Hi....IV nurses out there. I can not find my copy of the new standards and I would like to know what the exact wording if any there is on PICC advancement post placement . Yes I know it is a controversial practice and that a few years back there was a suggestion of keeping the new PICC off the skin by putting gauze under the PICC. I believe Stanford Medical Center in Ca does this currently, unless they have changed their practice. If teams are not using EKG assistance/tip locating system what are they doing IF they get a PICC in the BC or upper SVC? Do you exchange it...start from scratch and replace..use it as is . I think is some situations you need to look at the risk vs the benefit. If a patient is had an increased risk for thrombosis I am very uncomfortable leaving the tip in the upper SVC. What happens often is someone else places the PICC, goes home without viewing the CXR and I am left to decide the most appopriate action in that individual case. Also if you do advance do you have a time frame in which you do it? I understand about the bacteria on the skin and using the CHG prep you still only get 80 percent of the bacteria off the skin and that there is little we can do about the bacteria in the deeper layers of the skin. I have looked at a lot of resouces ,including the new INS "Infusion Nursing" and it too is vague only saying "adjust as needed to place the tip in the correct position". So what is everyone really doing out there? We are going to purchase the Sapiens TLS but even this will not entirely resolve the issue as there will be patients we will still need to verify tip placement by chest radiograph. Realistically, we are so busy with new orders I know we will not go back and place a new PICC if it is in the upper SVC. In addition it leaves no room for loss of insertion depth. For the most part, if a nurse decides to change a PICC dressing and not call us.they always seem to pull back a few cm and with tip in upper SVC it will only take the loss of a few cms before you are in the BC vein. I would always like to measure perfectly but would much rather measure deep than be short.
This level of detail is not addressed in a standards document. The bottom line is that any portion of the catheter that touches the skin can not be advanced into the vein - ever! Skin can not be rendered sterile. I also have a problem with inserters who do not finish the procedure up to and including ensuring correct tip location. This is a dangerous practice to leave without it being in the correct place and leaving this for someone else to do. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you Lynn...I agree and do not like to be placed in that position. This just happened to me last week..I suspect the PICC was rushed as it was the last PICC placed that day..also the person was training a new PICC nurse and I also suspect the measurement was not done by the trainer as well. This was a left sided placement and I also suspect they did not make any accomodation for the depth of the vein and the increased length of the left BC vein. This was also placed with a Sherlock TLS. The angle coming into the upper SVC is so sharp that often the catheter is up against the wall of the SVC and I worry about erosion as well. Is anyone still wrapping the PICC in a sterile dsg until CXR. Also some of our nurses remove the dilator after threading the PICC ..then they often double check the TLS read by pulling out the stylet and re-inserting it ..then they may decide to advance the PICC some more...what to you think about that? I just leave th dilator in until I am am happy with the internal amt.
We are currently using the Sapiens TCS. As I understand the language, it is approved (to replace the xray) only if you are using the Sherlock TLS as well. Tip confirmation is a priority for our team; it would be unacceptable to me if someone did not adequately confirm placement. With a team that is familiar and feels comfortable with the technology, the combination of Sherlock and Sapiens can get the tip of that line precisely where it should be. I cannot speak to the other devices that are out there.
I would not advance a line that was found to be too short under any circumstances.
Genine M Schwinge, ANP-BC,PNP,MSN
Vascular Access Coordinator
John T Mather Memorial Hospital
Port Jefferson, NY