When to insert PICC/Central Lines?

[LibraNurse27, BSN, RN]

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?

[humerusRN]

It depends. What is she in the hospital for?

Being a "tough stick" really isn't criteria for a central line. In the case of your patient, I would have advocated for a midline however.

[LibraNurse27, BSN, RN]

Thanks for your reply! She is in the hospital for an infected hardware from a hip replacement she had years ago as well as a DVT. She will need surgery to repair and possibly remove the infected hardware as well as IV antibiotics and heparin drip. What is a midline? Never seen one placed at my facility.

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi,

As the previous poster said being a tough stick doesn't mean you get a central line, as they are not absent of risk.

Given that she has difficult vasculature, I think that putting IVs in deeper veins using ultrasound is a good alternative, as long as she will not need long term IV antibiotics (greater then 7 days). I would also be concerned about being able to find a suitable vein for a PICC since you said she is contracted and has small fragile veins even deep in her upper extremities. I am guessing this is also a patient that would clot easily and that would present as another issue.

I would stop drawing from her PIVs as that probably making them infiltrate even quicker and have the lab find other spots. You only need a spec of a vein to get blood off of so they will have more options, even in a foot vein (if she doesn't walk and hospital policy allows it).

You should not administer vancomycin through a midline because of its location and the fact that infiltrations can go unnoticed for some time. Also it is generally pretty tough to draw labs on midlines, so this is another reason this isn't a good option for this patient.

Honestly if this is a patient who frequently requires IVs and has poor vasculature a port would be a much better option, but obviously she needs to get rid of this infection first.

Annie

[offlabel]

Thanks for your reply! She is in the hospital for an infected hardware from a hip replacement she had years ago as well as a DVT. She will need surgery to repair and possibly remove the infected hardware as well as IV antibiotics and heparin drip. What is a midline? Never seen one placed at my facility.

She needs a picc line.

[KelRN215, BSN, RN]

Thanks for your reply! She is in the hospital for an infected hardware from a hip replacement she had years ago as well as a DVT. She will need surgery to repair and possibly remove the infected hardware as well as IV antibiotics and heparin drip. What is a midline? Never seen one placed at my facility.

Infected hardware from a hip replacement usually requires long term IV antibiotics so, yes, a PICC would be appropriate. If the patient is going to be discharged on IV antibiotics she will need one. The home infusion pharmacy I worked for wouldn't take vanco patients who didn't have a central line. The PICC may or may not help you for the lab draws for the heparin drip. Everywhere I've worked, we've only used heparin dependent PICCs and you can't get an accurate PTT from a heparinized line. That said, I work in pediatrics and I know some adult facilities don't use heparin with PICC lines.

[Wuzzie]

It depends. What is she in the hospital for?

Being a "tough stick" really isn't criteria for a central line.

Hi,

As the previous poster said being a tough stick doesn't mean you get a central line, as they are not absent of risk.

Given that she has difficult vasculature, I think that putting IVs in deeper veins using ultrasound is a good alternative, as long as she will not need long term IV antibiotics (greater then 7 days). I would also be concerned about being able to find a suitable vein for a PICC since you said she is contracted and has small fragile veins even deep in her upper extremities. I am guessing this is also a patient that would clot easily and that would present as another issue.

I would stop drawing from her PIVs as that probably making them infiltrate even quicker and have the lab find other spots. You only need a spec of a vein to get blood off of so they will have more options, even in a foot vein (if she doesn't walk and hospital policy allows it).

You should not administer vancomycin through a midline because of its location and the fact that infiltrations can go unnoticed for some time. Also it is generally pretty tough to draw labs on midlines, so this is another reason this isn't a good option for this patient.

Honestly if this is a patient who frequently requires IVs and has poor vasculature a port would be a much better option, but obviously she needs to get rid of this infection first. Annie

A patient requiring multiple attempts at IV placement who is also on a heparin drip and frequent IV antibiotics with anticipation of requiring them long term (as noted in the OP) is most certainly a candidate for a PICC line. IV's placed by ultrasound are a godsend for sure but they are also finicky and prone to infiltration. So much so that my center no longer allows chemotherapy to be administered through them and I wouldn't trust one for Vanco either. I agree that a port would probably be optimal but then we have issues with ECF's and rehabs not being able to manage them.

[iluvivt, BSN, RN]

CDC has a recommendation,and I stress recommendation, that any patient requiring IV therapy for more than 6 days needs some type of central access.You must look at everything in each case and that includes anticipated length of therapy,type of therapy and its chemical charactetistics, quality of peripheral veins, and disposition of the patient (home versus SNF) and arm or site limitations ( CKD patients or dialysis patients.patient with a new pacemaker).Overall,you weigh the risk versus the benefit and then there is the brick wall you run into and that is no one can get a decent IV in or no IV ar all.At that brick wall you must get some type of CVAD placed.In your patient you can consider a PICC if she is not too contracted or a tunneled powerline or equivalent via the IJ.

[AnnieOaklyRN, BSN, RN, EMT-P]

A patient requiring multiple attempts at IV placement who is also on a heparin drip and frequent IV antibiotics with anticipation of requiring them long term (as noted in the OP) is most certainly a candidate for a PICC line. IV's placed by ultrasound are a godsend for sure but they are also finicky and prone to infiltration. So much so that my center no longer allows chemotherapy to be administered through them and I wouldn't trust one for Vanco either. I agree that a port would probably be optimal but then we have issues with ECF's and rehabs not being able to manage them.

Umm, ok, I guess you didn't read my post which clearly stated if she needed long term antibiotics that a PICC was more appropriate and US IVs were not.

[Wuzzie]

Umm, ok, I guess you didn't read my post which clearly stated if she needed long term antibiotics that a PICC was more appropriate and US IVs were not.

Reread your post. It really isn't that clear. You did not say a PICC was more appropriate. You said a port was and I agreed with you. We don't use US placed IV's even for short term medications anymore (same day infusion appts) and that was what I was referring to.

[humerusRN]

You're right, Annie! Totally missed the vanco reference.

A PICC would definitely be more appropriate for long term / sclerosing antibiotics.

[DowntheRiver]

I think port is going to be the best option. Most people typically think they are placed for cancer patients or Rheumatology patients, but I've seen them placed for patients on vancomycin who had self care deficits and a PICC was too risky. I've also seen them placed on pregnant HG ladies. I also have seen them on difficult long term dialysis patients who had short term needs.