Victoria Sallese, RN, VAT, PICC service
The sherlock does not give you an exact location for your picc. It just gives you an indicator arrow in the general direction it "could" have gone in, and possible ways it could be, so it is your guess where it is if it does not show up in the SVC. There is however, a navigational device called the Navigator, made by Viasys, that we here at U of L use, that will not only tell you exactly where your tip is, but it can also help in your placements. My group has fairly perfect placements everytime we place a line thanks to Navigator. It also helps to evaluate how to reposition your patient during difficult picc placements, by letting you track your line as you insert it, so you know where it is that you are going off track. We have been using Navigator for about 6 years, and most of us refuse to work without it. It is also not hard to use. No recalibrating, or placing anything in a certian area on your patient. Just a stylet in the picc of your choice, and a small device (sterilly sheathed like your ultrasound) to attach it to. Its simple! Good luck!
Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA
I have been using the Sherlock since Dec.2006. We have had great success with it. It does work on real time and you can tell if you are malpositioned by the arrow indicators on the device. We are able to use it on all of our pt.,including those with pacers and ICD's. The Sherlock has made our PICC team much more efficient in our placement of PICC's.
Karen Ratz,RN, VA-BC Unity Point St. Lukes Hospital, Cedar Rapids,IA
We are relatively new with use of Sherlock and have not found it all that helpful. I'm sure placement of the sensor is key, but it just seems to be not that reliable and has to be recalibrated each time before you attempt re-advancing. Most of the time, the information that the Sherlock can provide, it seems, can be determined or ruled out simply by assessment techniques like flushing and assessing patient for "swish" in same side ear, by the "feel" of the catheter as you advance and by promptness/ease of blood return, etc.. Interesting comment on the Navigator device. Does it work with any manufacturer's line? Do you still confirm placement with CXR if using this device?
Navigator works with any line you want to put it in. We have even used it in central lines on people who were allergic to contrast. Viasys states that within the year, they will even have a wire small enough to fit into the 2 french lines, which is the only thing it will not fit into at this time. I do not believe there is a device out there yet that you can use (someone tell me if I am wrong, cause I want that device if I am) that does not require a CXR after placement, but with the Navigator, we have been able to get our tip placement so exact, we rarely ever have to change it. Therefore it is one CXR and one only. We showed a real cost savings when we started using Navigator.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
As Tim said, this is VERY interesting technology. I as well would like to know the answer to Tim's questions. I would also like to know how knowledgable about ECG readings you have to be to interpret this. It is really hard enough to hire a good PICC nurse without having to ensure that they are knowledgable about ECG readings to interpret picc tip location, or am I misunderstanding this? I always hated CCU for that particular reason. ;-)
This seems really kool. I am going to try it. Wish me luck. It seems like they (the engineers) could put something on the tip of a picc that could pick up the electromagnativity of the heart when you approach it to let you know when you reach the SA node, but not affect the heart in any way of course, or am I off base on this? It seems really simple (even for me). Thank you for the great explanation.
Is it possible to use the ECG tip positioning technique with Groshong PICCs?
If so, guide wire or saline method or both?
If so, has anyone used it for Groshong PICCs?
Mats in Stockholm
Hi Mats. Hadn't heard from you in a while. Everything going ok over there in your end of the PICC world?
all OK. We place all PICC with US now and this technique is spreading fast in the country. We're getting better and better at it. The next big step for us would be this ECG technique. We will be first in the country with that if we get it going.
I've only used the Sherlock about a dozen times and was sceptical about its usefulness at first. The situation that sold me on it was a patient who had a rather abnormal central vasculature,t-shaped rather than the textbook y-shaped. See 'tshaped' CXR--first PICC attempt was from the right,and it crossed straight over to the left BCV. A few days later someone else put one in from the left and it went straight over to the right BCV/IJ. Pt too unstable to go for adjustments in IR.
About a week later the right one had come out and so I tried again from the right,this time with a Sherlock. The PICC icon on the Sherlock screen showed up and scooted straight across like the previous one. In fact it did this multiple times before it finally started to point down and I was able to get the line central. See 'tyvm' CXR.
That is great Mats! Isn't U/S wonderful? I do not know haw we ever got along without it. ;-)
Isn't this an awesome bit of conversation about tip location? The ECG stuff is a bit intimidating to me, I will admit. It seems a whole lot easier to get a CXR, or use a navigational device. I have been looking for a chance to try it myself though. Good Luck! Keep in touch.
for your explanations, now I think I understand the basics in theory. I would really like to try this. To be able to get the tip right almost every time without CXR and without correcting afterwards sounds really great. Not intimidating with this new technique perhaps Heather, but it will probably take some time to learn. But that's OK I think, ultrasound also takes some time to learn and there's always new aspects to learn in every new technique. And US is great, I would not want to go back to work without it.
I think you'll find the learning curve with ECG guidance very short. The changes from SVC to right atrium are not subtle by any stretch. The P wave voltage increase is usually on the order of several fold and you see an obvious "double spike" with the QRS (again, as long as the patient is not in atrial fibrillation or pacemaker dependent). When I have shown local PICC nurses how to do it, 1 or 2 times and they've got it (and the tracings look just like on the PacerView website)
for the reassurance. I have contacted my BBraun rep to see their things and I will hopefully meet with Vygon reps as well. I will go look at the PacerView web site again also.
If you do try ECG guidance, I would be very interested in your experience, what products you used, and how user-friendly (or difficult) you found it. Any suggestions as to how to improve it would also be appreciated.
I'll look for your comments here or feel free to email me directly at [email protected]
I was wondering if you ever got around to trying ECG guidance for CVC / PICC tip location? Please let me know, either through this forum or through the "Contact Us" page on www.PacerView.com.