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alison57
PICC insetion, measurement for obese pts.

I  just placed a 4 fr single lumn Picc line in a very obese pt.  Used the ultrasound and sherlock.   Pt is 400lbs and 5'8" tall.  She needs 2-3 weeks IV Ancef.   I had a very hard time with the initial measurements as she has so much breast and chest tissue.     I could not even palpate any bone, ribs etc. in the chest and she has no neck, her neck fat folds over her chest.  I measured it too long on purpose, probablly because the pt stated that the last Picc she had was too short and she had to have it replaced.   I had to get several CXR's before the Optimal placement was obtained.    The tip was in too far.  We finally got a pretty good look with an oblique.  I ended up having to pull it back twice to 9 cm!   I can't remember ever doing that!   The insertion was easy except that the sherlock would not pick up the signal in the chest.   I had to rely on my old instincts from before there were such devices.   She had no 'rushing' sound in ear/neck during flushing and insertion was smooth, with good and easy blood return.   Does anyone have any advice for initial measument for obese pts?    I did notice that her heart seemed very high in the chest upon XRay.  Maybe due to the huge belly pressing it up?   Any way it is working great with the tip in the CAJ!

KRALSTON
      I always check to see

      I always check to see if the patient has had a previous CXR in my facility, that way I get a preview and can "catch" those pts.  Before I started routinely reviewing CXRs pre-insertion, I was surprised a few times like you.  The way I explain it to my patients is "You might have two 6' tall people, one with a 30in inseam, and the other with a 36" inseam".  No other measuring advice, sorry.

Keely Ralston RN-BC, VA-BC, CPUI, RCIS

KRALSTON
      I always check to see

      I always check to see if the patient has had a previous CXR in my facility, that way I get a preview and can "catch" those pts.  Before I started routinely reviewing CXRs pre-insertion, I was surprised a few times like you.  The way I explain it to my patients is "You might have two 6' tall people, one with a 30in inseam, and the other with a 36" inseam".  No other measuring advice, sorry.

Keely Ralston RN-BC, VA-BC, CPUI, RCIS

alison57
Very good advice.  

Very good advice.   Thankyou.  I will definately check the CXR's.   Live and learn.  Esp. with the hep of the good nurses on this site!!

dcole
Obese patients can be very

Obese patients can be very diffucult to measure.  I always allow for extra length if needed.  Sometimes it is impossible to get into the low svc from the left side with a 55cm catheter.  We need 65cm "bariatric catheters".

 

Darilyn

MarkCVL
Placement on the Right (if an

Placement on the Right (if an option) will give you and additional 1 inch of catheter compaired to Left placement....Just something to think about when making your selection.

mattgibsonrn
There are several different I

There are several different I have learn over the years. Currently I know five different ways. Routinely I measure two different ways and take my longest measurement. Another method is to have another clinician measure and compare. I also review the chest xray to see if the heart hangs low or is pushed up high in the chest. This is not a clear indication to cut shorter or longer but is just another piece of information. Give me a call I would love to talk to you about this.

Matt Gibson RN, CRNI, VA-BC

270-577-6159

Matt Gibson RN, CRNI, VA-BC

Sheila
Sheila's picture
Accurate measurement

 This is very difficult to do.  The best you can do is like others have said, look at a previous CXR to see how long the SVC is, measure twice or get someone else to double check.  Also correlate the patient's height with your measurement.  Even with all these things we do, it is difficult.  I placed one the other day where I had to leave 7 out!  I use Sapiens and so I didn't have to retract, but left 7 cm out according to the Sapiens.  I usually leave 1-2cm, occasionally 4-5, never 7, except in these patients.  Fortunately, I did have Sapiens as it is also very difficult to see the line on CXR, as you said.  

Sheila Hale, BSN, RN, CRNI, VA-BC, Austin, TX

alison57
Yes,  I have heard of a

Yes,  I have heard of a method of taking into account the pts height to get the length.   How do you do it?    Thanks

Halle Utter
PICC measurement based on height

It's called the LUM method I believe. There was an article in JAVA in 2004 showing all his research.  He goes into a lot of detail about how he came up with it.  I do use the formula, and measure, and base my final measurement based on considering both.  If someone has really long or short arms, or is really wide or really narrow, you need to make adjustments.  An abbreviated version of the formula I discovered after I'd done it longhand a few times is : Height in inches x 0.75 = length in cm for the right sided insertions. Add 4 cm for the left side.  The formula is calculated from 2.5cm below the antecubital fossa, so after you determine the calculation, you will need to subtract the distance from your insertion site to the spot that is 2.5cm below the ACF.   I find it a helpful tool, as a checkpoint.  I still measure. 

 

Halle Utter, RN, BSN

Intravenous Care, INC

Hallene E Utter, RN, BSN Intravenous Care, INC

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