In the past, at our hospital we would advance our picc lines after our sterile field was taken down . For example , if the tip of the picc was in the brachiocephalic and not in the svc after viewing our x-ray , we would go back to our patient ,do a sterile dressing change,advance the picc using sterile technique and take another x-ray. Is this a common practice for picc teams at other hospitals? According to INS standards once a sterile field is broken/taken down a picc cannot be advanced. Under what circumstance can this be done{if any]. There seems to be some confusion about the definition of "taking down a sterile field" among us. Thank you for any input into this matter.
It is highly recommended not to advance the catheter after the sterile field has been taken down. Some teams do wrap the PICC in a sterile fashion, i.e. allowing no portion of the catheter to come in contact with the skin at any time by wrapping the catheter well with sterile gauze during the PICC procedure, and covering it. If any advancement was required, it would be done very promptly.
I would think that advancing the catheter would be acceptable only in rare cases when the alternatives were more problematic.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
After taking our measurements and cutting the PICC, we insert the entire PICC and advancing is not even an option. Our measuring technique is very accurate. We use the LUMM scale. The only adaptation we make to the LUMM scale is on obese people we usu add a few centimeters, and if we see the vein at a 2 cm depth on anybody we will usu add those two centimeters. The vast majority of our lines end up in the cavo atrial junction. We used to grudgingly (knowing that it wasn't the best technique) reposition if the PICC was in the IJ, but with our buddy Sherlock, we don't ever h ave to do that anymore.
The last time I posted about the LUMM scale someone wanted more info about it. I tried to find the original article but I couldn't locate it. It described the process used to come up with the measurements for the LUMM scale. Based on a lot of research it was found that patients bone measurements (i.e. humerus, clavicle) had a direct correlation to their height. Based on those correlations the author made a chart. While I don't have the location of the article, here is the formula. After you pinpoint you insertion location, you measure the cm's from the antecubital fossa to the insertion site. You take those cm's and subtract them from the measurement on the LUMM chart. Those measurements are as follows:
Right sided PICC Left sided PICC
Pt height 4'8" 42.5cm 46.5 cm
4'10" 44 cm 48 cm
5 ft 45.5 49.5 cm
5'2" 47 cm 51 cm
5'4" 48.5 cm 52.5 cm
5'6" 50 cm 54 cm
5'8" 51.5 cm 55.5 cm
5'10" 53 cm 57 cm
6' 54.5 cm 58.5 cm
6'2" 56 cm 60 cm
6'4" 57.5 cm 61.5 cm
Remeber this is based on patient height so you need to have an accurate height. We carry a tape measure to measure patients who are unable to communicate. Also a lot of people will say "well I used to be 5'5" but i shrunk, now I'm 5'3". We tend to use the original height because shrinkage occurs from diminished discs in the spine, the other parameters haven't changed that much. I LOVE LOVE LOVE this formula.
Sheila McChesney RN CRNI
I googled LUMM and found and article by Philip Lum from JAVA vol. 9 no. 2 2004. Very interesting reading especiially since we tend to see many of our PICC's a little short. Thanks for the info!
Sheila McChesney RN CRNI
The skin is never sterile, therefore, once you remove the introducer sheath, the sterile field the PICC cannot be advanced. It can be backed out if it is too long. I do not agree with the idea of being able to "wrap the catheter with sterile gauze". If the PICC touches the skin, that part of the PICC is no longer sterile. I don't think wrapping with sterile gauze would be safe enough, and what if microparticles from the sterile gauze came off onto the PICC? Would this increase the risk of phlebitis or worse, thrombosis?
I wonder if anyone who has practiced the technique of "wrapping with sterile gauze" or readvancing after the field has broken down has done any tracking to see if there were any untoward outcomes--(irritation, phlebitis, infection, occlusion) with PICCs handled in that fashion.
I think it is safer to be too long and have to pull back than too short and have to exchange the catheter or readvance in such a fashion.
Since advancing the catheter would be considered insertion, I woiuld imagine CDC and IHI guidelines would apply, as in maximum barrier technique as with initial insertions. Is this also being done in these cases?
Chris Cavanaugh, CRNI
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I agree with Chris. The skin can never be made sterile regardless of the antiseptic agent or technique for applying it. Therefore, if the catheter has been in contact with the skin it can never be advanced into the vein after the initial sterile field has been removed.
Many years ago, my hospital practiced the wrapping method leaving the guidewire in place and protecting the external catheter from the skin. Go the xray, nurse assessed it and them we completed the procedure making any necessary changes to the top location. We did report our outcomes in a published study in 1993. There were no cases of infection and very few cases of early stage mechanical phlebitis. Remember this was long before MST and US was used. Here is the study:
1. James L, Bledsoe L, Hadaway LC. A retrospective look at tip location and complications of peripherally inserted central catheter lines. Journal of Intravenous Nursing. 1993;16(2):104-109.After the intial sterile field is broken, the only method for getting a longer catheter would be to exchange over a wire. This is one reason why external measurement is so critical and I would also recommend your follow the method from Phillip Lum. He worked on this for many years at MD Anderson and took careful measurements.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
Staff R.N. with no affiliation to any product or health care company(your basic front line grunt/wage slave)
I had a difficult time through Google. I'll make it eaiser for the next person.
http://www.ingentaconnect.com/content/ava/javac/2004/00000009/00000002/art00005
A New Formula-Based Measurement Guide for Optimal Positioning of Central Venous Catheters
Author: Lum, Philip
Source: Journal of the Association for Vascular Access, Volume 9, Number 2, June 2004 , pp. 80-85(6)
Publisher: Association for Vascular Access
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
This is the perfect time to plead your case for a navigational device such as Navigator. It will not only decrease the cost of the repeat CXR's, it will make sure you do not place your patient at risk for increased infection possibilities by advancing the catheter after you have broken down your sterile field. That is never good practice, as everyone has already told you in the previous postings. A navigational device such as Navigator will tell you where you are before you break down your sterile field, and then you will not need your extra CXR's which are usually not reimbursed to the facility. It is very easy to show cost savings for these devices. Email me privately if you would like to talk more about it and how you can get it done in your facility.
[email protected]
Heather