GailAnne

I agree with Texas! and IVRUS, the subclavian is totally inappropriate, as is using a PICC as a midline. This leads to potential confusion and complications. There are midline catheters and they should be used as such. Why use a PICC at about 3-4 X the cost than a proper midline?

We also use a 5ml amp but use a 1ml syringe. I rarely give more than 0.4-0.5 ml. We do have a spare needle incase we need to freeze in another area, either because we change our approach or have to go to try #2. Since the main point is to freeze for the introducer/dilator, that's all that's needed. Why add extra fluid to make the image less on the U/S. I find the order being up to 1ml is fine as we consider it per attempt. If you insert on peds, that order is still good, don't need a second set of orders.

A couple other things to consider..... Some types of catheters will want to go north, or contra-laterally at first. Just use a little patience, it seems they are more pliable as they warm up in the body. I've seen a Rad use the heartbeat to judge when to insert a couple to drop, when they insist on going north instead of south (so to speak) which, of course, we can't do at the bedside. i'm just pointing out the there are sometimes things beyond our control, so again use patience. As well as the suggestions already made, sometimes twisting the catheter a bit helps. The head positioning can certainly be of help, as you tried. Try again with a bit of a different position. I totally surprised one nurse I was assisting, when she couldn't get one to drop, by having the person look straight ahead and raise their chin up a bit. Line when in right away and likely all it was was getting the person in a better alignment i.e. more relaxed, as I felt they were scrunched up. Good luck with your continued insertions.

It can take anywhere from 30-100 PICC insertions before people feel truely competent. Remember, it's not so much of an issue when things go right....it's the ability to quickly run all the possible senarios through your head and deal with the times things don't go well. I agree with many of the comments in response above. There's alot to this, not the job for everyone, however, those who do it usually enjoy it. My concern is that you spend long enough with an established PICC RN looking over your shoulder. Here, we insist that the trainee does 3 non-assisted PICCs before they go out on their own. That can take 15-20 insertions. This isn't the type of thing you can only do on occasion. I suggest starting with a mini-study as to how many people would really need a PICC in a month. Sometimes "if you build it, they will come"! Is TPN used? ABX IV over a week? Chemo given? All of these people could benefit from a PICC. If there will be enough call for a PICC RN, how much money are they going to invest in this? A vascular purpose U/S costs in the $20000-$40000 range, or are they thinking you will use an U/S already in Medical Imaging? It sounds like you aren't using PICCs at all right now. Who will decide what you'll be using? How much education will be available through that company? I've only dealt with BARD and find them pretty good for assistance and education. (Same goes with an U/S....who's will be bought and what education and support do they provide?) I suggest you check out IV-Therapy.net if you aren't familiar with it. Good luck

To look at this very simply, a PICC is a pipe, if it's clogged or partly clogged, then the fluid will either go down very sluggishly, or not at all....no different than if the pipes off your kitchen sink are clogged. The kitchen sink either doesn't drain or drains slowly. So, if the PICC instills without difficulty you know that's not the problem, First, have you made sure to instill before withdrawing to activate the valve? Are you using proper syringe size and easy pressure so as not to collapse the PICC? Have you tried repositioning the pt, having them cough, do valsalva manuever (if okay for them to do) in case the openning is sucking on the vein wall? Have you ensured that the PICC is free of twists and kinks...oddly, sometimes it's possible to instill but not withdraw in some instances of a twisted PICC. You are likely looking at a fibrin tail of fibrin sheath on the outside of the PICC, this needs fluro to confirm and may be dealt with using tPa. Usually an infusion of tPa (not just instilling in the line) is needed. Hope that helps. G

You may want to check out IV-Therapy.net as well as this site. g

Do you mean that you have only tried 4 PICC insertions total? If so, aren't you still working with an experienced PICC insertor? Yes, you are correct to remove needle from an artery ASAP and hold pressure for quite some time (10 minutes can be used as a guide). To be frank, I'm concerned at someone trying a Brachial vein, with little experience, unless they have confidence that they can access the vein without difficulty. I'm not trying to put a damper on your PICC inserting, however, worse than bruising can occur when in the Brachial bundle.....like permanant nerve damage. Do you not have some Medical Intervention available for back-up? If this person only has a Brachial vein to use, not Basilic or Cephalic, that may be best. Using the same vein immediately may not be ideal, however, we deal with reality, not ideal. As you said, PICC was removed as it was thought to not be needed, not due to infection or thrombus, so placing it in the same vein may be necessary. By the way, when accessing the Brachial vein, it sometimes works best to enter a bit to the side of the vein (away from the artery and nerves of course) and then angle over into the vein. Hope that helps.

