[SWAT_RN]

Hi! I have been putting in PICCs for about 8 months. I completed a course and did 3 insertions under direct observation and was given the blessing to out and stick. Anyway, during the last several months I have had several unsucessful attempts with the U/S tech blamed on calcified vessels. I need some info please on your technique for insertion and any sage advice such as angle of entry, bevel up vs. bevel down and anything else you can think of. Thanks so much!

[Gail-Anne]

Did you learn to place only by palpation or always use U/S? Are you having trouble with a particular vein? Cephalic is more likely to have trouble than Basilic (having said that- I've had about 6 people in the last couple of months that I couldn't thread Basilic and had no problem with Cephalic!) What technique do you use? I use Modified Seldinger. Do you have trouble mostly with introducer, threading guidewire or catheter? I use bevel up, if I have trouble with threading guidewire then I likely spin it. Also, do you get sedation for most people, can make quite a difference with venospasms.
Don't know that I've helped but, if you have more specific info I'll try again if I have any suggestions.
I find it just goes in runs sometimes. The person you expect to be easy won't thread----then 3 drug abusers in a row with @#!* for veins and they thread easy. Go figure! To quote another PICC nurse "this job really humbles you"

[SWAT_RN]

Originally Posted by Gail-Anne

Did you learn to place only by palpation or always use U/S? Are you having trouble with a particular vein? Cephalic is more likely to have trouble than Basilic (having said that- I've had about 6 people in the last couple of months that I couldn't thread Basilic and had no problem with Cephalic!) What technique do you use? I use Modified Seldinger. Do you have trouble mostly with introducer, threading guidewire or catheter? I use bevel up, if I have trouble with threading guidewire then I likely spin it. Also, do you get sedation for most people, can make quite a difference with venospasms.
Don't know that I've helped but, if you have more specific info I'll try again if I have any suggestions.
I find it just goes in runs sometimes. The person you expect to be easy won't thread----then 3 drug abusers in a row with @#!* for veins and they thread easy. Go figure! To quote another PICC nurse "this job really humbles you"

Actually learned years ago by palpation, but the hospital never allowed us to actually insert the PICCs (they sent us to the class, but never allowed the skill...go figure). Now am using U/S, with mod. Seldinger. I have had several times where I get the needle in, but can't advance the guidewire even with lowering the angle of the needle and twisting the wire. Also have had a couple veins which appeared to "blow" right there on the screen, lovely.
The nurse who taught us demo'd inserting the needle bevel down, and at nearly a 90 degree angle, which we are having trouble with. One of the U/S techs recently showed me why this acute angle of entry bites, since you can't "see" where you are.
What are you using for sedation?
Anyway, I keep wanting to relate PICC insertion to my peripheral IV experience. I rarely miss a peripheral stick, so missing these PICCs is really burning my butt. And my brain tells me that bevel up makes more sense, as well as a lower angle. I even watched a Rad using a longitudinal view on U/S while he advanced the needle. I know that I can do this, I just hate having the failures that I punt to IR.
Thanks for your help!

[Gail-Anne]

I assume you are using a straight needle. You may want to try using an IV catheter instead, that way you are using a needle you are more familiar with. Try a long #20 Jelco (or whatever brand) or a 1" #22 if it's a shallow vein. You may thread easier, then get guidewire through easier, not lose the vein because the needle isn't far into vein. With using U/S (I'd been inserting by palpation already) the person who taught me used a very steep angle too, I don't go as steep, maybe 45-65 degrees(from the skin) depending on the depth of vein. I try to picture a triangle of the skin, line of the needle and the other line of triangle from the vein to the U/S. I tend to put the U/S transverse as I find it easier to see where the needle is if I miss the vein. Longitudinal may work to your advantage though if you're hitting the vein but not getting the needle in cleanly to thread guide-wire.
When you are putting wire through do you press and pull downward on the skin/tissue below the needle? That helps to reduce the angle for the wire going in. As I said before, I'll spin the needle around some too if needed.
Did you only insert 3 PICCs with someone else, then on your own? Doesn't sound like much. Is there anyone you can buddy with for a day as a recap and for moral support? I work alone (no tech) as does my counterpart at another hospital. We arranged to work together for a couple of days after getting the U/S to exchange ideas and tips. (our hospitals are connected and we have the same boss)
I don't have all my pts get sedation, for in-pts who seem nervous I ask for a bit of Ativan sl, just enough to take the edge off. If a Dr is sending me an outpt who is needlephobic or nervous, I have to hope they thought ahead and sent something with the pt. (and told them to have a driver too of course) Hope that helps. And I admit that I feel better when I find out IR has difficulty with some of the people I send them too!

[birdhouse]

Assuming you use a modified seldinger tech, you can use a sharp angle. I use approx 60 to 80. Your wire might not advance if you are not in the center of the vein. So stick the patient, with the hand holding the doppler press down on the needle in the vein, so you do not have to change hands pick up your wire and attempt to thread.

[sureshot]

I have been placing PICC lines for about 19 years, but only recently started using ultrasound for placements (started about 9 months ago). I have had many of those frustrating moments as you describe with the most being able to cannulate but not able to feed the guidewire. I use the needle for insertion and have gone back and forth with using needle guide to assist with the angle issues versus not using the needle guide. For now I am using the needle guides to assist with the angle based on depth of the vessel. The angle of the insertion seems to matter most with the Dialator/Introducer placement. The steeper the angle coupled with a vessel that is 2cm deep the more difficulty in threading the introducer into vein. I have also found that when using the needle guide if I maintain the probe positioning and pressure after obtaining my flashback and gently begin to feed the MST wire I have less issue feeding the guide wire. Once I know the wire has fed into the vein I will lower the angle to finish feeding the wire. I insert the MST needle bevel up because that is the way I was taught. Hope this helps. Keep on sticking.

[snapshot1]

Is there any research about pulling picc lines if pt spikes temp.Also in regurads to DVT's and treating it without pulling the picc.

[bobnurse]

Originally Posted by snapshot1

Is there any research about pulling picc lines if pt spikes temp.Also in regurads to DVT's and treating it without pulling the picc.

The new guidelines say not to remove a cvc because of a temp spike. could be an infection somewhere else, so why remove a good line. You can go to the CDC website and i think the IHI as well.

If your having trouble manipulating the needle, what works good for practice is to get a piece of tofu and put a grape in the middle. Use the ultrasound and go for the grape. I was training a new picc nurse who had quite a bit of difficulty manipulating the needle, especially on a real person, so she spent about 20 minutes practicing on a piece of tofu and was much more confident and has excelled ever since.