My first emergent PICC insertion

Specialties MICU

Published

Specializes in Critical Care at Level 1 trauma center.

Okay I know PICCs aren't supposed to be "emergent" lines but reality dictated differently. Here is the scenario, I am an MICU nurse certified to drop PICC lines. I had a status post code from the floor. Patient came up on multiple pressors maxed out and we needed a central line. Surgery was unable to place a femoral central line so our internal med team attempted to place an IJ twice. On the second attempt the patient received a pneumo and needed a stat chest tube. Surgery was busy inserting a chest tube so our internal med team asked me if I could do a PICC on the fly to run our pressors (levo @ 60mcg/hr and Vaso @.04/hr both running through a sketchy hand IV). I gladly accepted and quickly measured the PICC line and dropped the PICC within 10-15 min. Stat chest xray, confirmed placement and we had a usable central line.

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Specializes in Telemetry, ICU.

Obviously you are more vaulable in an emergency than the gen surgery or internal med teams, lol... Good thing you came though, and helped the patient out.

We have a dedicated PICC team at my facility. They say we in CCU are the only ones who actually notice and come running when they tickle the ventricle on a deep insertion...

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Specializes in Quality, Cardiac Stepdown, MICU.

You are a rock star! (seriously, they couldn't get a femoral line in?!)

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Specializes in Vascular Access.

The reason, as you may know, why PICC's aren't emergent is that it is virtually impossible to place a PICC quickly without comprimising sterile technique. This is one reason why IV catheters which get placed in an emergent situation, should be changed out within 24 hours... The nurse who places the line has to worry more about the patient dying, rather than maintaining sterile technique. But, if you maintained it, you're amazing, and thank you.

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Specializes in Critical Care at Level 1 trauma center.

Luckily I work in a facility that has a very strong support team plus we have procedure carts that carry just about every type of access one would need at a given moment. One technique that I have pick up along the way that has allowed me to drastically cut down on the time of my PICC lines is positioning the patients head correctly when feeding the catheter. Most of the PICC nurses at my facility use a special transducer that is placed over the patients chest that detects the guidewire inside the catheter. I have found that you can bypass this step an save significant amounts of time simply bringing the patients chin to the shoulder on the side you are accessing. This closes off the EJ/IJ and prevents the catheter from traveling up the neck an almost always directs the catheter into the correct position. Another tip I have learned is to also twist the catheter in a clockwise motion (right side access) or counter clockwise motion (left side access). This further directs the catheter into the right position. I was lucky enough to have another nurse available to drop all my tools using sterile technique while I was setting up my sterile field. Additionally, once you find your entry point on the vein, place your ultrasound probe parallel to the vein. This gives you a longitudinal view of the vein and you can see the needle enter the vein and your guidewire travel down the needle and up the vein. This technique assures that you are in the correct spot and eliminates the chance of puncturing through the opposite wall of the vein. Further more I have a really good relationship with all of our docs and they will let me place PICCs in lieu of traditional central lines when ever possible. Every time a place a PICC I try to get a little better and a little faster while still providing a safe level of care. #LoveMyJob!!!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What is the name of this special device? I'm curious. I want to look it up.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The reason, as you may know, why PICC's aren't emergent is that it is virtually impossible to place a PICC quickly without comprimising sterile technique. This is one reason why IV catheters which get placed in an emergent situation, should be changed out within 24 hours... The nurse who places the line has to worry more about the patient dying, rather than maintaining sterile technique. But, if you maintained it, you're amazing, and thank you.
Absolutely... I have been in situations that a peripheral IV can't be obtained. I have also seen a cut down during a pedi code.

It happens and we as nurses do the very best we can.

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Specializes in Critical Care at Level 1 trauma center.

Google sherlock ultrasound and you will see it.

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Great job! Sounds like you really came through for your patient in a very difficult situation.

Something else you may want to keep in your back pocket (especially if you are good at dropping a PICC) is using ultrasound for peripheral IV access. We are utilizing this in our ED for difficult sticks. We keep 2 inch 20g IV catheters specifically for this purpose. With a little practice, you can learn to insert these fairly quick.

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Specializes in Critical Care at Level 1 trauma center.

Ya so I use ultrasound for all the difficult sticks... I still stick at least once without it to keep my skills up (unless they are +4 edema or something). Also I have 2 inch needles in all the gauges an I use them anytime the vein is >1cm deep because it cuts down on infiltration especially for deep upper arm veins.

Plus I can drop a 2 inch 14 gauge in a PICC site faster than doing a central line if we are in a pinch with a massive GI bleed. Obviously in a massive hemorrhage you want solid large bore central access (cordis) but you can use a level one rapid transfuser with a 14 gauge in a PICC site or EJ until the medical team can come up and drop the central line. When someone is vomiting liters of blood at a time 5-10 minutes can be the difference between keeping your patient alive and coding. Additionally in the last few GI MASSIVE GI bleeds I have had the docs would rather me drop bilateral 14 gauges so they can focus on placing a minnesota or blakemore tube. God I love where I work... Like I truly thank God for the opportunities that he has placed in my life. I love our medical, team they trust our core team of "go-to" nurses without question.

When all shizzz hits the fan we just react, Docs do procedures while we drop large access, initiate mass transfusion protocol, start pressors, ect. They let us mix all our drugs on the floor and start them without specifically giving us orders. Example.. A few weeks ago we had a GI bleed and while they were placing a blakemore me and my charge started transfusing blood, Levo, vaso, and epi. When they were done intubating and securing the blakemore they looked up and said start pressors and transfuse.. Me and my charge looked at them and laughed, "all ready done doc." They smiled gave us that "look" and bought us lunch that night.

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