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Pauline Hodge RN
PICC advancing

I attempted to start a picc line yesterday and only got about 12cm in, I flushed without any improvement.  Anything else I could have done?


Can you tell, I new to all of this. 

Wendy Erickson RN
Welcome to the sometimes
Welcome to the sometimes frustrating world of placing PICC lines!!  There are any number of reasons why a PICC line does not thread all the way to the low SVC: previous central lines which may leave thrombi, fibrin, etc. which you run into when placing a new line; bifurcations; hitting valves; vessels that "peter out"; etc.  You can try repositioning of the arm - pull it out to 90 degrees or more, or pull it closer to the body, whatever works.  Try retracting the line several centimeters, then readvance - sometimes you get lucky and it goes.  Try rotating the whole catheter in the vessel so that the tip points in a new direction.  Try waiting a bit - it might be spasm that may relax with time. Try praying!  We have all done all of the above, often on the same patient - you just keep trying.  If I gave it my best and it would not advance, I would remove it and try a new site - not in the same vein system.  For example, if I'm in a basilic, try the cephalic.  If all else fails, then refer it to Interventional Radiology for placement, if you have that availability.  Or investigate a different central line for the patient.  Unfortunately there are patients that have such poor vasculature, they are not candidates for PICCs.

Wendy Erickson RN
Eau Claire WI

rivka livni
If referal to IR is an
If referal to IR is an option, I leave whatever catheter I could get in, try the other arm. If other arm is OK I remove the first catheter and just go on my merry way, if other arm is also a problem, I leave second catheter in, send pt to IR, they do a venogram through both catheters to see what's the problem and proceed to convert the catheter into a PICC in the one that has the better chance. A lot of time it's stenosis that IR can get through with a special guide wire. If they find total occlusions with a bunch of collateral veins, we put that pt on our special list of patients we call "Don't Even Think About It".
Gwen Irwin
Since you are new to this, I

Since you are new to this, I also have to think that the catheter wasn't threading into the vein.  We have had many times during training that the limit is about 12-15 cm.  threaded fairly easily without blood return and without flushing helping.

Think about the insertion that you described.  Was there excellent blood return via the introducer?  If not, it could have been partially in the vein and when the PICC was inserted it "tunneled" along the vein, instead of being in the vein.

 We have no proof that this is the occurrence for all of them, but we did have a few referrals to IR, that the PICCs were not in the vein.  However, we also have a list of people that we don't even try.

It gets so much better with more experience.  Hang in there!  And good luck.

Gwen Irwin

Austin, Texas

Pauline Hodge RN
I had great blood return. 

I had great blood return.  This forum is awesome, I so appreciate the feed back/



How did it feel as you
How did it feel as you threaded your guidewire? If it feels like it's dragging, probably not in the vein. Did you hit a wall, or did the line bounce? Sometimes the pts. spasm, so we do try heat. And sometimes you have to wait it out for the spasm to stop. Did you also try repositioning the pt.'s arm?

Victoria Sallese, RN, VAT, PICC service

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