Forum topic

 I work in a facility that uses the Sherlock 3CG tip confirmation system and for the most part I am satisfied with the 3CG addition the the existing Sherlock system.  There are inherent problems as with any system.  I have also used Teleflex's Vasonova VPS system as well.  So I come to the table with pro's and con's for each system.   Bard has just recently added "Diamond" software to the 3CG and it gives you a color coded feature as you pass  through the vascular system, giving more information which is always good.  With the 3CG system, you have no other choice of catheter and no other choice for ultrasound. I find the ultrasound with Bard's Site Rite challenging.  

With the Teleflex system you use their doppler wire which transmits information on blood flow velocity and direction along with ECG.  Arrow has catheters that come preloaded with this wire, which can be a plus if you like Arrow catheters.  With this system you can use many different catheters and you have to use an independent  ultrasound system.  I like the portability of the Bard "all in one" package as the facility I work in is multi leveled and large.  With the Teleflex VPS, you have to customize your transport system, which can be expensive and cumbersome. We managed with an old crash cart which worked, but was very hard to use at the bedside.

  If you have never worked with an ECG tip positioning system before, the Bard system provides you with the visual (Sherlock) as well as the ECG of the tip direction.  Teleflex VPS in my experience has a longer, more difficult learning curve,  as you rely solely on the doppler sound quality along with the ECG portion of the system.  If you have never used ECG tip confirmation it can be confusing for implementation purposes, escalating resistance to change among staff, but I have witnessed resistance to using the 3CG in staff as well who have relied soley on the Sherlock/CXR procedure.   Both companies in my region in my opinion have excellent clinical specialists to help with the  process.  

   The problems I see with the Bard system in my practice is the Sherlock paddle does not have a very secure way to adhere it to the patients chest, especially if the patient is diaphoretic, agitated or has a fresh sternotomy and sternal wires, or has any chest wall abnormality causing the paddle to wobble, or if the patient has large breasts.  So without secure placement of the paddle, your information is not reliable as far as the visual part of the system.  The ECG portion can be reliable, but sporatic if placement of the paddle is not textbook.  The system is also sensitive to any other electrical transmission in the room, we cannot plug it in while in use at the bedside and especially not in ICU. The battery is sufficient for a long bedside placement, but needs to be plugged in absolutely for storage and back to back PICC insertions can get dicey with the battery charge.  As stated above, the ultrasound images are not wonderful, so you are stuck with that and you are only able to use the Bard catheters.   The pro's are the portablilty of the system to the bedside and if you like the Bard catheters that is a non issue.  I like the Sherlock concept as you get immediate visual feed back that you are progressing in the right or wrong direction and can correct it immediately.  We are currently using an older version of the Sherlock 3CG, and there is a new version available, which I have only seen at an  I.N.S. conference.  The ultrasound screen is larger, but I cannot comment on the ultrasound clarity as I have not used it.  Lastly my facillity requires each PICC RN learning 3CG to follow up with 20 CXR's to verify their proficiency with the Sherlock 3CG.  I am not sure of the number that was required during the initial implementation of the 3CG system as I was not there at that time.  

I hope this information is helpful.  I do not have any connections with either company, just hands on experience with both and felt compelled to share.

Tami Neumann, RN 

 Tami, you took a lot of time to write that very interesting assessment.  Thanks!  good information.

We have recently added the 3CG feature to our existing Bard/Sherlock system. For me the added 3CG is a great feature to have. We frequently go into ICU with a lot of interference and if my Sherlock is misbehaving (due to magnetic interference) I know my tip has went down in lower SVC by the added 3CG. That I do love. Now for the Bard Site Rite 6 (our ultrasound), I have issues with the picture quality. You can see your artery and veins easily, but hard to find the nerve, if you can find it at all... I have experience with a SonoSite in the past. It is far superior than our current machine.

One must be aware of precautions with any procedure. If one does a literature search for inadvertent arterial access, you will find arterial cannulation occurs more frequent than one would hope to see. With a ECG system one article displayed strips from venous and arterial cannulation and they are identical.
Many would say, I know when I am arterial and would not cannula and advance a PICC line in an artery. Clinical complexity and circumstance has shown even the best have had this same feeling. Just be careful and mindful, if there is any question obtain a blood gas, it will answer your question. You can also connect to pressure monitoring for a waveform but this also can be deceiving in the hemodynamically challenged patient.

Here are some references:
Central venous catheters—the inability of ‘intra-atrial ECG’ to prove adequate positioning - W. Schummer1,*, C. Schummer1, C. Schelenz1, H. Brandes2, U. Stock3, T. Mu¨ ller3,
U. Leder4 and E. Hu¨ttemann1

Novel Catheter Positioning System for Intravenous Central Lines: A Report of 1 Hospital’s Experience
Linda Smith, MSN, RN, CRRN, VA-BC, CRNI
Catherine M. Brown, MSN, RN-BC, RVT
Julie Mendoza, BSN, RN, VA-BC
James A. Haley Veterans’ Hospital, Tampa, FL

Misplaced central venous catheters: applied anatomy and practical management
F. Gibson and A. Bodenham*

The above being said, I think ECG guidance has solid grounding and is a helpful tool. One must always be mindful of the pitfalls in any system.

 any time I have to chest xray my lines now, I'm annoyed.  From the time I walk in the room to the time the nurse is able to use the line is generally about 30 minutes, and I'm a fairly slow picc placer.  An added bonus - the stylet for the 3CG Piccs has a good feel to it, the tip seems to guide itself to the SVC.  I could be a commercial for Bard at this point, absolutely love 3CG!  

hello

 What is your experience with it?

we started using bard 3cg june 2017 , we are two interventional radiology technologitsts , we are using this machine as option not replacing the conventional way which is using flouroscopy.

Are you satisfied with it compared to using the Sherlock and a chest x-ray for tip confirmation? 

so far, only 34% from our cases done with 3cg for several resons, 1-the storage , the 3cg bard kit is big comparing with conventional picc set, there for we store more of conventional piccs and few of the 3cg kits, 2-in bard 3cg we can move easly to blind approch becouse some kits has fault in the stylet, means we do not have ecg reading for the p-wave and magnet is not enought to determine the top position 3-3cg is a great help for nurses and profissions who does picc line blindly, not to those health profissionals who do picc line with c-arm , because it is like going back a step for them 

How many chest x-rays did you do before not requiring one (for patients with no P-wave problem).

so far chest x-ray is part of determine the ready to use status. based on out data so far, we can not rely on the machine or p-wave even it is more acurate than xray.