I am attempting to write a protocol for US guided PIV starts and have been unable to find any to use as a guideline for best practice. I know that lots of us who place PICC's are using US to place PIV's as the topic comes up regularly here on the forum, but does anyone have a protocol in place? I'm specificly wondering if those doing the procedure are using a sterile probe cover and sterile gloves as is done for all other US guided procedures (biopsy, centeiss), and if the site limitations discussed here are in your protocol. Â Any help would be much appreciated.
send me your email and I will be glad to share the policy I wrote for starting PIV with the use of ultrasound. I wrote it based on some information I received at a breakout session at AVA in 2007.
[email protected]
Robb,
We struggle with this issue too. Our team places many US guided PIVs. Since we were sailing into unchartered waters, we had to live and learn. At first, we seemed to focus on the veins of the upper extremities. Yes the veins were deep but with a 2.5" catheter we thought as long as the catheter would reach the vein we were doing OK. What we found is that there were alot of deep infiltrations, etc. Since there are so many surrounding structures around these deep veins-patient moves their arm and wella, the catheter is out of the vein infiltrating. Now I only place in the upper arms if the vein is superficial (1-1.25cm max), but am pretty proficient in the lower arms as well and use this as a first choice. The ER has trained nurses in US use as well. Unfortunately we get many PICC requests for patients with these PIVs and massive infiltrations and can't use that arm for the PICC. I feel that the ER staff are unfortunately not witnessing the outcomes of these PIVs they are placing, which I think would have a major impact on their practice. In the right hands- knowledgeable clinicians, it is definitely an asset to our patients! Good luck! [email protected]
Cindy Hunchusky, BSN, RN, CRNI
Rob,
I meant to also add that we use the sterile US sleeve and sterile gloves for all PIV placements. Cindy
Cindy Hunchusky, BSN, RN, CRNI
We are discussing the use of US to place peripheral IV, primarily training the ED nurses. I have my reservations regarding this practice. My primary concern is getting the right access for the patient. I am afraid that needed PICC line placement may be delayed and multiple veins damage in placement of PIV's making PICC line placement more difficult.
Jeffery Fizer RN, BSN
I also have my reservations about this practice. I worry about sterile access. Again, what is right access? Why destroy an upper arm vein, when they really needed access for longer than the time to infiltration.
We have found that those placed in the ED are at greater risk for infiltration in the upper arm.
Gwen Irwin
Austin, Texas
A lot of people seem to get really offended when discussing US assisted PIV starts. Using the US doesn't always mean using the deep upper arm veins that we would want to be saving for a PICC...I use it for lower arm veins that are not palpable or visualized dut to third spacing, or a 400 pound woman which has a strong forearm vein that will tolerate a 20 ga just fine but getting do it over adipose tissue may not be easy as it too isn't visualized or palpable. In these circumstances I will use a tool that is offered to me and take a quick glance at the lower arm veins that are being covered from edema or tissue and then use a 20gax2in insyte to make sure the PIV is seated well within the vein. So my point, just because we sayPIV placed with the assistance of US, doesn't mean we jeopordized a upper arm basilic, brachihal, or cephalic vein. Sometime too I take a peek at their severely scarred anticubital region to see if their is any luck for threading a PIV into that area. Sometimes you will quicklly see that it cuts off to a sharp angle and when not able to feel it, for whatever reason, you are now able to visualize and have a better idea of where to go so your patient can get the access that is needed (i.e. R sided AC PIV for CT scan).
Liz Holowasko BSN, RN, CRNI
Liz Holowasko BSN, RN, CRNI
I have no problem with a qualified vasuclar access nurse using US to place peripheral IV's. I was an ED nurse with limited tools, only my eyes and hands for 13 years. I have put and tried to put IV's everywhere. Turning me loose with an US machine that time would probably been devastating to the patient in the long run. I would feel comfortable with nurses using ultrasound with a strong set of quidelines for its use. I would feel more comfortable teaching ED physician to use US to start IJ's for emergent use. And I use US just the way you are discussing, I always use ultrasound when starting IV's, it's been so long since I've started and IV or PICC line without it I don't trust what I'm feeling a lot times.
I sorry Liz but I just don't think it practical the logistics training and competency would be horrible
Jeffery Fizer RN, BSN
Cindy,
We are also seeing bad outcomes with the placement of PIVs in the upper arm. We just had a patient with an extravasation of blood with a brachial placed PIV. This was a renal patient with AV fistula on the other arm. Now what??
I think that the traditional length of IV catheters aren't reliable in the upper arm and will lead to complications. I am trying to track these complications with the help of the others that work with me. We need to give feedback to the ones doing these insertions in our facility. That is the only way that we can impact changes in their practice.
Gwen Irwin
Austin, Texas
I think we really need to see some published studies of success or lack of success regarding this practice. I know of one hospital in Florida that is starting a study for this type of practice, but their process is a bit different, they do not use a "normal" peripheral IV catheter.
I think there are issues with placing a "normal" peripheral IV catheter in a deep upper arm vein, especially if it is going to be used for power injections, the catheters on the market now may not be long enough to tolerate the pressure and back out of the vein, leading to extravasations. Extravasations of contrast are difficult to detect quickly and treat in the upper arm veins, this is one reason not to use midlines for contrast injections.
