Hello all,
I just wanted to ask your opinion on placing PICCs without a tip location system. A little background: I've been placing PICCs since 2009, first at a large hospital on a dedicated PICC team, now at a 100 bed hospital where I am the Interventional Radiology RN and the PICC RN. Prior to coming to this hospital, I used Sherlock 3CG for placing PICCs, now I just have a SiteRite 6 with Sherlock TLS. The problem is, it just died, and biomed is working on a solution. In the interim, I am getting pressure to use another SiteRite 6 that does not have any tip location device at all to place "blind" PICCs.
The rationale from the House Supervisor is that nurses all over the country still place blind PICCs, and I should too. He seems to think that all that one has to do is measure correctly and it just falls into place, never contralateral or IJ.
I argue that I do not know any RN's not using TLS or 3CG, and that the standard of care has changed over the past 10 years. I do not feel comfortable exposing my patients to repeat Xrays for placement due to malposition, and also the question of the sterility of PICC repositioning after malpositioning comes up. We do not have the resources to have Xray at bedside prior to final position, and it basically means I would be redoing the entire PICC from scratch, which opens up a whole other can of worms.
Does anyone have any insight on this? Do you know anyone that still places PICCs only using ultrasound? What do you feel is the standard of care? What would you do in my position?
Thanks so much in advance!
Joni
I would not call this a "blind" PICC as that term is more commonly used when doing the venipuncture only. Since the mid-1970's PICCs were placed as you described with a post-procedure chest xray to id tip locaiton. And yes, there were some that required repositioning (can't quote recent numbers) but you can use your US to rule out IJ placement before you break your sterile fileld. Both post procedure chest xray and ECG remain within the standard of practice for PICC insertion. See the 2016 INS Standard on CVAD Tip Location. So your house supervisor is correct that many nurses all over the country still use this post procedure xray and do not have access to any type of ECG for tip location. You do need to measure well, but that is true regardless of whether you are using ECG or not. Sorry, but I don't understand your argument for this interim period. 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
Sorry, I will clarify! I haven't used 3CG in 2 years, we use Xray confirmation at this facility. I have not placed a PICC without using Sherlock to verify that the PICC tip is heading downward in 6 years, and feel very uncomfortable placing the PICC without this guidance. The house supervisor wasn't talking about the confirmation chest Xray, just the guidance into the SVC.
Still, the majority of PICCs are placed without such guidance. a 3CG machine does not really guide the PICC, it merely confirms tip location when the tip is at the SA node. But even with 3CG, the PICC could go in any direction. So I still do not understand your hesitancy. 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
My hesitancy is that without the Sherlock (not the 3cg that's not a factor in this at all) I cannot tell if the picc is contralateral, up the IJ or in the azygous until the chest xray. We do not have the capability to have xray do the imaging immediately afterward before dressing placement, so the picc would be very difficult to reposition without contamination. Also, I understand that one can use the probe to view the IJ before taking down the sterile field, but how do you keep your probe sterile while doing this?
Why not place the PICC's in IR in the interim? You could xray while still sterile so if you need to reposition you don't have to worry about contamintion
That's exactly where my thinking was going!!! I just do not want to increase the cost to the patient... but it would just be short time thing!
You are describing the majority of PICC insertions now! This is the standard pratice by far. You finish the insertion procedure, remove the wire, place the stabilization device and dressing and then get the xray. Usually the US probe is placed over the IJ area at the end of the procedure to rule in or out the presence of the PICC in the IJ. This will contaminate the probe cover but it is at the end of the procedure. If there is no evidence of its presence in the IJ, your chances of it being in the SVC are very high. The xray may show contralateral subclavian or inside the RA too far. If contralateral subclavian, blood flow will usually move it to the SVC in s short period of time. If too far into the RA, use the xray to calculate the distance to retract the PICC. After the external PICC has been in contact with the skin, you cannot do anything but withdraw it from the insertion site. Once it has touched the skin, it can not be advanced into the vein, regardless of whether you have ECG or not. These are the processes used by the majority of nurses inserting PICCs now and always have. 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
I guess I've just always been spoiled with good equipment!!! It's hard to go backward with technology!
Have you requested help from your picc manufacturer? sometimes they can locate equipment for the interim, or you might be able to purchase a navigation device from ebay or dotmed.com or another second hand equipment outlet. If all else fails and you must have a Sherlock, email me I have a free standing unit, it'll be our secret ;)
Can you not get your old Sherlock and plug it into your "temp" Site-Rite 6? Contact your Bard rep, you may need a software upgrade, or it may work! Even with the software upgrade, it may be economical enought that they will do it. Our ED has some old Site-Rite Vision 1's and if I have to use it, I just plug the Sherlock into the USB port and Voila!
Kathleen Crowe BSN RN CRNI VA-BC
n
This discourse is alarming.
Kevin Arnold RN, MSN