I'm trying this post again - we have a meeting tomorrow, and this is on the list of issues to discuss. I'd love to bring other folks' thoughts, experience, and data references to the meeting.
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One of our IV Therapy nurses posed this question to the IV Therapy Professional Practice Council (PPC):
"PICC Guidelines - If multiple attempts are made @ basilic and unsuccessful (assuming she also includes brachial here) - okay to use cephalic (?) IR does - should we change protocol if cephalic inserted, i.e. daily checks? How much time is reasonable to spend? > 2hrs? Please advise."
The PPC is in the process of gathering appropriate data to back up whatever guidelines we create related to her questions, but I thought I'd pose this RN's questions to all of you as well.
What would you say? Do you have data to back it up (please refer to it if you do, for our benefit).
Thank you,
Mari Cordes
Thank you - that's helpful. We've been having a challenge trying to find data/guidelines re: vein diameter and size of catheter. I've seen some posts with general info, like "greater than 5mm best for DL", or greater than 50% space around catheter for blood flow, etc.
Since you mention vein diameter as an important criteria, what are your guidelines, and do you have data you could share?
We also have a good IR team, but with some different points of view (they routinely will tell their residents to cannulate the cephalic prior to trying the brachial vein because of the risk of puncturing an artery. I'd rather use the brachial vein and am confident both in my cannulation skills, and ability to determine when NOT to use a brachial vein).
Thanks again,
Mari
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Robbin George RN VA-BC
We use GE Logiqbook U/S machines for our PICC placements (our IV department is under radiology, not nursing, and our manager got a good deal purchasing multiple units for us and U/S). We are now able to include mm measurements of not only the vein diameter, but the depth of the vein, name of vein, L or R arm, and print all of this out on an U/S picture that has those measurements, plus the pt. name, medical record number, U/S operator ID, referring MD, etc. This becomes a part of the pt.'s permanent medical record.
We can also visualize the nerves - as well as the arteries (as we could before) - and know exactly how near or far our needle would be if we chose to attempt. It is because of this that we do use brachial veins - IF appropriate with re: to orientation/distance of arteries and nerves. If we choose not to use a brachial vein, then we're back at my earlier question: send to IR, or attempt cephalic?
From what I'm hearing (or not hearing?) on this forum, it seems that many PICC nurses seem quite comfortable using the cephalic vein for PICC placement. Any guidelines that other folks use about the choice of cephalic? Would you say no to a double lumen in a 3.5 or 4mm cephalic vein?
I realize this situation needs to be handled on a case by case basis and guidelines would not be black and white - especially if a PICC line was absolutely the best line for the patient.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Robbin George RN VA-BC