Lots of questions lately! Really appreciate this forum!
If a PICC nurse assesses a patient and finds NO adequate vessel size-wise in either arm, we typically refer to Interventional Radiology for placement, where they place a big line in the small vessels that we decided were too small. If we are doing what is right for the patient, should we NOT be referring these patients to IR? Just because they CAN place a PICC doesn't mean it is the right thing to do for the patient.
You may suggest we start placing IJ PICCS ourselves - we are moving toward that, and that should help with some of these patients but aren't there yet.
My question: should we NOT refer if we have determined there are no suitable vessels for a PICC? Contact the ordering MD for a different CVC?
I think this is a question for the appropriate committee to decide after assessing all of the evidence. What are the outcomes of these IR placed PICCs? Have patients had injuries due to this practice? I would involve risk management with this issue. I would also discuss it with IR and tell them your concerns. The fact is that some type of VAD is required and your team are the experts. So your recommendation should be the accepted one. If it is too small in your judgement, then IR should not be expected to put one in. What is their assessment process and criteria, if any? Or are they just inserting catheters simply because they have been asked to? Your committee may decide one of several options I can think of, but I do think the direction for referral should be a collaborative decision by the appropriate committee. 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
Soap Box time: Remember a Catheter in the IJ is that...a catheter in the IJ...it's not a PICC.....Not sure yet what the profession wants to call it... confusion is starting and we must take control!
They are all CVADs. The EJ could be considered a PICC as it could be consider a peripheral vein. It is definitely a superficial vein. The IJ is a deep vein. They still fall into the category of nontunneled, noncuffed, percutaneous CVADs. This group covers a lot of different designs of devices that are used for this purpose. Frankly I do not see that we need another category or type of devices. It only adds confusion. I doubt many, if any, are using the EJ now. So technically it is not a PICC for peripherally inserted. IJ and subclavian have always been centrally inserted CVADs. 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
Please correct me if I am wrong. My understanding is that the EJ has too tortous of a route for "PICC" placement. INS standards say it is okay to use the EJ for peripheral IV access until better access can be secured but I have not found anything approving it for CVC access. I know it is an inappropriate name to use but until we get the correct kit that is how we have to order to get the softer smaller gauge CVCs for IJ placement. It is highly unlikely that out IVR department is going to stock 2 kits.
Mary Penn RN Vascular Access Team
St Charles MO
See INS Standard 33 Site Selection, Practice Criteria VII. External Jugular Vein Access. I agree EJ is not the best insertion site due to the vein anatomy but it is recognized by the SOP and some may still be doing it. 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
Because our patients (neonates and peds) have less useable (or available) veins than adults, it does not take long to deplete them. Therefore, we do place PICCs in EJs as a last choice but primarily in young infants. A bigger problem than the vein path is maintaining the integrity of the dressing. It does provide access that would otherwise have to be obtained in the OR and for the patient is the best choice for intermediate length therapy. Patients who require prolonged tx are referred to the surgeon.
It's unlikely we will be placing IJs anytime soon. We would have the same concerns regarding the dressing and the smaller structures in an infant would give me pause.