When to insert PICC/Central Lines?

[LibraNurse27]

Hi all, I am hoping to get some feedback on patients with difficult venous access. I am wondering at what point do most of you advocate for a PICC or central line vs peripheral IVs and peripheral blood draws. Do you factor in only how long the patient will need the access or also the difficulty of access?

For example my patient today had very poor access due to many factors: unable to straighten one arm due to contractures, unable to tolerate tourniquet being placed unless medicated due to rashes/wounds on arms and sensitive skin, and tiny/fragile veins. Her superficial veins had been mostly blown after many lab draws (on heparin drip and vanco with frequent draws for aPtts and vanco troughs). Her deep veins visible with ultrasound were also small and fragile. She had severe venous stasis.

Throughout my 8 hour shift 2 IVs infiltrated, a new one was placed with difficulty by ultrasound. Multiple people tried to get her labs and were unsuccessful. When yet another IV infiltrated I asked the doctor if we could consider PICC or central line. MD was hesitant stating he wasn't sure if she would be admitted for long after her surgery. I had to call IV team to place an IV by ultrasound to have one for heparin and one for all her other meds. It is in a bigger, deeper vein so we will be able to use it to draw blood at least until it clots off. But I am pretty sure her IVs will keep infiltrating and it will continue to be difficult to draw her labs if she is there even just a few more days... I feel we are torturing her with so many sticks.

opinions?

[MikeyT-c-IV]

I would probably advocate for a midline or a PICC. It sounds like multiple meds are infusing. Given the nature of her vasculature and especially this pt's plan of care, I think a PICC would probably be best. Remember though, your docs are going to be hesitant because they don't want a CLABSI on their hands. A midline would probably work fine but they don't always draw blood so well, especially after a few days. In my experience, even when we know a patient is going to be on long term antibiotics, the doc will wait until the last minute before discharge to place the order. ugh.

[AlwaysLearning247, BSN]

The fact that she is on a heparin drip, which is a very important drug, along with antibiotics for an infected hip replacement calls for adequate access in my book. At my hospital, they would have definitely sent this patient for a PICC.