We recently started using U/S for PICC insertions. There is no problem with getting a blood return when accessing the vein, but we are having difficulty threading the wire. Has anyone else had this problem? What is causing it and what is the solution?
TIme time, I remember learning the U/S. Try a slight change of angle, when the wire does not pass. Make sure you are watching for blood return as soon as the needle dents the vein, on the U/S. Let go of the needle and let the needle angle they way it wants then try the wire. I try all these things and it really love it....
I have been using the Sherlock since Sept. and love it.
It takes a lot of practice. If the entire bevel of the needle is not in the center of the vein, the wire will not advance because it is betweethe vein layers. What you will learn with time is to "see" on the U/S the needle tip in the center of the vein, most needles are echogenic, and are visible on U/S. Once the needle is in the vein, let it go, then insert the wire without holding the needle and allow the wire to "guide" the needle into the right angle.
If you use U/S you can go pretty high up in the arm where you will see a nice large vein circumfrence, those veins are easier to "learn" on.
I learned PICC insertion only with U/S and I have no idea how you guys did it without it. I NEVER insert a PICC in AC. When we get patients w/ PICC from other institutions I can always tell if they don't use U/S the PICC seem to always be in the AC.
Good Luck, Don't give up.
A few tips:
1. On your US, get the needle tip distal in the vein. Sometimes the needle looks like it has just nicked the inferior wall of the vein even. Then when you release your needle, it floats the bevel to the center of the lumen allowing for smoother threading of the wire.
2. Try adding a Nytinol wire to your PICC tray. They are stiffer and pure gold in my opinion. I have used wires made by Vascular Solutions and Cook and they are both good. The Nytinol wire threads smoother, is unlikely to get stuck in the bevel of the needle and nearly impossible to bend or curl when threading the sheath. This is how I finally learned, and then after X amount of insertions I was able to wean myself from using a Nytinol exclusively. I still keep a few around for those difficult placements.
Good Luck and keep trying. US PICCs are far superior then those old 14G AC placements!
One other tip which seems to work when everything else fails.
Once you get the bevel into the vein, DO NOT REMOVE THE PROBE. When you remove the probe, no matter how your gentle touch is with the probe on the skin, the skin will pull the needle up out of the vein and you will be trying to thread the wire into the surrounding tissue.
Steps: Right handed (left handed reverse the roles of the hands)
1. Make sure your wire is right next to you to grab with your right hand (for the right handed person). Wire needs to be out of the loop 10cm.
2. Advance the bevel of the needle with your right hand into the center of the vein.
3. Let go of the needle (it will stay in the vein as long as you hold the probe still).
4. Still holding the probe with your left hand, thread the wire to the bottom of the needle. Now you have part of the wire in the vein.
5. Slowly released the probe.
6. Gradually thread the wire into the vein as you are moving the hub of the needle with one finger to the skin (aligns the needle parallel with the vein).
I have seen a lot of people improve their practice this way.
All good tips so far.What they mostly have in common is that if the wire won't thread,you probably don't have the needle in the vein properly to start with. It's like peripheral IV placement--you may get a great 'flash' into your angiocath and still not be able to cannulate the vessel.
There are a few anatomical aspects to look for as well,though they are uncommon. Make sure you scan the vein for its full visible length. You may find a thrombus,stenosis,venous aneurysm,weird tortuosity or bifurcation that will also prevent proper advancement of a wire.
Out of curiosity,Stephanie,which needle and wire are you using and are you using a needle guide?
Lisa Y., Team Leader IV Team UPMC St. Margaret Pittsburgh
I had the same problem when I leard US. I found it easier to go through the vein and watch the needle "dimple" back up through the bottom layer of the vein. It seems I was always in a layer not the middle.
Don't give up...if can hit the vein you have won 1/2 the battle.
Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy
In training nurses for unltrasound, I find that many get the blood return and do not visualize the needle in the center of the vein. Blood return is possible with only a part of the needle in the vein, either at the top of the vein or at the bottom of the vein.
With new people, it is usually at the top of the vein, with very good blood return and the inability to thread the wire easily. They also do not continue to hold the probe. They change from looking at the screen (to be in the middle of the screen) to looking at the blood return.
I hope this helps.
Gwen Irwin
Austin, Texas
Lots of great tips here and thanks for them. I have found that difficulty advancing the wire is a very common problem when learning US. I consider it to be the second hardest part after getting into the vein to bigin with.
One major issue that I see is, if you try to advance the wire trough the needle and have difficulty, it is important to back the wire up so that it is not protruding through the bevel before you reposition your needle. If you reposition the needle and the wire is sticking out (prehaps buried in the media of the vein) it will never work. I think it is important to always know where you wire tip is and stop advancing the moment you meet resistance. If you have difficulty advancing the wire and it is all bent up when you withdrawl it - it's probably because your wire tip was beyond the needle tip.
If you are having trouble, try this:
Grasp the wire firmly a little more that a needles leangth back and advance in one smooth slow motion. This way you know that if you make it to your fingers you have gone into the vein. If you meet resistance - stop - back up the wire a cm or so, lower the angle of the needle ant try again. Repeat this while gently repositioning the needle (pull back, right, left) until it goes.
If this does not work, remove the wire and see if you still have blood dripping from the needle, if not , sorry, you'll have to reassess the tip placement with the US.
I hope this helps