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James Sissons
6 french, triple lumen Power PICC

I placed my first Triple Lumen Power PICC last week and, alas, it went up the Pt's jugular. I tried to reposition 2 times, then power flush to no avail. Has anyone else had a problem with the positioning of the TL. Our Sherlock is currently being repaired, so that probably has a lot to do with it, but why was it so difficult to reposition or why did the power flush not work?

lynncrni
My guess would be that the

My guess would be that the power flushing did not work because this is a larger stiffer catheter than what was originally used to create the power flushing procedure. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

rivka livni
I have inserted a few

I have inserted a few hundreds 6 FR dual and triple. They are harder to flush out of IJ but sometimes if you attach 3 syringes (1 per lumen) and flush them all at the same time a second after the pt does a Val Salva manuver (if they are intubated get the RT to hold their breath for about 10 seconds and then flush a second after they let go of their breath), you may get lucky.

Otherwise, get into the habit of always looking with your U/S in the IJ after positioning a PICC, it can be avoided. We do not use sherlock and have not had an IJ placement since we ALWAYS check there before we complete a procedure.

There is a great trick to keep a catheter from going into an IJ in the rare cases when it persistently goes in there despite everything you do, but that is another story. 

 

Janet Steves
My question to you has to do
My question to you has to do with the Sherlock.  It was in repair?  Can you explain the events surrounding that, how long it was gone for, how responsive was Bard to caring for the problem, etc.  Thank you.
James Sissons
Bard has been great
Bard has been great with getting a replacement Sherlock back to us; unfortunately, we had some big snow storms the last few weeks that has all but halted our incoming truck and train deliveries. We hope to get it back later this week. The only thing we can figure was wrong with it was that the internal gain was not reading the depth of the PICC tip well enough, causing multable "ghost" images when trying to isolate the PICC position. This caused us to have to repeatedly recalibrate the Sherlock before it reaquired the signal, it eventually worked, but who has the time to deal with that?
Karen Day
Karen Day's picture
we place very few 6FR TL

we place very few 6FR TL Solo piccs here, but in the rare cases it has gone into the IJ, we had difficulty flushing it into the SVC as well.  I guess it just took some persistence, very frustrating though because usually the patient that requires a triple lumen is very sick and needs to not have their access delayed.

For RIVKA LIVNI, I would be very interested in hearing your trick for the catheter that insists on traveling north as I call it.  We too use the ultrasound to look at the IJ or we feel with our fingers over the neck (over the drape) prior to completing our procedure and breaking down.  Many, many times when we flush the catheter we will give it a power flush and you can actually hear it (without the aid of a stethoscope) if it is in the IJ.  If you prefer to email me your trick individually, my email is

[email protected]

I know this has nothing to do with IJ placements, but a few months ago, my co-worker and I read a thread about difficulty in passing the picc around the shoulder and the trick given was to either push downward just medial to the shoulder(actually medial to the head of the humerus) or actually lift the shoulder area and try to advance then.  We have used these techniques several times and have had great success with them. 

Cudos to whomever posted that tip.

thanks

 

afruitloop
Here are some tips to get

Here are some tips to get the PICC south.

v     Advance the catheter VERY SLOWLY especially after the tip is advanced to the axillary - about 1 cm per second. This helps head it to the SVC by advancing it with blood flow, rather than against it. By threading slowly like this, when the PICC gets to the jugular subclavian junction, the blood flow from the jugular assists in taking the PICC south to the SVC.

 

v      Pull back the stylet a few - 5-10 cms before advancing, once you have reached the axillary area. This makes the tip of the PICC “floppy” and helps it to “fall” to the SVC.

 

v     Turn patient's head towards side of insertion, this will not keep the PICC from going up the jugular, but it will “allow” the clinician the ability to “feel” it, if she has mastered the feel of threading.

 

v     Flush slowly as you advance the PICC by adding a 10 cc syringe of saline on the PICC-to "float" the PICC while threading.  This opens up the vessel allowing easier threading.

 

v     If the PICC continues to malposition up the jugular according to what you feel, or if it won’t advance, when you get to the area of obstruction (or at the jugular subclavian junction area) “twirl” the PICC while advancing,  From the right, twirl it clockwise and from the left twirl it counterclockwise.  This can assist it in “flipping” to the SVC.

 

v     Advance each cm with slow deep inspirations as this dilates vessels.

 

v     Of course, use Navigation when ever possible.  Use the device to show you where your catheter is at, from the time it enters the subclavian area.

 

 

Cheryl Kelley RN BSN, VA-BC

Karen Day
Karen Day's picture
thank you so much.  I was

thank you so much.  I was using some of the tips, but was not aware of the others.  good to have this knowledge.

 

needles
[quote=James Sissons] I
[quote=James Sissons]

I placed my first Triple Lumen Power PICC last week and, alas, it went up the Pt's jugular. I tried to reposition 2 times, then power flush to no avail. Has anyone else had a problem with the positioning of the TL. Our Sherlock is currently being repaired, so that probably has a lot to do with it, but why was it so difficult to reposition or why did the power flush not work?

