Tricks of the Trade for PICC placement

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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)?

I am in the same position. Recently, I've had 2 PICCs go up the IJ. Another PICC nurse had the same trouble. When a PICC is inserted, the procedure has been completed, and CXR confirms it's in the IJ, what troubleshoot techniques would y'all recommend? Pull back the PICC and use it as a midline or...?

All of the posts in this discussion has been very insightful.

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There are some great power flushing techniques published in the last journal of vascular access. If you belong to AVA you should have a copy. For patients who the catheter is IJ, sitting them up and power flushing is a technique that has consistently worked for me.

It is not recommended to leave a PICC as a midline. You can do a wire exchange if needed to change from the PICC to the midline.

Hope this helps!

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Thank you VascularNurse! I will definitely give that one a try! It makes perfect sense to use gravity to help the line drop.

About midlines.....I always wondered what folks are talking about when they say to use the PICC as a midline. I have never learned to insert midlines and understand that it is a completely different kit with a much shorter catheter. If you used a PICC line as a midline, wouldn't there be a large amount of exposed catheter coiled up under the dressing? Not a good idea. What am I missing? Our hospital never uses midlines.

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Thank you VascularNurse! I will definitely give that one a try! It makes perfect sense to use gravity to help the line drop.

About midlines.....I always wondered what folks are talking about when they say to use the PICC as a midline. I have never learned to insert midlines and understand that it is a completely different kit with a much shorter catheter. If you used a PICC line as a midline, wouldn't there be a large amount of exposed catheter coiled up under the dressing? Not a good idea. What am I missing? Our hospital never uses midlines.

if for some reason we can't get a picc to thread, but if the pt needs IV access right now, we will convert to a midline. Basically you bring the picc back and cut it around 8-10cm long on a sterile surface. Pull it back again till about 6cm left in the vein and cut there. Run a guidewire through the cut piece and pull the cut piece away. Put an introducer over the wire and thread the picc that has been converted to midline length. Peel away the introducer and you have a midline. If done correctly and in a sterile fashion, it's a good reliable access that can stay in for a couple of weeks. Obviously you can't infuse anything that needs a central tip. If at all possible, we will try to insert a picc in the opposite side and pull the midline when we can

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Just out of curiousity, has anyone ever used the "midline" that is labeled PICC, as a PICC? How would you handle if they infused something inappropriately- meaning they think it's a PICC so they infuse a vesicant. That would be my fear of leaving it.

Our practice would be to do a wire exchange but open a midline kit and place the midline in lieu of the PICC.

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To the OP, I wanted to answer some of your other questions.

To get the PICC to drop:

--patient positioning is important. Remove most of the pillows and get them as flat as possible if they can tolerate. Do this before getting sterile so you don't have to change your gloves.

--when inserting the PICC you can have them turn their head toward you and put their chin to their shoulder. This helps "kink" the IJ and directs the catheter down. It only works on patients who are awake and can follow commands

--retracting the stylet from the tip of the PICC about 4-5cm while inserting makes the PICC tip floppy. This helps the PICC float with the blood flow and guide it down. Once you insert you can re-advance the stylet for your tip confirmation system.

--if retracting the stylet doesn't work another trick would be to make the catheter stiff. You can try to insert the stylet and the guidewire which will make the catheter stiff and then advance.

--if the patient is ventilated, sometimes I'll use the ultrasound probe on their IJ to occlude it. I'll press the probe down to compress the vein while advancing the catheter. Make sure you don't need your probe any more and don't put it back on your sterile field

--if the catheter won't drop with the patient laying flat, try sitting them up and using gravity.

--LAST!, if. None of these work, you can try asking the patient to take a deep breath and forcefully blow it out. Start inserting as they are exhaling. Make sure their head is turned away from the sterile field though.

those are some tips and tricks I learned and have used regularly to be successful!

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Just out of curiousity, has anyone ever used the "midline" that is labeled PICC, as a PICC? How would you handle if they infused something inappropriately- meaning they think it's a PICC so they infuse a vesicant. That would be my fear of leaving it.

Our practice would be to do a wire exchange but open a midline kit and place the midline in lieu of the PICC.

we make sure to label ours clearly that it is a midline and not a picc. The label is right there on the dressing. We also make sure Epic clearly states that it is a midline

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Thank you to everyone who has responded.You all have generously provided a wonderful compilation of tips that could not be found anywhere else! I will be sharing this thread and checking in regularly for anything new.

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I am starting my second year of placing PICCs and have been on a success and emotional rollercoaster (I work by myself with no backup). My question is regarding an extremely anxious post surgical patient (shaking, weeping, "this will never work" kind of patient). She spent an entire day refusing the PICC and finally said yes the next day. Assessing her arms, I visualized great basilics in both arms. However, when I accessed the right I could not advance the wire and the vein appeared to have clamped down. I waited however was never able to advance the wire. On the left, the basilic was basically gone when I was ready to access it and never tried. I have found conflicting literature on venous dilation versus constriction with anxiety. I am curious about the physiology and any suggestions with extremely anxious patients? I can usually talk even the most anxious patient through the procedure but feel there must be more. She had already had pain medication and conscious sedation is not an option in my facility.

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Specializes in Vascular Access.

Pain medication alone, may not be the best.. I would add an antianxiety med: Xanax or Ativan. Then, I have always found much better compliance

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I agree with you IVRUS, however, I have a hard time getting docs to order that. When they do, I only get 1mg out of them which doesn't really do the trick for many of my pts. Have you found that? When they do order for you, how many mgs of Ativan do you usually see written for?

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Specializes in Infusion Nursing, Home Health Infusion.

If I believe that I need an anxiolytic to be ordered so the PICC can be placed safely and maximal barrier precautions can be maintained and they refuse to order then I tell them that I will be unable to safely place it.I have been doing this an awfully long time and I used to rarely ask for a sedative and then I realized that when providers place CVADs or do other bedside procedures they do not hesitate to order anything that will help them and the patient get through it! I can assess and can tell when there us a high liklihood it will be needed. I get an order for 1 mg of Ativan and a repeat order.

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