I would love to see some of these stories listed here turned into some published evidence.
Chris Cavanaugh, CRNI
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
dsnyrn
There is no midline catheter that I know of with a labeled indication for power injection. Any infiltration or extravasation injury from a midline would be most difficult to detect early because the tip is in deep tissue.
Also regarding the legal ramifications for use of ultrasound - this device increases the nurses ability to locate veins and arteries and consequently their liability for using the device accurately. Therefore it would put a greater responsibility on the nurse to be able to discern the difference. Of course the facts in all legal cases are very different, however using an ultrasound for placement of any catheter that resulted in placing a venous catheter in an artery could present a situation of increased liability for the nurse. Without the ultrasound, it might be plausible for the nurse to testify that she/he did not feel a pulse in the area where the venipuncture was made and this lead them to decide that the vessel was a vein instead of an artery. With ultrasound you would have another tool to add to your decision, so a greater liability for it to be correct. But I must add, that this is my opinion only!
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
I would not recommend midline catheters being used for power injection. If a patient doesn't have a power injectable central catheter, then the next best option is a short catheter in as large a vein as possible - usually the median cubital, median basilic, or median cephalic.
Occasionally we can't advance PICCs because of stenosis and/or thrombus or some other reason we can't determine at the time, and the patients go to IR. If they can't get a catheter to advance and it is left at "midline" length - it's a setup for potentially serious problems.
Recently, one of our patients had a power injectable PICC that couldn't be advanced. The staff knew it was not central, had been educated about power injectable catheters from CT to ICU to IV Therapy to MDs.....the MD approved use of the PICC for a power injection, the staff nurse went along with it, the PICC was not marked "DO NOT POWER INJECT"....and the patient received a contrast extravasation in the shoulder. FORTUNATELY .....the extravasation was not near her brachial plexus and all of her follow up exams up to now have been good, but she could have lost function of her arm.
Even though a lot of education had been done, there were PICC product posters in all the right places - because the catheter was power injectable, the staff used it as such. This would be a common point of system break-down that would cause serious patient injury.
Technology is advancing so rapidly; staff must manage an incredible amount of information about a lot of medical devices, and they must know the technical specifications and instructions for use for all of them. If we, as access and infusion experts, are telling them or demonstrating that a catheter is a catheter is a catheter, we're putting our patients at serious risk. The design of devices can often engineer in "hard stops" to prevent incorrect use of the device (like the design of the male prongs of an electrical plug - only one way to put it in the outlet - the safe way) - but we don't always have that design feature available. In the case with our patient, she was the victim of the human element of a system failure.
The catheter probably couldn't be advanced because of some problem with the vessel - stenosis, thrombosis - now imagine the scenario of power injecting into that! Of course the vein will rupture. Or something else - embolizing a thrombus with the power injector.
There is much more tissue involved when you use a longer catheter - much more risk for serious damage with infiltration and extravasation. Because of the depth and because the full extent of damage from extravasation often doesn't surface until a week or weeks later.....you may not know it's happened if you're not paying attention.
Infiltration and extravasation are not good in the shallower veins either, but at least not as much tissue is being damaged, and you can see it right away and be able to treat it. And - you're not near the brachial plexus.
Finally, Nursing Administration is correct that you're using a device off-label. If there's a problem, liability is definitely an issue.
It sounds like you're already a good patient advocate because you want to be able to provide greatly needed access to your patients. Consider the patient safety info and be really cautious about using those longer length catheters. You can use them for some infusions, but there are very few infusates that are appropriate for midline and long peripheral catheters. Either short - or central.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Jeffery Fizer RN, BSN
Trimming any PICC, including a "Power" PICC to a midline length and then leaving the tip outside of the SVC would leave the RN placing it liable for any complications that may occur, since it would be considered off lable use of the device, against manufacturer's guidelines. This would also be against FDA, CDC, AVA and INS guidelines and recommendations, since they all state that a PICC line tip must reside in the SVC.
The product is still labled as a PICC, creating this liablity, as well as confusion for the floor staff caring for the line.
An extravasation of CT or MRI Contrast in a deep vein will not be noticed as quickly as one occuring in a more shallow vein as with a peripheral IV. This will result in more damage to the patient's tissues and may require a plastic surgery consult to treat.
Be Careful
Chris Cavanaugh, CRNI
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
James M. Joseph RN , BSN, CRNI
In 2006 I started PIV using U/S with one nurse on a 3 month trial basis. The primary needle used was a 20 guage, introcan 13/4 inch. I restricted the sites to arms between wrist and AC. This service has grown and now has 3 FTE. We use a Vascular Access Algorithm to assess the patient's VA needs and make recommendations for best line for therapy and duration. The database has thousands of entries now. I can not find research on the subject that can help me decide if we are using the right sized catheters or choosing the right sites for insertion. There are units throughout the house that would like to train super users for the off shifts. Does anyone have any outcome based research or any advise? Maybe we need to publish our data?
James M. Joseph MPH, RN , BSN, CRNI, VA-BC
I think it would be really helpful if you published your data. Do you also list the specific veins you were using? That would be even more helpful.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
To Karen Day:
Could you send the policy on starting PIV using ultrasound to my email address? I tried sending you an email request but it came back undeliverable. My email address is [email protected]. Thanks, Vickey