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Kathleen M. Wilson
PICC insertion difficulties

We recently had a pt. needing a picc. The nurse started in the right arm.  The nurse obtained blood flow easily but could not thread the wire. The needle was removed. The site was adjusted proximally, and some time for rest was given. The same thing happened on her second attempt. To note, the pt.'s pain throughout the procedure to this point was much greater than most pts. (of course, numbing was used). After a rest, the pt. was willing to allow the nurse to try on the left arm. Again, blood was easily obtained via the needle, the guidewire did thread, but extra slowly with long pauses. It would not advance, then would, etc. alternating. The dilator/introducer was then placed fairly easily. As the picc started to be inserted, there was resisitance. Different modifications were attempted that we have been taught (for example, arm reposition, pull out introducer a bit, attempt to flush a cc of saline, waiting in case of spasm, palpating to determine if there was a coil, etc). Although we don't usually do this, with all the difficulty, we ordered a CXR to see how far we were to know if we should just go to fluoro, or if we were just coiled right there in the arm. The xray showed the picc was to the axilla but have way between insertion, there was a "turn" or bend. We had left the introducer in for the xray. It looked like the bend was about where the end of the introducer would be. The introducer was then peeled away, and the picc attempted to advance further. This was unsuccessful. A fourth total attempt was made on the left, proximal to the first attempt on the left. The same thing happended as on the right, easily blood flow and venous access, but no threading the guidewire.


We need some help on thinking through what is going on. We felt spasm could be likely, esp. as we noted her pain levels, but tried to accomodate by giving pauses/breaks. We have had this happen before and if you wait out the spasm, you can continue (most of the time). Also, we considered, was there just anatomical variation? Well, possible we did not detect a bifurcation on the U/S but we do examine for that. But, it seems unlikely that we would have that be the issue on 4 sites. Why did the introducer "bend"?  The veins ranged between 1.5 and 2 cm deep. Should we have been using an extra long introducer? We do not think the needle was dislodged, because there was continued blood flow and the picc nurse is experienced. Yes, there could be flow if the needle was dislodged, but I do not believe this could have happened 4 times with the experience of the nurse. The pt. was cooperative--not moving or anything like that.


We are truly appreciative of any words of wisdom shared.


Thank you,



Could it be DVT? Did the

Could it be DVT? Did the patient have a history of CVADs, any surgery in the chest and the arms?

Kathleen M. Wilson
Thanks for reply. No hx of

Thanks for reply. No hx of CVADS. We always ask about the chest/arm surgery hx. Negative.


Kathleen Wilson, CRNI

Gwen Irwin
PICC insertion difficulties

I wonder if it was a problem with the needle tip being completely in the vein.

If the needle is partially in the vein, you will get blood return. You will even get great blood return, but can't thread the wire.  If the bevel of the needle is not completely in the vein, but you get blood return.  When you try to thread the wire, it is not advancing in the vein.  We call this "tunnellling" the wire.  This is our term.  The wire doesn't thread into the vein, but tunnels into the sub-q outside of the vein.  And yes, patients do complain about the discomfort.  In our years of experience, we believe that we can tunnel about 15-20 cm and then meet resistance and not able to thread any more.  Also, the microintroducer threads easily in this situation.  The PICC won't and usually there isn't blood return from the introducer in these situations.  Was there blood return from the introducer in this situation?  What distance were you able to thread the wire? 

I think that the turn or bend that you saw on the x-ray could have been the angle that it took outside of the vein.

If I was having this type of situation, I would try to visualize that the whole needle tip is in the middle of the vein.  If the wire doesn't float in easily, I would wonder where that needle tip was and re-examine using ultrasound.

I hope this makes sense and helps.

Gwen Irwin

Austin, Texas

I agreed with Gwen. I could

I agreed with Gwen. I could get good blood return and I was able to thread the guidewire quite far. However, there was no blood return when the introducer was inserted. Did you get good blood return after the introducer was in?

Kathleen M. Wilson
Gwen and achoosa 1 Thanks for

Gwen and achoosa 1

Thanks for your replies. To answer your questions. The wire was in about 15 cm. The introducer did not have blood flow. This was not a procedure stopper as we have had occasions where this is the case, where the picc easily went in and worked (rare). Since it was the 3rd attempt and the introducer was in, it was worth attempting to thread the picc.  But, no luck as you know.

