Would appreciate information on your institucions protocol for pediatric PICC insertion.
1. Are the lines placed at the bedside or in IR?
2. Is sedation used? What works best?
3. What brand of catheter do you use?
If anyone would be willing to share their policy on pediatric PICC insertion I would appreciate it.
Thank you in advance for your reply.
We do not have IR. We place PICCs at the bedside, in the procedure rooms on the unit and in our sedation room. Each patient is assessed and a customized approach is used.
We have a great sedation service that uses Propofol exclusively. I have in the past used po Versed at the bedside which works well but requires intensive monitoring so now it's more efficient to take the patient to sedation. In our PICU patients may get a combo of Versed and fentanyl.
Currently we use Bard both silicone and polyurethane, Clinicath's 2 Fr and Kendall 1.9 Fr.
You may e-mail direct if you wish.
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The PICC service I work with is a part of the Radiology service. We have our own PICC procedure room. We also have IR backup for difficult cases. We work in collaboration the the PICU sedation service for those kids who need sedation as well as the OR anesthsia for those patients that the PICU service feels are at high risk for sedation with just porpofol (our drug of choice). We use the 2,3 and 4 french BD catheter, as well as a 3 french bard, and 4,5 french solo power picc.
Jeffery Fizer RN, BSN
I am also interested in procedural sedation for Pediatric PICCs. I work in a 300 bed hospital that places approx. 100 adult PICCs each month but only a hand full of Pediatric ones. I was a bedside Pediatric nurse before joining our Infusion Team. I seem to be having issues with sedation (our doctors rely on chloral hydrate) and venous spasm. We place our PICCs at the bedside but do have portable flueroscopy. Any suggestion or especially articles would be greatly appreciated.
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Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
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I to was having a significant number of problems I preceived as vasospasm. The thing that I have done to try to reduce this risk is removing the tourniquet before dialating the vessel. Usually after having inserted the MST wire. This seems to have reduced this preceived problem.
Jeffery Fizer RN, BSN
My experience with Chloral Hydrate is that patients can easily over ride the effects during the procedure when they become anxious or stressed and it is as if there is nothing on board. Then after you have struggled with them and the procedure is done they are zonked for hours. I do not use it for that reason as well as the fact that we have a very effective sedation service.
If the sedation service were not available I would prefer to use po Versed rather than chloral hydrate.
We place most PICCs in a treatment room located on each peds floor. They are done at the bedside for those pts who can't go to that room for whatever reason. If we use sedation, we use a procedure room. Our sedation is provided by our Peds critical care/sedation team and is almost exclusively propofol. In my opinion, chloral hydrate is worthless for the reasons others have mentioned. Our guidelines for sedation are: in general, between the ages of 1 and 5, or previous failed attempt without sedation, or highly sensitized/fearful to IV access, emotionally/developmentally delayed, strong desire for sedation expressed by parents after having risks/benefits explained. For those others who need something but probaly not a full sedation, oral versed and child life is a quite successful combination. We also try to coordinate placement in the OR under anesthesia if they are undergoing a procedure, such as endoscopy, bronch, I & D, or drain placement.
We use Bard 3 fr silicone and poly, 4 fr Power, and 4 fr dual. For neonates we use B-D silicone, first PICC. I also like the Vygon 2 fr dual poly for those neonates who need more access, we don't stock that yet, we have only had samples.
Anyone who needs precepting on peds, contact your product rep. They should have nurses such as myself, who can precept those just learning peds.
If you still need a policy I will send one.
Holly Hess
I am from an approximately 300 bed hospital. We have a 20 bed Pediatric unit. I was a Pediatric nurse for 10 years before advancing to the Infusion Team. I am very comfortable placing IV in Pediatric patients but have had difficulty with PICCs. I seem to have a lot of trouble with venous spasm. We do not have a child life specialist. Propofol would require an anesthiologist. What other suggestions do you have? Please forward any policies to me. I would love to have someone precept me.
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Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]
Rose,
When you say you are having venous spasm, do you mean when you access or as you thread the catheter? I experience very little of what I would consider vasospasm. However, warm compress and oral versed work well. I use a warm compress on every patient prior to insertion. If they are very anxious, oral versed definitely helps them relax.
Holly
Holly,
The Venous spasms I am talking about are with threading the guidewire and/or catheter. I have access with good blood return but cannot get any further. I have had one child and one adult that the venous spasms were seen during Interventional Radiology attempts. I have tried heat.
Thanks for your input.
I am interested in Pediatric PICC internship if anyone has this available please send me the details. I am especially interested in the hands on.
Rose
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Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]
Answers:
1. I will place the PICC in the patient room if
a)the room is smaller than usual
b)the patient is a teen
c)patient is in PICU
d)patient has 'equipment' that would be best not to manipulate
e)it would be difficult to get patient to procedure room
PICC will be placed in procedure room ESPECIALLY if toddler/preschool/early elementary age. We want to keep their patient room 'the safe place'.
2. Usually use a less than conscious sedation dose of Versed, although we are working towards having anesthesia do sedation for PICC placement. I use LMX cream over the site, and will add heat (with heel warmer) over the LMX or instruct parent to massage LMX while I am getting set up. I always have a Child Life Specialist with me, and either the bedside RN or aide (someone who can tie a tournaquet and keep arms and legs from kicking me if needed). Preparation for a PICC by the CLS is very important. They even have a PICC line book they show kids that are old enough. Children do better when they know what to expect, AND what is expected of them. Be totally honest. Also, some kids want to know what you are doing and what they will be feeling, and others just want to get it over with. Just ask them if they want to know everything (although I have them look the other way when I'm ready to do the dermatotomy).
3. Bard Per-Q-Caths 2 and 3 FR mostly. I have a few 4 FR, and am trialing some Churchill lines.Our NICU uses mostly BD.
Thanks Gretchen
Is this PICC book something I can purcahse or was it made by the CLS?
Donna: The book we have currently is called "My PICC line" and is from Bard Access Systems. BUT we are in the process of creating our own with pictures of our own staff... one of the CLS is doing it as her masters project. I'm real excited about it!
Hope this helps.
Gretchen
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