Picc Question...technique

Wow- I've never heard of trying that. Do you mind telling which brand of picc needle is giving you the trouble threading the wire?

i am finding i do better inserting picc's using no needle guide, just a #20 angiocath and the u/s screen. i feel as though when i use the silver needle in the microintroducer kits my wire can get hung up. i go through the vein and slowly pull back until the blood flows through the angio. i usually try to angle down the angio as i slowly pull back, something i can"t do with the steel needle as well. any thoughts on this technique? what ways do the more experienced picc nurses think is the best? i am still learning!

i was taught to do piccs using a 20g (2inch) angiocath, not the steel needle, and have had great success with it.

however, i have recently started using the steel needle some, as well, i have found the steel needle is better for the sclerotic, "rolly" veins.

i can think of two problems you may be having with the steel needle: 1, when you have accessed the vein, insert the wire before you lift the us probe off the skin. it takes a bit of practice/dexterity, but sometimes when you lift the probe, you relese some pressure, and move the needle out of the vein. 2, flatten the angle of the needle once you have flashback, but before you put the wire in (you naturally do this when advancing the cannula of the angiocath). if you leave the needle too perpendicular, you can create too sharp of an angle for the wire, and it won't move smoothly into the vein.

am i making any sense?

at any rate, when i precept new picc nurses, i always tell them that the bottom line is to do what works for them.

blsmom--When you say you "go through the vein and pull back" do you mean you go in one side of the vein and then out the other? The name for this is "double-walling" and is not something to make a habit of. Whenever you disrupt the single layer of epithelium that lines a vein,you set in motion the process that leads to a clot at that spot. That's OK at the insertion site--you want a little clotting there to seal the vein. You don't want another clot on the other side as well-you could occlude the vein enough to thrombose the whole vein. Also if the patients platelets are low or their INR high,you could cause a leak from the other stick and form a hematoma. So,while this technique works,it's not without it's risks. Definitely not in any of the IFU's for the US's or PICC's.

blsmom--when you say you "go through the vein and pull back" do you mean you go in one side of the vein and then out the other? the name for this is "double-walling" and is not something to make a habit of. whenever you disrupt the single layer of epithelium that lines a vein,you set in motion the process that leads to a clot at that spot. that's ok at the insertion site--you want a little clotting there to seal the vein. you don't want another clot on the other side as well-you could occlude the vein enough to thrombose the whole vein. also if the patients platelets are low or their inr high,you could cause a leak from the other stick and form a hematoma. so,while this technique works,it's not without it's risks. definitely not in any of the ifu's for the us's or picc's.

and, blsmom, you shouldn't have to go through the back wall of the vein to use an angiocath to start the picc, just like you shouldn't be going through the back wall of the vein when starting any iv.

i think you need to drop your angle sooner. i'll try to explain:

when you are starting a picc with an angiocath, do it just like any other iv, only with the us as a guide. once you see a flash in the chamber, look at the us screen to see if the tip of the angiocath is inside the vein lumen. you may need to advance the whole angiocath a bit as a unit. once you see the tip inside the lumen of the vein, drop the angle and slide the catheter off the needle and into the vein. then you should be able to put your wire in through the catheter.

does this make sense?

Thanks for the tips...I appreciate it!!

I've found that sometimes when the wire gets snagged up, the problem is the wire itself and not the needle or anything you are doing. Try a good quality floppy tipped wire, like a Nitinol and see if that doesn't solve your snagging issues. I was a doubting Thomas myself until I used a few, now I hate not to use a Nitinol, no more getting the wire snarled and having to pull out the wire and needle too, that always fried my fanny. Good luck!

I frequently place PICC lines by placing a 1-1/4 in Protect IV in the basilic/cephalic vein with ultrasound and then using the MST wire and so forth. I do this mostly with medium to large vessels. There are times with the MST needle, when that darned wire simply will not thread, no matter what angle one is at, or if you keep the transducer on the site or not, or whatever. When you place an IV, THE WIRE IS GOING TO THREAD, period!

What's interesting is that sometimes I can see the IV much better on the US screen than the MST needle, and other times it is completely the opposite. I'm not sure why that is.

As far as using IV's to place PICC lines, I think it is perfectly acceptable. After all, the kits we use come with 20 gauge 1-3/4 in IV's already in them. And I do occaisonally use them if the vessel is more than 1 inch "underground"--so to speak. Heck, I even use 22 gauge protects every now and then.

sam