I am new to the world of PICCs. I hope someone out there can give me some advice..... troubleshooting really.
   My two biggest problems are: tip not turning down - ending up in neck. Looking for some tips on how to reposition it. Also I am pretty much 100% when it comes to accessing the vein but I cannot always advance the guidewire. Am I doing something wrong? Am I still in vein wall?
Our pt population is >70 years old. I work at an LTAC hospital. Pt's here have usually been in the hospital somewhere for at least 3 - 6 months before I see them. Almost every PICC is a challenging one. I use a SiteRite ultrasound machine and Bard power PICC triple lumen. (6french). Thanks in advance for any information.
My PICC experience is only 10 months long, but these issues are apparently very common to most PICC newcomers, as we had the same issues. Don't feel alone.
As far as avoiding the jugular, proper positioning of the patient during advancement of the wire helps to prevent. Always have the patient turn their head to face you and do their best to touch chin to shoulder. After awhile, you will generally begin to "feel" if the catheter is malpositioning upwards, usually by the way it feels as you insert. Making sure your blood return is not sluggish is another assessment tool (but not always reliable). After making sure you have good blood return, having the patient listen as you inject sterile saline is another assessment technique to use. If the patient hears something "like the ocean" your positioning is upward and you need to reposition.
Repositioning techniques I was taught include:
Pull the catheter back to the mid-line area and forceful flush as you go back in with the catheter. More often what works is to also pull the stiffener wire back approx. 1-2 cm (bend a crimp in the wire just beyond where it exits the catheter so you'll have an idea of how far you've come back) Pull your catheter back to Mid-line level and then advance quickly while flushing forcefully with saline. This usually helps "pull" the catheter downward. Also, it has been recommended that you "twirl" the catheter between your fingers while advancing.
As far as the guidewire, this too is a matter of experience that gets better over time. Goal placement for the needle is in the center of the vein as opposed to off to one side..........sometimes easier said than done, especially with those whose vessels have lost their elasticity. Are you laying the needle down against the patient's arm prior to inserting the wire? This helps "lift up" on the vein so your wire can advance in the center. Try rotating the needle ever so slightly. Also sometimes lowering the HOB will make all the difference in the wire advancing.
I only insert triple lumens in patients with really large vessels that absolutely need all 3 ports. Otherwise, I feel the risk of DVT outweighs the benefit. Remember the Bard has a reverse taper that actually starts at about 7cm and the 6Fr becomes 8Fr. (not your typical vein size for those 80 and 90 year olds) at the zero mark, so some of the catheter in the patient (if you go all the way to 0) is larger than 6 Fr. We typically use the 5Fr. dual (it tapers to 7Fr.) and we have the SiteRite 5 which make estimation of vein size pretty easy.
Bard also has the device "Sherlock" which is a tip indicator system. It does not replace the CXR, but can help you cut down on repeat x-rays d/t initial malpositioning. Check with your rep.
Above all, hang in there. I am continually learning and this forum is one way that we have to learn from those who went before us.
I have found that pulling your picc stylet back several centimeters (about 5) instead of one or two, sometimes can help. A navigational device, like Navigator, is also beneficial to help cut down on cxr's and picc manipulation after the sterile field has been removed. PICC's also seem to drop nicely from the IJ when you sit the patient up and power flush the lumens. Has worked several times for me over the years. Good luck. Do not give up.
Heather
We have used Phil Lum's approach for dual lumen PICCs, by using the double barrel flushing power flush and before xray. We have had IJ PICCs (via Sherlock Tip Locator) and use 2 syrringes attached to each limen and flush simultaneosly. Using the Sherlock, you see the position change toward the SVC.
This info might help. It did twice this week for us.
Gwen Irwiin
Austin, Texas