measuring PICCs

Hi everyone,

I wanted to ask for any pointers in measuring a pt. for a PICC. We use Bard caths which are trimmed at the distal end, so once it's in, it's in. It seems that my insertions are like the 3 bears...first one is too long, second is too short and third is just right....LOL. I want to be more consistant with my tip placement. Help all you old pros!

Thanks!

I was precepting a new picc nurse who had that problem and found that he was measuring the patient with a gown on. This lead to poor measurements. Ever since he takes their gown off to the insertion side and has been pretty accurate ever since.

What exactly is your measuring technique/landmarks? If you list how you measure, maybe we can be of more help.

I was taught to find the vein with US and mark the skin, then measure from the mark to the shoulder, then to MCL, then to the 3rd ICS. I've had the opportunity to assist with PICCs placed under fluro and I lust after that kind of accuracy!:bowingpur

Hi everyone,

I wanted to ask for any pointers in measuring a pt. for a PICC. We use Bard caths which are trimmed at the distal end, so once it's in, it's in. It seems that my insertions are like the 3 bears...first one is too long, second is too short and third is just right....LOL. I want to be more consistant with my tip placement. Help all you old pros!

Thanks!

Hi it is me again cant sleep what can i say this is almost an art form in and of itself marcia ryders guide is great see if you can find it......always remember that left-sided approaches will always be longer all things being equal bc brachiocephalic is much longer on left than right. also we discovered that we must add the vein depth to our measurment when using especially on the left.Another thing we do if available is view a previous film ...some people have veryshort SVCs.....not the usual 7cms any pt with liver diseaseor pregnant ( etc,) your measurments may be too deep also make sure you are locating the third intercostal space correctly we rarely use the cephalic vein anymore (rate of thrombosis toohigh) but remember that that vein also takes a less direct route hope this helps cant type well that is why i chose nursing so long ago

i did two different measurments when i placed piccs.

the first was the standard insertion point --> clavicle (only i used the clavicular head, rather than mid-clavicular) --> 3rd ic space.

the second was more of a "the path i see the picc take on xray" approach, and more difficult to describe: insertion point--> along the top of the axilla --> under the clavicle --> turn down at the sternum --> stop at nipple line.

i then would keep re-doing these measurements until they agreed within 1cm.

then i would ask myself, "does this measurement make sense?" i'd ask them how tall they are, and look at how long their arms/torsos were, and how far down on the arm my insertion site was.

make sure, esp with very obese patients, that you aren't "walking" the tape measure. keep it pulled tight to try to keep all of the fat out of the measurement. for the most part, you only need to consider it (the extra fat)when you think of how deep you are sticking at the insertion site.

i realize that my second measurement isn't standard anywhere, but it worked for me. using this approach, i usually hit the distal 1/3 of the svc. in two years of full-time work, i only had to re-do one picc because it was too short. i occasionally had to pull lines back a little, but no one is going to be perfect without fluro.

i also would adjust for cardiomegally (make the line shorter). and like an above poster, i would check their old xrays (though in doing this, you need to be sure you look at what angle the xray was shot at, as this can distort how long the svc appears to be).

are you looking at your xrays? i found that invaluable for learning how to "aim" correctly. it does take extra time, but looking at the xray soon after you have placed the line will help in time, if more subconsciously than anything else. ask yourself "did that line go -- and stop -- where i thought it would?" some people have odd vein paths. if something looked really odd to me, i'd ask the radiologist to explain it to me.

i got to the point with on some really obese patients, i could look at them and make an educated guess as to how long to make the line. i was usually right.

the other thing is that there are standard measurements out there for how long the picc should be, from ac to svc, according to height. i never relied on them, but did use them as a double check.

I am a PICC Nurse and have been placing them for approximately a year now my question is for anyone who might be able to answer this is what kind of documentation do you do and does your team keep some kind of record or flowsheet of PICCS inserted?

nurse 2370 see the thread about documenting insertion and read my comments posted on april 01 o8 and see if that answers your question. and yes we keep track of every PICC we place. I deviced a tracking sheet. every time we place we fill one out. Imade most of the sheet as check bobes or to circle daa so it can be done quickly so we are not bogged down with paper work...this includes and allows us to track any complications on those pts that will remain in our care

hello,

hope you are having better sleep now that you've got lots of information. it may seem very obvious but if you've still got your bard workshop book, you'll find all your answers there.

are you inserting the piccs peripherally or with ultra sound as each would give you different lengths to insert (the higher above the ante cubital fossa you go, the shorter the length to be inserted.

this is how i measure my lines

asuuming i'm using a peripheral cannula (therefore belove or just aboce the acf),with the arm at 90 degrees, measure the distance from the insertion site to the head of the humerus across to the sternoclavicular junction (bard). in miss dubbie's language-measure from the chosen vein site to the sternal notch, from the sternal notch to the lower third intercostal space and the total of both measurements is the length of line i insert. **i was taught to add extra 2-3 cm if using the left arm for same reasons explained earlier in the forum.

re documentation- bard has a sticky label in the picc pack all you need to fill in is the lot number, date of insertion and name of clinician.

in the medical notes, i always make sure i include the following:

consent

local anaethetic used

what skin is cleansed with

number of attempts before successful picc insertion

amount of bleeding

back flow/ability to confirm placement

lenth of picc inserted

lenght of line cut off 9(if applicable), length of line from exit to hub

medications and flushes administrated,

strength of heparinisation 9if required)

type of bung/cap used

dressing used.

then in bold letters, i write :chest x-ray ordered to confirm correct position of picc before use. dressing to be changed 24 hrs post insertion (***please apply pressure pressure dressing if excessive bleeding noted but leave dressing in situ for 24 hrs). dressings to be changed every 7 days please unless otherwiae indicated.

do let me know if i've missed anything- best thing about this forum is we learn from eachother:idea: