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Penny
getting PICC's to thread around shoulder
I have been doing PICC's for 2 years, just recently learning to use the SiteRite to put them in. I had an excellent blood return and could advance catheter 30 cm but could not maneuver around the shoulder. I tried everything I could think of. Moving arm close to body, 45 degree angle, flushing the catheter, turning head away from the side I was working on.  Nothing worked. Any suggestions?
karrenberg
When nothing else works
When nothing else works after repeated attempts to advance, we have found a technique that works almost all the time.  We try to turn the patient's torso about 20 degrees away from the side we are working on, while keeping their arm in the same position.  If the patient is cooperative they can do this, otherwise someone else needs to go under the drape sheet and move them.  The point is to "open up" the area around the shoulder eliminating the blocked area.  Unless the area is completely stenosed or blocked, this works.
rivka livni
The comments by karenberg

The comments by karenberg will work if it is a Basilic or Brachial vein, if however it is a Cephalic vein, you may try puting the arm right next to the torso, palm down, to try and allow the catheter to "slide" easier by the anatomical "hump / turn" the vein takes as it joins the Subclavia. From a Cephalic approach the tip of the catheter can get caught on that turn.

pjean
Wish this posting had been

Wish this posting had been done at the end of last week.  Had a patient, tried to insert from Rt.....stopped at shoulder level.  Moved to the other side and attempted from left........same thing at the shoulder.  Would have loved to have seen if karrenberg's technique would have worked.  I do have question though if this type of manipulation has to be done to simply float the line, wouldn't this increase the possibility of DVT since this would not be the patient's normal positioning?  I wonder sometimes, just because we finally "get in", is this in the best interest of the patient?

karrenberg
I have not seen any
I have not seen any problems  with increased dvt rates.  My guess is  the reason the line won't go in the first place is a real sharp angle that the tip just gets caught up in.  While I'm on the subject,  another thing that sometimes works is to retract the guidewire a little bit allowing the tip to be that much softer and maybe getting past those tight areas.
Mike Brazunas
Penny,  Even with all the

Penny,

 Even with all the great advice given so far, remember that sometimes no matter what you do the PICC will not advance into the SVC.  It is possible that the patient had some prior damage to their axillary or subclavian vein that prevented you from advancing the catheter.  Repeated peripheral infusions of acidic (e.g. vancomycin) or other solutions that should be given in a central line, can cause cumulative damage to the axillary vein. Prior lines or attempted lines in the subclavian can cause damage there as well.

 Many people brag about 100% success rates but in reality, sometimes after gaining access the PICC cannot be threaded.   If this is a persistant problem I would look at my technique, but if it  happened just this once, I wouldn't get down on myself.

 thanks,

Mike Brazunas

Clinical Specialist

AngioDynamics

 

Angela Lee
I agree that sometimes
I agree that sometimes retracting the guide wire a little bit can facilitate advancement.  Another thing one of my sedation docs does is to put downward (toward the bed) pressure on the shoulder presumably to straighten out that pathway--I have seen it work occasionally.  That may be accomplishing the same thing as a 20 degree angle change in the torso.  I have also just waited a few minutes--relaxation may help. 
Gwen Irwin
What vein was accessed? 

What vein was accessed?  This sounds like the trouble with advancing cephalic access.

Just wondering.

Gwen Irwin

Austin, Texas

Rhonda Wojtas
In the past 2 weeks, the 2

In the past 2 weeks, the 2 lines that we have not been able to get to advance where just like this. We took the patients down to IR. They also had a difficult time. Use a  little contrast and reason became clear. Subclavin occulsion. There was no way the lines were going in. It happened again yesterday.

 

Rhonda

Rhonda Wojtas, RN VA-BC

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