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.