Normally our practice is to avoid placing a PICC in an arm when there is a vessel that does not compress (indicating clot), even if the other 2 are open. If the other arm is not an option for a PICC for whatever reason and longterm iv therapy is needed, we will refer the ordering physician to the IR MD for a tunneled line, or if it is short-term iv therapy we recommend the MD place a TLC at bedside. Our rational is that if blood flow is already complicated from the one clotted vessel ,placing a PICC into another vein would also serve to compromise blood flow. And of course no one out there seems to have great cephalic, brachial and basilic veins in the same arm. Usually one or more are small to begin with. So plugging up yet another vein and placing them at a higher risk of developing a DVT doesn't seem like the better option if a tunneled line or TLC at bedside is an option. What are your cutoffs/boundaries? Do you look at how much of the vein is clotted? How large the other veins are? Which vein is clotted? What is everyones practice? At our facility there is a great move by the physicians to stop placing TLC secondary to fearing the nonimbursement for CRBSI in hospital and plain old no one has the skills to do it so no one wants to. Pressure to place PICCs and ultrasound guided peripheral ivs have increased substantially, and there are many physicians who don't care or don't understand standards for when a central line vs PICC vs piv are needed. They just want us to follow orders. On top of that our IR department is not helpful with looking at the whole picture and having a discussion on the best line for the patient. Thoughts/opinions pls. Thank you.
Ok, maybe a simpler question is needed. What type of pt/circumstance would you refer the pt for a TLC at bedside or a tunneled line instead of a PICC? Our facility does not like to place TLC and will blow out all the peripheral veins in a person before getting some type of central line. We see a lot of non-compressing vessels in our pt's arms. I am just trying to get an idea for the standards of practice for other vascular access nurses who place PICCs. It is good to know what everyone else is doing to see if we are operating outside of reasonable practice. If the standard out there is to place a PICC in a compressing vein even if the other veins in that arm do not compress then I would like to know. Pls share your practice, there is no judgement here. I just want to learn. Thank you.
We are encountering this situation more often ourselves. Hard to have a hard line in my opinion.
Just a few days ago one of our patients needed a picc for Amiodarone. He had a horrible infiltrate on the left. When I scanned the vessels of the right the basilic was partially compressible to above the junction with the brachial. This was result of an amiodarone infusion just a few weeks prior (anyone else hating this drug?) The arm was asymtomatic so I opted to go to the high cephalic vein with a 4 french catheter. He needed it before we did any more damage with the amio. But normallly I would not take this chance. We just didn't have time for him to get on the IR schedule. We'll see how it plays out in a few days. Our docs are also very hesitant to place lines at the bedside anymore. Takes an act of congress.
Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA
Below you mention PICC insertion related to Amioderone
I have recently noticed an increase in peripheral administration of Amioderone and was wondering if this an acceptable practice
Robbin George RN VA-BC
A dedicated CVC lumen is preferred for amiodarone. Use DEHP-free tubing, and non-PVC containers. Phlebitis is greatly increased with concentrations above 2.5 mg/ml so a CVC should be used. Although it is not listed as a vesicant, it can cause pain on infusion and phlebitis. 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