Two groups come to mind - those that should not get a PICC at all and those where a specific extremity is contraindicated. Basically, a PICC should not be used in critical care or oncology patients due to the very high risk of thrombosis. Also, check the KDOQI guidelines from the National Kidney Foundation for lab parameters for when a PICC is not used in renal patients. Other reasons to not use a PICC in a specific extremity would be ortho, neuro, burns problems/surgeries on extremity. Lymphedema and/or axillary dissection on an extremity. Paralysis of an extremity also. Lynn
You can post a chart, sure. But I'm telling you that PICC's are used in oncology patients and critical care patients all the time. I think you really have to assess which would be better and try and get your way on that decision. Today with CLABSI's being such an issue for hospitals, it's not easy to change the mindset. But don't drive yourself up a wall trying to NOT put in PICC's because you'll meet more resistence than you know
“Would like to have input for posting a chart for staff knowing when a PICC vs central cath is most appropriate. Any input most appreciated.”
Can you define your setting a bit more? Is this chart for the entire hospital? ED? ICU? Regular floors? Or for your vascular access nurses? Also, what does your vascular access team offer? What lines do they place? When are they available?
Defining your setting will help you develop an algorithm. There are many algorithms already made to help nurses request the most appropriate devices, but each facility may need to adjust based on their capabilities and product selection.
To answer your initial question only… PICC or central line?, what nurse is your audience of this poster? Staff nurse or vascular access nurses in training? Your decision tree should include thoughts on several factors: how emergent is this line needed? Expected length of therapy? Will they be going home with it later? What will be infused (not that important if you are only discussing 2 types of central lines)?
And of course, contraindications, as Lynn stated, may alter your decision… History of CKD (refer to fistula first campaign for guidance). The rule out for CKD should also consider current stage, age, co-morbidities, etc. to know if it very relevant or can be ignored. And other contraindications: mastectomies, lymphedema, skin issues, etc.
The risk for thrombosis is there for both lines and should be considered. This should be part of your decision at the patient to patient level. If you never use PICCs in critical care, you may reduce thrombosis but increase pneumothorax. If you always use PICCs in critical care, you may increase thrombosis, but decrease pneumothorax. (Although personally, I have never experienced high levels of thrombosis in the critical care setting. Validation of vein/catheter ratio is a big part of controlling that issue). Each patient has a different history and current health status that should be considered. Most float to the side of reducing pnemos.
Overall, PICCs are traditionally considered a safer procedure and usually the line of choice…assuming it can be placed fast enough and meets the flow needs. Rarely is there a situation when a PICC does not meet all the patient needs compared to a CVC. Usually the issue is the vascular access team may not have the staffing pattern to meet the patient needs.
A poster is a great idea to educate and create awareness, but it is best to have the flow eventually point to a vascular access nurse or physician for consult. There are so many points to consider, it’s difficult to present on a piece of paper… but it is good to educate staff nurses with expectations of the proper device.
I have been monitoring CAUEDVT from PICCs/Midlines at our facility for the last 3.5 years. We started out with 22 the first year. We implemented vein asessment with no tourniquet, the 45% ratio, smallest catheter needed, absolute lowest number of sticks, and we reduced that number to 14 for 2016 and 15 for 2017. In 2017, we implemented IR referral for antithrombogenic PICC placement after extensive assessment of DVT risk deemed the patient high risk.That amounted to 1 to 3 patients per month; out of the 60 per month that we average bedside.
Midway through 2018, we have had 2 CAUEDVTs!!!
The electronic record has created a real challenge to clinicians to get a good history (all that copy and paste). We also use it to help us: we generate reports that cross reference PICC orders with DVT/PE/IVC filter history , and we also have a report that shows us when a patient is admitted who has had a PICCMidline in the past. We advocate heavily for port placement when appropriate.
Clinical staff listens to our recommendations, and we have the full support of IR. This really benefits the patients and we have had no CLABSI from a PICC for many years!
Been to the mat many times and some days am surprised I still have a position at all! Not for the faint-hearted, this type of work.
