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Robyn Whitlock ...
PICC Exchange

I just read the recently posted Sample PICC exchange document.  We recently spoke to BARD who advised us not to insert wires/stylets back into their catheters.  I know the policy stated to insert the floppy end, but we were told that if something happened to the catheter or the patient because of the reinsertion that we would not have Bard's backing as they do not recommend this practice. It is often difficult to do an exchange through the cannula and all of the nurses would prefer to do it with the wire.  Any feedback would be appreciated.

alice_cennamo
The exchange can be done

The exchange can be done without use of the floppy tipped guidewire.  You would need to keep tension on the skin at the insertion site of the catheter and slide the new introducer over the catheter into the vein. 

The guidewire makes it easier to get the introducer over the cath and into the vein, however there is a possibility it can be done incorrectly (wrong side of the guidewire inserted, etc.). 

Alice Cennamo

[quote=Robyn Whitlock RN MSN CRNI]

I just read the recently posted Sample PICC exchange document.  We recently spoke to BARD who advised us not to insert wires/stylets back into their catheters.  I know the policy stated to insert the floppy end, but we were told that if something happened to the catheter or the patient because of the reinsertion that we would not have Bard's backing as they do not recommend this practice. It is often difficult to do an exchange through the cannula and all of the nurses would prefer to do it with the wire.  Any feedback would be appreciated.

[/quote]
alice_cennamo
Hi Robyn, I can understand

Hi Robyn,

I can understand Bard's concern, the Groshong exchange policy I posted was orginally developed about 3 years ago with samples and input from the venous list group.  Use of the floppy end of the spring guidewire was considered safe by some of us.  

With that said, you would have to follow the manufacturer's reccomendations for their product to avoid legal liability. 

I have sent in a revision to the policy without the wire use in the procedure.  Give it a day or two to post.

Alice Cennamo

 

 

Robyn Whitlock ...
Thanks Alice.  My nurses
Thanks Alice.  My nurses are having a hard time because it is definitely easier with the wire.  We're all slowly adjusting!

Robyn Whitlock RN, MSN, CRNI

Paul L. Blackburn
It is very important to

It is very important to understand the context of a comment in order to understand the comment's meaning.  In this instance, Bard is cautioning clinicians not to insert a wire into an indwelling PICC.  This can be a dangerous practice as you can't really tell where the wire is going--unless you have the benefit of fluro and can see the wire as it is inserted.  The danger here of course is perforating the the PICC and causing damage to the vessel and/or underlying structures. 

On the other hand, Bard really doesn't have a position on catheter exchange over a wire.  Bard does not dictate clinical practice.  If your hospital allows this practice, and if your clinicians are trained properly, I see no reason why a PICC can not be exchanged over the wire.  The best of all settings would be to do this in fluro, but we all know that most of these procedures are done at the bedside. 

Paul L. Blackburn, RN, MNA

Senior Product Manager

Bard Access Systems

Robyn Whitlock ...
Paul, Thanks for your

Paul,

Thanks for your comments.  The question now is should we have a policy that allows it?  If we were to do an exchange over the wire and caused damage to the catheter and subsequently injured the patient, then where would we stand legally?  I know BARD doesn't dictate clinical practice, but you would be sought out as an expert in the field.

I would love to hear from others as to what your thoughts are and what you are doing clinically.

Robyn Whitlock RN, MSN, CRNI

ann zonderman
Ann Zonderman, BSN, JD,

Ann Zonderman, BSN, JD, CRNI, LHRM

I can't comment clinically, but offer some legal thoughts..... based on the info here if you have a policy, been trained, competent, explain the procedure, risks etc to the patient, ?? maybe a consent to proceed, and then your worst nightmare results in a patient injury, a legal battle may result in " Battle of the experts" 

However with the manufactures NOT backing up this practice it may be difficult to prevail =  But - if they do not come out and clearly state it should not be done, then there is room for debate.

I would be looking at the training, the track record, any established clinical results/ trials - Clear as mud - Right!  Always back up your practice with details to show it is safe, appropriate, competency is documented... We always have to consider new and evolving trends....

