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jibles23
How do you guys handle Failed PICC attempts

Hello guys! Im a very new vascular nurse and I have a questions about the rate of your failed PICC attempts in your hospital. I had multiple failed PICC attempt due this week and its very discouraging.

3 cases where wire is not advancing smoothly even thought im very sure that im in the vein, no bifurcations detected upon assessment in the ultrasound(i always go horizontally and follow the vein). cath;vein ration is about 30% or less but resistance is somewhat felt around the subclavian area when i insert the wire. I am very discourage and it is giving me fear and doubt about my abilities ive been working for 2 months by myself now and never had problems with other patient before. Ive inserted about about 80 piccs by myself without difficulty. I usually use provena 5FR/DL PICC. 

1 case where pt has both contracted arms, inserting wire is having resistance but when i repositioned the arm wire is going throught, however, when I attempted to insert the picc, even repositioning is not allowing me to thread it so I ended up changing the picc to midline. Did not attempt to do it on the other arm and just refer it to IR right away.

1 case where patient possibly have an SVC syndrome according to my preceptor. upon checking CXR picc coiled around brachiocephalic vein ended up changing to midline. 

I want to get some information/tips and tricks from you guys how you handle this situation. I already tried troubleshooting in many ways my preceptor told me that can help with difficult insertion but somehow it still failed. now I have to inform the doctor and refer the things to IR. very sad week for me.

JackDCD
Sounds like your going

Sounds like your going through the normal learning curve. I know in this business everyone seems to want to put a number on how many new inserters need to do to be considered competent. I never had that philosophy and I have trained many nurses. I believe your competent when your competent. I always used the 2+2 rule. I can teach you to do this in 2 months, but it will take 2 years to master it.  So it sounds like you

inbetween the 2 months and 2 year time frame. In the 2 years you will run into the situations you are encountering. First, don't be so hard on yourself. As you insert more and more you will begin to pick up "tricks" that you couldn't possibly know otherwise. Remember, your a proceduralist. as you continue you fine tune your craft. I would suggest you learn from every insertion. Know what works and what doesn't. In time your convidence will grow and these situations wont haunt you.

lynncrni
I agree that competency is

I agree that competency is not a matter of time or numbers. You are competent when you have mastered the full procedure. My first question in reading the first post was why are you going to the subclavian area with the guidewire? Going into the thorax with a guidewire is usually only done under fluoroscopy so you know exactly where the wire is going. Just remember your insertion success is dependent upon many things. It sounds like you are not having trouble entering the ven and advancing for a certain distance, then encounter obstructions. This might be overcome by repositioning the patient's arm and shoulder but not always. If wire/catheter is abutting the vein wall, underneath a valve or near a bifurcation, repositining could help. but if you are dealing with vein stenosis and a very narrow vein lumen, it is going to take much more than a wire or catheter to get through that. Sometimes, the soft very flexible catheter with a stylet all the way through the catheter lumen will advance easier around obstructions than the catheter with a stylet wire in the lumen. As you advance the catheter and meet resistance, you could try retracting the stylet leaving a softer tip. This would not be the thing to do if you are using ECG guidance though as you would not be able to determine where the actual tip was located. You may have just encountered a string of patients where nothing would work at the bedside. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bartina
Lynn, am I understanding

Lynn, am I understanding "sylet all the way THROUGH the catheter lumen," to mean exiting the catheter as opposed to "sylet wire IN the lumen?"  Thank you.

Nancy Rose 

lynncrni
Poor choice of words on my

Poor choice of words on my part. Sometimes you could try inserting a guidewire with a floppy-tip through the entire lumen and it may extend out of the tip. But remember a guidewire and a stylet wire is not the same thing. A guidewire is designed to be advanced alone through the vein, has a soft floppy tip and many safety features. A stylet wire is not safe enough to be the leading edge as it travels up the vein, and does not have the same safety features. If you encounter an obstruction that the catheter tip alone wil not pass by, then you could need the additional ridigity of the guidewire in the lumen. Sorry for my misuse of stylet. 

 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Ibraheem Y Aljediea
Ibraheem Y Aljediea's picture
Hello Jibles

Hello Jibles

In our hospital my team called it “difficult picc”  .. and here is our practice:

1-after reviewing the chart and considering the patient could be difficult, we start with 3cg.

2-if the catheter won’t go through to the svc, we leave like 10cm trimmed picc in the vein.

3-we move the patient to room 1 where we have the c-arm, we inject contrast and take it from there

6% of our cases end up with using 18 hydrophilic wire, rarely we find stenosis that requires angioplasty, and if blocked we move to the other arm

ibraheem aljediea

johns hopkins aramco healthcare

saudi arabia

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