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paul f halvachs
soft arms

I have had difficult placing PICC's on patient with soft flabby arms when using US.  I can see the needle approach the vein but will not enter it.  Even wqtched the needle pushing the vein away.  I remember hearing about using tape to secure the loose skin. Ideas?

Paul Halvachs

IV team Bangor me

Where on the arm are you

Where on the arm are you making your venipuncture? Superficial veins lie in loose connective tissue and will move around on all patients. We use one hand to pull the skin taut to anchor the vein while making the venipuncture and catheter advancement. Deep veins lie under the muscle usually within a protective sheath that contains the artery and nerve as well. Movement is usually not the issue with deep veins. The basillic vein used for most PICC insertion is a superficial vein in the lower forearm but transitions to a deep vein slightly above the antecubital fossa. Maybe you are making the venipuncture too close to the AC before this transition from superficial to deep vein. Use of the US does not allow a hand to pull the skin taut. Maybe moving up the arm a little bit to where the basilic vein is a deep vein would make a difference. 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

soft arms

Hello Paul,

Issues related to obesity, flabby arms and poor muscle tone are challenging for all of us with ultrasound guided needle access for PICCs in the upper arm. Positioning the patient is key and maintaining the ultrasound probe face between skin and bone. If the ultrasound is not positioned with a solid base such as bone then movement is increased and difficulty with access high. This is rather hard to explain and is best demonstrated. The ultrasound probe face must in fact rotate around the bone maintaining the vessel always between skin and bone.

Other tips focus on centering the needle on the vein, watching from the point of entry through the skin down to the top of the vein. By centering it is easier to penetrate and gain access. Tourniquet usage with obese patients can also be difficult making the veins softer without the pressure to distend. Softer vessels can be harder to penetrate, collapsing instead. In this case it may be necessary to do a through and through double wall access and pull back slowly aspirating for blood return.


I hope some of this is helpful.


Warmest regards, Paul and all!





Nancy L. Moureau, BSN, CRNI

PICC Excellence, Inc

706-377-3360 direct line

888-714-1952 toll free

706-614-8021 cell

[email protected]


National PICC Certification has arrived. Validate your experience and knowledge through the Certification process leading to CPUI Certified PICC Ultrasound Inserter. For more information see

Nancy L. Moureau, BSN, CRNI, CPUI, VA-BC

PICC Excellence, Inc


re: tourniquet

if the vein is large enough to allow, sometimes I have better luck without tightening the tourniquet.  Also, you have to be very intentional when you are about to cannulate the vein in these patients.  Never poke or stab, but be very intentional.  Pay attention to the angle of your needle.  You may have to increase it.  As always - try to visualize nerves, or be alert to signs you've connected with a nerve.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Cherokee people
Try placing a rolled up towel up against there extended arm

Try placing a rolled up towel right under there extended arm that you are placing a PICC in. Then scrub and place drapes as usual. Obese patients are a challenge. I used to cringe when I went in a patients room that was obese. Takes practice and more practice. Good luck! Vickey

Flabby arms

My challenge are the pts. that were obese and now have lost weight creating those "flabby" arms. As Vicky stated, try rolling up a washcloth or small towel and place it under the upper arm. There have been a few times when I have had to ask the pts nurse to put on a pair of sterile gloves and carefully go under the drapes and "pull" the skin taught.

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