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DonnaS
Pediatric PICC Insertions

Would appreciate information on your institucions protocol for pediatric PICC insertion.

1. Are the lines placed at the bedside or in IR?

2. Is sedation used? What works best?

3. What brand of catheter do you use?

If anyone would be willing to share their policy on pediatric PICC insertion I would appreciate it.

Thank you in advance for your reply.

Angela Lee
We do not have IR.  We

We do not have IR.  We place PICCs at the bedside, in the procedure rooms on the unit and in our sedation room.  Each patient is assessed and a customized approach is used.
We have a great sedation service that uses Propofol exclusively.  I have in the past used po Versed at the bedside which works well but requires intensive monitoring so now it's more efficient to take the patient to sedation.  In our PICU patients may get a combo of Versed and fentanyl.

Currently we use Bard both silicone and polyurethane, Clinicath's 2 Fr and Kendall 1.9 Fr.

You may e-mail direct if you wish.

[email protected]

fizerjk
The PICC service I work with

The PICC service I work with is a part of the Radiology service. We have our own PICC procedure room. We also have IR backup for difficult cases. We work in collaboration the the PICU sedation service for those kids who need sedation as well as the OR anesthsia  for those patients that the PICU service feels are at high risk for sedation with just porpofol  (our drug of  choice). We use the 2,3 and 4 french BD catheter, as well as a 3 french bard, and 4,5 french solo power picc.

Jeffery Fizer RN, BSN

RoseFeltner
I am also interested in

I am also interested in procedural sedation for Pediatric PICCs.  I work in a 300 bed hospital that places approx. 100 adult PICCs each month but only a hand full of Pediatric ones.  I was a bedside Pediatric nurse before joining our Infusion Team.  I seem to be having issues with sedation (our doctors rely on chloral hydrate) and venous spasm.  We place our PICCs at the bedside but do have portable flueroscopy. Any suggestion or especially articles would be greatly appreciated.

 [email protected]

fizerjk
I to was having a

I to was having a significant number of problems I preceived as vasospasm. The thing that I have done to try to reduce this risk is removing the tourniquet before dialating the vessel. Usually after having inserted the MST wire.  This seems to have reduced this preceived problem.

Jeffery Fizer RN, BSN

Angela Lee
My experience with Chloral

My experience with Chloral Hydrate is that patients can easily over ride the effects during the procedure when they become anxious or stressed and it is as if there is nothing on board.  Then after you have struggled with them and the procedure is done they are zonked for hours.  I do not use it for that reason as well as the fact that we have a very effective sedation service. 

If the sedation service were not available I would prefer to use po Versed rather than chloral hydrate. 

DonnaS
Does your sedation service
Does your sedation service tend to use Propofol for the most part.  Do you have a criteria or tool to determine who needs to be sedation? 
Angela Lee
Our sedation service uses
Our sedation service uses propofol exclusively.  The decision about whom to sedate is made individually by the PICC nurse.  Criteria includes but is not limited to high anxiety and/or inability to cooperate whether related to age or developmental delay.  Certainly other factors may indicate the need for sedation as well.  Once we determine a patient would be best served by sedation the sedation MD then reviews the H&P, assesses the patient and then makes the final determination that it is safe to sedate.   If they refuse to sedate, which is seldom, it is related to the clinical condition of the patient.  Once that is improved they will sedate.
holly hess
We place most PICCs in a

We place most PICCs in a treatment room located on each peds floor. They are done at the bedside for those pts who can't go to that room for whatever reason. If we use sedation, we use a procedure room. Our sedation is provided by our Peds critical care/sedation team and is almost exclusively propofol. In my opinion, chloral hydrate is worthless for the reasons others have mentioned. Our guidelines for sedation are: in general, between the ages of 1 and 5, or previous failed attempt without sedation, or highly sensitized/fearful to IV access, emotionally/developmentally delayed, strong desire for sedation expressed by parents after having risks/benefits explained. For those others who need something but probaly not a full sedation, oral versed and child life is a quite successful combination. We also try to coordinate placement in the OR under anesthesia if they are undergoing a procedure, such as endoscopy, bronch, I & D, or drain placement.

We use Bard 3 fr silicone and poly, 4 fr Power, and 4 fr dual. For neonates we use B-D silicone, first PICC. I also like the Vygon 2 fr dual poly for those neonates who need more access, we don't stock that yet, we have only had samples.

Anyone who needs precepting on peds, contact your product rep. They should have nurses such as myself, who can precept those just learning peds.

If you still need a policy I will send one.

Holly Hess

RoseFeltner
I am from an approximately

I am from an approximately 300 bed hospital.  We have a 20 bed Pediatric unit. I was a Pediatric nurse for 10 years before advancing to the Infusion Team.  I am very comfortable placing IV in Pediatric patients but have had difficulty with PICCs.  I seem to have a lot of trouble with venous spasm.  We do not have a child life specialist.  Propofol would require an anesthiologist. What other suggestions do you have?  Please forward any policies to me.  I would love to have someone precept me. 

 

[email protected]

holly hess
Rose, When you say you are

Rose,

When you say you are having venous spasm, do you mean when you access or as you thread the catheter? I experience very little of what I would consider vasospasm. However, warm compress and oral versed work well. I use a warm compress on every patient prior to insertion. If they are very anxious, oral versed definitely helps them relax.

Holly

RoseFeltner
Holly,   The Venous spasms

Holly,

 

The Venous spasms I am talking about are with threading the guidewire and/or catheter.  I have access with good blood return but cannot get any further.  I have had one child and one adult that the venous spasms were seen during Interventional Radiology attempts.  I have tried heat. 

 Thanks for your input.

I am interested in Pediatric PICC internship if anyone has this available please send me the details.  I am especially interested in the hands on.

 

Rose

[email protected] 

gretchen
Answers: 1.  I will place

Answers:

1.  I will place the PICC in the patient room if  

a)the room is smaller than usual 

b)the patient is a teen 

c)patient is in PICU 

d)patient has 'equipment' that would be best not to manipulate 

e)it would be difficult to get patient to procedure room

PICC will be placed in procedure room ESPECIALLY if toddler/preschool/early elementary age.  We want to keep their patient room 'the safe place'. 

2.  Usually use a less than conscious sedation dose of Versed, although we are working towards having anesthesia do sedation for PICC placement.  I use LMX cream over the site, and will add heat (with heel warmer) over the LMX or instruct parent to massage LMX while I am getting set up.  I always have a Child Life Specialist with me, and either the bedside RN or aide (someone who can tie a tournaquet and keep arms and  legs from kicking me if needed).  Preparation for a PICC by the CLS is very important.  They even have a PICC line book they show kids that are old enough.  Children do better when they know what to expect, AND what is expected of them.  Be totally honest.  Also, some kids want to know what you are doing and what they will be feeling, and others just want to get it over with.  Just ask them if they want to know everything (although I have them look the other way when I'm ready to do the dermatotomy). 

3.  Bard Per-Q-Caths 2 and 3 FR mostly.  I have a few 4 FR, and am trialing some Churchill lines.Our NICU uses mostly BD.

DonnaS
Thanks Gretchen  Is this

Thanks Gretchen 

Is this PICC book something I can purcahse or was it made by the CLS?

gretchen
Donna:   The book we have
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