Tricks of the Trade for PICC placement

[Infusion50]

To all the experienced PICC nurses out there...Will you please share your tried and true tricks of the trade for getting your PICC tip pass the axilla and also to drop down toward the CAJ?

I've been doing PICCs for about 1 yr now. I only have approximately 50 under my belt with a 90% success rate.

Unlike many PICC nurses who go out with an assistant to the bedside, I am alone in the procedure. I am trying to get more efficient and faster in my placements (which take me about 1.5 hours soup to nuts), but because I am alone, finessing the tip to go where I want it is sometimes a challenge and therefore extremely time-consuming. Sometimes I have to break sterility to remove a pillow or help the pt reposition an arm. Then re-don new sterile gloves to continue (I always have at least 3 pair open and ready to go).

My biggest challenges have been 1)unable to thread guide wire passed the axilla with both basilic and cephalic veins and 2) getting the tip to drop down toward the heart instead up the neck. Sometimes I've used cope wires with variant success. On several occassions, I have had to send puts to IR.

I would appreciate any advice you may have regarding any of these issues. Soon I will be expected to precept another nurse who will also be going solo so I thought you all would be a great resource.

Anyone out there doing this solo? If so, how long does it take you start to finish (from room set-up, assessment and clean-up to charting)?

[IVRUS, BSN, RN]

Couple of things to note here:

1. You should NOT be advancing the guide wire past the AXILLA. A guide wire is just that: a wire to guide the dilator/introducer into the vein.

2. I too place PICC's solo, and it still takes, 1.5 hrs from start to finish to do it correctly, and I've been placing them since 1990. Now, most institutions have their vascular access teams pair up, so one person assists and acts as a "time out" individual" to stop and assist you if their is a compromise in patient care, but you apparently, like I, do not have that luxury.

3. I still make them chin tuck when I know that the PICC is rounding the shoulder to prevent a jugular placement, and it hasn't failed me yet.

Every once in a while, I am unable to advance despite all nrsg interventions..then, I either make it a midline, if the drug is appropriate, or I start over and put the PICC into another vessel.

[Infusion50]

Thank you so much for the quick response IVRUS!!! I misspoke regarding the axilla thing..... I meant to write PICC catheter. When you have the patient tuck their chin in, do you also have them turn their head toward you? I was taught to have the pt lie flat without a pillow but have found more success when they keep their pillow. Maybe because that's like a mini chin tuck. Also , do you ever use a cope wire, and if so, under what circumstance?

[IVRUS, BSN, RN]

Thank you so much for the quick response IVRUS!!! I misspoke regarding the axilla thing..... I meant to write PICC catheter. When you have the patient tuck their chin in, do you also have them turn their head toward you? I was taught to have the pt lie flat without a pillow but have found more success when they keep their pillow. Maybe because that's like a mini chin tuck. Also , do you ever use a cope wire, and if so, under what circumstance?

We use BARD® NICORE™Nitinol guidewire, and place only Groshong Midlines and PICC's. Patients are masked, and when I tell them to look and tuck, the instructions are given to them with their return demonstration before the procedure actually begins.

[Ellie G]

I have had to have the patient bring their arm beyond 90 degrees, sort of with the hand above the head. It helps to straighten that vessel out and direct it downwards. Luckily I now have the Sherlock locator so I can easily see what is working and What isn't. It's hard to do a completely sterile picc if you're having to move pillows etc. It's not just your hands that get contaminated. I use the patient's nurse as my assistant and I'm usually in and out in 30-45 minutes. If I need to do something that would require breaking sterility that nurse does it. I place the patients call button on the bedside table before I start so that I can push it with a syringe cap or something if they have had to leave the room for some reason. I make sure the floor nurses know I'm in there doing a picc and if they see the call light that I need some assistance.

[Infusion50]

Thanks Ellie, I will definitely give that a try. I have hyperextended the arm a bit before but never to the extent you mentioned. It makes sense though.

[iluvivt, BSN, RN]

I move the patient's pillow so their head is on the the last third of the pillow and thus is is away from their upper arm, It gives me room to move their arm if needed. Positioning the patient prior to insertion is critical. Make sure they are as anatomically correct as possible. I like them flat or up to a 30 degree angle, I use towels under the arm and NOT pillows. I will adjust if pt is SOB. I use this technique to get past an obstruction

and especially to get it to STOP going up the IJ.I pull their arm out at a 90 degree angle from their body and their palm towards you and then towards the floor. You almost need another nurse to do it for you because you will find that just a slight position change in the sequence of doing the position change and then the insertor trying to advance it that all of a sudden you found the sweet spot.

How is that you follow the protocol to have an empowered observer if you have no assistant?

Yes I use a Cope Mandril wire when needed.I will use it as a 2nd stylet so the PICC can navigate sharp turns

Of course this is usually on the left side or on the rare occasion I must use a Cephalic vein. I rarely use the Cepahlic vein due to its high complication rate!

[iluvivt, BSN, RN]

I see that Ellie does what I do.....because it works but you really need another nurse to do the postilion changes while you try to advance and please try multiple times and make sure you pull the PICC back several cms past the point of where you meet the resistance. You will find that just a slight adjustment once the pt has their arm in that position that all of a sudden you will get the PICC to thread! Make sure their shoulder is rolled towards you. I also will rapidly flush and advance if I feel I need to do that but this is usually for a persistent IJ. Just as you approach the turn into the IJ.... start flushing rapidly and have another 10 mls ready.

[Ellie G]

"I use towels under the arm and NOT pillows"

i dont use pillow under the arm either. Too floppy. I use folded bath blankets or pads.

[Infusion50]

Thank you ILUVIVT!

When I need to do the time-out and drape the pt, I use the call bell to get someone in the room and make then stay until that process is done (they often leave the room at this point.) Then I keep the call bell hidden under the sterile drape in case I need to get them back to help with repositioning. NOT the ideal , I know, but its all I've got to work with....believe me, I've tried to change this to no avail! Still working on it! Anyway, I am interested in your positioning technique. Just to clarify... you are advancing the catheter WHILE the pt is doing this arm rotation palm up, then palm down? Or are you trying one way, then if not successful, retrying the other way? I'm trying to get an idea of how fluid of a motion this is?

[Infusion50]

Yes , I agree Ellie. I use blankets and towels to cushion and immobilize the arm. Sometimes my pts can't outward rotate or extend their arms all the way though...makes things a lot more challenging.

[Ellie G]

Yes , I agree Ellie. I use blankets and towels to cushion and immobilize the arm. Sometimes my pts can't outward rotate or extend their arms all the way though...makes things a lot more challenging.

i find that more and more. I had one last week that could only get to around 50 degrees and couldn't lay flat either. Makes you want to dance when you get it though.