Sounds like you did alot of work. Good job!. But the bottom line is patients need lines. You can't come in to a hospital with a length of stay being over 5 days getting all kinds of IV meds with daily labs, and not have any access. We all know that in the US we are 30% heavier in general then we were in the 80's. So, sicker patients, bigger patients, means we need better access. We can exam how PICC cause DVT and CLABSI but isn't that a given?. It's like going for surgery and have zero risk. It's just not possible. All the lines that are inserted country wide, there are bound to be risks. We just need to minimize that risk. Good care and maintenance would be a start.
There is no MAGIC bullet here. As long as I have been inserting, we always knew there was a risk. Face it guys, the most experience nurses are leaving, getting older, that means a generation of younger inexperienced nurses. Many of which DON'T want to be bedside nurses forever. So, where is the buy in for great care of these lines. So what happens, we try to take short cuts.ie.....MAGIC study to select lines, take out PICC after 3-5 days or "no longer needed". All thease measures will never get to zero and I don't know the answer...That's right Lynn...for once, I don't know what to do about this problem.
I sent this article to the Intensivists in my organization. It worked very well as they are dedicated doctors who want to do the right thing. The calls to our service are appropriate and our outcomes are good. This article makes it clear that a CVC is preferred for this group most of the time. We support that with midlines and PICCs when they are indicated.
A chart for nurses is helpful but the ordering provider and the vascular access specialist should consult with one another and of course the patient. This is true not just for ICU but other areas as well.
A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill
Jean‑François Timsit1,2* , Mark Rupp3,4, Emilio Bouza5,6,7, Vineet Chopra8, Tarja Kärpänen9, Kevin Laupland10,
Thiago Lisboa11,12, Leonard Mermel13,14, Olivier Mimoz15,16,17, Jean‑Jacques Parienti18,19, Garyphalia Poulakou20,
Two groups come to mind - those that should not get a PICC at all and those where a specific extremity is contraindicated. Basically, a PICC should not be used in critical care or oncology patients due to the very high risk of thrombosis. Also, check the KDOQI guidelines from the National Kidney Foundation for lab parameters for when a PICC is not used in renal patients. Other reasons to not use a PICC in a specific extremity would be ortho, neuro, burns problems/surgeries on extremity. Lymphedema and/or axillary dissection on an extremity. Paralysis of an extremity also. 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
You can post a chart, sure. But I'm telling you that PICC's are used in oncology patients and critical care patients all the time. I think you really have to assess which would be better and try and get your way on that decision. Today with CLABSI's being such an issue for hospitals, it's not easy to change the mindset. But don't drive yourself up a wall trying to NOT put in PICC's because you'll meet more resistence than you know
“Would like to have input for posting a chart for staff knowing when a PICC vs central cath is most appropriate. Any input most appreciated.”
Can you define your setting a bit more? Is this chart for the entire hospital? ED? ICU? Regular floors? Or for your vascular access nurses? Also, what does your vascular access team offer? What lines do they place? When are they available?
Defining your setting will help you develop an algorithm. There are many algorithms already made to help nurses request the most appropriate devices, but each facility may need to adjust based on their capabilities and product selection.
To answer your initial question only… PICC or central line?, what nurse is your audience of this poster? Staff nurse or vascular access nurses in training? Your decision tree should include thoughts on several factors: how emergent is this line needed? Expected length of therapy? Will they be going home with it later? What will be infused (not that important if you are only discussing 2 types of central lines)?
And of course, contraindications, as Lynn stated, may alter your decision… History of CKD (refer to fistula first campaign for guidance). The rule out for CKD should also consider current stage, age, co-morbidities, etc. to know if it very relevant or can be ignored. And other contraindications: mastectomies, lymphedema, skin issues, etc.
The risk for thrombosis is there for both lines and should be considered. This should be part of your decision at the patient to patient level. If you never use PICCs in critical care, you may reduce thrombosis but increase pneumothorax. If you always use PICCs in critical care, you may increase thrombosis, but decrease pneumothorax. (Although personally, I have never experienced high levels of thrombosis in the critical care setting. Validation of vein/catheter ratio is a big part of controlling that issue). Each patient has a different history and current health status that should be considered. Most float to the side of reducing pnemos.
