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Halle Utter
Reverse taper catheters - how much do you leave out?

I have been placing PICCs with US & MST for years, prior to the arrival of the reverse taper catheters on the scene.  I would love some feedback from the rest of you regarding the following areas.  Does anyone insert the catheter all the way to the hub, having the hub push up into the site to use as pressure to stop the bleeding, or do you leave the approximately 1cm that is distal to the "0" hash mark outside?  Does anyone know if the catheter continues to taper larger beyond the "0" mark?  Are there any studies regarding increased thrombus formation when the catheter is shoved all the way up to the hub?In some people this may be less significant, i.e. if the patient is heavier, therefore vein is deeper, so fatter part of catheter and hub don't push into the vessel.  But what about the patient who is very thin with superficial vessels and very thin friable skin?  I have seen the hub shoved clear into the skin, and in some cases this pressure can erode the venipuncture & skin nick site into a large "hole".   I have had one very experienced nurse tell me she was taught to do this to prevent bleeding.  My goal used to be to have the "0" mark right at skin level.  Lately, I have been leaving 1-2cm external so I don't have the fattest part of the taper in the vessel, especially if the vessel is on the smaller size, where the catheter diameter is going to take up more than 1/3 of the vessel diameter.  Most of the facilities I go to use the Poly PerQCaths and the Bard PowerPICCs.  Some places use the Jet Medical lines.  Where does it tell you at what cm mark the reverse taper starts on these catheters?  I have not have trouble with bleeding.  If the site is bleeding, I have found I can push the catheter in to act as a tamponade while I have cleaning up, skinprepping the site, etc, and by the time I am ready to secure it with a STATLOK, the bleeding has usually slowed significantly and I pull back to leave my 1-2cm external.  What are the rest of you doing in terms of amount of catheter left external?  I used to put it in further, but over the years with the larger catheter and the reverse tapers, I have become more concerned about having the larger diameter in the vessel.. Feedback appreciated.

 

Thank you.

 

Halle Utter, RN, BSN

Intravenous Care, INC 

lynncrni
There are no standards or

There are no standards or requirements for how catheters are marked. Some have the numbers start at the internal tip and others at the hub. There are several different designs on the size and length of the reverse tapers. And there is no published research on this type of catheter to my knowledge. This started as a product feature based on the request of some radiologists and has now become a huge marketing idea based on the theory that the larger portion of the catheter will act as a tamponade on the puncture site and prevent post-insertion bleeding from the site. All the questions that you have raised are valid issues but practice is based on experience and not science. I am curious to know the practices of others also. Lynn 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gack
I generally cut my catheter

I generally cut my catheter 2 cm's longer than what I require, then leave 2 cm's exposed.  I've done this for many years...probably since we started using reverse tapered PICC's.  Making a very small dermatomy like I do, I rarely need to fully insert the catheter for the reverse taper to fully "plug" the site.  I also feel that with the 2 cm's exposed, I can "angle" my stat-lock and secure it in a position that directs the lumens towards the front of the arm as opposed to straight down...imagine a very lazy "j" I guess would best describe it. 

 

Brian Gackenbach RN, BSN, CRNI

University of Louisville Hospital

brianga(at)ulh(dot)org

Brian Gackenbach RN, BSN, CRNI

University of Louisville Hospital

brianga(at)ulh(dot)org

Glenda Dennis
I look at the patient's INR

I look at the patient's INR and plateltes as part of my assessment.  Then I usually trim the catheter a little long if there are normal lab values and close to the measurement if there is bleeding potential.  I rarely insert the taper to the hub.  It is just too much taper for my comfort zone as a rule.  For the occasional patient with very low platelets, I will use the whole taper to the hub.  I have rarely had a symptomatic thrombus around the catheter.

 

afruitloop
You didn't mention if you
You didn't mention if you preformed a skin nick with your insertion.  Perhaps eliminating the nick would eliminate the need for putting the reverse taper part in the vein.

Cheryl Kelley RN BSN, VA-BC

Robbin George
I have nurses on the team
I have nurses on the team that cannot fathom the concept of inserting the dialator without a skin nick--Those that follow this practice could you please describe how this is done successfully without causing pain and/or injury to the patient--Perhaps it is dependent on the anesthetic and/or the quality of the dialator?  

Robbin George RN VA-BC

Daphne Broadhurst
We use to do dermatotomies

We use to do dermatotomies for all insertions until we switched to a smoother microintroducer, ~ 1 year ago. Rarely do we ever need to nick the skin- our micro kits don't have scalpel blades & we don't carry them with us as they're just not needed anymore. We tend to "twirl" the dilator as we're advancing the dilator through the tissue/vein. On occasion (not often), if the patient does experience discomfort, we'll administer a wheal of buffered lido to the dilator area.

