harpoon

Our hospital uses the Sonosite for placement of PICC's and after review of the directional guides available concluded that the time used to set one of them up,the added cost of the equipment and STILL having to get a CXR to determine placement did not make sense. A small number of PICC's we place require redirection after going up the neck,curling,looping,rarely transversing. I use the Sonosite to view the neck vessels after placement and have caught the PICC up the neck and redirected BEFORE the CXR. Occasionally I have missed the catheters presence there even when I try my best to see it before the CXR.Also,it is not even possible to do this manuever if the pt has a trach strap,is intubated or has an existing IJ line on the PICC side already.The end game is that there is still a CXR necessary for absolute tip confirmation.Relying on a directional guide, though helpful to some practitioners has it's limitations but I will concede that if using the device helps to better your practice then continue with it's use.

I first PICC'd in 89 and enjoy what I do. 2 years ago our hospital finally evolved th U/S PICC's. I can place about 4 per 8 hour day with the Sonosite and seldom refer to IR for failed attempts.The BARD rep has sold the Sherlock to other hospitals but we elected to not add the $50 expense to each kit for several reasons: 1) Added cost 2) added insertion time due to extra set-up time fiddling with the ( reportedly temperamental) device.3) Before I call for the CXR/placement I place the probe on the neck and visualize the vessel-if it has floated up the neck I can still "save" and reposition.On the infrequent occasion that I am fooled and can't see it there I can take comfort knowing a radiologist will read and clear the PICC for use. Regarding the use of this device it seems clear that is is marketed as a "navigational aid". I don't begrudge others using it and loving it-we all need certain things to achieve what we feel to be our "best practice".At this point I can't see anyone approving them for confirmation of placement. I am content to let the Dr read the CXR and get the very best read possible for the patient.