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pjean
new technique required

I have recently changed jobs and have moved from a smaller hospital where we x-rayed the line for placement prior to securing it to the skin (with stat-lock) and performing the final dressing, to a very large hospital where it is the practice to secure, (with stat-lock), dress the site, then x-raying.  If the line requires adjustment, the dressing is removed, the line removed from the stat-lock and the line is adjusted......in or out.  I am not comfortable with this practice, as I was always taught that once the site was dresssed, the line was no longer sterile and thus could not be advanced in....only out.  I know there are others of you out there that are dressing in a special fashion prior to x-ray to "preserve the sterility" of the line for later adjustments as needed.  Can anyone share their techniques with me?  I would be very grateful for your help.

 

lynncrni
You are absolutely correct.

You are absolutely correct. Skin can never be made sterile and once that catheter has come into contact with the skin it can never be advanced into the vein. The only way I have managed this in the past was to leave the stylet wire inside the catheter, encase the entire external portion of catheter and wire in sterile 4X4 gauze then wrap with sterile towels, get the xray, then finish the procedure. If that dressing has been applied, then insertion of more catheter length should never be done. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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

Leigh Ann Bowegeddes
I disagree with both of you.

I disagree with both of you. Once you break your sterile field that catheter should not be advanced into the skin. It should not be pulled out and readvanced. We certainly do not allow this with any other central catheter. There are conservative ways of repositioning catheters that end up in the IJ or contralateral subclavian. There are also navigational devices that effectively track the line before the sterile field is broken. We need to improve this practice with appropriate use of technology and/or safer methods of repositioning.

 Leigh Ann Bowe-Geddes

lynncrni
I think we are saying the

I think we are saying the same thing about never advancing the catheter after it has been in contact with the skin. I was talking about ways that have previously been used in the past and did not include a discussion of navigational devices as you did.

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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

Gwen Irwin
We do use navigational

We do use navigational devices and never advance or reposition a PICC once it has been positioned while in the sterile field.  We have never wrapped a PICC in sterile gauze and waited for xrays.

Gwen Irwin

Austin, Texas

PMRMD
ECG guidance remains an
ECG guidance remains an important technique for tip positioning for exactly the reasons discussed here: Once a sterile field is broken, your options to adjust positioning are very limited. As documented by transesophageal echocardiogram, ECG guidance is more accurate than surface landmarks (the cornerstone of navigational systems) and chest x-ray (see http://www.pacerview.com/index_files/ECG_GUIDANCE_FOR_CVC_PLACEMENT_IN_THE_LITERATURE.htm) and provides tip location in real time. It is also less expensive to do.
IV GUY
Best way we have found
Best way we have found (either in the hospital or outside the hospital) is to pull back and re-dress if too long, and do a "over the cath" or over the guidewire replacement if too short. "Knowingly" advancing a catheter once secured goes against quite a few Standards of Care. I have found no literature that supports the practice of advancing a PICC (or any venous access device for that matter) once the line is secured and dressed. I would ask for a source reference that supports this practice so that you are covered legally, and (more importantly) so that the patients are protected.  

IV GUY

Heather Nichols
    That sounds like a

    That sounds like a lot of distress for both patient and PICC nurse, not to mention expense, when a simple navigational device could be used to determine tip position.  We have used one for several years, and it really helps piece of mind, and decreases expense is several ways. 

    One should NEVER push a portion of catheter in that has laid on the skin.  Even if it has been sterilly wraped, I would have trouble, (unless I was watching it the entire time), believing that it was not comtaminated in some way during the x-ray procedure.  

pjean
I appreciate the feedback

I appreciate the feedback from all.  Unfortunately, I do not have the latest technology available at this time.  Where I came from, we utilized Sherlock and it worked quite well, however, don't have that or anything similar available to me at the present hospital. 

Leigh Ann, I was wondering if you could describe those conservative methods of repositioning you mentioned.  I am not concerned so much about jugular as I am in the habit of verifying with my ultrasound, but contralateral reposition techniques would be very helpful.

 

rivka livni
Most malpositioning, if the

Most malpositioning, if the tip of the catheter is pointed against blood flow, can be repostioned by attaching a NS flush and using Val-Salva, quickly flush the catheter about a second after the patient lets go of his breath.

When patients are intubated we get Resp therapy to hold their breath. When it is a double lumen, we use the flush on both lumens at the same time. Since all our catheters are Power PICC we sometime use a 5cc syringe.

It rarely fails.

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