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

blodahl
Which micro-introducer are
Which micro-introducer are you using? Thanks.

Barbara

DML RN
Single-lumen 4Fr Groshongs

Single-lumen 4Fr Groshongs do not have a tapered end,so that would not be an issue for the patient's DVT.

 

Robbin George
It seems to me that the
It seems to me that the majority of venous trauma during PICC insertion occurs during the initial stages (a) Vein capture (you may have to stick the pt more than once for a myriad of reasons or perhaps you backwall the vein) (b) Thread the wire (which insults the vein wall---we've all had wires curl or catch as well as get stuck) and (c) Insert the dilator which stretches and further injures the vein wall---If  my comprehension of the clotting cascade is correct any or all of these could be the root cause of a DVT--In the adverse event report below besides the fact that it is a BARD 4FR PICC (Lots of missing info--Groshong v Poly/Single v Double Lumen/or Power v Non Power) and we know   nothing about the events of the insertion process so to assume that Tapering and/or Power are the source of the adverse event is a GIGANTIC leap! 

Robbin George RN VA-BC

lynncrni
You are correct - every

You are correct - every venipuncture with any type of needle will disrupt the tunica intima. Blood then comes into contact with the basement membrane beneath the endothelial layer and this immediately begins the clotting process. Depending upon the patient's clotting factors, this could be lyzed in a few days or could progress on to a major thrombosis. Minimal trauma to the vein wall is the key to reducing vein thrombosis.  

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

One report of thrombosis on Maude

2 million PICC lines are sold a year 

I would say overall PICC lines have a very low thrombosis rate.

 National avg. thrombosis  2-4% in the literature that is symptomatic.  Non symptomatic 20-70%.  All types of PICC lines were used over the last 20 years in these studies.  SIR benchmark of acceptable symptomatic range 6% regardless of PICC line used

96% of patients have no symptomatic thrombosis in the reported iterature nationally

I would continue to say PICC lines have a very low symptomatic thrombosis rate

 

 

Kathy Kokotis

Bard Access Systems

afruitloop
Kathy, I think the key word

Kathy,

I think the key word in your statement is "symptomatic." The vasculature of the upper extremity is such that if venous occlusion occurs in one vein, then the other vessels assume the bulk of the blood flow and return it to the heart.  Therefore the common symptoms of edema, is not evident in many of these cases.  Can we "overlook" asymptomatic thrombus?  For what it's worth, I think we should not.

Thrombus can be minimized (but you must first believe it exists) with appropriate catheter selection, detailed education related to patient and vessel assessment and catheter design.  Only by utilizing everything in our PICC nurse arsenal can we begin to do what is truely best for the patient.  Overlooking any of these components does not do justice to our practice and our patient.

Cheryl Kelley RN BSN, VA-BC

windstrings
That main advantage I see in

That main advantage I see in tapering it to prevent kinking... but I don't see the need for several cm's of tapering my any means....all that does is force you to strip off your dialator when your not truely in all the way.... "unless you plan on leaving several cm's out", which in some cases causes regret as the last few cm's won't pass and if forced to make a midline you have to leave a ton out or do an over the wire to make a clean install of a midline. Leaving "midclavical" is not a practice we do.

Nevertheless, I think a 1 - 2 cm taper is sufficient to give the catheter strength against kinking and also affords a fair amount to leave out to allow statlock positioning somewhere besides straight down "which often precipitates kinking".....

The part of the catheter going in the skin, I prefer to not be tapered at all if reasonable.... the hole in the skin is smaller that way and any accidental movement outwards later along the line will not leave a big hole left for germs to get in and/or bleeding. 

The second mouse gets the cheese!

Halle Utter
Different microintroducers

Different microintroducers with different PICCs - Bard's in the PolyPerqcath and Galt.  I am not having trouble. I simply wondered what others in the industry were doing. I don't like having the hub pushed all the way up into the site, especially on the patients with thin friable skin because it can erodes into a larger hole.  I don't know why the taper has to start 7-10cm out from the "0" mark.  I believe there is less trauma with a dermatotomy, and chose to do one unless there is a concern regarding bleeding or patient has very superficial vessel and thin friable skin. I appreciate all the feedback and healthy discussion.  

 

 

 

Hallene E Utter, RN, BSN Intravenous Care, INC

afruitloop
Depending on the transition

Depending on the transition between the dilator and the introducer sheath, keep in mind that you don't always need a skin nick to advance the introducer.  There are introducers on the market that are so smoothe that when you run your fingers down the device,  there is practically no "step-off" between the dilator and the sheath. 

