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Who uses cephalics for PICCs? guidelines?

I'm trying this post again - we have a meeting tomorrow, and this is on the list of issues to discuss.  I'd love to bring other folks' thoughts, experience, and data references to the meeting.


One of our IV Therapy nurses posed this question to the IV Therapy Professional Practice Council (PPC):

"PICC Guidelines - If multiple attempts are made @ basilic and unsuccessful (assuming she also includes brachial here) - okay to use cephalic (?) IR does - should we change protocol if cephalic inserted, i.e. daily checks?  How much time is reasonable to spend?  > 2hrs?  Please advise."

The PPC is in the process of gathering appropriate data to back up whatever guidelines we create related to her questions, but I thought I'd pose this RN's questions to all of you as well.

What would you say?  Do you have data to back it up (please refer to it if you do, for our benefit).


Thank you,

Mari Cordes

Laurie Hill
This comment is actually my
This comment is actually my response to 2 posted questions (determining cephalic and left sided placements). We (our picc team) have actually talked about these subjects a lot and our placement depends on the individual patient. Previous placement problems, previous thrombosis problems, PPM, existing port or neck line placement, inflammatory process with either arm and even our ability to position the pt's arm to have access to the medial aspect. We also look at the type of picc that needs to be inserted; single lumen all the way up to a triple lumen power picc to decide the diameter of the vessel that would be best. We all know everybody's anatomy is different. Looking at the vessels using ultrasound, I have seen cephalics bigger than Montana and Basilics smaller than a period. We have a large geriatric population where we live/work and it is sometimes impossible for the patient to rotate their shoulder out to put the arm in the anterior position say nothing about the ability to abduct their arm, to give us access to their Basilic/Brachial vein therefore our only option is the cephalic. However, the turn from the cephalic into the subclavian vein is also difficult compared to the brachial/basilic vein, that along with it usually being a smaller diameter makes it our last choice if all else is fine. All of our picc tips go into the distal aspect of the SVC. We don't leave any that have just barely dropped into the proximal aspect because of the mentioned problem (the tip pushing up against the wall). We place all of our piccs at bedside and only take to fluoro if unable to redirect a malposition or unable to advance into the central area. The left sided approach puts a little more catheter into the pt which of course then raises the risk of infection. We work with some really good interventionalists that always give us good tips...the recent one was: the left side approach is easier as far as avoiding jugular placement. So our usual order of preference would be: rt basilic, rt brachial, left basilic, left brachial, rt cephalic then left cephalic....but this all depends on the individual pt as mentioned above.
Thank you - that's

Thank you - that's helpful.  We've been having a challenge trying to find data/guidelines re: vein diameter and size of catheter.  I've seen some posts with general info, like "greater than 5mm best for DL", or greater than 50% space around catheter for blood flow, etc. 

Since you mention vein diameter as an important criteria, what are your guidelines, and do you have data you could share?

We also have a good IR team, but with some different points of view (they routinely will tell their residents to cannulate the cephalic prior to trying the brachial vein because of the risk of puncturing an artery.  I'd rather use the brachial vein and am confident both in my cannulation skills, and ability to determine when NOT to use a brachial vein).

Thanks again,


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

As a general guideline, I
As a general guideline, I would strongly recommend using the cephalic before the use of a brachial vein due to the closer proximity of nerves and the artery to the brachial vein. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

I was hoping for your
I was hoping for your response, Lynn - thank you.  Can you help us with additional support - links to data about brachial vein or cephalic vein selection?Mari

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

Robbin George
Cheryl's comments regarding
Cheryl's comments regarding the expanded abilities of Ultrasound to do more then act as a "vein finding'" device are very important--More PICC Nurses (myself included) need reinforced education regarding all the nuiances of US (Sono-site in particular)--While they have been shown to me via Rep demos I still don't have enough hands on experience to replicate the task at the bedside--A good preprocedure assessment and mapping of the upperarm venous/arterial system is crucial to a successful PICC   insertion at the bedside--A document with the results of this assessment should be included as part of the patient's permanent record--If anyone has such a document they could share please post it on the IV-Therapy web site--And by all means please direct us to a site where all the tips and tricks for maximal use of US are illuminate   

Robbin George RN VA-BC

We use GE Logiqbook U/S

We use GE Logiqbook U/S machines for our PICC placements (our IV department is under radiology, not nursing, and our manager got a good deal purchasing multiple units for us and U/S).  We are now able to include mm measurements of not only the vein diameter, but the depth of the vein, name of vein, L or R arm, and print all of this out on an U/S picture that has those measurements, plus the pt. name, medical record number, U/S operator ID, referring MD, etc.  This becomes a part of the pt.'s permanent medical record.

We can also visualize the nerves - as well as the arteries (as we could before) - and know exactly how near or far our needle would be if we chose to attempt.  It is because of this that we do use brachial veins - IF appropriate with re: to orientation/distance of arteries and nerves.  If we choose not to use a brachial vein, then we're back at my earlier question:  send to IR, or attempt cephalic? 

From what I'm hearing (or not hearing?) on this forum, it seems that many PICC nurses seem quite comfortable using the cephalic vein for PICC placement.  Any guidelines that other folks use about the choice of cephalic?  Would you say no to a double lumen in a 3.5 or 4mm cephalic vein? 

I realize this situation needs to be handled on a case by case basis and guidelines would not be black and white - especially if a PICC line was absolutely the best line for the patient.

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

I only use cephalics on big
I only use cephalics on big fat people if they have a big fat cephalic.  Haven't had any problems
Robbin George
Our sentiments exactly--5000
Our sentiments exactly--5000 PICC insertions--"5" Cephalic insertions all on larger patients with a large vein if the basilic and /or brachial were poorly located too close to the AC--I think the added tissue/fat pads the PICC and helps resist phlebitis resulting from repeated  arm movement and catheter pistoning

Robbin George RN VA-BC

I would be very interested
I would be very interested in reviewing and having at hand anyone's U/S images of upper arm venous/nerve positioning as a teaching tool for new PICC nurses. Would be a great project for those who can collect and sell. I'd buy it.
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