Hello- i come from a small community hospital where our PICC volumes are low. I recently had a pt that I placed a picc in her Brachial vein. She got a DVT that extended to her subclavian with a collateral already formed. The only sign was that her arm was slightly swollen. My concern is that I was taught to use the brachial vein as a second choice, which i did for this pt after making my assessment with US. After the vascular sergeon was called for a consult on this he asked me why I would use the brachial vein. He said he doesn't agree with the brachial as a choice at all. I explained that our assessment we use is that we want the vein to be 1.5-2 times the size of the catheter we are placing. He asked why not the cephalic as a second choice? I explained that it is a small vein with a more torturous route. He said he puts fistulas in the cephalic so he doesn't understand that. He explained that if a brachial should thrombous then we could prevent draining of the arm and that could be bad. He explained that the brachial is a deeper vein with less valves leading to more risk for a DVT and not superficial as we might see in a basilic or cephalic. He said he would prefer us use the cephalic as a second choice for this reason. He also said he doesn't think any vascular surgeon would support us in a court of law, which really made me nervous. Can someone please advise? I want some articles stating what I think is right if indeed I am correct. Thanks!
First of all, take a deep breath. In a court of law, your practice would not be measured by a vascular surgeon. It would be measured against the Infusion Nursing Standards of Practice plus other scientific evidence put forward by a nursing expert. Now, with that being said, I do agree that the brachial vein would not be my second choice. My rationale for this is because the brachial vein is inside the protective sheath along side the artery and nerves controling arm function. I have been the expert on several cases involving injury to nerves from bleeding into this protective sheath. The paired brachial veins are deep veins inside this sheath. The basilic vein is also a deep vein beginning several cms above the antecubital crease. The basilic veins moves from being a superficial vein under the muscle tissue and becomes a deep vein in this location. This is the reason for use of ultrasound. The cephalic vein is a superficial vein from its origin just above the thumb all the way up the arm to the infraclavicular fossa in the shoulder. You are correct that DVT is related to the size of the catheter and vein. Was the basilic vein in both arms unusable? Did you assess both arms? I would choose the cephalic vein as my second choice but not because of its size and pathway. My choice would be based on the very high need to avoid nerve damage with a bracial puncture. Nerve damage can result in lifelong complex regional pain syndrome and the need for narcotics the rest of the patient's life. I have seen far too many legal cases of this complication and would do anything to prevent this injury. I would choose a smaller catheter in the cephalic vein if the basilic in both arms was not acceptable. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn- We currently do not have risk of nerve puncture on our consent for PICC placement. Should we? I don't even tell the pt unless I am going into that vein. Also, inresponse to your answer I don't eval the other arm if I have a good basilic and brachial. The reason I don't look at the cephalic is I find it is almost always too small (unless they are morbidly obese) and it would not be in my prepped sterile field. The basilic and cephalic are not both in my window of my drape, but my brachial is.
My answer is based on how I would and have approached my review and critic of nursing practice in lawsuits along with my clinical practice experience. Your approaches will allow an expert and lawyer to clean your clock in a legal case. You absolutely must have nerve injury on your consent form. There are numerous cases documented in the literature of nerve damage from all venipunctures procedures including PICCs and short peripheral catheters. The risk of nerve injury is present regardless of which vein you were using. In my opinion, correct assessment for site selection mandates assessment of both upper extremities. Your choice is based on a risk vs benefit analysis for each patient. I would choose a basilic in either arm first. If neither is available then you are forced to evaluate the cephalic and brachial. Due to the location of other critical arteries and large nerves inside the protective sheath with the brachial veins, this would be my last choice. You always have the option of inserting a smaller catheter to accommodate the smaller vein diameter. Not being inside your prepped sterile field is not sufficient reason to avoid evaluation of any vein. Your vein evalution and site selection should be prior to your skin prep and sterile field set up. This is not an adequate reason to choose the brachial vein, in my opinion. Site selection is not limited to the side of the table you are working from or the size of the sterile field. Can you imagine how easy it would be for a lawyer to destroy your rationale when you were testifying in a lawsuit?