Logical deduction tells me that if I don't need a skin nick, then I do not need a reverse taper catheter.  If a physican can place a central line without a skin nick, then why can't a nurse?  Just thinking our loud here.

 For years and years we preformed a skin nick, and then suddenly with the introduction of the reverse taper catheter, we now need to "gently plug" the hole. Also, why have a reverse taper catheter if we are going to leave the taper out of the skin.

I throroghly enjoy the conversation too Halle and appreciate that fact that most of us can offer our opinions and experience in a constructive manner.  Have a good day.

Cheryl Kelley RN BSN, VA-BC

holly hess
Regarding this hot topic of

Regarding this hot topic of reverse taper and potential increases in complications from the increased size of the catheter...2 comments:

1) We have been using this type of catheter for 3 years in our pediatric practice and have seen no problems, although I'm not arguing that the theoretical risk exists

2) I think we need to keep in mind that even in my peds practice, we are almost always accessing veins that are 1-2 cm or more below the surface, and occasionally 2-4 cms in large adolescents(which I assume would be more like an adult practice). I picture the angle of the needle as kind of like the hypotenuse of a triangle, which means the needle path is really even longer before it intersects the vein. My reasoning, therefore, is that a large portion of the tapered part of the catheter in actually in the tissue, not in the vein. Is this flawed thinking?

spqr
You say you have no
You say you have no problems. You are of course aware that as much as 80% of all DVT's are asymptomatic, yet the patient has indeed had a DVT. The only way that you can possible know that you have no problems is to do a detailed ultrasound study; thus you can determine how many DVT's you have that are asymptomatic. In medicine there is a  simple rule that I have found to be very sound, especially in surgery: The less invasive the better.
windstrings
[quote=Cheryl
[quote=Cheryl Kelley]

Logical deduction tells me that if I don't need a skin nick, then I do not need a reverse taper catheter. If a physican can place a central line without a skin nick, then why can't a nurse? Just thinking our loud here.

[/quote]

 The catheters doctors use are usually quite a bit bigger and thicker than the ones provided for piccs.

The patients I talk to usually have an unpleasant report to give about their experience if they were conscious. 

Making the experience the least traumatic with the least amount of pain is always the best way to get a patient to want to come back to your facility.

It always amazes me how patients came come to get their legs amputated, C sections etc etc, but the only thing that really stresses them is the IV or the access they will be getting.

I recon thats because thats "still" the one area of care that often is not painless and carries a mass amount of negative psychological connotations.

The more we can "sneak" in our accesses without the body feeling the stress, the longer they will last and those positive reports coming back from patients will only increase the likelihood that PICCs will become a standard everywhere. 

The second mouse gets the cheese!

afruitloop
I must add here that, NO,

I must add here that, NO, the catheters that physicians place in the subclavian vein (most popular size of Arrow subclavian CVC is a 7F (non taper)) are not all that much larger than the ones many are placing in the arm.  One particular reverse taper PICC tapers from a 5F to a 7F over the course of the last 8 cm.  The 6F tapers to a 8F again, over the course of the last 8 cm.  This being said, there are large PICC's being placed in arm veins, some larger than a subclavian triple lumen.  Yes, I am aware that the taper is a gradual transition form 6F to 8F and that this does not mean that an 8F is in the vessel.  Which brings me to my point, why use a reverse taper catheter if you are not putting it in all the way?

 Additionally, I would hope that everyone agrees that the subclavian is much larger than the basilic and brachial veins.  I have been measuring EVERY vessel that I stick for the last 6 years so I am fully aware of vessel size.  Even neat the armpit, the basilic and brachial measure anwhere from 3.4mm to 7mm.

Not every catheter is made for every patient.  A true patient assessment AND a vessel assessment must be completed on EVERY patient prior to PICC placement.  Isn't that our job?

Cheryl Kelley RN BSN, VA-BC

Robbin George
"A true patient assessment
"A true patient assessment AND a vessel assessment must be completed on EVERY patient prior to PICC placement.  Isn't that our job?"--Most of us didn't know that was part of our job--No one ever described the process and we have no idea how to do a vessel assessment--You are the only person I ever heard talk so passionately on the subject--Really wish our friend Cheryl would write it down and have it published

Robbin George RN VA-BC

afruitloop
  It is presently being

 

It is presently being written...... and just for you! LOL  Please contact me and I can help you! 

Cheryl Kelley RN BSN, VA-BC

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