Tricks of the Trade for PICC placement

[Infusion50]

To all the experienced PICC nurses out there...Will you please share your tried and true tricks of the trade for getting your PICC tip pass the axilla and also to drop down toward the CAJ?

I've been doing PICCs for about 1 yr now. I only have approximately 50 under my belt with a 90% success rate.

Unlike many PICC nurses who go out with an assistant to the bedside, I am alone in the procedure. I am trying to get more efficient and faster in my placements (which take me about 1.5 hours soup to nuts), but because I am alone, finessing the tip to go where I want it is sometimes a challenge and therefore extremely time-consuming. Sometimes I have to break sterility to remove a pillow or help the pt reposition an arm. Then re-don new sterile gloves to continue (I always have at least 3 pair open and ready to go).

My biggest challenges have been 1)unable to thread guide wire passed the axilla with both basilic and cephalic veins and 2) getting the tip to drop down toward the heart instead up the neck. Sometimes I've used cope wires with variant success. On several occassions, I have had to send puts to IR.

I would appreciate any advice you may have regarding any of these issues. Soon I will be expected to precept another nurse who will also be going solo so I thought you all would be a great resource.

Anyone out there doing this solo? If so, how long does it take you start to finish (from room set-up, assessment and clean-up to charting)?

[bethchpn]

I agree with all the ideas Vascular nurse 1006 has. i would add two more.

My favorite if a pt is awake to have them cough at the point right before it goes up the jugular.

Second I have had some really tough ones that I have just waited a short time and then it slide right in. I think maybe the vein spasms after several tries and resting it works. If I have to I get warm blanket to it (I put a medium drape over everything to set the warm pack on).

Sitting the patient upright is another favorite.

I usually take 2 hrs from start to after X-ray and charting. After hours we have to send X-ray to another facility to read.I work in a small hospital and do them alone. We plan to get the ECG/ US soon so it will be quicker then. I have been doing them for 9 years now.

[MikeyT-c-IV]

I know this thread is a few months old but I'll just add my 2 cents. I love reading and helping with these issues. I've been placing PICC's about 8-9 or so years. It took a while to get my process just right but here's a few of my pointers. Some may have already made these points.

Positioning is so important. Get your patient in the right position that works best for you and the patient. Usually for me the patient HOB is inclined like 15 or 20 degrees with arm as perpendicular as they can tolerate. With resp patients sometimes I have to have them sitting as high as possible which as you might know makes things a bit more difficult. Sometimes with contractured patients it seems like I'll be standing on my head to get access. I put the ultrasound directly in front of me (not across the bed like I've seen some nurses do) with a bedside table and arm laying on the table. I do not use towels or pillows underneath the upper arm. I just use a towel draped over the bedside table for patient comfort.

Vein selection: first choice is basilic, 2nd brachial (watch out for nerves), 3rd cephalic (difficulty advancing past the shoulder region.) I believe the studies suggest using the right arm is best for the patient (shorter length, less risk for DVT) but the left arm has always worked better for me. But still, if possible I use the right.

Have you started using Sherlock and 3CG yet? LIFESAVERS! The technology is amazing and has cut procedure time dramatically. Let's say I have a patient on the vent. I can be in and out in about 30 minutes. Love it.

Now using Sherlock I can see where the line is going. Rather than having them turn, tuck, etc I retract the line prior to where it starts going jugular, twist, and re-advance. Most times it'll go right down.

And above all else sometimes it just takes time and patience. I've been very fortunate in not having a failed PICC since 2010. And believe me I remember it very clearly. It was a very contractured patient who I KNEW I wouldn't be successful but it was a case of the doc insisting I attempt before they did. Go figure.

And VascularNurse1006 is right on.... Done those tricks over the years too and they work... :)

[Infusion50]

Thank you mta1976! Everyone responding to my original question has been so helpful! Just last week, I have employed several tips with great success. The question I have is...How do you know you are near nerves? Using my Sherlock Sapiens 3CG, I can see some white streaks on US. Is this the nerve tissue? Some say yes and some say no. How can you tell for sure?

[MikeyT-c-IV]

I can see some white streaks on US. Is this the nerve tissue?

For me, it's a situation where I would have to show you on ultrasound. Let's say when you look at the brachial artery and vein(s), let's pretend we're looking at a silhouette of a mickey mouse head. Between the two ears you will usually see a little cluster of nerves in that area. You'll train your eye to see them very easily (and the variability) over time. It only took a couple of nerve sticks to freak me out. Now days if I have nerves blocking my entry to a vessel I've learned how to navigate around them. All that to say I always go for the basilic vein if possible to avoid those nerves.

[Infusion50]

Let me put another question out there for all you generous PICC nurses...

With the Sherlock Sapiens 3CG technology, do you always place your needle into the needle guide or do you have the best shot free-handing the needle? I was trained to ALWAYS use the needle guide, but wonder if free-handing it is easier for any of you.

