Picc Insertion

How about asking new staff for their evidence-based research on this? I'm betting that it's all word of mouth, starting with someone who was incorrect! For a PICC (or any other central line) to be called a central line, tip should be SVC, distal or junction of SVC/ RAtrium or into RA. Major concerns giving vesicants, irritants etc into what is really a mid-line or into subclavian.

Does your institutions medical library carry JAVA? Have the librarian do a search on this for you. JAVA vol 9 no2, 2004 has a good article on positioning, re: tips above carina having a higher incidence of malfunction, malposition and migration. Also, try googling Nancy Moureau PICC Excellence Inc, she's a nurse who has written alot on PICC teaching etc. Our PICCs are all put in low SVC, we replace if not.

I like to leave 8-9 cm out if possible, as we find it easier to tape in a loop and can keep it away from the bicep (less kinking with arm movement). We rarely have a leak, however, since it's most likely to spring a leak at the hub, this way you can repair (a single lumen only) without pulling the line out too far.

So the simple answer is... you're right as far as I'm concerned!

I.ve been doing Piccs both in home health and ICU for 15 years. Today I had a newly certified Picc Rn tell me that the standard is now to use the 45cm instead of the 55cm and always insert it to the hub. I've always carefully measured the length of the insertion based on the patients size. To insert to the hub is totally against what I've been taught. What if the line breaks? How far out do the rest of you leave the cath from the insertion site? It used to be that a line wasn't considered a true picc unless it was in the superior vena cava? The newly certifieds are telling me anyplace such as the suclavian is a picc and not a midline cath. Can anyone help clear up these questions for me? Thanks.

You cannot simply insert a 45cm PICC in any patient to the hub. At the facility in which I am employed, we have been using Ultra Sound for venous identification, and since our insertions are now much higher above the antecubital, (Brachial/Cephalic/High Medial) the 45cm catheter is most desirable. You still must measure the patient from the insertion site to the SVC. The closer the hub is to the insertion site, the less chance there is to the catheter being tugged upon. When Radiology inserts PICCS, they are always to the hub. It also depends upon the type of PICC you are using. If you use an open ended PICC, they can be trimmed to the "ideal" length, but if you are using a double lumen Groshong, they cannot be trimmed and measurement must be more accurate if you wish it to be inserted up to the hub. With a single lumen Groshong, it can be trimmed to the desired length. We also now use stat-locks to secure our catheters, and change them once a week along with our dressing changes. If the catheter is not inserted to the hub, we place a flexible wing adapter to the insertion site, then attach it to the stat-lock. The new Groshongs (which we use) now have much more durable extension lumens and since these have been released from the company (Bard), I cannot remember the last time I have repaired one.

Who are the new certifieds? They are "wrong" if they are telling you that a PICC is a PICC if it is in the subclavian. It is only considered a PICC if it is in the SVC/Cavio Atrial Junction, or the Right Atrium. If a PICC is in the sub-clavian, it is considered to be "Mid-clavicular". If it is anywhere from 6 ins to axilary, it is then considered to be a mid-line. FYI, it is also recommended that TPN, and Vancomycin only be infused through a "true PICC", SVC or R. Atrium, because of the nature of sub-clavian stenosis. The pH of Vancomycin is so caustic that it causes severe irritation of the peripheral, and subclavian vessel and should only be infused in a true PICC placed catheter, and we all know the rules of TPN. I hope this information has helped.

How about scratching PICCs and just putting in Central lines?

How about scratching PICCs and just putting in Central lines?

Not to insult your intelligence but a PICC IS a central line, but inserted peripherally (Peripherally Inserted Central Catheter) The advantage of a PICC is that it can be left in from months to a year or more. A non peripherally inserted central line is inserted directly into the central vein, therefore there is a much higher incidence of infection, and they should not be left in any longer than a week.

No insult taken, however I would like to talk with you more on this subject. If they are both central lines than how is it that one has a higher infection rate? If you are concerned about the infection rate at the contact site would a impregnated antibacterial patch eliminate any infection? Thirdly may I ask what your area is that you see these repeated infections to central lines?

Not to insult your intelligence but a PICC IS a central line, but inserted peripherally (Peripherally Inserted Central Catheter) The advantage of a PICC is that it can be left in from months to a year or more. A non peripherally inserted central line is inserted directly into the central vein, therefore there is a much higher incidence of infection, and they should not be left in any longer than a week.

No insult taken, however I would like to talk with you more on this subject. If they are both central lines than how is it that one has a higher infection rate? If you are concerned about the infection rate at the contact site would a impregnated antibacterial patch eliminate any infection? Thirdly may I ask what your area is that you see these repeated infections to central lines?

The central line that is placed directly into the subclavian vein has direct, close access to the heart. A central line that is peripherally placed is just that.....peripheral, inserted into a vein in the arm that travels up into the subclavian, then into the heart.....a much longer path to travel, and a much smaller vein until it terminates into the SVC/Atrium. An analogy made could be comparing a directly placed central line into the subclavian exiting through the subclavian, and a central line placed into the subclavian, but exiting through a tunnel under the skin, with a dacron cuff about 1" from the exit site. You are correct in that an impregnated antimicrobial patch decreases the incidence of infection, but does not eliminate it.

The area that I am presently employed is on the IV Team at a University hospital that encompasses three hospitals connected through tunnels. The largest majority of our patients are transplant patients receiving livers, kidneys, hearts, lungs, and small bowels. A very high population of immune depressed patients, as well as major traumas, neuros and cardiac. We place on an average of 25 to 30 PICCs per day. Our centrally placed catheters (directly into the subclavian or IJs) are usually replaced after a few days by PICC lines (Peripherally Inserted Central Catheters)

Hope I have addressed your questions...

Just to elaborate...

One reason that the central lines that are placed in the subclavian or IJ area have a 10-15% infection rate is because the trunk is moist and warm and bacteria can colonate in greater numbers. A PICC, which is a central catheter, but one that is introduced peripherally has a lower infection rate because the extremities are cooler and drier.

A Bio-patch is an excellent disc to use one patients especially when they have therapies which have a high incidence of catheter infection ie TPN.

We use them on all patient's central lines prophylactically to ward of line sepsis.

I'm with the prior repliers...a PICC tip must be in the SVC. Each patient must be measured individually.

We had physicians tells our PICC team this before and it is completely wrong. Yes the catheter is in a central vein, however the complication rate increases dramatically the further away you get from the lower third of the SVC. Also, while a physician can make any decision he wants about where he places a catheter, a nurse is held to INS standards - to my knowledge, INS does not condone the placement of a PICC in the subclavian.