Overall, PICCs are traditionally considered a safer procedure and usually the line of choice…assuming it can be placed fast enough and meets the flow needs. Rarely is there a situation when a PICC does not meet all the patient needs compared to a CVC. Usually the issue is the vascular access team may not have the staffing pattern to meet the patient needs.
A poster is a great idea to educate and create awareness, but it is best to have the flow eventually point to a vascular access nurse or physician for consult. There are so many points to consider, it’s difficult to present on a piece of paper… but it is good to educate staff nurses with expectations of the proper device.
Kevin Arnold, MSN, BBA, BS, BSN, RN
Web Manager, www.iv-therapy.net
For the other group (those with 2 arms to choose from for PICC placement).......you could use MAGIC.
https://www.teleflex.com/anz/australia-education/clinical-resources/Chop...
Nancy Rose
I have been monitoring CAUEDVT from PICCs/Midlines at our facility for the last 3.5 years. We started out with 22 the first year. We implemented vein asessment with no tourniquet, the 45% ratio, smallest catheter needed, absolute lowest number of sticks, and we reduced that number to 14 for 2016 and 15 for 2017. In 2017, we implemented IR referral for antithrombogenic PICC placement after extensive assessment of DVT risk deemed the patient high risk.That amounted to 1 to 3 patients per month; out of the 60 per month that we average bedside.
Midway through 2018, we have had 2 CAUEDVTs!!!
The electronic record has created a real challenge to clinicians to get a good history (all that copy and paste). We also use it to help us: we generate reports that cross reference PICC orders with DVT/PE/IVC filter history , and we also have a report that shows us when a patient is admitted who has had a PICCMidline in the past. We advocate heavily for port placement when appropriate.
Clinical staff listens to our recommendations, and we have the full support of IR. This really benefits the patients and we have had no CLABSI from a PICC for many years!
Been to the mat many times and some days am surprised I still have a position at all! Not for the faint-hearted, this type of work.
Sounds like you did alot of work. Good job!. But the bottom line is patients need lines. You can't come in to a hospital with a length of stay being over 5 days getting all kinds of IV meds with daily labs, and not have any access. We all know that in the US we are 30% heavier in general then we were in the 80's. So, sicker patients, bigger patients, means we need better access. We can exam how PICC cause DVT and CLABSI but isn't that a given?. It's like going for surgery and have zero risk. It's just not possible. All the lines that are inserted country wide, there are bound to be risks. We just need to minimize that risk. Good care and maintenance would be a start.
There is no MAGIC bullet here. As long as I have been inserting, we always knew there was a risk. Face it guys, the most experience nurses are leaving, getting older, that means a generation of younger inexperienced nurses. Many of which DON'T want to be bedside nurses forever. So, where is the buy in for great care of these lines. So what happens, we try to take short cuts.ie.....MAGIC study to select lines, take out PICC after 3-5 days or "no longer needed". All thease measures will never get to zero and I don't know the answer...That's right Lynn...for once, I don't know what to do about this problem.
I sent this article to the Intensivists in my organization. It worked very well as they are dedicated doctors who want to do the right thing. The calls to our service are appropriate and our outcomes are good. This article makes it clear that a CVC is preferred for this group most of the time. We support that with midlines and PICCs when they are indicated.
A chart for nurses is helpful but the ordering provider and the vascular access specialist should consult with one another and of course the patient. This is true not just for ICU but other areas as well.
A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill
Jean‑François Timsit1,2* , Mark Rupp3,4, Emilio Bouza5,6,7, Vineet Chopra8, Tarja Kärpänen9, Kevin Laupland10,
Thiago Lisboa11,12, Leonard Mermel13,14, Olivier Mimoz15,16,17, Jean‑Jacques Parienti18,19, Garyphalia Poulakou20,
Bertrand Souweine21,22 and Walter Zingg23
© 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM