The Infusion Nursing Standard of Practice 2011 do not contain any reference to mid-arm circumference. There are no studies supporting this practice yet many issues can be identified. The most important one is a wide variation in where the measurement is or should be taken, again no evidence for this practice - good, bad or neutral. Lynn
Our PICC Team measure 5 cm above the AC and 5 cm below the AC bilaterally pre PICC placement. This practice has helped our Central Line Team identify early thrombosis formations and gives them reinforcement when requesting Doppler studies. We have not done a formal study on this but several clots have been identified and further damage has been prevented. Our doctors have been receptive when shown concrete evidence of unilateral circumference increases of 2 cm. Of course other observations may lead to requesting Dopplers with less than a 2 cm increase. We request bilateral Doppler studies to ensure placement in the other arm is recommended.
Debbie Graham BSN, RN, CRNI, VA-BC
"It takes many people to make a team, but only one to break it" --A. R. R. Tripp
I measure one tape-measure width above the intended insertion site before I start the procedure. I feel that this is the patient's "natural" state before I intrude with my invasive procedure. I measure with their arm flat on the table/support surface because that is how a nurse would assess the patient -- with the patient's arm laying down, although not necessarily out to the side. Since there is no true recommendation I feel that at least my own practice is consistent.
When I have more time I would like to compare arm measurements with arm flat, held up, down at side, and see what other nurses' measurements are on the same patient's arm just out of curiosity.
Looking to eliminate mid-arm circumference, because if any arm becomes swollen due to a DVT from the PICC, the swelling happens below the PICC and for the most part does not go up as high as that mid-arm unless the DVT is above that level.
As Lynn has implied no studies have been done and everyone measures differently. This produced unnecessary test for the patients. We stopped doing the arm circ a year ago. It has been beneficial and the nurses have great assessment skills to know when there is a problem
Carol Busch
Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse
We measure cicrumference at 5cm above the AC and chart it as such. However, it is only a reference #. Not a number that stands alone to be making a decision.
We do not follow our PICC lines so often the nurses will call us from the floor or the home health or nursing home nurse will call to say, "I think this arm may be swollen". Our response is always to measure and compare the numbers then add that data to the information you will be giving the physician so he/she can make a decision on the next step.
Our picc's are almost always at least 8-10cm above the AC since we started measuring the diameter of the vein and having a goal of <50% occlusion.
I have been a proponent of arm measurement, in fact I just completed a research study in which the measurement of the arm circumference was statisically significant. The research study was Prospective observation co-hort pilot study of the risk factors associated with catheter-related upper extremity deep vein thrombosis in patients with peripherally inserted central catheters. The purpose of this study was to identify a comprehensive list of risk factors for the development of upper extremity deep vein thrombosis. One of the variables identified was the measurement of upper extremity circumference. We measured the arm 10 cm from the antecubital fossa before PICC insertion, on days 3, 7 and 14 post insertion. The measure of the arm was statistically significant at p=0.001. Therefore my answer is YES we should be measuring arm circumference.
When and where will your study be published? That is what will be needed for it to serve as a reference if any organization wishes to use it to develop a standard for this practice. Lack of any studies is the reason why it is not a standard today. Lynn
no further comment
Dorothy J Bennett
The Infusion Nursing Standard of Practice 2011 do not contain any reference to mid-arm circumference. There are no studies supporting this practice yet many issues can be identified. The most important one is a wide variation in where the measurement is or should be taken, again no evidence for this practice - good, bad or neutral. 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
Our PICC Team measure 5 cm above the AC and 5 cm below the AC bilaterally pre PICC placement. This practice has helped our Central Line Team identify early thrombosis formations and gives them reinforcement when requesting Doppler studies. We have not done a formal study on this but several clots have been identified and further damage has been prevented. Our doctors have been receptive when shown concrete evidence of unilateral circumference increases of 2 cm. Of course other observations may lead to requesting Dopplers with less than a 2 cm increase. We request bilateral Doppler studies to ensure placement in the other arm is recommended.
Debbie Graham BSN, RN, CRNI, VA-BC
"It takes many people to make a team, but only one to break it" --A. R. R. Tripp
Dorothy,
I measure one tape-measure width above the intended insertion site before I start the procedure. I feel that this is the patient's "natural" state before I intrude with my invasive procedure. I measure with their arm flat on the table/support surface because that is how a nurse would assess the patient -- with the patient's arm laying down, although not necessarily out to the side. Since there is no true recommendation I feel that at least my own practice is consistent.
When I have more time I would like to compare arm measurements with arm flat, held up, down at side, and see what other nurses' measurements are on the same patient's arm just out of curiosity.
Looking to eliminate mid-arm circumference, because if any arm becomes swollen due to a DVT from the PICC, the swelling happens below the PICC and for the most part does not go up as high as that mid-arm unless the DVT is above that level.
As Lynn has implied no studies have been done and everyone measures differently. This produced unnecessary test for the patients. We stopped doing the arm circ a year ago. It has been beneficial and the nurses have great assessment skills to know when there is a problem
Carol Busch
Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse
We measure cicrumference at 5cm above the AC and chart it as such. However, it is only a reference #. Not a number that stands alone to be making a decision.
We do not follow our PICC lines so often the nurses will call us from the floor or the home health or nursing home nurse will call to say, "I think this arm may be swollen". Our response is always to measure and compare the numbers then add that data to the information you will be giving the physician so he/she can make a decision on the next step.
Our picc's are almost always at least 8-10cm above the AC since we started measuring the diameter of the vein and having a goal of <50% occlusion.
Martha
I have been a proponent of arm measurement, in fact I just completed a research study in which the measurement of the arm circumference was statisically significant. The research study was Prospective observation co-hort pilot study of the risk factors associated with catheter-related upper extremity deep vein thrombosis in patients with peripherally inserted central catheters. The purpose of this study was to identify a comprehensive list of risk factors for the development of upper extremity deep vein thrombosis. One of the variables identified was the measurement of upper extremity circumference. We measured the arm 10 cm from the antecubital fossa before PICC insertion, on days 3, 7 and 14 post insertion. The measure of the arm was statistically significant at p=0.001. Therefore my answer is YES we should be measuring arm circumference.
Bonnie Clemence, MSN, RN, CRNI
When and where will your study be published? That is what will be needed for it to serve as a reference if any organization wishes to use it to develop a standard for this practice. Lack of any studies is the reason why it is not a standard today. 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