Another agreement with the last 2 posts. In fact I just, this week, inserted a PICC on a person who was at 5.4. Barely bruised. Of course, the brachial vein wouldn't be top choice on these people! I'm more concerned with low platelets than PT/INR, I've had to turn away someone, who was a walking bruise, with platelets of 4. Usually we make sure people with very low platelets receive a top-up first. As stated, it can be much safer to insert a PICC in some-one who has high anti-coags, than a jugular or subclavian.

Is the rad saying it is "in" the azoyous vein or "at the level"? It looks like they are saying "at". That's similair to saying at the level of the corina or at the level of T7 for example. If this is the case, maybe you could explain that it gets confusing for the different nursing staff and ask that he/she stick with stating proximal SVC, mid-SVC, distal SVC or cavoatrial junction. (hopefully it is distal or RA/SVC junction of course) Of course, if it has done that pesky checkmark-looking turn up the azyous then reposition as stated already.

When you say that you are "interested" in PICC insertion, do you mean that you are not currently trained? It takes anywhere from 40 to 100 insertions to feel really comfortable with all that can happen. Setting up on your own also means having an Ultrasound as well as the basic supplies. Many places put the person on the moniter, requiring you to have monitoring skills. Lots of issues that you need to address to be prepared. The big issue for you may be, who will be your back-up? I've been inserting PICCs for years and still have the occasional person who must be done in radiology. Also, you need x-rays read in a timely manner. If the radiology docs are peeved at at you, how will that be done? As for your comment re "something really silly", remember, the silly part here may be true....just not you, only the situation. I'd say that the approach of going in well trained with a plan to one hospital will be your best bet, when other places see that it can be done locally, they are more likely to be interested. This takes years, not months though. All the best

You may want to try a private course, such as through PICC Excellence Inc or Lynn Hadaway Associates Inc. There are others as well. Try looking for links on the AVA or INS sites. Good luck

Motdog, it's great that you have an ultrasound, with use of Basilic (and then Brachial at times) veins away from the ACF, you should see a drop in the rate of thromous. We rarely have a known thrombous, is your rate of 7.5% actually backed-up by doppler? Often when someone has a doppler for a firm/sore area along vein, it's not actually a thrombous (yet!) and can be settled with warmth, reasonable movement, elevation etc. Just wondering.

First question would be, where is the tip? Is it really in distal SVC or RA/SVC? If it's back at a curve it could easily be up against the vein wall. (which also means you are giving the TPN against the vein wall) What size is the catheter? Hopefully the doc put in an adequate size! I assume you had the person do all the usual things like cough, turn head, change arm position, go for a walk etc? And, obviously, if a Groshong Valved line that it was flushed before trying blood withdrawal? Was flouro done to check for a fibrin sheath? Often a tPa infusion is necessary, not intralumen tPa. I've also had the conversation with a surgeon, who tried to say that ports weren't meant to show blood back and that chemo should be given anyway....'cause he says so! A different doc was getting annoyed with calls re no blood back and admitted that he put "a baby size" in the pt with tip @ carina because he hadn't realized the pt needed blood drawn! He totally missed the point that pt was receiving a CVC as he had terrible peripheral access.

Dilantin and silicone PICCs are a problem (can't speak for polyurathane ones). I've seen them turned to cement with one dose, regardless of flushing, when a minibag is used. If you MUST use the PICC, give the Dilantin push with extra saline pre and post (not just a paltry 5cc, I'd say at least 20cc). Phosphenytoin sure sounds like the way to go, can't remember the ph of it. Unfortunately, there may need to go to litagation a few times over extravagastions before bean-counters decde cost isn't a factor! Gail-Anne