Hi there,
Do any of you seasoned inserters have any tricks for getting a PICC past a stubborn shoulder?
How about the PICC that wants to curl up in the upper SVC?
And PICCs that want to creep up the I.J.? (when turning their head towards the PICC, then holding their chin to their shoulder doesn't do the trick)
I have be told a few things but all ideas are welcome!
Thanks
Nell
We have found that arm position can influence the catheter at many different points of advancement. PICC's that are difficult to advance through the shoulder can respond to abduction or adduction, with angles affecting each person differently. Arm position also influences advancement into the central vessels of the chest, and can be used to help direct a catheter into the SVC versus the IJ. We also will frequently ask the patient to cough a couple of times as the catheter is at the point of 'deciding' whether to head for the IJ or SVC, and advance the catheter while the coughing is occurring. Usually the guidance system you may be using may be adversely affected with coughing, but withdrawing your stylet, zeroing your system and readvancing the stylet after the insertion will offer a view of the advancements success or failure. When I have a PICC that tries to be persistently jugular, I will frequently back my stylet out an inch or so, and allow the floppier catheter tip to more easily follow the direction of blood flow. We have also applied supra-clavicular pressure during advancement of persistently jugular lines. If the patient has arm flexibility and you can control the sterile field, having the patient put the hand on that side under their head will dramatically affect the vessel angles. I have seen the effects of this with flouro. Patients who are independently mobile may also turn their body away from the insertion side, which also alters the angles slightly in the chest.
PICC's that want to curl in the upper SVC will tend to respond well to withdrawing the stylet an inch or so before advancing. We have had good results with 'power flushing' lines with advancement in this situation as well. When all else fails, have friends with a flouro bed, and a friendly radiologist.
Kelly Smith
PICC Nurse
Boone Hospital Center
Columbia, Missouri
I concur with the prior commenter. I would also encourage you to assess the chosen vein all the way up to axillary region to identify any potential problems. On occasion a vein will split into smaller branches. Often the guidewire will advance but the catheter will not if it takes a small offshoot. In patients who have used crutches in the past the veins sometimes become tortuous in the axilla.
Sometimes just backing up a bit and flushing may be helpful if the catheter is catching on a valve. I've also had luck removing the catheter and reinstering the guidewire. I have to assume this also helps opening up valves.
Another strategy if the catheter resists advancement in the axilla is to have the patient pronate their hand (this worked for me just a few days ago).
Persistent IJ can be very frustrating. My first manuever is to position the catheter in the subclavian vein then pull back my stylet about 10 cm making the tip floppy, then dvance very slowly, one cm at a time. Sometimes I advance with inspiration. Failing that manuever pulling the patient's arm up towards their head is the second most successful manuever I have found. It just makes me nervous for air embolis. It's times like that I wish our introtruders were valved.
Raising or lowering the head of the bed can also be helpful.
My thoughts on catheters curling in the SVC;
If you are using a magnetic tip location device this is often a sign of Azygos placement. As the catheter enters the vein and travels back it shows the tip is going up but diving on the depth indicator, which it does as it heads toward the spine. The azygos comes up slightly as it crosses over the right mainstem bronchus. On a cxr this makes it appear to be curled up or hooked. A lateral film will show it going down the svc, heading up slightly and then going straight back. These are often misread by radiologists. I have never actually seen a picc "curled in the SVC". Azygos positioning is much more common coming from the left side, especially if you are advancing with a floppy tip.
Other stratigies I have found helpful with persistent Azygos placement is to flush while advancing and raising the head of the bed so gravity has less chance to pull the line down what I call the rabbit hole.
I have found that if I pull the stylet back to get the line to avoid IJ placement it will often go into the azygos. Now I pull the sytlet back, advance until I think the tip is past the IJ junction, readvance the stylet to make certain it is going down, then advance to the terminal position.
I have also found that what appears to be azygos positioning on the tip location system can be interference caused by something electronic. A power cord in the bed is a big culprit or a cardiac lead that has crept under the device. I have also seen this phenomenon with implanted AICDs or pacemakers. Sometimes recalibrating can help but not always. If all the usual manuevers don't work I'll advance to my measurement and get a cxr. We have had several lately where the tip ended up exactly where it should be despite what it showed on the TLS.
Good luck, I hope these tips are helpful.
Darilyn