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Peds, PICCS and Paphooses

Hello everyone, Newbie here. New to PICCs, but not new to taking care of kids. I just completed a 2 hr marathon where 3 of us got the stuffing kicked out of us by a 2 year old. (BTW, I'm 6'4" 230#) Our PICC service assists the pediatric STAT RN staff when they are requested to place PICC lines. It usually takes 3 of us to hold, administer subtheraputic doses of benzos and analgesics, and stick. I suggest subtheraputic, because time after time we end up using BRUTAINE to just hold these wigglers down and hope for the best. The Peds attending staff are of the opinion that we need to "attempt first, then if necessary, we'll do moderate sedation" to really get them down. In my humble opinion (formulated over the past 25 years of ED, EMS and cath lab experience), this mindset is antiquated and just wrong. What are the rest of you guys doing ? I need ammunition because I'm gearing up for a fight...Thanks.

DB RN

Upstate NY 

Heather Nichols
And good luck to you big

And good luck to you big guy!  I will say that I have minimal experience with pediatric picc insertion, but I was a peds nurse for 5 years in the ER, and I can tell you one thing for certian, if that was MY child you were sticking like that, I would have to hurt someone.  There are other ways to do this. Try to appeal to your docs with their own kids.  They will be more apt to listen to you.  Any dad or mom would.  Contact Darcy Doleman at Cinn. Ohio Childrens hospital.  She could probably give you a lot of info. on how to help, and what to do.

Heather 

Angela Lee
I have been working in peds
I have been working in peds for over 35 years with 26 years in ped and neonatal IV therapy.  We have been placing PICCs since 1994(although we started out very slowly).   For very anxious patients and toddlers we use our sedation service which consists of an intensivist to administer propofol, a sedation nurse to monitor the patient and  then all we have to do is focus on the patient and the procedure--it works very well.  We always assess individually for sedation needs.  We try to manage most patients on the units but don't hesitate to use the service when necessary.  For infants we "mummy" them in a sheet or blanket with the PICC extremity out.  All patients except very small infants or neonates receive a topical cream anesthetic well before the procedure.  In rare instances when anesthesia is contraindicated we give po Versed at the bedside which is also very effective.  There are better ways of getting the job done as Heather said.  You may contact me at [email protected]
Gwen Irwin
I think an extra part of the

I think an extra part of the pediatric PICC nurses role is assessing the child for their sedation needs or child life needs. 

I may not have those skills but I rely on the skills of those PICC RNs, when I am working with them.  They do the largest percentage awake with child life, with LMX4 topically and they do great.  They probably do less than 5 a month with general anesthesia or sedation.

If it is their assessment that the child needs sedation or general anesthesia, they don't stick.  I support them in following their judgment/assessment.  Like you wouldn't give 80 mg IV Lasix to a 2 year old, you would have to hold that dose and question the order.  If the doctor said just give it......you wouldn't.  That is the same as standing your ground and NOT attempting first without sedation.

I would also point out to them the success rate is better without the wrestling match, the child is less traumatized with sedation, and less equipment and manpower is wasted with higher success rate.  But mainly, it is inhumane to do that and if it were your kid would you let that happen?  I have to agree with Heather about that approach too.

Gwen Irwin, Adult PICC Nurse that does some pediatric patients, but not the expert pediatric PICC nurse  :)

 

Anne Marie Frey
Having just gotten wacked in

Having just gotten wacked in the head by a sparkle wand in the hand of an 11 year old, I can sympathize!  Actually for PICCs, we assess the child for veins first, and the pre-sedation NP comes around and assesses sedation needs/risk.  We use some sort of sedation plus child life for almost everyone, except older kids that don't want any sedation, and neonates, who are often on fentanyl and versed infusions comcomitantly.  We do mostly modified seldinger technique [micro-introducer] whcih is quite invasive, in my opinion, so we use the sedation plus local and do PICCs in IR suite or intensive care units at bedside.  I have done PICCs in non-sedated kids and that is a bear!!!  Although, I know Cincinnatti children's Darcy only uses child life except in the most recalcitrant children.  Hope this is helpful....

Anne Marie Frey

Anne Marie Frey RN, BSN, CRNI, VA-BC
Clinical Expert
Vascular Access Service: I.V. Team
The Children's Hospital of Philadelphia
[email protected]

holly hess
I'll be echoing the other
I'll be echoing the other comments already made...when we began our pediatric picc service 3 years ago no one was sedated. We have evolved to recommend sedation from our Critical Care Sedation Service(using propofol with a ARNP, MD, and sedation RN) for most kids between 2 and 5, and others who have been previously sensitized to needles and and (understandably) uncooperative. This takes into account all of the factors previously mentioned: higher success rate, less emotional trauma, and just plain kindness. If you have a Child Life department they are invaluable and we use them on all non-sedated PICCs even up through teens. I've had this conversation with Darcy from Cinncinnati and, without putting words in her mouth,  my recollection is that they use little sedation, but have a very capable assistant who holds, and an awesome child life staff. We also use LMX topically and have used po versed in those instances where deeper sedation was not available or contraindicated. We also have made every attempt to get physicians to assist in coordinating PICCs with other procedures that will be done under anesthesia/sedation such as surgery, CT guided drainage, etc. They have gotten very good at remembering this, for the most part. Sedation done under the right circumstances in the right environment by the right people is highly effective and safe (although of course, not without potential risks). Having participated in both types of procedures, I would certainly advocate for sedation for my children if they were young.
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