RE: [vascular] RE: tunneled small-bore CVCs

[Nadine Nakazawa]

I do think this needs a new term.  It will not be commonly done, but 
possibly as often as 150 to 200 per year at our hospital (with a total PICC 
volume of about 1800).    This is after an intense discussion with our 
interventional radiology chief (who was at Johns Hopkins and is now at 
Stanford as chief) who feels that if the PICC team CAN'T get the pICC in, 
it's for a good reason---the patient has tiny veins in the arms, or there is 
so much damage that IR will spend hours trying to get a PICC in and that is 
NOT the best VAD for that patient.  He knows that a small-bore catheter with 
s short tunnel  but NO cuff, inserted into the IJ will accompllish the 
following:   get reliable venous access quickly  in a patient with few other 
realistic options, and be safe:   they insert all lines using maximum 
sterile barrier precautions and use Chloraprep, and we use Biopatch on all 
central lines.   These catheters won't need a cuff because they won't be in 
for longer than 6 weeks (eg, Vanco), and when pulled, they will have a very 
low risk of air embolism because of the tunnel.   They will need to be 
secured carefully at the exit site.    The small bore refers to the fact 
that IR plans on using a poly PICC (probably the PowerPICC because we're 
already using that PICC), and it will only be a 5 Fr catheter (single or 
dual).

There will need to be an extensive education process for the nursing staff 
and home care agencies to recognize a familiar looking catheter (PICC) but 
exiting out on the chest with a short tunnel.  It will look different than 
the larger bore white silicone tunneled (Hickman-type) catheters used for 
BMT and long-term TPN patients where the catheter develops firm traction in 
the tunnel and the cuff scars over.    Nurses will need to recognize it, how 
to dress and stabiliize it so that it won't migrate, and how to safely 
remove it (require lying flat, all the other steps as with a percutaneous 
CVC removal).

The PICC team will need to be inserviced to understand when to refer a 
patient for such a device, and to educate the referring physician or NP, and 
the patient and family as to what this device looks like, and where it will 
exit, and the risks and benefits.

IR feels it will safe an enormous amount of time that they are currently 
wasting trying to get PICCs in patients whose vasculature is so truly 
damaged that a PICC is no longer an option.   These patients include:   ESRD 
patients, venous stenoses/thromboses along the vein path, bilateral 
mastectomy and lymph node dissection patients, patients with very tiny veins 
that the nurse cannot access despite attempts.

Our referral rate to IR is only about 5% but it has a tremendous impact on 
their workload, and they dread our referrals to them.  They know they will 
get only the most difficult vasculature.  If it's just a persistent 
malposition, then they'll just reposition it using fluoro, but that is not 
the situation I'm talking about.

I'm just opening this up for discussion as this will be a 6 month process in 
my hospital to get all the procedures changed, and the education out there 
and through all the appropriate committees and councils.

Nadine Nakazawa



From: "Lynn Hadaway" <[EMAIL PROTECTED]>
To: [EMAIL PROTECTED], [EMAIL PROTECTED]
Subject: [vascular] RE: tunneled small-bore CVCs
Date: Wed, 16 Aug 2006 12:20:06 -0400

I guess I am having a hard time getting to the point where I can accept 
that we need another type of catheter with a different design. We already 
have catheters designed for insertion into the jugular and subclavian veins 
that are being used for long term dwell (e.g., Hohn made of silicone). 
These, just like any catheter can be tunneled. Are you saying that the OD 
is too large and a smaller one is needed?

Regardless of the material, there is a greater density of skin flora in 
this area, so the infection risk will always be greater. So this should be 
one of the last options for long-term use. Is the market large enough to 
motivate a manufacturer to go through all that is necessary to introduce a 
new design?

I am all for being on the cutting edge of advancement. I have been there 
all of my 30+ year career. But I can also appreciate what it takes to bring 
a product to market successfully and but have concerns about adding another 
layer of complexity. Lynn

At 11:40 AM -0400 8/16/06, Nancy Moureau wrote:
Tunneled PICCs are the up and coming thing, primarily reimbursement 
driven.
Lynn mentioned having a devices designed for that purpose, tunneled
insertion into the IJ, well isn't that what we all do over time, help with
the development of such devices? (truly we already have IJs but this is a
different twist). Hickman catheters, Broviacs, Hohn etc were all catheters
developed from someone's idea and usually when another catheter existed 
that
required some modification and then miraculously the catheter acquired
another name (most common branded with the developer's name). Right now we
may call them IJ PICCs, tunneled PICCs, SBTC small bore tunneled catheter 
or
whatever, later we will have devices designed for this purpose. Don't you
remember when PICCs were long lines, perc lines, piclets, pics and pic-cs
and so many other names? Usage has to occur before development. How can we
use a line developed for a particular purpose if no one has thought to use
it yet? We are on the cutting edge of vascular access development and have
the privilege of seeing new and different things. My goal is to help 
develop
the ideal device. What would a perfect PICC look like, how about a perfect
IJ? Envision it and it can happen

