changing a IJ central line for a PICC

[HyperRNRachel]

First a little background information. I work for a small hospital in the cath lab, we currently have two nurses who cover PICC placements not done by the interventional radiologist in Special Procedures and also help start PIV's and ultrasound guided IV's for the entire hospital except the ER. The PICC team is available during our scheduled work hours of 0630 to 1700 Monday-Friday. We take on-call until 1900 every day of the week with guidelines in place for minimal call outs (although they seem to be ignored by EVERYONE). We do not get on-call pay during the week or on weekends. We only get our regular salary plus any shift diff. when we do come out -two hour max per PICC. Ive only been placing PICC lines since Feb and am learning as I go. I don't know it all and don't ever plan on knowing it all - and now i need help from you. So here is my situation.......Tuesday at 1830 I get called from the ICU, nurse states she got an order from the primary MD for PICC placement for antibiotics. On further assessment I find the patient has a newly placed ( in the OR by GI surgeon), functioning, non infected double lumen right sided IJ and is getting amiodarone and cardizem in one lumen and TPN with lipids in the other. The problem is she needed to give Zosyn (not antibiotics as she originally stated but one antibiotic and needs an additional port. Instead of starting a PIV she called the attending MD to get an order and then called me for PICC placement. I told her I would not come out because this did not fit our on-call guidelines and if the line was still needed it would be done in the am. The next morning I go to check on the patient- cardizem stopped per MD order. Nurses started PIV the previous night. I go to nurses station and tell the charge nurse that we will not be placing a PICC- they had enough access. She states "well we still need a PICC- we struggled to get the PIV". I told her I would do some checking and be back. After talking with my picc partner he states we could remove the IJ and place a PICC. I was blown away!!!! WHY?WHY?WHY?

1.Am i missing the logic in removing a functioning central catheter to place a PICC??? After talking with the admitting MD she stated to hold the PICC order until after the surgeon saw the patient. No new orders since his last assessment.

2.Ive tried to find information on what the standards of care would be in this situation. I feel like the ICU nurse thought that two central lines would give her enough access. What are the standards?

3.Is there a such thing as having two central lines in place? Ive never heard of such a thing.

4.How cost effective is it to replace a central line with a PICC?

5. How would you have handled this?

6. How does this benefit the patient?

HELP! I am one confused PICC nurse!

[iluvivt, BSN, RN]

I will answer all your questions once I get home just leaving work now.

[Nannette1]

Not sure why the doctor just put a double lumen cvc , if the patient has poor venous access and on cardizem , amiodarone and TPN the minimun would need 3 ports also blood draws..yes we have had picc line as well as ij central. Sounds like this is a patient that needed his two central lines

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi

1) You cannot have two central lines in at once, that would be dangerous in my opinion, and a very high risk for infection of both simultaneously!

2) At my hospital central lines, other than PICCs have to be removed after a certain number of days for infection risk. I believe it is 7. My guess is they feel the patent has poor vasculature and are looking more at the long term, than the right now, which is what you are looking at. If the patient needs long term antibiotics and TPN, then he needs a PICC. Also at my hospital only the ICU can take patients with central lines (other than a PICC), because of the risk of bleeding if it gets accidentally pulled etc, so if your hospital happens to have the same policy that would mean this patient would be stuck in an ICU for the time he has the central line in, which is taking up an expensive bed.

This patent sounds like a train wreck, and like someone who will need a PICC line for long term TPN and antibiotic therapy. That is someone who you should pull the central placed by the physician, although I would possibly give it a couple more days to make sure he is going to turn the corner and is heading in the right direction, and place the PICC for more long term therapy.

Annie

[iluvivt, BSN, RN]

Of course you can have 2 CVADs in one patient and I have seen it quite a bit.We even have placed 2 PICCs on a few patients but usually can get by with just one triple if they have a lot of IV therapies .Is the risk for infection greater...well yes it is but its always about weighing the risk vs the benefit.This often does fall on the vascular access nurses hands as you are the one assessing the veins and their quality and availability to handle what has been prescribed.If you can manage with a triple PICC and one PIV or an IJ and DL PICC or whatever the combonation.It's OK too to have a conversation with the primary nurse and provider and give your opinion based on your assessment.

[IVRUS, BSN, RN]

While a patient may have two central IV catheters in at once, I agree with Annie, it's not best practice. Having

two catheters in the SVC at the same time, not only increases infection risks, but it severely diminishes the

blood flow in this major vessel. I've seen them knotted together, and one can easily cause the other to be

malpositioned especially when one is removed.