I know there are times when a skin nick for PICC insertion is not even necessary based on the patient's skin. This has been a hot topic before, but is seems it was moslty related to bleeding issues.
In my practice it is situational, and when I use a nick it is very small and don't have issues with the site bleeding. The times I don't the patient's skin is usually so thin the dilator and introducer just slide right in. I have heard of some nurses that are getting away from the skin nick all together. They are pre-dilating the skin and vessel then reinserting the dilator and introducer as one. I understand not using a skin nick if you don't have to, but what are your thoughts on this practice and how are you practicing at your institution?
Skin would stretch but not dilate in the same manner as a vein wall. How are you talking about predilating the vein? If your procedure involves steps that are different from what the manufacturer is stating in their IFU, I would first ask the manufactuer about what you are proposing to change. If the manufactuer will not support your suggestion, by giving you a written statement about this change, then it would be considered an off-label use. This would mean that you and your facility would be assuming all legal liability for any patient harm that might come from this change. The manufacturer would not be named (or would be dropped from a lawsuit) once it was known that your practice involved a change in the procedure and you did not follow their instructions. I think it is acceptable to eliminate the skin nick if the skin type will allow for ease of insertion without this step. But I am not convinced that this could happen on every patient. Lynn
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
We have been able to reduce the number of times we have to do a dermatotomy by removing the dilator from the introducer and predilating the skin and vessel with it, then putting the dilator back into the introducer and inserting them together over the guidewire. This seems to work pretty well particularly on the single and dual lumen PICC.
I believe this is the same exact method I am referring to, I am not personally practicing this way. I can't say for sure that they are taking the inner tissue dilator all the way into the vessel the first time to predilate it or if they are just stretching the skin taking it part way in before removing it. Then placing it back into the peelable sheath and inserting them over the guidewire.
My concern with predilating the skin and vessel with the inner dilator first means you are increasing the risk of dragging bacteria into the bloodstream, and increasing vessel wall trauma to the intima when the dilator and sheath enter the vein twice instead of once.
Wouldn't it make more sense to me to eliminate the dermatotomy when you can, but use it very sparingly when you need to?
Here are some thoughts
The skin can never be made sterile. You leave 20% of flora behind at minimal (see nice Hadaway article and AORN guidelines 2012)
Every time you introduce anything as said previously (very nicely said by the way) you drag bacterial into the site. It makes sense if you dilate and than pull dialator back out and reattach to introducer you have contamined introducer as it went through the non sterile skin The number one goal is reduce steps and reduce bioburden.
The problems I often see with skin nick is the size and the depth. This is often the biggest issue and not the nick itself. I think we need a good course on making the best nick possible. I think that is an AVA session as skin nicks are really dependent on who trained you and what you added after training. They are so varied.
My thoughts from someone who does not actually put these in so they are my observations. I can be totally off the wall on this so tell me I can take it.
Kathy Kokotis