Nancy


Nancy Moureau, BSN, CRNI
PICC Excellence, Inc.
888-714-1951
 <http://www.piccexcellence.com/> www.piccexcellence.com
 <mailto:[EMAIL PROTECTED]> [EMAIL PROTECTED]

-----Original Message-----
From: [EMAIL PROTECTED] 
[mailto:[EMAIL PROTECTED]
On Behalf Of Lynn Hadaway
Sent: Wednesday, August 16, 2006 9:33 AM
To: [EMAIL PROTECTED]; Nadine Nakazawa; [EMAIL PROTECTED]
Subject: RE: tunneled small-bore CVCs


Tunneling for a subclavian or jugular catheter is not a new concept. There
have been several publications about this. But this should not be confused
with a tunneled and cuffed catheter.


Nurses have been placing PICCs through the external jugular for some time
now. Several years ago, there was an article in JVAD about this.


In my opinion, a catheter that is designed for insertion at this site is
more appropriate than using a PICC and adapting it. This includes a Hohn
catheter.


We have also had a discussion on the listserv in the past about whether 
the
EJ is considered to be a peripheral vein. I would say that veins of the 
neck
are peripheral veins. EJ is a superficial peripheral vein while the IJ is 
a
deep peripheral vein in the neck.


The infection risk for any catheter placed in the neck is greater than the
PICCs in the arm because of the density of skin flora and the difficulty 
in
maintaining an intact dressing.


So this would only be for those situations where nothing else is 
available.


As far as a name, why do we need to start using a different name for this
placement? Seems to me this would add to the confusion. It also adds to 
the
confusion when the external catheter segment is stamped with "PICC" and it
is coming from the lower neck. That is why it would seem more appropriate 
to
use a Hohn designed for this site. Lots to consider with this one! Lynn


At 12:52 PM +0000 8/16/06, [EMAIL PROTECTED] wrote:

        I have seen such a line. When I first saw the patient I was quite
perplexed.   It was a dialysis patient with a dialysis catheter in Right
subclavian.  About an inch away from the insertion site of the dialysis
cath, there was a PASV catheter inserted.  Being a PICC nurse I know the
different PICC catheters, my first thought was:  " why did they use a PICC
cath as a subclavian.?"  Then I looked at the CXR.......the dialysis was
placed Subclavian, but the "PICC" apparently was tunneled because the path
sent up the neck and then down the jugular!!!  I wonder who was the first
person to 'invent' using a PICC in the IJ.  I have heard MD call it an IJ
PICC.  Mostly these are nephrologist.

     If this is going to become more prevalent, we need a better name for
it, in my humble opinion.  First of all this is not a "peripheral" site.
Secondly, would the dwell time be as long as a true PICC??  I think not
because of the insertion site being in  the dirtier chest.  Isn't this how 
a
HOHN catheter is placed??

    One thing for sure......I do admire peoples ingenuity in getting
vascular access for those TOUGH ONES!.





--
Susan Schuetrumpf, CRNI
VASPRO
Atlanta, GA
cell-404-606-1194




-------------- Original message --------------
From: "Nadine Nakazawa" <[EMAIL PROTECTED]>


Does anyone have a good name for these "small bore tunneled CVCs" that can
be placed into the IJ with a short tunnel, that are 6 or 7 Fr in size?   
Tim
or Ann:   What do you call these lines?  Especially if they are a PICC 
that
has been trimmed and used in the IJs for patients with no decent 
vasculature
in the arms for a regular PICC??


Our IR Chief feels that if the PICC team refers them a patient where we
failed to get the PICC in, they will likely have the same troubles.  Bad
veins are bad veins.  He wants to start putting in these lines when we 
refer
them to IR for a failed PICC insertion.  I think it dovetails very well 
with
earlier discussions about all the bad vasculature out there.  It's getting
to be a real problem.


Our numbers are excellent and we seen to only refer the truly difficult
access situations.


Nadine Nakazawa, RN, BS, OCN

PICC Program Coordinator



Stanford University Hospital and Clinics



Stanford University Medical Center






--

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


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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