[/quote]
needles
I have been putting in TL

I have been putting in TL PICCS for about 4 years. The hints I can give are:

Pulling the wire back didn't help me cause the catheter was stiffer than the Groshong etc but the positioning of the arm. An anesthesiologist gave me a hint one time. He suggested placing the arm in an angle where the arm is straight and above the shoulder. It's at the 10 or 11 oclock on the right or 1 or 2 oclock on the left. This makes a straight alignment to aide it the route going down. The obese individuals did not make much of a difference but I never put the arm down to the side anymore if possible (due to restraints the the patient).

Twirling is a big thing I do as well. Hope that helps some.

karrenberg
the vast majority of times
the vast majority of times if we have difficulty advancing, we change the bed position.  If the HOB is initially in the more up position, we lower it almost flat.  If the patinet is relatively flat we raise the head of the bed.  This works almost miraculously.  Don't ask me why, it just does!!!
Heather Nichols
   When you get the triple
   When you get the triple PICC out of the box, it has a curl to the end of it.  If you put a gentle "twirl" to it as you insert, it is the luck of the draw, but it will usually flip down into the SVC.  It may take a couple of times, but it usually works for me.  Also, pull the stylet you are using back REAL far.  I noticed that if I pull the stylet about half way back the PICC (I mark it with a peice of tape so that I can reinsert it when I get the PICC in) it floats in much easier.  My Navigator (our navigational device) makes it easier to.  I can follow the PICC from insertion to SVC with my Navigator.  There is less trauma to the vessel that way.  I have used Navigator for about 6 years now, and we have never had to have it repaired for anything.  Sorry about all your snow problems.  It is 2 degrees here in Louisville.  I HATE cold!  Good luck!  Those stiffer PICC's are a pain in the patootie.
Timothy L. Creamer
Happy to hear Bard "has

Happy to hear Bard "has been great" in response to Sherlock repairs. James, curious on what model Sherlock you are using? Sherlock I, Sherlock II integrated or Sherlock II stand alone? In my recent full time hospital position the integrated Sherlock II never required servicing. I'm sure the snow storms can disrupt any service delivery, we experience similiar disruptions when hurricanes visit.

Some great tips have already  been posted for preventing internal jugular involvement on catheter advancement which you should find helpful. I would caution regarding use of ultrasound probe to determine internal jugular involvement as the potential to compromise the sterile field is significant when utilizing maximal barrier draping (head to toe), especially if performing insertions without another PICC nurse.

Remember the external diameter of the catheter only increases 1/3 of a mm from the 5Fr to the 6Fr (not including reverse taper) so you should not experience a problematic trend when inserting triple lumen catheters. I have felt stiffer 5fr catheters, not all polyurethane is equal.

Hope this helps.

Timothy L. Creamer, RN  

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

estevens102206
Hi Tim, how large is the

Hi Tim, how large is the external diameter of the Bard 6 French triple with the reverse taper? 

 

Eric

Eric

Timothy L. Creamer
Bard's reverse taper begins

Bard's reverse taper begins at 7cm proximally and gradually increases approximately 1.5Fr to 2Fr at the proximal end (an external diameter maximum increase of 0.49mm to 0.66mm.) Roughly 80% of all PICC's currently available have a reverse taper design. A thorough prescan assessment including correlation of vein diameter, vein depth, and reverse taper to calculate appropriate external length of catheter (if indicated) is just as important as determining internal length of catheter. This aspect of the prescan is required for any size catheter being placed, not just triple lumens. Bard's reverse taper design not only gently plugs the subcutaneous tract but also provides kink resistance resulting in numerous other benefits and positive outcomes. 

Eric, hope this helps. Still curious what role you are involved regarding vascular access, RN? Specialist? Pharmacist? PICC team member? Patient? Vendor?

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

estevens102206
Good to see you have

Good to see you have memorized the Bard "company line" there Tim. 

Eric

Eric

lynncrni
The problem is that the

The problem is that the "other benefits and positive outcomes" have not been demonstrated in any published studies. So this is really anecdotal information at this point. There was also a lively discussion at AVA in Sept about this feature and a radiologist was discussing doing a study because he along with several others questioned the concept of having the largest part of the catheter in the smallest vein lumen.

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

T. Nauman RN, CRNI  IV

T. Nauman RN, CRNI  IV Educator SHMC Eugene, OR

We place a lot of 6.0Fr, triple-lumen power piccs in our ICU's.  One thing we do with all our power piccs is to hold the catheter up to see its natural curve, then insert it so the natural curve is "down", rather than up toward the patient's head...maybe this is too simplistic, but we don't have a lot of malpositions in the IJ

T. Nauman RN, CRNI

rivka livni
Tim, about the sterile field

Tim, about the sterile field when checking the IJ with the U/S probe. Contamination can be avoided if you ALWAYS put the probe UNDER the sterile towel which is over the patient's chest.

We have our own custom insertion tray which has in it 2 large sterile sheets and 6 sterile cloth towels to place in strategic places on the sterile field. But it does not matter, every nurse should be able to figure out how to keep the contaminated probe from contaminating the sterile field. 

Remember, that probe does not have to be used for insertion anymore, only to check the IJ for malposition. We have not had an infection due to insertion, and we check every IJ before completing an insertion.

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