sherlock

picclineman · Apr 2, 2009

If we as nurses or bard and corpak cannot use the PICC after insertion with use of the sherlock or corpak, what is the point of using this product. this becomes just an additional expense to the already high expense for inserting a picc. My experience is 99 % of my picc end up in the SVC as long as they advance to my intended lenght. My 1% is azygous, contralateral, coiled on itself. With this situation can i justify spending more for a 1% non SVC placement? The only way i can justify the use of sherlock and corpak is if the report from it can be used as an official report meaning i dont need an xray. I cannot understand why sherlock will sell a product but cannot stand behind its report. It is similar to them (sherlock) saying i want you to use this product but i cannot support you if something goes wrong. i chalenge sherlock and corpak to do a 10,000 patient study, present it to the mdical community and i am convinced they will take this study seriously and hopefully agree to use its report. HOW ABOUT THAT!!

iluvivt, BSN, RN · Apr 2, 2009

The use of a Sherlock or any TLS for that matter still has HUGE benefits. I have been putting PICCs in since 1989...when we started out we only had single lumens and only had a huge breakaway needle or sheath...I used to have to access with a 12 gauge to place a dual lumen...so I certainly have placed thousands of PICCS. The use of a tip locating system is NOT to verify tip location..it is rather to follow the direction of the catheter tip DURING insertion so you can correct it at the bedside. I think I have seen every malposition there is too see...and believe me I do not see that anymore b/c we can correct them in real time AND it still saves money as we often ended up getting 2-3 CXRs when we did have a malposition....and that does not include the nursing time..additional supplies and possible re-insertion and delays in treatment...it is still a HUGE improvement in our practice and our ability to get a usable PICC so we can get our IV therapies started.....infusion is growing so rapidly that I know it will only get better for PICC nurses out there as well as our patients

accessqueen · Apr 2, 2009

There are many many things that are done in the medical field to prevent that 1% bad outcome. The Sherlock does not present itself as a final determination of tip location, it is a navigational aide. If you always see things as black or white, all or none, you are going to get in trouble. As an example, I just read a post on another site that addressed the rare occasion of PICC placed in an artery that no one (incl Radiology) picked up on until the arm started to turn blue. There are all kinds of thngs that can happen, one in a thousand times, so to be confident cuz you're success rate is 99% is setting yourself up for a problem.

picclineman · Apr 4, 2009

my point is is it worth spending 99% to solve a one percent problem? You can look at it from different angles. I agree with you that problems happen when you least expect it. But what i am trying to drive at is if the sherlock or corpak wire technolgy or navigation technology is used, the company should back up it s claim. otherwise, if you just keep on spending without really getting your moneys worth t is not practical. I am trying to share my experience with you not to compete with you. What i am urging everybody is to encourage sherlock or corpak to do a study and present it to the medical community so this technology becomes a standard, because in my humble opinion, if it is not acceptable to the medical community, it is not worth the money spent on it.

iluvivt, BSN, RN · Apr 6, 2009

Nope....... not trying to compete just give my opinion and experience....and do not agree it only helps 1 percent of the population...many studies have been done pre and post TLS systems and pre...malposition rates were very high...as high as 50 % if you included the RA....so clearly there is a great benefit to patients and nurses and it does save $...ask the PICC nurses if they want to give up that technology and I think you will hear a LOUD "NO WAY" I see your point but again...these are meant to correct malpositions in real time and not used to determine final tip location please clarify a bit about what you mean by the companies not standing behind their products so I can further understand what you are saying....love to have conversations like this

accessqueen · Apr 6, 2009

What CLAIM do you say Sherlock is making that they won't back up? I'm going to quote Bard here: "may eliminate REPEAT x-rays", "signal indicates direction of tip position" "increases confidence that catheter is properly positioned". bard then goes on to state that placement should be verified by radiology. I am not familiar with Corpak or the claims that they make. But I get the impression that you are not familiar with Sherlock and the claims that

Bard makes. Bard is actually working on a a new EKG guided product and they are working on clinical studies to prove the accuracy of the product. By the way i have no connection with Bard. When their product comes out, and then I'm sure other companies will get on the bandwagon, I think in due time we will no longer need x-rays. I'm in no hurry. If the day comes that PICC position will be my call, I want to make darn sure that the whatever procedure/equipment I'm using is 100% accurate (not 99%) because I don't want to be responsible for that 1%.

harpoon · Apr 13, 2009

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.

picclineman · Nov 4, 2009

I would like to ask the opinion of the PICC experts out there. How does the sherlock system manifest/show when the tip of the PICC is in the azygous vein. I am under the impression that the tip locating machine are directional in nature, in other words it tells you the direction of the tip as opposed to where exactly the tip is. I use the Corpak Navigator Bionavigation System and i have encountered a case where the machine indicated the tip of my PICC to be projecting towards the SVCregion however the chest xray shows the tip is in the azygous vein by approxximately 2 cms. I adjusted this line, but before i retracted the catheter, i used the navigator to see how it would look like ( directional wise). It showed the same as the first time. I proceeded to adjust it and used the navigator which again indicated the tip to be directionally positioned in the SVc region. second xray showed the same with a little difference,but the tip was not too deep n the azygous vein. I have come to a conclusion that the machine cannot really identify when it is in the azygous vein.

Hope to hear from somebody.

Thanks for your opinion

harpoon · Nov 5, 2009

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.

picclineman · Nov 5, 2009

How does the sherlock show when the tip of the PICC is in the azygous vein. This is my question. As far a effectiveness, it depends on who pays for it. If i were to pay for it, i will not use it. If the hospital pays for it, i go for it. The only time that this equipment will be totally and convincingly be useful is if its result is acceptable to the medical community. Its a good help in terms of time but not financially helpful.

Thanks for your opinion.

Rexie68 · Nov 5, 2009

Sherlock won't tell you that either. It gives you the approximate location of the tip of the PICC, but a lot depends on your measurement. It gives you a change in tone when it believes the PICC is SVC, but the CXR is still needed to confirm. As an aside, I love the Sherlock because there are times when I wouldn't know the PICC was going up the jugular without it. To me, it's worth the cost. So far this week I've put in about 8 PICCS (we trade assignments and I was only the PICC nurse one day, but did an extra two PICCS to help out) and the PICC was trying to go up the jugular on two of those patients. That fact alone justifies the cost of Sherlock to me! We average about 50 PICCS per week in my hospital and the savings in having to reposition and re-xray makes the Sherlock worth it! Hope this helps, PICCLINEMAN

picclineman · Nov 5, 2009

you will still know when your tip is in the jugular vein WITHOUT sherlock or naviagtor. Use your ultrasound. So the sherlock/naviagtor is really useful to help identify your line is in the rpojection of the SVC RA region/contralateral/retrograde. This is also useful for me in cases where i dont want to readjust lines such as combative /confused/severly anxious/ cases where you opnly have one arm to work on.This is probably in my experinece 1% of my population. If not for this and the fact that i have to cater to several hospitals, i probably will not use it. I just got frustrated over one of my cases thw other week where two times i used the naviagtor and it was in the azygous vein. Thanks for your opinion.