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PICC insertion techniques

2 questions as a result of orienting new PICC RN.  Even though we have tip location, this nurse insists on using "jugular pressure" whereby she uses the ultrasound probe to push into the jugular vien above the clavicle to prevent tip going into jugular.  Sometimes the pressure causes discomfort and I also wonder about massaging the carotid while doing this. What say you? I would like to have some expert opinion to convince.

Also, she sometimes places PICCs very high, as far as an inch or two below the axilla (so thereby accessing the axillary vein in some cases). Although she states this is not her usual practise, I have seen it frequently and the reasons are usually, too small of veins or multiple bifurcations. What can I say to discourage this? How high is too high.  My thoughts are that the axillary vien is not considered to be a vein for access for piccs and also increased chance of infection.

 Thanks for your opinions

Sharon Symons

Scripps Green Hospital

There is no evidence that I

There is no evidence that I have ever seen to support the practice of using the US probe to prevent tip location into the IJ. You can use the US probe to rule out malpositioning in the IJ immediately after insertion, but I also have serious concerns about this practice of excessive pressure in the absence of evidence about its effectiveness and safety. 

The insertion site that you describe would not be a puncture of the axillary vein. Any puncture in the extremity would still be in either the basilic, brachial or cephalic veins. The axillary vein begins at the lateral edge of the thorax and extends to the lateral edge of the clavicle at its junction with the sternum. So a puncture in the axillary vein would have to be in the thorax/shoulder area. A puncture site high on the arm will increase the risk of infection because you would be puncturing in the axilla or arm pit, an area known for wet skin. This type of skin found in the axilla and groin have the greatest number and types of organisms. So if the puncture is being made high enough to be considered the arm pit or axilla, this is a great risk to the patient for infection and discomfort from arm movement. 


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Thanks, Lynn.  Much

Thanks, Lynn.  Much appreciated

The easiest way I have found
The easiest way I have found to prevent the line going up the jugular is to retract the guidewire during the insertion.  If my PICC is advancing well and on Sherlock is going down, I just advance.  The minute it starts to veer upwards, I pull the PICC back to the point of where it was still advacing properly, then pull the quidewire back about halfway, advance the picc very slowly until it's all the way in, then advance the guidewire.  Works almost everytime without having to turn heads, move arms etc.
Timothy L. Creamer
Clarification regarding

Clarification regarding guidewires, they have a floppy nontraumatic tip. Stylets are wires within the catheter to provide formness of catheter allowing advancement, no floppy nontraumatic tip. The Sherlock wire is a stylet. IFU does not include readvancing stylet into catheter, INS Standards clearly indicates not to readvance a stylet to prevent damage to catheter. In my clinical experience, retracting the Sherlock stylet only 3cm to 5cm is adequate for the jugular flow rate to assist catheter advancement toward the SVC. Sherlock will indicate a directional display with catheter advancement without stylet readvancement, just higher on image screen.

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

Hello.  Here's some you

Hello.  Here's some you might want to try.

1. during fluro guided placement, once line passes the shoulder, tell the patient to face the side the picc is being placed on (turn head to right if placing line on right basilic/ cephalic).

2. It is very uncomfortable to push a hard object, on the jugular area. Tell her to try it on herself and see how uncomfortable it is.

3.  Once the tip reaches midclavicular area, pull back stylet about two cms to make tip abit flloppy and avance catheter slowly.

4. If it continously want to migrate upward towards the jugular, straighten the head midline, pull back catheter back at midclavicle, readvance slowly in a twist like motion. This works for me a lot.

let me know if this helps you out.

Michelle Todd CRNI
The CRNI's that taught me to

The CRNI's that taught me to place PICCs in 1995 advocated placing pressure on the neck with the hand of the assistant to keep the PICC out of the jugular. I think there may have been some validity to it but I only place PICCs alone now, and do not have that option. I had forgotten about that though and I think I will try it next time I have a line that wants to go up to see if it does help. I don't see how using a probe to block a vein would be much more pressure than using the probe to see the vein. The biggest trick I have is having the arm perpendicular during the pass through the shoulder. If that doesn't work, I pull the arm up even higher through the drapes and that usually works. I also use the head-turn, but most of my vent patients can't do this. Pulling the wire out a bit is also very effective. One of my first instructor's, Karen Holmes, used to insert the PICC 1cm, flush a little, insert 1cm, flush, insert 1cm, flush and put the line up very slowly in addition to doing the head-turn and perpendicular arm placement.

 I feel that PICCs should be placed as distally as possible once in the upper arm. The area where the basilic vein meets the medial cubital-basilic vein is high enough. What happens to me is that nurses from other hospitals place the PICCs very high sometimes and then the patient pulls out the line. I have no where else to go when the last nurse used the best vein and then placed it so high. If you can not get access lower, then that is one thing, but it is best for the patients if this is not routine practice. Aside from the patient removing the line, they may need another PICC some day and each PICC may cause scarring in the vein which may make it impossible to pass through with subsequent PICCs. This means there may be less options in the future if you place very near the axilla. 



Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]

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