weight and pressure more evenly.

• Massage may help. Do not massage bony areas of the body such as knees and elbows.

• Exercise to relieve pressure, such as “push-ups” from the wheelchair or bed and shifting weight.

Use devices to relieve pressure

• Use a foam, gel, or air cushion or mattress to relieve pressure. Ask your healthcare provider which is best. Avoid donut-shape cushions because they reduce blood flow and cause tissue to swell, which can increase the risk of getting a pressure ulcer.

• The head of the bed should be raised as little and for as short a time as possible depending on the medical condition. When the head of the bed is raised more than 30[degrees], skin may slide over the bed surface, damaging skin and tiny blood vessels.

• Use pillows or wedges to keep knees or ankles from touching each other. If completely immobile, put pillows under the legs from mid-calf to ankle to keep the heels off the bed.

• Keep sheets wrinkle-free.

• Wear clothing without thick seams.

• Never put a heating pad where there is no sensation.

Eat well

• Eat a balanced diet. Protein and calories are very important. Healthy skin is less likely to be damaged.

• Drink plenty of liquids.

• If unable to eat a normal diet, talk to your healthcare provider about nutritional supplements.

• Some studies show zinc and Vitamin C help promote healing of large wounds.

• Limit stretching the areas around your wound. This will help prevent bleeding and swelling of the wound area. Try not to bump or hit your wound site on anything as this could open the wound up.

• Ask your caregiver how you should bathe or shower. You may need to cover your wound with a waterproof dressing. If you do not need to use a waterproof dressing, remove your bandage. Throw it away in the trash. Carefully wash your wound with soap and water. Pat the area dry with a clean towel. Ask your caregiver if you need to put medicine, such as an antibiotic (germ-killing) ointment, on your wound. Cover your wound with a clean, new bandage.

• Wear a binder. Conditions such as a long-term illness and weighing too much put you at a higher risk of your wound coming apart. Using steroid medicine can increase this risk. If you are at a high risk, you may need to use a binder over the area of your wound. A binder is a snug piece of clothing that you wear to help keep your wound from pulling apart.

• Manage your medical conditions. If you have certain diseases, such as diabetes (high blood sugar) or heart disease, it may take longer for your wounds to heal. Conditions where there is poor blood flow to your arms and legs can also slow healing. Take your medicines as ordered. If you have diabetes, keep your blood sugar level in the right range. Ask caregivers for help managing other medical conditions.

• If your wound is on your arm or leg, raise the wound higher than the level of your heart. Doing this may help decrease pain and swelling. You can use pillows to elevate your arm or leg while you are sitting or lying down.

• Drink enough liquids. Men 19 years old and older should drink about 13 eight- ounce cups of liquid each day. Women 19 years old and older should drink about 9 eight-ounce cups of liquid each day. Follow your caregiver’s advice if you must change the amount of liquid you drink. For most people, good liquids to drink are water, juices and milk. Limit juices to avoid too much sugar calories intake.

• Tell caregivers about all of the medicines that you use. Using certain medicines, such as steroids, cancer medicines and blood thinners may delay wound healing.

• Eat foods that are high in protein. Taking vitamins and eating healthy foods that are high in protein may help your wound heal. Poultry, meat, and dairy products such as eggs and cheese, are high in protein. Ask your caregiver if you should use vitamins, and for more information about a high-protein diet.

• Do not smoke cigars, pipes or cigarettes. Smoking may cause blood vessels on your wound site to get smaller. When this happens, your wound will not have a good supply of blood. A good blood supply is needed to carry oxygen and nutrients to your wound so that it will heal.

PICC lines are my favorite access because unlike other central lines like subclavian and internal jugular central lines, PICC lines are more durable and not as delicate. Although PICC lines are more durable, they tend to clot easily and fail to give blood return easily than other central lines.

Here are some tips for taking care of a PICC line.

1. Flush each port at least twice a shift. Use different 5cc or 10 cc syringe on each port to prevent cross contamination
2. Use turbulence flushing technique. This simply means, you flush intermittently with a whole 10cc syringe. This creates good enough pressure to prevent red blood cells clumping causing clots and blocked ports.
3. Never use less than 5 cc syringes on a PICC like or any other central line. To be on the safe side, always use 10cc syringe. The smaller the syringe, the higher the pressure it exerts on the ports and this can make the tip to break off and result in more serious damage like strokes and cardiac ischemia.
4. Always verify that there is a date and an initial on the date the last dressing was done. If there is a bio-patch™, the PICC line dressing can be done every 7 days unless it is not intact or signs of infection are noticed.
5. Always check your drugs compatibility to prevent drugs crystallization in the PICC causing blockage.
6. When PICC line is not in use, always make sure one port has normal saline “to keep open” (TKO). This again is to prevent from blockage from red blood cells clumping together.
7. When drawing blood from a PICC line, use turbulence technique (pull intermittently). This will not only prevent red blood cells clumping but it will also keep red blood cells intact. If you pull continuously and the pressure is high, the red blood cells will hemolyze, making it impossible to give accurate results on labs like CMP, BMP, CBC etc
8. Incase of PICC line blockage, always notify the provider and/or PICC nurse. If not comfortable, do not try to de-clot using TPA. Some facilities does not allow use of TPA on PICC lines except by PICC line nurses or MD
9. After removing a PICC line, always verify the tip is intact. Always make sure the measurements after removing the PICC corresponds with those documented on insertion date
10. If your PICC line is not working, you have no reason keeping it. Remove it and follow your facility protocol. Most facility required culture done for the tip.

Enjoy the great convenience of a PICC LINE