Forum topic

10 posts / 0 new
Last post
Jim
To cut or not to cut??? Whose introducer do you use???
I'd love some feedback & some opinions please.
 
Two questions... first, do you make a cut before inserting your introducer over the wire?  Would it increase the risk of infection by making a cut in your opinion?  I'm thinking the moisture from bloody or serous drainage can be prevented by placing the line through a puncture site rather than through a small cut.  Everything I rationalize about this tells me that it has to be better to avoid a cut.  I'd love to hear some opinions...
Next question, whose introducer do you use & what's your opinion of its ease of insertion... especially without a cut? 
I have opinions of my own but would prefer to hear what others are thinking & experiencing before I share mine.  
Some history:  We've been using the same picc kit manufacturer for many, many years.  We started with their kit back when all we had was the Excalibur introducer (AC insertion w/o ultrasound).  When ultrasound came along... we were making the cut & placing a pressure dressing.  There were some that bleeding was still a BIG problem &, I think this was when we started drawing a line at INR & PLT's.  We were also having issues with catheter kinking in the tissues between skin & vein.  This was what brought about the reverse taper... it was intended to reinforce the tunneled portion of the catheter & reduce the occurrence of kinking.  A beneficial side affect was noticed... it acted as a tamponade of the site.  We found that with a cut...many would still ooze & bleed.  We started inserting the introducers w/o a cut... wow, what a difference!!!  We completely eliminated the gauze pressure dressing & rarely (very rarely) ever had oozing of any kind.  This also changed the way we handled orders for pt's in need of a line but with high INR or low PLT's.  The company we've been with has changed their introducer to one that can not be inserted w/o a cut the majority of the time.  We first insert the dilator w/o difficulty, reassemble with the introducer & it will not go... if it does go, it feels like it's causing much unnecessary trauma as it passes.
 
Thanks in advance for your input... I'm finding this very frustrating.  I feel like our current manufacture is forcing us to either stay with them & take a giant step backward in the way we practice or, start shopping for better equipment.
Julie Shomo
I very rarely use a scalpel

I very rarely use a scalpel anymore.  I agree with you in the thought that any extra open area increases the potential for infection.  The extra oozing increases the moisture under the dressing creating a cozy environment for germs to multiply. The open area increases the risk of contamination when the dressing is changed.  A diabetic or immunocompromised patient may have more difficulty healing that wound which is also a problem. 

I haven't used all of the kits, so I certainly can't speak for all of them, but most all of the companies have at least one good introducer.  You may pay more for it. I've recently used,(in alphabetical order)BD, BARD, Galt, and Medcomp. The only one that I needed a scalpel consistently for was BD.  But I only used one type.  They may have another one that is better.  I've been happy with the introducer we use, so I really haven't evaluated all on the market.

 I applaud your attempts to get equipment that will cause the fewest complications.  Contract and purchasing issues are a "pain in the patoot", if you'll pardon my country girl slang.

Julie Shomo BS, BSN, RN, CRNI

Infusion Solution LLC

Julie Shomo BS, BSN, RN, CRNI

Infusion Solution LLC

Vera Deacon
We use the Galt introducer
We use the Galt introducer and generally always cut. We have been having some supply issues and are in the process of changing vendors. We use the Vaxcel PASV. Bleeding is an occasional issue but we just use a pressure dressing. Our infection rates are very low so. How do you get away without making a cut? 
Jim
Thank you so much for your

Thank you so much for your responses... 

The introducer we'd been using for years was a grey dilator w/ a black introducer... very similar to Vaxcel's.  We placed PASV for pt's getting a picc for chemo & could easily insert their introducer w/o a cut.  Prior to Nitinol, the wires were sometimes a bit tricky to keep from kinking.  The local Arrow Rep left us some of their introducers to try... in my opinion, this has got to be the easiest introducer I've ever inserted w/o a cut.  We won't be switching companies just for their introducer though.  They have to have the whole package... great MST (Nitinol wire, good needle & an introducer that doesn't require a mallet to insert), well set up kit, power injectable, reverse taper & a good customer service.  We're paying premium $$$ for these kits & should be getting quality products.  What's your thoughts on the Medcomp MST, catheter & overall kit?  I like the idea that they will build custom kits, as long as the introducers don't feel like pushing a nail through sheetrock by hand.  Personally, I've never tried an introducer that couldn't be inserted w/o a cut till now... that's why this seems like such a huge step backward in the evolution of this procedure. 
Thanks again for your help with our pursuit of usability & quality!!
afruitloop
Jim, Please email me off

Jim,

Please email me off line and I can offer a solution to your "complete PICC package" need. I do not think that this is the forum to promote a company's agenda and do not really want to a commercial for one!  LOL

Cheryl Kelley

Cheryl Kelley RN BSN, VA-BC

Jim
Thanks Cheryl… I sent you

Thanks Cheryl… I sent you a note. 

This subject didn’t spur much conversation… what’s the popular opinions?  Is avoiding a skin nick for introducer insertion as big of a deal as I’m making it?  Leaving product manufacturers out of the question… here’s an abbreviated version of the original question:  Do you attempt to insert the introducer through the needle’s puncture site or, go straight to making a cut to insert through?  Any opinions about pro’s & con’s of both methods? 

Just curious if my feelings on the subject are among the popular majority or the minority.  Thanks again!!  

lynncrni
In my opinion, anytime the

In my opinion, anytime the skin nick or cut can be avoided, it should be. In the past, there has been no way to avoid it because of the technology. The transition between the introducer sheath and the dilator was usually the problem. It was not a smooth transition between the two pieces . Now technology is better. That transition is smoother and the shoulder of the introducer sheath is a more gradual taper. I don't think there is any data showing that anything positive or negative about this cut because local insertion site infection has not generally been reported to be a problem . But I am sure doing without the cut would be much more comfortable for patients. The less insult to the tissue, the better. Technology improvements have made that possible. With the original MST, there was less trauma to the vein and skin to make skin cut.

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

Karen Day
Karen Day's picture
interesting to find this

interesting to find this thread when we were discussing this very problem this morning when we arrived to work.  We have always used the technique of making a cut or nick to help ease the insertion of the introducer/dilator.  However, I am looking for ways to avoid this nick so as to reduce any bleeding or oozing issues, therefore requiring fewer dressing changes (i.e a cost savings and decreases catheter manipulation thus lowering the potential for line infections).

Does anyone find that "dilating up" helps (inserting the introducer by itself, then reassembling the combo and inserting both together) or what other techniques do you use.

In answer to your question, yes we do currently make a cut but are looking for alternatives to this method.

Jim
Vera… You say you’re

Vera… You say you’re using a Galt introducer.  Our team was shown the Galt introducer the other day…. Impressive!!  It was inserted with VERY little effort over a Nitinol wire without a cut.  In fact, she held the introducer/dilator by one of the wings, in one hand & merely pushed forward.  It looked absolutely effortless.  We’re supposed to be receiving several in the near future for the whole team to trial… I’ll come back w/ my own opinion after that happens.

  

Lynn Thank you VERY much for sharing your opinion on this subject.  I was actually hoping you might chime in with your thoughts... again, thank you!!

 

Karen… Before our brand’s recent change in introducer’s, I very rarely “dilated up”.  With this new introducer it’s a must.  Even then it won’t go without a cut most of the time.  We’re a team of 4 & the other 3 do & have been routinely “dilating up”.
Log in or register to post comments