As a retired PICC nurse, I was asked to provide a solution for short term frequent blood draws to a drug research clientele. All the clients have a history of at least 25 years of IVDU with a lot of scar tissue along both arms (it can be seen on U/S) however, they do seem to have a somewhat decent Brachial vein, though as seen on U/S, most have interruption of that vein as you go along the arm, with the best uninterrupted view about 10-15 cm above the AC . The RNs who work on that ward do not use U/S and have been having a very hard time accessing veins. So far the investigating MD have been inserting IJ CVC in those patients, they asked me if there is a better option.
The blood draws schedule is for 24 hours with each draw requiring at least two blood tubes. After the subject swallows the investigated medications, initially the draws are q 15 min x 2 then q30 minutes x 2, then q1 hour x 2 then q2 hours x 2 and so on for a total of about 14 times.
I thought that a PICC would be wrong for 24 hours dwell when I consider the risks vs. benefits.
I had inserted a PIV using BD 20g. w/length of 1.88 inches but it worked only 75% of the time for the entire 24 hours. The problem was when the PIV did not give blood back within a 10 min window of the scheduled draw, the study had to be thrown out.
Does anyone have any ideas of a catheter that will work with minimum risks? Am I wrong to think that a PICC for 24 hours of blood draws is over the top? Should the investigators go back for IJ? Any helpful suggestions are welcome.
How about a US-guided insertion of a midline catheter? Tip in largest diameter peripheral vein but not in the central circulation with the added expense and risk - xray, thrombosis, etc. Or would an 18 g PIV produce better results than a 20 g? Just a thought. It does seem that any form a peripheral would be far better than any type of CVC. Lynn
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
Hi Lynn,
A Midline sounds good but if I insert it in the upper portion of the upper arm, closer to Axilla where the "better" looking vein is, would the tip still be OK?
The 18g sounds good, I think BD has a 1.75 inches long catheter, so it will not dislodge.
Rivka
Rivka Livni PICC RN
So are you saying that you could not actually make the puncture in the mid-bicep area and advance to the traditional midline location? It sounds like you are saying you need to make the puncture at what should be the tip location. If this is true and you advanced for several inches this would be the old midclavicular location. But they are now using that location for the aquapheresis procedures with recommendations that the catheter is not to be used for any type of infusion. You could do that if these catheters would only be used for aspiration and not infusion. Do you have control over the situation enough for this or could it get out of hand where these catheters would be used for infusion after the blood sampling procedure? BBraun also may make a long PIV, but am not totally sure about that. Let us know what you decide. Lynn
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
Thanks Lynn,
I think I can find a decent enough Brachial at the mid-bicep location in most of the patients.
Yes, these venous access will be used only for aspiration, the clients get their investigation drugs PO, so I think it will be OK to puncture anywhere in the arm.
I never inserted a Midline before and the catheters I saw do not have micropuncture/MST technique, is that pretty much true for all Midlines? Any suggestions on technique? Are there any MST / Micropuncture Midlines on the market?
I will also look into B.Braun #18g long PIV.
Rivka Livni PICC RN
You can try Bard or Medcomp midlines. I use Medcomp midlines (either 4 Fr or 5 Fr) and the midline kits contain MST.
Midlines are not ideal for blood draws. It has been my experience that they will give blood back a few times after initially placed and then usually stop. I'm not sure exactly why unless it is because they are in the bend of the shoulder at the axilla vein and in a smaller vein versus the SVC. When we place midlines we use a 4 french Arrow, but we rarely place them because they are not ideal for blood draws. One of the reasons that patient's need this kind of access is because they have no veins and there is a need for lab draws. We usually opt to place a PICC. Let us know how it goes. Good luck!
A 5 french power or open-ended PICC used as a midline would work (you can cut it down to 15 cm). Groshongs (usually what midlines are) aren't good for midline blood draws as the valves that open are on the side of the catheter & therefore rest against the wall of the vein, preventing blood drawing into the catheter.
ReneMaslow, MSN, VA-BC PICC/Proc RN Kaiser Permanente Santa Rosa, CA
While it is true that midlines usually quit returning blood, that is more likely to occur after a few days rather than a few hours. I think for the period of this test that midlines would be the best option. MST kits can be obtained separately so that any midline catheter can be used. Galt is one company that provides individual MST kits. Another option is a peripheral EJ catheter...less risk ,in my opinion, than the IJ CVC.