Stupid question...why can't we start IV's in PICC arm?

RochesterRN-BSN, BSN, RN · Mar 10, 2009

Don't really know really.........never needed a PIV once the PICC was placed. Maybe an ICU nurse here would know since that is where they tend to run 15 different things at the same time! lol ....or maybe there's a PICC nurse here.

Southern Fried RN · Mar 10, 2009

I ran into this problem when I worked ICU. One port was for TPN and the other was for some vasoactive. It was frustrating to say the least having to look up compatibilities for drips and antibiotics! Once I had to give a drug that wasn't compatible and no one could get a PIV in the other arm. A fellow nurse, who used to be on the IV/PICC team placed a PIV in the hand of the PICC arm. I questioned her about it, since it's drilled into our heads that sticks in the PICC arm are a no-no. She gave a roundabout explanantion that as long as the tourniquet was not over the PICC or too close to it that it's OK to do a stick in the hand.

I wouldn't routinely do that unless I'd absolutely exhausted all options of compatibility and having people try for sticks in the other arm/feet. Of course at night with a situation you are describing I would just go with it. Perhaps the AM shift could have a chat with the doctor about placing another line if the patient is truly that sick to need TPN, amio, abx, etc.

nrsang97, BSN, RN · Mar 10, 2009

I think at this point the pt needs more access and as long as you don't put the tourniquet around the PICC site for immeidate needed access it is alright. Maybe this pt needs a central line at this point too. Too bad they don't use the triple lumen PICCs more often.

Roy Fokker, BSN, RN · Mar 10, 2009

The nurse started a peripheral line in the right hand, placing the tourniquet slightly above the wrist to avoid any pressure near the PICC site.

I'm assuming the PICC was in the AC of the same arm?

We all know that we're not supposed to start peripherals in a PICC arm, but why?

As far as I can recall, that was never taught to us - we were only taught to avoid blood draws/BPs/access on or above the PICC site with the rationale that normal venous circulation was compromised because of the presence of the PICC and any furthur irritation to the veins on the extremity could compromise the PICC and/or cause other complications.

I asked two of our ED docs about this and they backed me up on this - further adding that if needed (as in an "emergency") using that arm for blood draws/venous access was perfectly acceptable ["any port in a storm" being their rationale.]

One of the docs told me that "it's more an 'avoidance' issue than a 'critical' issue" - and it makes sense (think about it - what about the pts. who have bilat. mastectomies? We still use their arms for BPs/venous access... we're just a little more careful about it, right?)

cheers,

chenoaspirit, ASN, RN · Mar 10, 2009

One other concern also is that if there is a venous complication/infection, it would be harder to determine if its the PICC or the PIV.

mama_d, BSN, RN · Mar 11, 2009

Thanks again for your replies.

To clarify, the PICC was midway between AC and shoulder, slightly higher than we usually see. The nurse placed the tourniquet as far away as possible without compromising her ability to place the peripheral access.

I must say that your answers are making me breathe a sigh of relief, we were concerned that we were potentially causing a huge issue, but the patient desperately needed that access.

cannulator · Mar 11, 2009

Roy,Would never use an arm from a bilateral mastectomy for BP or venous access....I have seen a lymphedema twelve years out from mastectomy. We always use the calf for BP and foot vein for blood draw.

But, I would feel ok using the same arm as a PICC, if that's all that was available, especially for a blood draw.

island40 · Mar 11, 2009

i've used a PICC arm for a peripheral IV when there was only a dual lumen and there was no other arm to use (amputee). When questioned about it from my nurse manager I pointed out that the mistake was in not putting a PICC with more lumen in place when the surgeon should have known it would be needed. I got taught in school that you have to stay away from the site (pressure making it leak etcetera), and that there is a higher likelihood of infection due to the stick but these people are high risk for infection anyway. You did fine. :)

Roy Fokker, BSN, RN · Mar 12, 2009

Roy,Would never use an arm from a bilateral mastectomy for BP or venous access....I have seen a lymphedema twelve years out from mastectomy. We always use the calf for BP and foot vein for blood draw.

Interesting - I've had 4 cases so far where we ended up using the arm for short periods (pts. almost always ended up getting central lines anyway). Haven't seen a complication so far - and it was all done with physician approval.

I guess the setting makes a difference too (ER nurses, raise your hands - how may patients have told you they had breast cancer and lumpectomies AFTER you've taken BP and drawn blood and started an IV on affected side?)

Thanks for sharing :)

cheers,

iluvivt, BSN, RN · Mar 12, 2009

No not a stupid question at all......first we put in a lot of triple lumen PICCs where I work...we do a complete assessment before placing any PICC and try to place a PICC with enough lumens to support current presribed IV therapies and we try to anticipate further needs....we usually place a triple lumen on anyone with TPN. There is a loose rule in the PICC world that you do not take up more than 33-50 % of the vein lumen with the PICC. We tell this by bedside ultrasound.....the reason is that if we stuff a PICC in that is too large for the vein..it effects the flow dynamics in the vein and could increase the pts risk for thrombosis....so it is not always a matter of matching up the number of IV therapies with the appopriate number of lumens. OK now about the IV.....yes if you need to start an IV in a PICC arm and it is your only option at that time....yes do it....go below the PICC site so you do not damage the PICC. Generally, you want to avoid this as all these veins below the PICC lead into the larger vessels upstream where the PICC is and this can set up the pt for increased risk of complications,such as thrombosis. If this is going to be a long term need..they need to place another PICC...or take this one out and put in a triple...we do this all the time...but we are pretty good at anticipating the pts needs.. DO not go anywhere near that PICC with a needle...I have seen nurses do this and pierce or slice the PICC, If you have to juggle give the least irritating things in the PIV......TPN of course must be given centrally

cannulator · Mar 12, 2009

Even though you have had 4 cases using the affected arm, I might suggest that as an ER nurse, you may not have known about lymphedema that occurs as a subsequent result of an action. The pt may be discharged from the ER by the time such an event occurs. In addition, the fact that a physician orders or approves such an intervention does not mean that nursing judgment goes out the window (as your signature states "liberty means responsibility", I would carry it further to include "medical and nursing judgment means responsibility"). I understand that a physician order does not clear me of liability, or responsibility.

How long does it take to ask every pt (as you are putting on the BP cuff or tourniquet) every time "have you had surgery or any procedures on this arm?". An easy and quick question that may save the pt from a lifetime of a painful condition that may have been avoided.