I have placed more PICCs than I can count over the years...and the use of these lines increase daily..Does anyone else get a creepy feeling that we are damaging patients vessels at a faster rate than ever?...then what?
I sincerely do not feel that we are damaging vessesls at a faster rate than ever. Take two identical patients side by side. Put a PICC line in one and a PIV in the other. Keep them in the hospital for two weeks. Look at the arms at the end of two weeks. (this is all hypothetical) The patient with the PICC is going to have a PICC. The patient with the PIV is going to have two black and blue, swollen bruised arms. I hear horror stories from my patients every single day. " I told my nurse my IV hurt but she said it was fine", "three people had to stick me before they could get a line in", "the student put this IV in, and it's been hurting ever since", etc. etc. A whole lot of damage is done before we ever get there. Hopefully we are preventing more damage from occuring. As usual, the only good answer is education, education, education. There is really no good alternative, how would you deliver 6 weeks of Vanco to treat an osteo from MRSA? TPN? Dopamine?, etc??
You have asked how to deliver 6 weeks of Vanc therapy which we know is thru a PICC. And you certainly are correct that education is key in successful vascular access therapy. In that eduation, perhaps we should think of a different spin on this eduaction, that being preforming a vessel assessment pre-insertion AND posti-insertion. This assessment should include a detailed look at how the blood flows thru the vein, is there any obstruction of flow, what is the thickness of the vessel walls, what is the catheter vessel ratio, etc. You are definitely correct, we must continue to advance our practice thru education and move away from the fact that every patient is a candidate for a dual lumen or a triple lumen PICC. Thanks for the eye open-er on the basics of our practice.
I have often thought about that as well. What we can do in our expertise is just what you said - educate and screen these patients prior to picc placing. Vessel to catheter ratio is a huge issue and should be adhered to when placing picc lines. We have been trialing a 6FR triple lumen picc line and once our docs found this out, they wanted it in everyone. Our comeback was that the patient had to meet certain criteria prior to receiving this line i.e. multiple incompatible drugs and most importantly their vessel has to be large enough to accomodate the catheter. We have stood firm to this and although we do place them, we don't place very many. We have to be advocates for our patients and although the docs don't always want to hear what we have to say, we believe in our standards of care. There have been many times when the floor nurses can not seem to place a PIV and they call the doc and they say just get a picc, well when we review the chart and the meds and find out a picc was ordered for INT purposes; we will call the doc and tell them we won't place a picc for an INT purpose. There are those few docs who won't budge and don't seem to give to give a hoot about your opinion, but we are working on them.
We use PICC frequently in our oncology and cysitic fibrosis patient. Many of the CF have been seen for years. They come in for tune-ups (2-3 weeks of abx therapy), and have had no apparent vascular damage.
Yes, Cathie, I agree, I think that sometimes PICCs are being inerted for the convience of staff and patient requests that are really not needed. I see a number of patients that have had so many central lines, midlines and PICCs that there is no longer a patent pathway to the central veins. Most of the vein damage is not noticed until we try to place the 2nd or 3rd and have difficulty advancing. We try to assess each patient carefully but also find we are placing due to no peripheral access available. Because we give so much fluid & medication via the IV route a large number of patients have extremely difficult peripheral access available and most staff nurses are not able to get a saline lock in so a PICC is ordered. We need education to use veins wisely and give proper care so they can heal and be used again. We need to preserve and conserve veins so they are available for use the next admission. What is going to happen when we cannot get IV access?
I think part of the reason we see PICCs increasing has been the fact that there are now power injectible PICCs and the large "Fear Factor" surrounding a subclavian non-tunneled CVC. Interestingly enough, some data is showing that in the hospital ICU setting there is little difference in infection rates between PICCs and non-tunneled CVCs.
Also, non-tunneled CVCs that are impregnated have greatly reduced BSI rates as long as they are properly inserted and maintained.
The key is to be sure you are using the best line for the patient to deliver the therapy and preserve vessel health. Having said that, I feel like the desire to place triple lumen PICC lines "just in case" we need those extra lumens or one clots off has been contributory to some increase in thrombosis.
We tend to forget the standard to use the smallest gauge device that will deliver the therapy.
6 weeks of vancomycin daily or every other day would not require a double or triple lumen but maybe only a 4 french single lumen that would give you a better catheter to vessel ratio.
Also, don't be afraid to use a 3fr. if the patient vasculature demands it.
Having many return customers without changes to the vein (viewed by ultrasound), I don't think that we are damaging their veins. We do have a few exceptions that we have noted changes, but that is the very smallest percentage of patients. Most of our CF patients do not have vessel changes after having many years of PICCs.
Cheryl Kelley RN BSN, VA-BC
Jeffery Fizer RN, BSN
Cathie,
I think part of the reason we see PICCs increasing has been the fact that there are now power injectible PICCs and the large "Fear Factor" surrounding a subclavian non-tunneled CVC. Interestingly enough, some data is showing that in the hospital ICU setting there is little difference in infection rates between PICCs and non-tunneled CVCs.
Also, non-tunneled CVCs that are impregnated have greatly reduced BSI rates as long as they are properly inserted and maintained.
The key is to be sure you are using the best line for the patient to deliver the therapy and preserve vessel health. Having said that, I feel like the desire to place triple lumen PICC lines "just in case" we need those extra lumens or one clots off has been contributory to some increase in thrombosis.
We tend to forget the standard to use the smallest gauge device that will deliver the therapy.
6 weeks of vancomycin daily or every other day would not require a double or triple lumen but maybe only a 4 french single lumen that would give you a better catheter to vessel ratio.
Also, don't be afraid to use a 3fr. if the patient vasculature demands it.
Having many return customers without changes to the vein (viewed by ultrasound), I don't think that we are damaging their veins. We do have a few exceptions that we have noted changes, but that is the very smallest percentage of patients. Most of our CF patients do not have vessel changes after having many years of PICCs.
Gwen Irwin
Austin, Texas