[Infusion50]

If any of you are still reading this post, I have another dilemma requiring advice please. I had 2 challenging PICC accesses yesterday on bariatric patients who had TONS of flabby tissue hampering my needle access. What tricks do you use to prevent tissue displacement as you try to needle your vessel? No matter how hard I tried to maintain the basilic vessel in a centered US location, my needle(positioned in a needle guide) somehow ended up off to the side totally missing the vessel altogether! I've gotten pretty good at doing PICCs , but when I have all this extra flabby skin, my success rate dwindles.

[UnbrokenRN09, BSN]

My preceptor pulls the catheter back a bit and then pulls several cm of the guidwire out of the line and then flushes it while advancing it. Makes the tip flimsy so it will drop instead of going up.

[sonovascpro]

I am in the same position. Recently, I've had 2 PICCs go up the IJ. Another PICC nurse had the same trouble. When a PICC is inserted, the procedure has been completed, and CXR confirms it's in the IJ, what troubleshoot techniques would y'all recommend? Pull back the PICC and use it as a midline or...?

All of the posts in this discussion has been very insightful.

I would assume that you aren't using 3CG ECG technology for your PICCs? If not then there are a couple of things you can do to check if your PICC is sitting IJ before you break sterile field.

1) flush with a little saline then ask the patient if they heard a strange noise, usually a woosh or bubbling noise. Just don't ask them to listen for it before you do it, or they will hear it every time.

2) The stylet wire and guide wire will both show up under ultrasound as white dots if you scan the IJ. Now this of course breaks sterility of your probe (but you already have access in the arm by this point so you shouldn't need it again anyway), and you will have to pull back your drape and have the patient turn their head away from you. But if your patient says they heard the flush this is a a pretty logical next step to confirm IJ placement. I scan the IJ with my probe in the left hand and my right hand slightly manipulating the PICC to make it move along its length. If its in the IJ you will see the white dot of the wire dancing around in the IJ as you manipulate the PICC.

3) Not sure of your knowledge, training, PICC kit, or experience. But PICCs generally have a natural curve molded into them. On Bard PICCs numbers up at the hub is for R arm insertion, numbers down for left. That's just how their PICC naturally curves.

Anyway, may be stuff you already know. I'm lucky to have all 3CG PICC kits only now. But I worked a long time without them too. So this was a really useful assessment before I tore down and called for an xray. Especially when I was traveling for PICCs and was going to leave the facility before an xray was done.

[sonovascpro]

If any of you are still reading this post, I have another dilemma requiring advice please. I had 2 challenging PICC accesses yesterday on bariatric patients who had TONS of flabby tissue hampering my needle access. What tricks do you use to prevent tissue displacement as you try to needle your vessel? No matter how hard I tried to maintain the basilic vessel in a centered US location, my needle(positioned in a needle guide) somehow ended up off to the side totally missing the vessel altogether! I've gotten pretty good at doing PICCs , but when I have all this extra flabby skin, my success rate dwindles.

I don't use needle guides. Never have and never will. PICC insertion involves a lot of "feel" from start to finish. I have always freehanded my PICC needle and my US IVs. This is also why I prefer to reinforce my PICCs by having both the stylet and guidewires in my PICC during advancement. I can feel what is happening with my PICC as it is advancing and adjust accordingly.

As far as large or loose skinned patients I stretch the skin from above and below with the pinky finger of each of my hands. My probe hand pinky is resting on the skin anyway, and I hold my needle like I'm throwing a dart so my pinky is pointing down to skin. I have found this to be useful on almost all my insertions, not just large patients.

I am also a big fan of cephalics in large patients. The extra tissue in their arms seems to kind of flatten out that sharp curve where the cephalic joins up with the basilic/brachial. Plus the tissue in that area wont be as prone to shifting as you stick. Once again a reinforced PICC will let you feel what your PICC is doing as it approaches this junction.

You also asked about white streaks under US. My guess is you are seeing fascia or other connective tissue. Visible nerve bundles tend to follow blood supply. So if you are looking at out of plane blood vessels, you will generally be looking at an out of plane cross section of the nerve bundle too. So in that case it would look more like a large whitish/grey dot in close proximity to the vessel, rather than a streak across your screen.

[UnbrokenRN09, BSN]

Sometimes they can flip into the IJ after insertion, particularly if they are on a vent or coughing a lot. You can try to power flush with them sitting straight up, hoping that gravity will pull it back down. But at our facility we usually just end up doing a wire exchange and placing a new PICC so long as the insertion site looks good with no suspicion of infection. Or if the PICC is no longer really necessary, we just do a wire exchange with a new midline. We never use a PICC as a midline so there is no confusion about what type of line it really is. Some nurses see the double or triple lumens and would automatically think it's a PICC, so we just eliminate that.