I need some help. I originally post this to the Neonatal discussion but need more feedback.
I work in a small Level 3 NICU. Our Neo is an Ols School sort of guy. He is very hesitant to allow us to place picc lines on kids that need longer term IV therapy. His rationale is that he does not want to put an invasive line in a kid if he can avoid it. Our Primary TPN solution is D12.5 HA. We also give lots of gentamicin, vancomysin, amikacin, acyclovir, etc. Now we all know that these solutions are vesicants etc. Plus our HA comes up with the label that clearly says in bold type "GIVE THROUGH CENTRAL LINE ONLY."
If we try and petition early on for a picc he will often say that he wants to get the kiddo of IV's in a few days etc. Then when everyting has been blown he will allow us to attempt a picc. Unfortunately this is when there is no acces left.
What I am needing is some journal articles, stats or other info regarding infection rates of piccs vs peripheral. Cost efficacy of the same.
He will sometimes alter his position if the proper information is presented.
Can anyone please help???
Needless to say this is a very difficult situation for us nurses. We are having babies stuck in excess of 20++ times in a single day. He thinks it is a skill issue, I assure you that it is not. Most of us are experienced nurses in our area.
I know all of the arguments, but I must have soem reputable documentation to present. I am working towards us developing a unit guideline so that this issue can possibly be put to rest. The Haldol in the coffe pot didn't do the trick so now I must do my homework.....
Dec 21, '01
im certainly not a peds nurse but i do work with a lot of geriatric patients who have NO access. i LOVE picc lines because it cuts out all of the sticks and they are more reliable than peripheral lines. unfortunately, we have some docs like yours. their patients are bruised all over from attempts at peripheral lines and blood draws. im not sure what these docs think they are saving their patients from by not putting in a picc.
surely there must be an iv nurse here who can give you some guidence.
if this doc truly believes its a matter of skill (sometimes it IS..im terrible at blood draws and iv insertions)then ask him to show you how its done on one of your more challenging patients. then ask him who he would suggest has the appropriate skills for insertion or other suggestions to avoid multiple sticks.
Dec 22, '01
No experience with kids.....
I'd go to Doc with infection control AND quality assurance issues.
Maybe great QA project for your unit! Do you have QA person that would do this for you, or maybe involve all nursing staff.
Do a review of 10 charts of kids with multiple attempts.
A. 20 sticks per day = 20 chances of infection.
B. Cost of each IV device and IV start kit= Money spent per child/per day vs cost of one PICC insertion.
C. Average nursing time spent per IV insertion that COULD have been spent otherwise on behalf of this baby or another child.
(time = gathering supplies, restaining baby, insertion, cleanup, documentation)
D. PICC rates of complications/infections known at your facility per infection control reports.
Another thing to do is keep just a 72 hr log of all IV starts on all NICU babies.
Bet he'll be suprised by the numbers.
Dec 22, '01
HA through a peripheral? I don't work NICU or peds either, but I was taught that HA should never ever go through a periphal line, period!! I haven't had much success with the PICC lines in the older adults though. I think our docs wait until the patient is too fragile, dehydrated or whatever before they think about IV access. By that time, it is very difficult to get a PICC line established (at least in my observations). Love the infusaports though!! They are great for someone who is going to need longterm access or frequent blood transfusions. I had a patient the other day who came in for 3 units of PRBC's and it took 8
attempts at a peripheral line before we finally got one. I talked to her and her doctor about a port, but they thought maybe they would try once again the next time she needs blood. (She has anemia and requires frequent transfusions). Oh well, it isn't my arms that are getting banged up!!! I just don't understand the thinking of these physicians sometimes!!
Dec 25, '01
2 peripheral IV starts will pay for one picc line with placcement included.
I can assure you that it is not a skill issue as most of our nurses have work at this same unit a mean of 15 years. I have been in NICU for 6 years.
I do plan to get with the infection control nurse and the VAD team nurse at work. He is also notorious about pulling umbilical lines or not even placing lines on vent babies which means sometimes Q2 hr art sticks on them. Now bear in mind these kids weigh anywhere from 600g on up
It has been a great deal of stress and frustration for the staff as well as the babies. It is really hard to look these parents in the eye after you have shaved their baby bald and bruised him from head to toe.
Dec 25, '01
I am, currently taking the IV certification course. I am convinced Picc lines are the best choice. You might find some usefull information from the intrvenous nurse society. They are the governing body when it comes to IV therapy. Good Luck
Dec 25, '01
Anyone who is looking at extensive IV treatment needs a central line. It's the most humane and cost effective way to go. Has this guy ever worked in your area? Or as a nurse for that matter?
Dec 26, '01
I've only worked with adults, but my experience has been that we can only administer TPN through a central line. Furthermore, my hospital requires written documentation of the location of the central line tip placement before the pharmacy will release the TPN to the floor. Does your pharmacist have any literature supporting giving TPN through a peripheral line?
Dec 26, '01
At Texas Childrens Hospital we have 2 different formulas for TPN. for Central line use we use 25% dextrose and for PIV we use 12.5%. We routinely administer TPN through Periphrial lines. We have had some pt's on it as long as a month with little to no complications going through a PIV. We prefer having a PICC or Central line but we will give it through the PIV. As for the ABX, we give those through the PIV all the time with no problems and actually they are irritants not vesicants. Most of your vesicants are in the chemotherapy class of drugs. and even those are given through PIV's with careful monitering. Even on kids.
Dec 26, '01
I posted on the other board too. There are articles on PICC insertion and such in the Neonatal Network and Neonatal Intensive care journals. Any HAL and IL under 15% dextrose can be administered thru a PIV...your pharmacy needs updated on this. We also have attendings that pull lines early...due to issues with NEC and infection...but you will find some institutions that leave the lines in for a very long time. There is nothing consistent about Neonatal Nursing unfortunately as this is considered a "new" area. I understand your frustration...I have been a NICU nurse for greater than 15 years and see this all the time. If we have a kid that gets really septic and they have a PICC in, it is the first thing to be pulled. Same with UAC and UVC's. Also, all antibiotics can be given PIV....the pharmacy can dilute them down further to lessen the vicousity and irritant factor. If a kid has a fungal infection..no central line until clear, unless it is a dire emergency. Our unit has been fighting this battle for years. The larger volume doesn't matter too much in the long run. Also keep in mind that you can not give blood thru a PICC line and will always need a separate line for that. Same if you have multiple gtts running.
You need to go to your nurse manager and specialist with this. Infection control will only recommend what they think but the attending has the last say. Who is the director in your unit? That is another source to go to. In our unit, only fellows and NP's can place PICC lines on neonatal patients, so that may be another issue you have to overcome.
Dec 27, '01
No our Neo has been at this about 20 years and that is where his thinking still lies. This goes right to the fact he also fluid overloads all of our kids. I am talking daily intakes as much as 350 cc/kg/day. I have a baby lasst night that I laced a picc in thas IV was running at 20cc/hr with 3 iv burns measuring at least 1.5cmX1.5cm that are signifigant enough to require silvadine to be applied. These burns are all the worse since there is a national shortage on wydase to treat them proptly.
Yes I do know we can't give blood through a picc, but if we haven't blown out every vein in the first few days then if a peripheral is needed access may be possible.
Nurses are allowed to place piccs with the proper training and check offs everywhere that I have worked.
Dec 27, '01
I'm embarassed to ask this: Why can't you give blood through a PICC?
Dec 28, '01
My understanding is that the lumen of a PICC is too small to run PRBC's through.
As for q2hr art sticks for gases... I'm absolutely horrified! How sad! Not only is it painful, but the simple fact that you have to monitor gases that often tells me that the baby is very unstable and definitely can't handle frequent art sticks.
Must Read Topics