Hello All
We are reviewing our guidelines for Picc placement in our pediatric population. Our team currently feels that our success rate for pediatric Picc is not good. Ok, pitiful. In conjunction with our Pediatric Intensivists doing the moderate sedation, we are supposed to place Piccs in any child old enough to be out of NICU. We use a Site Rite 3 and do not have the Sherlock type technology to do vein measurements. At this point we are not sure if the problem is us and lack of training or the patient population.
What do other vascular access teams do?
Who is placing your pediatric piccs on children less than 18mo-2yrs of age?
What is your cutoff for attempts? ie: how many pokes per nurse?
Any information or tips you could share would be fantastic.
THANKS!!
ps....Our interest in this topic has been renewed after reading about a child that was left with a paralyzed limb after her brachial nerve was severed by the access needle.
I'm a pediatric nurse that uses the modified seldinger technique in my pediatric pop. I have found that in most case the baslic and cephalic vein are usually the best. Having said that I have run into a group of kids who's brachial are the best choices. I personally feel the number of sticks depends on the number of trained nurses. If you have a dedicated team of pediatric picc nurses then you should not attempt more than twice (same as piv attempts). If you are the solo access provider and you feel competent then it may take 4-5 attempts. I fit into the latter category. When measuring the pediatrician pop I have found it significantly different from adults [ even in 17 yo] . I measure from left and right to Rt sternal notch and add 1 cm. It's not always perfect based on the child height and weight but it's works for my pop. Hope this helps.
Ps if you go brachial vein and hit artery it's pretty obvious when you dilate..gush! it is possible to hit vein and dilate through an artery. My advice is "if ever in doubt draw a gas...unless you have a right to lt shunter then get a waveform. Hope this helps! Nurses are (super)human too!
Doing the best we can!
Pay extra careful attention to the possiblity of accessing the brachial artery on small babies and children. The chest film isn't always clear cut from a left side approach if artery is accessed. Would recommend getting venous blood gases on pediatric picc placements to prevent any problems. I am aware of a child that sadly lost an arm from an arterial picc insertion that was left in place and used for several days.
The cut off for attempts should depend on the dynamics with the patient, if a parent is in the room, how confident the inserter feels, etc.
Laura McRae, RN, BSN, CRNI
Thanks for posting this information. I have been reading about accessing the brachial vein and accidently cannulating the brachial artery. I have come to the conclusion that accessing the brachial vein in children should be a last resort. We use ultrasound but sometimes it seems that in the ped population vessels can be deceiving.
Thanks,
Beth
Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL
One of the paired brachial veins should be the last resort in all ages of patients. The median nerve is located within the same sheath as the brachial artery and both brachial veins. So nerve damage and arterial puncture are very easy to do with this location, 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
Thanks for posting Lynn. I agree that it should be a last resort in all ages. I work with children now and have only accessed one of the brachial veins on a very few attempts. I never sought out to access the brachial in adults either but I didn't ever have any negative outcomes with adults. I had a few docs (mainly renal) that would write a specific order to only use brachial and to spare the basilic/cephalic for possible future dialysis use. My thoughts on that are that if the patient may need dialysis we need to preserve the vasculature in the arms as a whole.
Beth
Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL
I can place a PICC in an infant or toddler often without the use of ultrasound. Visualizing and palpating veins can be valuable tools that will also help you avoid the brachial artery and other structures you'd just rather not hit. Children with signifcant edema or extra adipose can benefit from the use of ultrasound but it's certainly not necessary on everyone. Because everything is so much smaller it can actually be more difficult trying to access deeper veins, imo.
I agree with Laura that cutoff for attempts vary based on the situation...how important is central access, how is the pt tolerating the stress (even with sedation), is family present, is there a lot of anxiety, is there sufficient veins to continue to try and is the inserter becoming anxious to the point of no longer making good decisions. I have certainly had situations in which I recognized that things were going downhill and the best thing was to stop. Sometimes that's after one attempt, other times it may be more...every patient is different.
If you would like to discuss further, please feel free to email me at [email protected].
1. We have a team who now only uses U/S for Pediatric PICC placements. Since 2008 our success from a "PICC and Stick" team to an U/S guided team increased greatly. Highly recommend U/S to access intended vein and avoid arteries and nerve bundles.
2. We place PICC lines in patients ranging from a day or two old (when pt is not in NICU as our NICU have their own PICC insertion team) to 21y/o.
3. We don't have a cutoff for attempts. As one person said in their comments, it highly depends on the situation. We do have a 2 PICC trained RN team inserting PICCs and will switch off when appropriate.
4.We have a Sonosite U/S and highly recommend it. Even our IR docs like it better than their Zonare.
5. We have Sherlock tip navigating system that we use when we can't place the pt. on a flouro stretcher.
If you want more information, our team would gladly share information.
Staci Beck, RN BSN, VA-BC
Vascular Access RN at St. Louis Children's Hospital
314-454-7643
Staci Krebel, BSN, RN, VA-BC
Clincial Development Manager
Biolife, LLC
Sarasota, FL 34243
314-807-3631
Generally there isn't a cut off as far as age goes, but like any other PICC procedure the patient has to have veins. I have placed PICCs both with and with out ultrasound- pretty much it depends on what kind of PICC you use, where you place the line, and whether the patient has veins you can see. Blind sticks- no matter the patient age or reason should not be part of our practice.
I've placed PICCs in patients with mild sedation but my preference is deep sedation. I tell the intensivist it can be done as long as the patient is in slow motion. To increase my success I will use an IV needle because if I can access the vein and advance the catheter, it doesn't matter much if the child moves - I still have access, it is easier to advance the guidewire, and I don't have to be as careful as I would with a steel needle. With a steel needle all the child has to do is move a little bit and the bevel is out of the vein.
To increase your success I would suggest losing the ultrasound you presently have and get one that gives you better visualization of the vein.
Two attempts per nurse is the standard. No one, no matter how great they are, will be the end of the line. There has to be a back up plan.
S Gordon