Stupid question...why can't we start IV's in PICC arm?
- 0Mar 10, '09 by mama_dSo we had a situation at work last night (not my patient, but I got asked for my input).
Patient has double lumen PICC line in right arm. We can't use the left arm. Patient has TPN/lipids going into one port, Amiodarone gtt into the other. Also had multiple IVPB antibiotics.
The nurse started a peripheral line in the right hand, placing the tourniquet slightly above the wrist to avoid any pressure near the PICC site.
We all know that we're not supposed to start peripherals in a PICC arm, but why? I went to several different manufacturer sites and googled it, but couldn't find the rationale anywhere. And working nights, of course there were no vascular access nurses available to ask.
The only thing we could come up with was to avoid the possiblitity of placing too much pressure on the PICC/vein when the tourniquet was used, or possible complications if the same vein was used (the peripheral was started in a different vein than the PICC was in).
It makes me nuts when I can't find the WHY behind this kind of thing, so someone help me out here please!
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- 1Mar 10, '09 by Southern Fried RNI ran into this problem when I worked ICU. One port was for TPN and the other was for some vasoactive. It was frustrating to say the least having to look up compatibilities for drips and antibiotics! Once I had to give a drug that wasn't compatible and no one could get a PIV in the other arm. A fellow nurse, who used to be on the IV/PICC team placed a PIV in the hand of the PICC arm. I questioned her about it, since it's drilled into our heads that sticks in the PICC arm are a no-no. She gave a roundabout explanantion that as long as the tourniquet was not over the PICC or too close to it that it's OK to do a stick in the hand.
I wouldn't routinely do that unless I'd absolutely exhausted all options of compatibility and having people try for sticks in the other arm/feet. Of course at night with a situation you are describing I would just go with it. Perhaps the AM shift could have a chat with the doctor about placing another line if the patient is truly that sick to need TPN, amio, abx, etc.
- 1Mar 10, '09 by nrsang97I think at this point the pt needs more access and as long as you don't put the tourniquet around the PICC site for immeidate needed access it is alright. Maybe this pt needs a central line at this point too. Too bad they don't use the triple lumen PICCs more often.
- 2Mar 10, '09 by Roy FokkerQuote from mama_dI'm assuming the PICC was in the AC of the same arm?The nurse started a peripheral line in the right hand, placing the tourniquet slightly above the wrist to avoid any pressure near the PICC site.
Quote from mama_dAs far as I can recall, that was never taught to us - we were only taught to avoid blood draws/BPs/access on or above the PICC site with the rationale that normal venous circulation was compromised because of the presence of the PICC and any furthur irritation to the veins on the extremity could compromise the PICC and/or cause other complications.We all know that we're not supposed to start peripherals in a PICC arm, but why?
I asked two of our ED docs about this and they backed me up on this - further adding that if needed (as in an "emergency") using that arm for blood draws/venous access was perfectly acceptable ["any port in a storm" being their rationale.]
One of the docs told me that "it's more an 'avoidance' issue than a 'critical' issue" - and it makes sense (think about it - what about the pts. who have bilat. mastectomies? We still use their arms for BPs/venous access... we're just a little more careful about it, right?)
- 0Mar 11, '09 by mama_dThanks again for your replies.
To clarify, the PICC was midway between AC and shoulder, slightly higher than we usually see. The nurse placed the tourniquet as far away as possible without compromising her ability to place the peripheral access.
I must say that your answers are making me breathe a sigh of relief, we were concerned that we were potentially causing a huge issue, but the patient desperately needed that access.
- 1Mar 11, '09 by cannulatorRoy,Would never use an arm from a bilateral mastectomy for BP or venous access....I have seen a lymphedema twelve years out from mastectomy. We always use the calf for BP and foot vein for blood draw.
But, I would feel ok using the same arm as a PICC, if that's all that was available, especially for a blood draw.
- 1Mar 11, '09 by island40i've used a PICC arm for a peripheral IV when there was only a dual lumen and there was no other arm to use (amputee). When questioned about it from my nurse manager I pointed out that the mistake was in not putting a PICC with more lumen in place when the surgeon should have known it would be needed. I got taught in school that you have to stay away from the site (pressure making it leak etcetera), and that there is a higher likelihood of infection due to the stick but these people are high risk for infection anyway. You did fine.
- 1Mar 11, '09 by Roy FokkerQuote from cannulatorInteresting - I've had 4 cases so far where we ended up using the arm for short periods (pts. almost always ended up getting central lines anyway). Haven't seen a complication so far - and it was all done with physician approval.Roy,Would never use an arm from a bilateral mastectomy for BP or venous access....I have seen a lymphedema twelve years out from mastectomy. We always use the calf for BP and foot vein for blood draw.
I guess the setting makes a difference too (ER nurses, raise your hands - how may patients have told you they had breast cancer and lumpectomies AFTER you've taken BP and drawn blood and started an IV on affected side?)
Thanks for sharing