Published Oct 27, 2020
This post is for anyone who has experience placing picc lines. I recently started training. I have wanted to do this for years, but never got the opportunity so I feel pretty fortunate and I want to do well.. But I am struggling. Any tips or tricks? First thing I want to ask is do you guys take down your tourniquet while you set up or leave it on? My preceptor wants me to leave it on while I set up my field, but I am not super fast at setting up so I feel it would be on for a long time. She feels this is the easiest way to find my spot after I set up, and this is how she does it. Second does anyone have any useful tips on using the ultrasound. Ugh it really is my biggest issue. I struggle with finding my spot even if I mark it. I practice on my co workers and locate their veins, but my issues are finding my spot if I take down the tourniquet, placing the local in the correct spot and accessing my veins. Sometime I am right on it and nothing. I have had some successes but lately its been tough. I refuse to quit, its something I really want to do. Any advice would be appreciated.
Just keep practicing every chance you get! I used to mark my spot and fret over loosing the vein but have since stopped needing it. You will get there. Have you tried adjusting the contrast to a lighter setting? Maybe it's too dark?
You actually want to decrease your tourniquet time to reduce the risk of blood clots. I undo it after I've marked my spot, then I set up my field and I re-tighten just before gowning up.
I also suggest adjusting your contrast on the US to a lighter setting, or just play with different settings until you find what you like best. Some people prefer it dark, but I feel like it's easier to see your needle on a lighter setting.
Something that helped me with the US is thinking of the probe like it's a flashlight. You can't see the needle if you aren't shining the "light" on it. Keep rocking it back and forth until you find your needle, don't advance if you haven't found it. Your needle is in the skin at at angle, so your probe needs to be angled too. if your angle is more shallow than steep, your probe needs to be farther back from your needle, so you don't end up with the needle behind the probe. Hope that helps. It gets better, you just have to stick with it.
I often don't use a tourniquet at all anymore, and know of quite a few PICC nurses who never use one. I'll usually find the vein I want without a tourniquet and measure the cath to vein ratio if it seems like a small vein (you don't ever want the catheter to take up more than 45% of the vein WITHOUT the tourniquet), then if I feel that I might have any trouble accessing it I'll put on the tourniquet.
When I first started doing PICCs though, I would use the tourniquet pretty much every time. In which case I would suggest minimizing tourniquet time by loosening it after you decide on a vein and are setting up, then tying it back just before you get sterile. Tourniquets can increase the chances of clotting and you really don't want it on there during an entire 20-30 minute procedure. Keep in mind though that the veins are smaller without the tourniquet, which is how the patient lives normally, so I suggest looking at the veins without the tourniquet to make sure they are big enough to have a PICC, especially for 5-6 french sized catheters.
As for the ultrasound, I've had this theory that a lot of younger people (under 40) who grew up playing video games tend to pick up on the US quicker than others because of the hand eye coordination and proprioception. If you can, I would try to get a fake arm or tissue that you could practice with. Our team can always borrow one from our Bard rep for a few days when we have a trainee. When I first started I sat with a fake arm for 30 minutes or so and just repeatedly guided my needle into the vein over and over until it felt more natural. Keep in mind that the beam of the US probe is only about as wide as a credit card, and your probe hand and needle hand have to always be working and moving in response to eachother. If you advance your needle, you'll have to also advance the probe to keep track of the needle tip. Usually I do a back and forth advancement alternating probe-needle-probe-needle, etc, each just a few millimeters at a time.
All this advice may be late for you anyway, I noticed your original post was 3 months ago. So hopefully you've figured alot of this out already. I'd also suggest just trying to learn as much as you can independently from your trainer too. Watch videos. Work with other PICC nurses to pick up tips and methods. Keep up with INS and KDOQI information and recommendations. There's even a very interesting facebook group called Vascular Access and Infusion Specialists that constantly has informative conversation and topics about the world of vascular access.
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