Hmmmmm. I follow your logic. Makes sense. I am perplexed that it would happend four times, using both  arms. One of the attempts was a different RN.

What are the factors people consider in technique and in pt. variation that might contribute to the needle not staying in the vein or not able to be fully in the vein? Does anyone have any changes in equipment stories that might help, ie new ultrasound, etc?

Does anyone have any thoughts on the Lidocaine in this circumstances?


Thank you!!!!


Kathleen Wilson, CRNI

Robbin George
If the target vessel is (1)

If the target vessel is (1) small (2) relatively close to the surface and/or (3) the brachial vein I will (1) not use lidocaine for the venipuncture (I use lidocaine at the wire site prior to skin nick and dilator placement) AND I also use a "B" bevel needle (shorter bevel prevents "back walling" and a more accurate needle tip location in the "center" of the vessel).

Robbin George RN Vascular Access Resource Department Alexandria Hospital Virginia

Robbin George RN VA-BC

Karen Day
Karen Day's picture
i agree with the previous

i agree with the previous answer regarding not being entirely in the center of the vessel.  We have had this happen a time or two when we get great blood return, but when we try to advance the catheter, we can not go beyond 15 to 20 cm.  I agree too that it is when the vessel is turning in the shoulder area and because you are between the layes of the vessel, you can not make this turn. 

I do, however, disagree with not numbing the patient prior to their stick.  Many patients fear this insertion procedure as if it were going to be the worse thing they ever encountered.  As practitioners, you and I know that it is usually much easier than starting a PIV on a patient, but to the patient it's always worse.  Once you tell them that we use numbing medication, it seems as if all their fears are alleviated and they become much more relaxed and tolerant of the procedure.  I have had many patients who have stated they had a picc attempt at a different facility and were not numbed and therefore the procedure was unsuccessful after multiple attempts due to the patients inability to tolerate.  Once we inform them we will numb from the start, they are more relaxed and I have been able to achieve success on the first attempt withe nearly all of these clients, and have a very satisified and relieved patient as well, which is our ultimate goal!


Kathleen M. Wilson
Thanks for everyone's ideas.

Thanks for everyone's ideas. We have talked about your ideas, and think in this situation--although rare and hard to imagine on four tries--we were not centered in the vessel, thus the wire couldn't go in or actually went in and out of the vessel......we don't think it was the Lidocaine in this case, as the target vessel was 1.5 to 2cm deep. We sent her home on a peripheral, she came back two days later, we premedicated with some valium (the first attempts were naturally stressful), used Lido, and it slid in. A few of use have noticed changes in our U/S and are going to ask for it to be checked. For example, just a loss of clarity.  Anyone have experience with U/S being the problem  in this type of scenario?

As an aside, the Lido discussion has been something we've been having. A few on our team feel that the shallow veins disappear with the lido, I always use it, I just vary how much and how deep based on the vessel.



Kathleen Wilson, CRNI

Gina Ward
us accuracy

I agree and think it sounds like the needle wasnt in the center of the vein but the us could be the culprit. 

do you check your us regularly for its accuracy?   We had an issue where we were doing a picc, could see vein on us, could  feel needle go in vein but couldnt see it on screen or thread.  ( or we say the needle in a position we did not desire or expect)  Come to find out, the us imaging was off;  the us probe probably had been bumped, dropped or something.  So, even though it thought I should be going right into the center of the vein it wasnt. 

Take a needle guide kit, attach  the needle guide and a needle to your ultrasound probe , then take your ultrasound probe with needle guide and needle and put the tip in a cup of water and advance the needle.  Does the needle tip show up on ultrasound on the desired mark according to the needle guide you picked and in the center?  If not you may need your probe adjusted.


Thanks,  Gina

Gina Ward R.N., VA-BC

Glenda Dennis
bacteriostatic normal saline

 Has anyone tried bacteriostatic normal saline prior to picc placement then lidocaine prior to the dermatotomy?  I have not because I haven't felt I had an issue with lidocaine but we have been using bacteriostatic saline for quite some time for peripheral IV starts.  It generally works well in controlling the pain.  It must have the alcohol in order to work.  Preservative free saline doesn't help.  I wonder if it would work for the deeper insertion of the picc introducer. 

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