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Rodney Allen
radiology wire for PICC placement

Our vascular access team uses a stiff radiology wire with PICC insertions.  The reasoning is that it is ok because the wire is never advanced past the tip of the PICC but just used to help advance the catheter.  Some on the team also use the wire for changes outs similar to an IR insertion ie. cutting the catheter,  inserting the rad wire, removing the old catheter over the rad wire, and then inserting the new catheter over the rad wire.  I looked through INS standards but didn't see anything against this practice.  Have felt uncomfortable about this practice and know that it would really cause controversy in our team if they had to change.  What is the evidence and best practice concerning this?

Gwen Irwin
radiology wire for PICC placement

I would wonder about replacing the stylet guidewire of a PICC.  Does the manufacturer of your PICC include a stylet guidewire?  Is it considered to be off label to take that wire out and replace with the radiology wire?  That is the evidence that I would look for.

I would worry about a stiffer wire being used for an exchange.  I think about trauma to the vein wall if it isn't a very floppy tip wire.

Just my thoughts.

Gwen Irwin

Austin, Texas

lynncrni
The original message is

The original message is referring to an exchange overwire procedure and there is an INS standard about this procedure. In Infusion Nursing Standards of Practice, Standard #59, page S64. Based on your description above, I would be most concerned about the "stiff radiology wire" that you are using for this purpose. The stiffness concerns me as there can be damage to the catheter and the vein. An exchange over wire does not require a stiff wire. It requires a guidewire that is appropriately sized for the catheter being exchanged. So look at the size of the wire in the catheters you are placing, locate a guidewire of the same size that has a floppy tip and use that. There is controversy about this practice due to having the external portion of the old catheter no longer being sterile nor are you able to make it sterile. So infection will be a risk. I have performed this procedure at the bedside and it can be quite cumbersome and usually requires 2 people in sterile attire. There are very few studies on this practice but it has been done since we began placing PICCs in the late 1970's. In fact, I had a poster at INS back in 1982 or 83 about this procedure. Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Rodney Allen
Thank you Lynn for pointing

Thank you Lynn for pointing out standard #59 although I don't see that it specifically addresses the length of the wire.  And thanks Kathy for your 2 cents.  The wire my that the nurses use is indeed a 110cm radiology wire with a floppy tip.  I am totally opposes to the use of this and do not use it in changeouts.  What really gets me is when they are teaching new PICC nurses to use it when they aren't used to placing PICCs and controlling a wire like that.  I cringe that they are putting a 110cm wire in someones chest.

lynncrni
I totally agree with your

I totally agree with your concerns about the length. That is why 2 people in sterile attire are usually necessary. The wire should be long enough to advance into the old catheter while holding on to the wire. Then place the new catheter over the wire and work it into the puncture site, also while holding on the distal end of the wire. So about half the length will be in the vein while the other half is external. To allow for proper control of the wire you will need a rather long wire. Of course, you are doing this with full body drape and complete max barriers. Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kathykokotis
rad wire

First off I would check with your catheter manufacturer to see if using a rad wire is off label usage

Second I woud investigate the hazards of this practice:

Is the wire in question 110 cm wire.  Quite a number are.  I have to wonder how a 110 cm wire used at the bedside is safe to begin with as most patients to their SVC is only 35 to 48 cm and therefore how does one control 90 cm of wire sticking out when one is only supposed to use a max of 20 cm of wire?  I see this all the time and am spellbound as to the safety let alone the sterility of such craziness  No company recommends a 110 cm wire at a patients bedside

Is the wire being used as a secondary wire (stiffening wire).  This whole idea of double wiring a catheter also has me begin to question the safety of PICC insertion at the bedside.  I cannot even begin to tell you how many facilities are practicing double wires to get beyond a stenoisis or obstruction.  This is insane.  Wires are breaking with this practice and it is usually the wire that the original manufacturer put into the PICC called the stylet (not wire).  No company recommends this practice

If it is not in the kit beware.

My two cents

Kathy Kokotis RN BS MBA

Bard Access Systems

Mike Brazunas
Radiology PICC kits being used at the bedsice

As I'm sure most everyone will agree; Radiology kits should be used in Radiology and bedside nursing kits should be use at the bedside.

 Many facilities try to simplify ordering or perhaps save money by using one kit for both.  I suspect that whoever manufactures your PICCs probably makes a bedside kit with a shorter wire.  The longer wire is used under flouro to measure the length of the PICC.  It is placed all the way to the SVC/RA junction, clamped at the insertion site and then the PICC is cut to that length and inserted.  Of course, you can't do this at the bedside without flouro so the long wire becomes a liability.  It often winds up hanging off the field or in your armpit!

I would talk with your PICC manufacturer/buyer/purchasing department to see about getting PICCs designed for use at the bedside. 

 

About catheter exchange:  A radiologist will often cut the old PICC, place a long wire through it, then place a new PICC OVER that wire.  At the bedside, I strongly recommend (and this might be what you meant) that you cut the PICC, place the wire through that PICC and then place a new INTRODUCER over the wire; then place the new PICC through the introducer.  

Thanks, 

Mike Brazunas RN, BSN

Clinical Specialist

AngioDynamics

[email protected]

Rodney Allen
well stated

well stated

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