Regarding nerve injury for any type of venipuncture, no nurse can assume that complaints of pain are all the same. Venipuncture can hurt but there are certain types of pain that should be more carefully assessed. You do not want to put ideas into the patient's thinking that are not already there, but you have to find a way to get the patient to explain the type of pain they are feeling. Complaints of paresthesias always mean stopping the procedure, and immediate withdrawal of the catheter. Paresthesias including electrical shock up or down the arm, feelings of "pins and needles", tingling, and/or numbness. All of these indicate that a nerve has been damaged. For large veins used for PICC insertion, you should know the locations of nerves in relationship to the chosen vein. For a peripheral venipunture, it is almost impossible to select a site that would avoid hitting a nerve. The one strong exception to this is the volar aspect (palm side) of the wrist. This is never an acceptable site for insertion of any peripheral catheter for any infusion of anything due to the close proximity of the median nerve which is very superficial.
Nerve damage can result in permanent injury to your patient. I get lots of lawsuits involving nerve injury that could have been prevented. This may end with a neuroma or it may produce complex regional pain syndrome requiring lifelong narcotics to manage that pain. So this is not something that should be taken lightly. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
It seems to me that if vascular access nurses set rules for themselves on vein selection, ie. "always go with basilic first" we are not using clinical judgment that is patient centered. I would go further and say we are not using clinical judgment at all. Patient assessment is always individually focused. The vein and catheter we select should be the best option for that patients needs and not based on fear of litigation. If the knowledge base and skillset is not adequate to meet those demands than more training is necessary. A perceived "safer" basilic that is smaller than a brachial could conceivably lead to a DVT, then PE, then death! Who benefits from that clinical judgment?
I certainly understand in this litigious society we need to have expertise and highly developed skills to protect ourselves, but our first responsibility should be to our patients. Last night I put a triple lumen PICC in a pt. with multiple cardiac drips, the brachial was by far the best choice for this patient, as the basilic was not large enough and to choose a smaller catheter would have forced the need for additional central lines.
Attorneys I have worked with all say a reasonable and prudent nurse who demonstrates expertise is tough to discredit. Counter that with a dogmatic approach, "I always choose that vein first". I think that logic can also lead to a bad outcome for a nurse in a deposition. A great discussion with some great information and strong opinions! To summarize my point...each vascular access procedure should proceed after a careful assessment is done for that individual patient, and their individual needs.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I do agree with you on the individual patient assessment by using US to scan for the most appropriate vein BEFORE the skin prep and draping. Based on general anatomy knowledge, and what is published in textbooks, the basilic vein is usually the largest and straightest vein in the upper arm. Every patient does not fit the criteria in the textbooks though. Of course one would do a complete assessment for each patient. That should be the way all infusion nurses practice for all patients. But, based on anatomy knowledge, that assessment would start with the basilic first in both extremities, then proceed to the other veins. As you mentioned, you must have the knowledge of all the required infusions, the patient's status so you can anticipate future needs for infusion therapy changes, and then make the best choice for that patient. Personally, I would have a goal to avoid the brachial veins if at all possible due to the risk of nerve damage and accidental artery damage. I have also had cases where the nurse inserter did not correctly document (or know how to identify) the specific vessel they entered. They documented basilic vein but actually entered the brachial artery. In one case a neonate required amputation of that arm. In another case, air emboli through the IV tubing resulted in several cerebral damage like a stroke. Each insertion site has risks and as inserters you are responsible for knowing those risk and you will be held accountable for the outcomes produced by your actions. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Does there need to be physician communication documented if the only vein available for PICC is the brachial? Sometimes due to vein size or only having one arm as an option for PICC placement, it seems like the brachial vein is the only viable vein option. Do we need to document that we have expressed concern r/t PICC placement because of limited vein choice. It seems like it is sometimes hard to convince a physician the reason for wanting to avoid certain placement issues (They just want their line placed.) Another question I have is, my facility uses a general consent form ("authorization for and consent to surgery or special diagnostic or therapeutic procedures"), should we be using a specific form for PICC insertion? Does anyone have any examples of a specific PICC insertion consent?
Thank you!
Do you mean informing the physician of the difficult choice or do you mean the need to obtain a physician order to proceed? There is a quite a difference in my mind. Communication with physician colleagues is very important, however this is your practice, not that of the physician. You do not need a physician order to proceed. In a legal situation it probably would not make any difference. You are the inserter, not the physician. You know more about the procedure, risks, benefits, etc than the physciain. You will need to make a wise decision, choose your course of action, then proceed. If your decision is that a PICC in a particular patient is not appropriate, then inform the physician but do not allow them to bully you to placing a line that is outside of your best clinical judgment.
Re consents, both forms are used. I think you will find examples of consent forms in the Resources section of this site. Just remember that the form is the very last step of the complete education process.
Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
My experience (based on years of assessment of UE vessels suitable for PICC insertion) has "generally" been that if the basilic is large the brachials are usually small. Same thing if the basilic is small, at least one of the brachials is large. I haven't seen too many patients with bracials AND basilics large enough for a PICC and still maintain a 1 to 3 catheter vessel ratio.
Cheryl Kelley RN BSN, VA-BC
We should choose the best vein for the patient we are assessing and proceed from there. Look at both arms and choose the best vein for that pt. If the brachial is the best vein I access that as the first choice, on a morbidly obese pt. the cephalic may be the best because the risk of fungal infection on the underside of an arm that may not see the light of day! Of course knowing and avoiding nerve tissue is crucial, as is avoiding DVT's(which can kill people!) I believe I read an article that said cephalics have a 35% higher chance of DVT than basilic or brachial, which makes sense due to the sharp angle of entry it makes at the axilla.
Our skill sets as vascular access nurses need to be high enough that we have the freedom to choose the best vein for the patient, not the vein that is the safest for us as clinicians.
I do not understand the surgeon's comment about DVTs in relation to the fistulas he places. You cannot compare a fistula to an indwelling catheter!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
Brachial and basilic merge with each other before the axilla. If the DVT extended to the subclavian, how can the surgeon proof that the using of a different vessel will make a difference? I agree with Stephen a lot that cephalic vein has a higher rate of DVT than any other veins on the upper arm. It is an evidence based practice and we can only do what the previous evidence showed us is the best for the patient. DVT happens to patients. It is not a news. Especially an extended DVT to subclavian, how can a surgeon blame you on the choosing of the vein? Is this a cancer patient? Is the patient hypercoagulate? If you do a doppler study on four extremities, you might find some thrombus in other veins without a catheter in place. And also, do you have a consent for the patient to sign before you place a PICC line? Isn't DVT part of the possible risks associated with PICC line? Who as a PICC nurse can guarantee that the PICC line we placed will not cause DVT for patient? Why do you have to go to court for this? But what I agree with Lynn is that causing a nerve damage or arterial puncture are considered accident that may need to be discussed in court if the patient wants to. That is why, some PICC nurses if not skillful enough, should not access brachial veins for PICC line placement.
Can you email me and I'll send you a great article on thrombus formations with the cephalic vein. I too try to avoid the cephalic vein due to high thrombus rates. I have never had any issues with nerve damage when placing brachial piccs. I was just curious about a few things. Where was the tip located? How many attempts were made during insertion? What kind of picc was it? Was it a triple, dual, or single lumen? What was the french size?
http://www.sciencedirect.com/science/article/pii/S1051044307613074
[email protected]
In peds I avoid brachials because the structures are even smaller and closer together than with adults. It is also easier to inadvertently puncture the artery.
I had a patient who had had a PICC for a number of weeks in the Rt basilic. He began to complain of burning in his left neck and headaches with infusions. I could not figure out what was going on...PICC has good return, functioned well, all diagnostic tests negative, tip in good location. Nevertheless, I could not ignore his complaints and had to replace his PICC. Symptoms resolved slowly over a few days and I never knew the cause. This was an adolescent but when I had a 3 year old suddenly complain of burning with infusions and no apparent cause, I still replaced the catheter. I pay attention to patient complaints even in peds and just cause I can't figure out what's going on does not negate that the complaint is valid and some action must be taken.
I am from a community hospital also. I place alot of PICC, just adult patients. I looked at the (posted) study on the increased rate of thrombosis when the cephalic vein is cannulated for a PICC. When I took my PICC insertion class years ago I was taught that the cephalic vein was the last choice. First basillic then brachial and lastly the cephalic. That always made sense to me because of the difficultly floating the catheter aroung the shoulder or sometimes in under the clavical. Of course it is always always the patient first. The size of the patients veins, the IV solutions required, and so forth. But this is coming as a big surprise to me, the advice to use the cephalic before the brachial. Do we have any studies to back up this approach? Also, I've got to say, you have to be able to see where the nerves are, and you have to be accurate enough to put your introducer into a tight spot, because often there is not much space between the brachial artery and vein. For the first few years of my practice i did not attempt the brachial cause I just was not sure I was accurate enough.
But this is very important to me,,,because I thought, if on my assessment the basilllic is a no go..Next best for the patient, if the vein is there, if the basillic, so as to reduce the risk of thrombus.
I am going to try to get some info from our hospital librarian on this issue. JVIR journal of vascular intervention radiology might have some studies on this.
If anyone has any studies that they know of please post.
thank you
Celia Brown