Forum topic

Philip,

The two references I have here at work that mention vein and cannula sizes are:

Alexander, M., Corrigan, A. Core Curriculum for Infusion Nursing 3rd edition, p. 37 4. b,  Lippincott williams & Wilkens 2004

&

Hankins, J.,   Hedrick, C., Lonsway, R., Perdue, M. Infusion Therapy in Clinical Practice, 2001 p. 380, W.B. Saunders Company

My INS standards of care are at my home but i am sure i remember that the new 2006 standards also call for the smallest gauge cannula in the largest vein that will accomadate the prescribed therapy (not including anticubitals as they are saved for emergencies and PICCs and blood drwas if possible).

Hope this helps,

Have a good day,

Julie May, RN, BSN, CRNI

Lancaster Regional Medical Center

Nursing Education

Is anyone out there very familiar with the Grove study that discusses thrombus rates and PICC French size? This study seems to have been done before all of these large tapered PICC lines like the Bard and MedComp came into the market so I was curious if anyone is seeing an increase in DVT's and phlebitis rates. There seems to be a growing call for these large triple lumen PICCs for the ICU/CCU patients but I wonder if we are looking "long term" enough for vessel preservation of these patients.

Eric

We have been using the larger PICCs (6fr) including those that are tapered.  We have not seen a change in our thrombus rate and our rate was low to begin with.  Will have to admit though that maybe 50% of the time the PICC is precut too long and not all of the taper is in. 

I do have a copy of the Grove file which I will try and attach.

first there is no publication that compares vein size to catheter size

Second the Grove study is worthless !!!

I need to publish this

The Grove study was conducted in 1997 with silicone catheters only.  I am not sure the reverse taper existed in silicone in 97 unless Cook had it.  The radiologists used the Cook silicone in the study and the nurses used Groshong silicone with no reverse taper.  The rad's put in 50% of the PICC lines and the RN's 50%.  The rads used upper arm, micro, and ultrasound.  The RN's used the break-away sheath in lower arm veins.  The RN's had a 10% thrombosis rate for the 5 french PICC line versus the rads 5.5%.  Could location and not using high tech technique account for this.  Yes.  Upper arm placement did lower the rate of thrombosis.  Therapy was the main factor however on thrombosis occurrence and not size of the catheter.  antibiotics led to a 1.6% rate of thrombosis accross all categories of french size versus chemo at over 8% and TPN at almost 5%.  If I were to make a conclusion based on Grove the following would apply:

Upper arm placement with ultraound and micro is mandatory to lower thrombosis

Patient therapy should be assessed in choosing the french size if possible. 

If the patient is receving chemotherapy use a port not a PICC as the rate of thrombosis is higher than the acceptable range in the SIR benchnmark of 6%

If the patient is getting nutritional support I have no idea on helping you out as they are the ones needing a triple lumen 6 french.  I would say make sure the tip is in the right place as the tip position in the grove study did effect thrombosis rate.

As far as french size went in the grove study one would actually have to pull out the data by therapy type and catheter size to determine the real results.

If I am not mistaken the 6 french PICC lines used in the Grove study were single lumen 6 french as the triple did not exist in 97 and the 6 french single lumen manufactured by Cook medical was used for oncology patients primarily.  The rate on the single lumen 6 french in oncology patients was 10% in the Grove study.  Since chemo had an overall rate of 8.3% I am not sure if it was the chemo or the size of the catheter or the cancer.  What is your reasoning.

Always pull apart a study and never take it for face value.  It may not say what you think it says 

I came across this post while googling about the recommendation re PICC catheter size vs vein size. It has been 7 years since this was originally posted and I still couldn't find any published articles for recommendation. Do any of you have some information about it or what is the guideline you are following in your facility?

Julie is correct that these statements are now and have always been in the INS resources. But ultrasound is now allowing us to measure the vein lumen size and choose a specific catheter diameter that will fill no more than a certain percentage of the vein lumen. That is the clinical study that I have not found yet. This is the only study I know of.
1. Nifong TP, McDevitt TJ. The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters. Chest. Jul 2011;140(1):48-53.

Lynn

Thanks to Lynn and Sarah on the article! I hope we can come up with the recommendation on the actual number on what is the the lowest catheter vein size ratio for PICC placement to guide us clinically. We sometimes have to place pedi PICCs on neonatal patients. Our success rate on the neonatal population is very high but none of them should be a candidate based on the size of the vein since the 3Fr catheter takes up the whole vessel space especially with the reverse taper. I am having a very hard time explaining to the doctors that pedi PICC we are doing should be their last resort after they have considered everything else. I am not getting any where. I have babies occluded bilaterally at age of 6 months from PICC lines. I have doctors swear to me that the baby is NOT going to need any other PICC lines in his/her life since he/she will be completely healthy...... I don't feel so good about what I have do to the new borns.

Hi All, Hope this is helpful to your discussion.
I found the following article by Sharp, R, Cummings, M., Fielder, A., Mikocka_Walus, A., Greech, C. and Esterman, A. Which I believe was published in mid January titled, "Catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): A prospective cohort study." International Journal of Nursing Studies. December 19th. The conclusion "found that a 45% catheter to vein ratio was the optimal cur off with high sensitivity and specificity to reduce the risk of VTE."

Chest. 2011 Jul;140(1):48-53. doi: 10.1378/chest.10-2637. Epub 2011 Feb 24.
The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters.
Nifong TP1, McDevitt TJ.