Re: PICC confusion

[Nadine Nakazawa]

We are facing this situation with increasing frequency.   If you were to 
walk into many ICUs or even on the intermediate ICUs, you would find 
patients on multiple drips, TPN, etc.  If the patient is starting TPN, the 
docs may want a dedicated lumen (and a new sterile one at that) and a PICC 
may be the logical choice.  Of course, as others have stated earlier, it's 
up to the PICC nurse to evaluate the patient's IV therapy needs to determine 
what device is best and how many lumens.

We place PICCs in nearly all of our solid organ transplant patients once 
they are stabilized while they are still in the ICU.   This can be day one 
post-op to several days post-op.  The docs want that triple  lumen out just 
as soon as we can get that PICC in.   but organ failure patients usually 
don't have much in terms of peripheral access so the nurses continue to use 
the triple lumen until we give the OK to use the PICC.  Then they remove the 
triple lumen.

I've had other patients where they had a dialysis catheter in the groin for 
continuous hemodialysis, bilateral triple lumens in both subclavians, and 
the patient was running fevers.  They wanted all lines pulled and new ones 
put in.  I put a PICC in one arm, and the docs put another triple lumen in 
one of the IJs.  This is a very sick patient on about 10 different drips (or 
so it looked like!!) and he definitely needed all the access.

There is a lot of room in the SVC for these lines.  The key question is how 
many lumens does the patient actually need, how long are the therapies 
anticipated to be, and other patient factors.  It is an increasingly 
challenging world in vascular access.  Before ultrasound it wasn't a 
question most of us had to face.

Nadine Nakazawa, RN
PICC Program Coordinator
Stanford Hospital

From: "Cindy Schrum" <[EMAIL PROTECTED]>
To: "Lynn Hadaway" <[EMAIL PROTECTED]>
CC: "Karen Douvillier RN" <[EMAIL PROTECTED]>, [EMAIL PROTECTED]
Subject: Re: PICC confusion
Date: Tue, 6 Jun 2006 12:22:50 -0400

Port a cath was my first (and only) thought about what you meant.
Sorry, my thoughts dwell on what I'm most familiar with.  As Lynn
says, careful assessment, risk vs benefit etc.  Those are assessments
you would make for each catheter insertion.  But the question was
about both lumens dwelling in the distal SVC.  I've never read about
entanglement, but anything's possible.  We had a picc that somehow
tied itself in a knot.  Who knows how that happened!

It doesn't happen frequently that a patient would need more than one
type of central access, if it did I would question the criteria for
evaluation.  The course of an illness isn't always completely
predictable.

On 6/6/06, Lynn Hadaway <[EMAIL PROTECTED]> wrote:
2 catheters residing inside the SVC is done but should be reserved
for those rare times when it is in the patient's best interest to do
it - risk vs benefit assessment. I don't know how you are using the
abbreviation PAC as this could be many things. What were your reasons
for thinking this PICC was unnecessary and why did the physician want
it? As Leigh Ann stated in a previous message, we are the vascular
access consultants and as nurses we must do our own assessment and
not be forced into doing something simply because it was ordered. Lynn

At 8:17 PM -0700 6/5/06, Karen Douvillier RN wrote:
>       Here is a situation the I encountered today and was not happy 
with.
>A doc ordered a PICC on a patient with a PAC.  The patient, of course 
has
>the PAC in the distal one third of the SVC.  I was instructed to place a
>PICC.  I didn't think this was a good idea simply because BOTH lumens 
would
>have resigned in the distal one third of the SVC and I was afraid that 
the
>PICC tip could cause a little bit of a problem with entanglement should 
this
>happen.  The reasons for wanting BOTH didn't make sense.
>
>Has anyone ever done this...both lumens in the SVC?  If so why?  I 
didn't
>want to do this because I felt that this was unnecessary.
>
>Please...give feedback.  The radiologist said it is done all of the
>time...but it's my license should something go wrong and I wasn't
>comfortable.
>
>Karen
>San Clemente, CA
>
>-----Original Message-----
>From: [EMAIL PROTECTED] 
[mailto:[EMAIL PROTECTED]
>On Behalf Of Gwen Irwin
>Sent: Monday, June 05, 2006 6:06 PM
>To: [EMAIL PROTECTED]
>Subject: Re: Arterial sticks
>
>Nina,
>We don't have a policy for this, but the PICC nurses know when they have
>inadvertently accessed an artery and document this and their response.  
It
>has occurred, but their response is immediately to remove the PICC and
>therefore, the access site and hold pressure x 5 minutes, then document 
the
>distal pulses after the occurrence.
>However, we have also had a few that were not arterial, but had such a 
brisk
>
>blood return that we reacted to that and REMOVED the PICC.  We have 
learned
>from that also.
>I do not have references that relate to arterial hematomas, like you 
asked.
>Gwen Irwin
>Austin, Texas
>
>----- Original Message -----
>From: "Nina Ainslie" <[EMAIL PROTECTED]>
>To: <[EMAIL PROTECTED]>
>Sent: Friday, June 02, 2006 12:23 PM
>Subject: Arterial sticks
>
>
>>  We are developing a competency to follow for inadvertent arterial
>>  sticks, and arterial cannulation when performing PICC insertions.  
Does
>>  anyone have references related to arterial hematomas?
>>
>>  Nina Ainslie, RN, BS, CRNI
>>  Infusion Nurse Specialist, PICC Services
>>
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--
Lynn Hadaway, M.Ed., RNC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861