I have found the cephalic vein is usually the vessel of choice for PICC placement on these patients.  Beyond the fact that cephalic insertion is least likely to be successful (too often it wants to send the PICC up the IJ) I have found that careful advancement with observation by Sherlock on these patients usually amounts to successful placement. 

I do as you do......leave the stylet in for the CXR.....but I would also ask for an RPO (right posterior oblique) view of the chest.  This super-imposes the PICC tip over the right lung and generally allows viewing of tip location.

Alma Kooistra CRNI

I agree that in these patients the cephalic vein is closer to the surface so is much easier to get access through.  I love the Vasonova guidance system for these people because the doppler flow really helps with early detection up the IJ and you don't need a chest x-ray to know that the PICC tip is at the caval atrial junction.  The other useful aspect is that the morbidly obese patient often can't lay down very well so occasionally the Sapiens system doesn't easily sit on their chest. 

In reference to the right posterior oblique (RPO) positioning that Alma mentioned, you may find the following reference helpful to convince your ordering physician to use this technique:

I have never had any issues with the Sherlock or Sapiens on obese patients, and I am looking forward to trying the Vasanova. I would also suggest the RT use a grid as this really helps with visualization. It seems many RT's resist the grid as it is an extra step so I often have to ask for it. I almost never use cephalic due to higher incidence of DVT but morbidly obese patients have a legitimate concern for fungal infection with a brachial or basilic approach so on really big arms cephalic is often my first choice.

We seem to have a lot of these.  Does that mean we have more obese people in our area?  Maybe so.  We rarely use the cephalic vein.  I would bet that it is less than 1% of our PICCs, with the morbidily obese.  Most often it is the basilic vein closer to the AC fold.  Advancement to the SVC is not much of an issue wehn using the basilic in these patients.

Radiology is very agreeable to using the grid on these patients.  However, seeing the tip on some of these patients is a challenge, even with a grid.  Due to the weight over 500 or 600 lbs., using the grid is and seeing the PICC tip is still tough.  The last one (about 500 lbs) that I did required getting contrast to fill the PICC in order to visualize.  The radiologists bet that the PICC was not in the right location.  With contrast 1ml (to fill the PICC) and repeat chest x-ray, the PICC was perfectly placed.

BTW our largest patient with a PICC insertion was 926 lbs.  SO sad, but successful PICC and however, we got the image of the tip location to be visible is a miracle.

Gwen 

Is there a limit to how deep a vein may be when being used to access for PICC insertion? I have only seen needle guides that allow access to a depth of 2cm.

If you use a needle guide then, yes, that would be the depth limit. Our team does not always use them. Our ultrasound has a good picture to a depth of 4cm and we place PICC's up to that deep on obese patients. However, the bigger question is how long are your cook needle, guidewire and introducer/sheath? Everything needs to be long enough to account for the extra depth. Our old mico-introducers were much shorter than the ones that come with the Bard Power PICC. I am much more comfortabe placing the deeper PICC's with the longer micro.

My other tips on large patients:

1. The outside does not always match the inside. Some folks are very wide chested and then you see the Xray and there is a little bitty rib cage underneath there. When this happens the PICC will be way too long based on external landmarks.

2. Measure long. You can always pull the PICC back but you can't advance it if you trimmed too short.

3. Leave the stiffening wire until tip placement is confirmed if you are still doing Xray's. Tape it off and then go back & remove it before you clear the PICC for use.

4. If the vein was deep (3-4cm) then account for that when measuring before you trim the PICC.

5. Request a grid be used and/or an RPO to facilitate visualization. Worst case scenario is request a dye study if you KNOW the tip is in the correct location but the radiologist can't see it.

Martha

Since it is a good idea to keep extra introducer sets in your cart in case something is dropped or contaminated, I stock introducers that are 10cm long in order to be prepared for these patients. If necessary you can use a 20ga x 3.5" spinal tap needle to give you sufficient angle to thread a wire and introducer. I just received some samples of Braun Introcan that are 18ga x 2.5" that I plan to use on heavy patients. I have had successful PICC placement and completed therapy on patients with arm circumference up to 85cm.