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PICCs in old graft,fistula sites

 Hello all,

Our team had a very troubling situation this past weekend and we are searching for best practice guidelines. We were called to place a PICC in an ICU patient for "possible pressors". The patient had two old graft sites in the left arm, one old graft in the right arm, and a hemodialysis Shiley catheter to the right chest. We were told none of the old grafts were functional. We recommended different central line placement as we did not feel it was appropriate to try to PICC this patient. We DID look with the ultrasound and saw torturous paths. The renal physician gave his blessing but we recommended against this. We also recommended that the patient go to interventional radiology. We were then ordered by the attending physician to place the line anyhow. On the third attempt, the line was able to be placed by us. Needless to say, we were scared out of our minds. We have always been under the impression that this is not best practice and should always be avoided. Now that this precedent has been set, we fear that we will be asked to do this regularly. Does anyone know of anything in the literature that addresses this?  Many thanks. 

 The reason for avoiding PICC

 The reason for avoiding PICC placement in a renal patient is to preserve veins for future grafts/fistulas. Also to reduce the risk of vein thrombosis due to length of veins needed for PICC insertion. This patient was at a very diffiernet place in his care. The only factor that should have influenced your decision to place a PICC would be the tortuosity of the veins and the ability of the PICC to thread through the veins. He required vasopressors, so a CVAD of some type of needed. Based solely on what you have included in your message (and there could be more details needed), I do not think you were wrong to attempt a PICC insertion and I do not think this would or should set a precedent for placing PICCs in patients where vessel preservation or thrombosis reduction is the most important factors. In other words, in this situation the benefit of a PICC outweighed the risk. Lynn

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

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