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I have had success placing PICC in the morbidly obese population using ultrasound guidance in the upper extremities.  I will use both hands as flesh stablizers/compressors as I access the vein with my IV catheter.  The pressure on the pt's flesh will reduce the depth of the vein so you can reach it with your needle. Once I access the vein I don't release my pressure until I have my wire in the vein.  Once you are ready to place your dilator you need to remember that your dilator is only so long.  Once you're in the vein and you have pulled out your wire don't release the compression of the flesh.  Hold that dilator compressed in the flesh especially once you remove the inner portion of the dilator until you pass your PICC line into the vein.  Hope this helps.

Cat Johnson RN

We too have had good success with placing PICCs in the morbidly obese pt population.  Things that I feel have contributed to our success are these:

We use Site-rite 5 ultrasound which gives good estimation of depth.

We select the appropriate needle guide based on that depth estimation.

We use BARD products and they have introducers of various lengths.  As Cat indicated, the tricky part comes when you remove the inner dilator of the introducer and only the peel away introducer remains (which is shorter).  If we anticipate the vessel being deeper than the standard length introducer, we drop a longer introducer on our tray up front and use it, typically the 7 cm as opposed to the 5cm.

Your patient having to be left sided definitely complicates things.  Ours are most often on the larger beds and can be positioned more like the general population with the benefit of these beds.

Hope this helps.

Does anyone have any info on placing PICC in morbidly obese pt?( Pt.'s >350 lbs) I do not have much luck placing PICC in these pt.s. Last one in 450lbs pt was on left side - ended up in artery. Crazy. Thanks

I also concur on the Cephalic approach for these group of patients. If you have trouble getting through the curve where the Cephalic joins the Subclavia, we found that it helps to rotate the hand w/ thumb next to the thigh and bringing the arm all the way by the body. (We saw in IR under fluro that it makes it easier to slide the catheter through that tough spot).

If Cephalic is not present, with a good ultrasound guide you should be able to access a vein in any weight. The challange of the arm folds can be over come by using the Ultrasound probe to keep the skin fold from "falling" into your insertion site field.

Sometime the dressing changes on the morbidly obese takes two nurses to do, with one nurse holding the fold "at bay".

I also go straight for the cephalic on very obese patients.  These veins are often huge. We see no more incidence of phlebitis or thrombosis using the cephalic on obese patients vs basillic on normal patients. 

At an early stage I made a commitment to access all veins with the IV cannula versus the steel needle.There was a learning curve to get the cannula in without crimping it. The pay off is I don't have to worry about losing position in the vein when removing the probe.  

 Darilyn

I think most of our morbidly obese patients do not get cephalic PICCs.  I can't remember the last one that was cephalic.  We look for the median basilic or basilic closer to the AC folds.  We also are using the Site Rite 5 now, but even before using the Site Rite 2 and 4, we most often looked at the AC fold.

Examples of these patients that we have done have been > 500 lbs, > 600 lbs, and one > 900 lbs.  I can't remember anyone these really large people getting a cephalic PICC.

 Gwen Irwin

Austin, Texas

When CXR is extremly hard to read we have used IV contrast to instill in the catheter only. The contrast comes from our IR department (usually Omnipac 300)

Needless to say we do not use contrast if the patient is allergic, elevated renal function etc. We also use one of our "sample" catheter to measure the exact amount of contrast it will take. As soon as the CXR is taken, we withdraw the contrast plus 5cc of blood, and flush the catheter.

It never failed us, we use it only in extreme situations.

We have placed PICCs in patients >500lbs, >600 lbs, >700lbs, and 1 >900lbs.  Most are placed in the basilic or median basilic vein close to the AC fold.  On several of these patients, we had numerous xrays and the use of contrast (if the patient didn't have conditions that it would be contraindicated) to determine the tip location.

As far as placement of PICCs in the morbidly obese, I think the success of accessing the vein is to be very careful about the pressure that you exert on the pts. with the ultrasound probe.  If the pressure is too great, when you think that you are in the vein and release the pressure of the probe the needle moves out of the vein when you lift the probe of the skin.  Hope this makes sense.

Gwen Irwin

Austin, Texas

Longer wire/longer introducer dilator is important.  Keep a very close eye on your wire.  If you're using the 21 gauge safety seldinger needle, I agree that you don't want to remove pressure on the probe until you get the wire in. 

I use a long 20 gauge IV catheter instead of the 21 gauge safety seldinger needle 99% of the time - once cannulated with the catheter, the wire usually floats right in.  It will work on obese patients as long as you're paying close attention to the depth of the vein (for both needles, actually).   

You'll probably find yourself using a vein closer to the antecubital fossa where there is less tissue.  Cephalic is ok if you have to (I try to avoid it even in obese patients, and usually can - haven't placed a cephalic vein PICC in years), but check out patient risk factors before hand (inflammatory disorders, coag issues like lupus, antiphospholipid syndrome).  

Remember that you must account for a longer vein depth when you cannulate; U/S vein depth measurement is a 90 degree relationship to the vein, but you'll probably enter at an angle (though you will be closer to 90 degrees for very deep veins than for shallower ones) which makes the distance longer.  

Have the same consideration when you're adding cm's to whatever measuring technique you use for catheter length - you're not adding a straight depth measurement from skin surface to upper wall of vein, it will be diagonal - at whatever angle you're entering.

Before sterile draping etc., try different positionings of the arm if possible.  Sometimes that helps put the vein temporarily in a shallower place. 

Mari Cordes, BS RN