Sherlock tips and procedures

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Procedure:   Use and Management of the BARD Sherlock ® PICC Tip Location System.    

General Information:   The PICC Tip Location Device is designed to accurately assess PICC tip during placement of the PICC only when a specially designed stylet is inserted into the PICC lumen.   This stylet has magnets on the tip that will be “sensed” by the sensor device and then displayed on a monitor screen. The device success is dependent on correct positioning of the sensor module, careful calibration, and patient cooperation in remaining still (no movement) during the final phase of PICC placement. The risk for malposition is greatest during this phase and is normally undetected until review of the post-insertion radiograph.  An assessment prior to “break-down” of the sterile field allows for immediate feedback, intervention and reassessment.    

Application/Benefits:   This procedure will assist the Registered Nurse in the proper use of the BARD Sherlock ® PICC Tip Location Device during central line placement.   Early detection of a malpositioned PICC tip and immediate adjustment during the initial placement will allow for the following: (1) greatly improve early detection of PICC tip, (2) decrease wait-time from insertion to use of the PICC due to tip malpositions,(3) eliminate the need for repeat chest radiographs, (4) reduce risk of infection or vein trauma due to repeated PICC placements or repositions,(5) increase patient safety and satisfaction with PICC placements, and (6) save nursing and physician labor costs due to tip malpositions.      

Warnings/Precautions:   In accordance with the Sherlock ® device manufacturer’s Instructions for Use (IFU), the following warnings and precautions shall be noted and followed by all users/operators of the Sherlock ® PICC Tip Location Device:  (1)                 Do not operate the device in the presence of flammable anesthesia gases due to potential for explosion hazard. (2)                 Do not submerge any parts of the device in water or other fluids.(3)                 Do not attempt to sterilize by any method. (4)                 Only use the device with catheters that contain the Sherlock ® stylet.(5)                 Avoid contact between the sensor module and any strong magnetic fields.(6)                 Wired clothing or undergarments may affect performance of the device.(7)                 Do not allow metal objects (ferromagnetic) within 12 inches (30cm) of the sensor module. (examples: scissors, watches, jewelry, metal bedrails, electronic detectors)(8)                 Keep all electronic infusion pumps (feeding or intravenous) at least 5 feet away from the sensor module. (9)                 Avoid insertion of a PICC containing the Sherlock magnetic stylet on the same side as a cardiac pacer.   Keep the stylet at least 2-3 cm away from the cardiac pacer to prevent disruption of the cardiac rhythm device. (10)       Do not attempt to dismantle or open any components of the Sherlock ® device and do not connect to any power source other than as provided. (11)       Repair or Help: Contact “Bard Access Systems” at 1-800-545-0890.  

Supplies and Equipment:    (1)                   Bard Sherlock ® PICC Tip Location Device (both sensor and display monitor.(2)                   Bard PICC tray with pre-packaged Sherlock ® stylet with magnetic tip.(3)                   Cover for Sherlock ® sensor device (found in PICC tray).(4)                   AC adapter for Sherlock system (optional)  

References:      (1) Bard Access Systems Information for Use Brochure for the Sherlock ® PICC Tip Location Device (2006). (2) Facility PICC Insertion Nursing Procedure.                                  

ProceduresKey points
1. Review the Bard Sherlock Detector System IFU and trouble shooting guide. Check battery level and connect AC adapter as needed.  1. All PICC RNs shall be competency evaluated with the Sherlock system prior to independentuse. Fully charged battery: 3-4 hoursIf battery icon is flashing: approx 20 minutes remain.
2. During patient education regarding PICC insertion, discuss method, benefits, risks, alternatives and safety of the Sherlock Detector System. Also assess for implanted cardiac pacing device.  2. Discuss benefits of detection system and need for patient participation (e.g. device location, methods, calibration of the Sherlock ®, and remains still).
3. Inspect PICC insertion tray for Sherlock stylet. Check all modules for cleanliness, damages, connections, and battery level.3. Must have Sherlock stylet available for system to operate.
4. Insure the Sherlock monitor screen is placed for ease of viewing during PICC insertion.  4. Place sensor across bed on Ultrasound stand or at head of bed above ipsilateral shoulder.
5. Position and prep patient for PICC insertion. Place Sherlock sensor into “single- use” plastic cover/pouch with cord leading toward patient’s feet.5. Sensor cover/pouch will be included in Sherlock stylet equipped PICC tray.
6. Place the covered sensor device (with adhesive strips) over the external landmarks as previously measured. Place the Sherlock “logo” on sensor module over the anatomical landmark of the 3rd intercostal space (or as desired).6. Insure that all metal objects are at least 12” away. (Watches, jewelry, scissors, etc) Pumps should be at least 60” (5ft) away from sensor. Lower bed rail on PICC insertion side of bed.
7. (Optional) Place the Sherlock sensor over the right or left clavicle to track catheter movement and tip orientation during insertion.7. Once the sensor is placed and calibrated, it should not be repositioned.
8. Immediately after placing Sensor module and all motion has stopped, Press the “Start/Calibration” button for two seconds to begin calibration.8. During and after calibration, ask the patient to remain still. Caution: Do not bring metal objects within 12 inches of sensor. (scissors, etc)
9. Continue with sterile prep of PICC materials and patient. When ready for PICC insertion, insure that Sherlock system remains calibrated.  
10. Insert PICC and observe monitor screen for icon of stylet tip.10. ICON appears on screen as a “shooting star” and will give location and direction of stylet tip.      
ProceduresKey Points
11.   Continue to monitor stylet icon for appropriate signals that indicate the PICC tip is moving, correctly oriented and finally located the desired location.    
12. If no signal is present or stylet icon (tip) does not come into view, check for calibration errors, or suspect malposition of PICC tip. 12. Consider malposition or need for re-calibration of Sherlock system.
13. Using the Sherlock ® stylet icon feedback as indicated by the sensor device, withdraw PICC and reinsert to obtain optimal tip position within the SVC. 13. Use all indications (patient feedback, blood aspiration, clinical experience and judgment to determine assessments and interventions.
14. Refer to Sherlock IFU for trouble shooting solutions as necessary.  
15. When completed, dispose of sensor cover. The system can be cleaned using PDI towelettes between patients. 15. Do not wash any component of the system under water, faucet or immerse in liquid.
16.   Follow-up placement with chest radiograph for confirmation of PICC tip.