Question regarding times it takes to infuse fluids through a PICC vs. CVC or PIV.
I am frequently asked to place "emergent" PICCs in the ED for one reason or another. While I understand this is an undesirable practice, it still happens. In an effort to reduce these requests, I am trying to gather information about flow rates for PICCs as many of the ED staff (physician and RNs) don't understand the limitations of rapid infusion through PICCs, specifically fluid resuscitation.
I'm not looking for max flow rates, because I'm not sure the PSI of our pumps. Also, I understand the max PSI of a pressure bag is 300 psi (which relates to the max flow ratings on the catheters) but I can't find any research on how that relates to length of catheter, as in a 40cm 5fr PICC vs. a 1.18in 18g PIV. What I would like to know is how much time (on average) does it take to infuse 1L of NS via a 40cm 5f PICC on a fully inflated pressure bag vs. 1L of NS via an 18g 1.18in PIV.
If this is a redundant topic, I apologize. I am new to the profession of vascular access. Any help with research or articles pertaining to answers are greatly appreciated.
The only place I have seen flow rates through any VAD is in the product instructions for use. All catheters are tested for flow rates but these tests are done according to ISO standards in a lab and not tested by infusion on people. The chart in all product literature will give you the flow rate through each lumen size. This flow rate is always done with an iso-osmotic fluid hanging at 1 meter, 39 inches head height at room temperature using a gravity infusion. These factors definnitely affect flow rate. Tip location, catheter internal diameter, also impact flow rate. I have never seen any study comparing these rates when any catheter is inside a real patient's vein. You will need to locate this data from the manufacturer of the specific brands you are using, then make your comparisons from lab tests. The basic facts of physics are that the length of any catheter adds resistance to fluid flow. So a longer PICC will have a slower gravity flow than a shorter CVAD. This is easily offset by an infusion pump. All catheters can tolerate the maximum rate set on the pump, even 999 or 1200 mL per hour, whatever is the maximum setting on the pump you are using. This data for catheters and pumps is available in the manufacturer instructions for use. So I don't think you can use flow rate limitations as your arguement for avoiding placement in the ED. I think we should make our services avaiable to meet patient needs whenever and whereever they are needed. Why not place in the ED?
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. How unfortunate that there is nothing concrete out there referencing this.
In regards to your comment, "Why not place in the ED?" - Well, I have very mixed feelings about this practice. First, going back to my initial question, I find ER Drs ording PICC lines for inappropriate reasons, such as a crashing patient that needs central access and they don't want to place a central line themselves. Unfortunately I also find Intensivists doing this as well. Our institutional policy for PICC placement states that PICCS are non-emergent central lines. ER Drs are also ordering PICCs for patients that may just need peripheral access, but because the ED RN can't get a line, they order a PICC line, when all the patient needs is access. For these reasons, orders for PICCs that originate in the ED are heavily scrutenized by me to ensure necessity. I would hate to blindly place a PICC in a patient that is being discharged tomorrow. Second, the ER is a busy, dirty place. I know, I've worked in many for many, many years. Each room is NOT completely disinfected inbetween patients like a regular hospital room. These ED areas are often separated by only curtains, and it is impossible to place masks on everyone that should have one. The rooms are also on average smaller, limiting my manuverability and it is much harder to place a PICC in a patient on a narrow ER gurney than a regular hospital bed. It would not serve the patient's best interest to insert a line in suboptimal conditions. While inserting a PICC in a patient may be heroic, I don't feel the need to subject myself or the patient to heroic efforts to place one. Therefore, I feel that a PICC is safest inserted in a hospital room, after the patient is transferred. I feel that if the patient needs EMERGENT access in the mean time, I would prefer to offer the ordering DR a US-PIV to bridge therapy, or suggest the patient truly needs a central line.
Wouldn't you agree?
Your original question is actually pretty savvy, flow rates for resuscitation considering length of catheter. Good on you for thinking this through. Definitely a PICC for fluid resuscitation is an inappropriate order. It doesn't make sense to place an emergent PICC because it takes too much time, a sterile field needs to be established and maintained, and we have other options.
If your physicians are ordering PICCs in an emergent setting because the real need is vascular access, offer options. There is always IO. Some have placed Powerglides for immediate use and performed an over-the-wire exchange once the patient is stable and moved to an appropriate environment. It might be useful to offer ultrasound guided PIVs. Assess the patient and the situation and consider all options.
You know your ED best, but I have placed many lines in the ED and never had infection issues. Most EDs have procedure rooms if needed. I wouldn't deny an ED patient a PICC if due diligence has been performed and that is the best device for therapy.
If what you really need is a voice in device selection, why not have a conversation with the medical chief of staff or administrative level decision makers and create a device selection protocol? Use the MAGIC recommendations or create one for your facility. If you approach them in a professional manner with evidence they will be all to happy to avoid unneccesary central lines. Be prepared to accomodate the needs of difficult venous access patients, because that really seems to be the bottom line here.
I agree with Jill that each ED requires evaluation and it is not an always or never situation. I have seen EDs that an easily accommodate a PICC insertion procedure but others can't. Also I don't think there is any data showing that infection rates are higher when inserted in the ED. I would also recommend using the MAGIC Guidelines to make appropriate choices for all VADs as many ED personnel may see it as a convenience for them while a PICC is not the best choice for trauma or critical care patients. Our work for education is never done. 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