Ann Zonderman, BSN, JD, CRNI

anna liang
In the case of picc
In the case of picc rewire/exchange for damaged picc, how do we assess that there is no clot at the end of the picc -- that the wire might push the clot into the blood stream?
Karen Nellums
First of all, I believe you
First of all, I believe you mean peel-away-sheath, instead of introducer.  We have used change over-the wire method, but this non-wire method sounds feasible.  We plan to try it with our next change order.  So far we have not had problems with using the wire, but we only do this if we can get blood return.  This situation happens because the patient had a double-lumen PICC placed and now health status worsened and pt needs more IV accesses, so we change to a triple-lumen.  If we were unable to get blood we would have to restick the patient. 
Robyn Whitlock ...
We only do exchanges within

We only do exchanges within 24 hours of insertion unless there are no other options.  I would like to know how long after insertion other facilities are exchanging catheters.  The peel away sheath must be stiff in order to accomplish this.  We currently use the micro-access tearaway introducer kit from Galt and have had good success with that. 

 If a catheter has been in place more than 24 hours and needs to be replaced, we prefer to do a new insertion.  We are a "free standing" PICC service and are not "in control" of our lines once they are placed.  We feel it is safer from an infection control stand point to place a new line.

Robyn Whitlock RN, MSN, CRNI

alice_cennamo
[quote=Robyn Whitlock RN MSN
[quote=Robyn Whitlock RN MSN CRNI]

I just read the recently posted Sample PICC exchange document.  We recently spoke to BARD who advised us not to insert wires/stylets back into their catheters.  I know the policy stated to insert the floppy end, but we were told that if something happened to the catheter or the patient because of the reinsertion that we would not have Bard's backing as they do not recommend this practice. It is often difficult to do an exchange through the cannula and all of the nurses would prefer to do it with the wire.  Any feedback would be appreciated.

[/quote]
Jamie Sharp
Our hospital has a policy
Our hospital has a policy that allows us to overwire an existing PICC.  But we assess the situation very seriously.  Many times an overwire is inappropriatley ordered. We've had interns order an overwire when the Pt. has a high WBC or a fever, and our PICC team will not overwire into what could be an infected PICC.  We've also had orders to overwire when a PICC won't flush and TPA didn't help, and we won't overwire a possible thrombis.  So, needless to say we don't overwire often, but when we do, we pull out the existing PICC so there is only about 10cm left in, we cut if off 5cm out of the Pt., then carelfully run the floppy ended guide wire in but only go in about 20cm.  The wire isn't anywhere near the SVC.  We have never had any problems with this at all.  We pull out the rest of the PICC and have our guide wire in the vein ready for the introducer.  
alice_cennamo
In our hospital we had a

In our hospital we had a need for a policy for catheter exchange by our PICC nurses.  When I wrote the policy for our hospital I compared seveal samples of catheter exchange policies and reviewed INS standards, etc.  In most cases of the policies I reviewed and contacts I made (3 or so years ago), a wire was used in the procedure.  The policy I implemented at the time utilized the floppy end of the spring guidewire inserted to 10 cm or less and it included a section that stated the nurse needed know the catheter's indwelling length (by measurement external and comparison to amount internal and external upon insertion or last dressing change.) 

Our team's PICC nurses were the only nurses that changed PICC dressings, troubleshot PICC problems, or did the exchanges, and insertions.  Radiology accepted pts for PICC problems after evaluation by one of our team's PICC nurses.  Since our PICC team nurses did all PICC care as far as dressing changes, etc. - We had very good control over the quality of care and were able to track data on the PICCs closely.  We did not have a problem with nurses doing the procedure incorrectly. But with that said I fully understand what Paul stated and agree with his post. 

Yes it is much easier to exchange a PICC if a wire is used in the procedure.  It is not as easy, but a PICC can be exchanged without the wire also.  I revised the sample policy I posted to reduce liability.  The policy is just a sample to share and give back to the venous group, and can be changed to organizational policy.

Alice Cennamo, CRNI

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