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Timeline for PICC placement
we all know that INS standards for things like Dopamine, Nipride,etc recommend a central line. Although we teach and teach, these standards are not always met. Our ICU patients often times have only PIV's when they should have CVLs.  Administration is looking into making it a hard and fast rule that these types of meds HAVE to go into a central line. Which is a good thing.  Here is the dilema:  Dopamine gets ordered at 2am.  MD says "we're not putting in a CVL in the middle of the night, get a STAT PICC."   Our 140 bed hospital cannot support a 24/7 PICC team.  Is there some kind of standard or recommendation that states it is acceptable to run Dopa (or whatever) for xxx amount of time until a CVL gets placed?  How is this handled in other facilities?
Mike Brazunas
My strong opinion is that

My strong opinion is that they should place the  CVL if that is what the pateint needs no matter what time of day.  But I know that it isn't always that easy.

If that dopamine infiltrated and there was a law suit, surely the lawyers wouldn't care about what time of day it was.  If the patient required regitine, would medicare pay for it?

 On another point; The CDC recomends a PICC line for patients requiring greater than 5 days of therapy regardless of what the infusate is.  Isn't it the rare ICU patient who is going home within 5 days anyway?  A good early assessment program would identify these patients automatically.

But, again, I know that it is much easier said than done.   

I wonder what your risk management team would suggest.



 Mike Brazunas RN

Clinical Specialist


Robbin George
MIKE--The CDC statement

MIKE--The CDC statement you site is very powerful (recommend a PICC for patients

 requiring > 5 days of Tx)--Can you please tell us what document to quote for this Best

 Practice--Thank you in advance of your response 

Robbin George RN VA-BC

Halle Utter
I am also very curious about

I am also very curious about the "5 day recommendation".  I don't think I have ever heard that recommendation before.  I would also like to know how hospitals that do not have 24 hour coverage for PICC placement handle administration of medications that should be given centrally.  Do you drop a central line before you will administer the medication(s)?  Is there an acceptable but probably unwritten "window" where you will allow the medications to be given peripherally prior to getting a central or PICC line placed?  And what about the scenario where a patient has had a PICC and it has gotten "accidentally" removed, only has 48 hours worth of IVAB therapy remaining?  I have gotten calls to replace these PICCs with a new one, gone to assess the patient and found clinically silent thrombus in the vessel where the PICC was, and the opposite arm was either not an option due to a type of dialysis access, or had an obstruction that prevented threading a new PICC to the SVC.  In these scenarios what do the rest of you consider to be the most reasonable and cost effective solution?


Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

Mike Brazunas
First of all, my apologies,

First of all, my apologies, I missquoted the CDC.

C. Use a midline catheter or PICC when the duration of IV therapy will likely exceed 6 days (244). Category IB

As you see it says 6 days not 5.

INS standards say to use a central line (eg PICC) when pH is less than 5 or greater than 9 or Osmilarity greater than 500. 

If the infusate is within these parameters, then the leanth of anticipated therapy needs to be considered.  I would say definitely greater than 6 days but maybe fewer based on the patients vascular status.


Mike Brazunas

mary ann ferrannini
This is how we generally
This is how we generally handle this. We also do not have 24/7 coverage. If the pt can not wait for a central line to be placed or in other words the delay could cause harm we go ahead and give it peripherally. As soon as it is feasable we insert a central line. It is usually a PICC, but sometimes an MD will insert a CVC. They do not like to leave percutaneousely placed CVCs placed for longer than 4 days so we often get a PICC order  request right away from the MD even if the CVC has only been in place for one day. Some MDs will write an order that says do not administer XXXXX until the PICC is placed. As is often the case in nursing you do the best you can at the time I have been in many life threatening situations when no one could get any access but me.  Did we use the line or wait for a CVC...we used the line!!!
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