Hello all,
We recently had a patient who presented with a Power PICC Solo inserted in the left chest, rather close to the breast. Two chest xrays were completed one day apart. The first xray was dictated as a left subclavian central line. The second xray was dictated as a PICC inserted in the left axillary vein. Either way, is this an appropriate insertion point? Our thoughts are that this would be a CVC, bordering on subclavian insertion at the least.
Thank you for any input.
This is an unusual site to insert a PICC, although PICCs have been used for IJ placements also. Maybe there was a clinical reason for this site - needing a CVAD smaller than any others that were available is a common reason. Or needing a power injectable CVAD when no others was available. The axillary vein is contiunued into the subclavian vein, virtually the same vein just changes names. Subclavian vein insertion is probably more unlikely than you think for any CVAD because it is very short and located under the junction of the clavicle and first rib. The axillary vein in a more lateral puncture site is preferred to remove the risk of pinch off syndrome. The most important point is where was the tip located. That is more critical to clinical outcomes than insertion site.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you for your response! For some added clarification, this PICC was inserted at that location due to small basilic/brachial/cephalic veins. This was also placed by a vascular access nurse, not a physician. I guess my question really is, is this insertion point within our scope for us, as vascular access nurses, to insert PICCs if other options are not available? I have also heard of nurses being training to insert PICCs in the IJ but not the axillary/subclavian region as this has been the domain of the physician.
Again, thank you for your input.
Wyatt Baker, BSN, RN
Insertion of a CVAD into the axillo-subclavian, IJ, or femoral veins is within your scope of practice IF your state board of nursing incudes this in your scope AND you have documented competency to insert in these sites. Your state board of nursing will probaby be using the scope of practice decision tree to guide you to make this decision. Most states now use this method.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Wyatt,
That is an acceptable insertion practice for Vascular Access nurses. It's a triangle of sorts, that falls short of a subclavian PICC. The line is inserted into the SVC just like a PICC line just originating in the Axillary vein. It changes it's name to "subclavian" when it dips under the clavicle, Lynn is correct. I have inserted quite of few of these lines and they are a wonderful option for certain patients. I wish more Vascular Access nurses would let go of their fears and move in this direction instead of falling back to dressing changes and peripheral IV's. There is so much we CAN do but for some reason...we don't.
Thank you for your input, Jack. I am a relatively new vascular access nurse (a little more than a year now), so there is still so much I am learning on a daily basis. I think that options, such as the one we are discussing, are valuable because of so many chronically difficult patients who may not have options otherwise. At our facility, we prioritize PICC and midline insertion as well as other CVAD maintenance, but we do perform routine care and start some peripheral IVs as well. A larger facility in our network utilizes other insertion points for PICCs and it would be helpful to adopt this as we have had many difficult patients with no viable basilic/brachial/cephalic option.
Wyatt Baker, BSN, RN
Ask the infusion/VA staff at that other hospital how they got this practice approved through the facility decision makers. Ask them to share their policies and procedures. Don't reinvent the wheel since especialy since they are already in your network.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree Wyatt, I like hearing cases like yours where you are a new practioner looking for better ways. In my experience, through several healthcare systems, I often feel it's the opposite. I'm NOT saying that peripherals and dressing changes should never be done by Vascular practioners, however, to do just that without the other is not something I'm interested in doing, Why would a heart surgeon only want to do bypass and never explore the more advance practices. I feel that way. We have a special talent and should be used for that talent and not just "assigned" to a team that is a catch-all.