Wow was that interesting. Leave it to you, Shirley to come up with something good. I have no clue how you wrapped the wire around the nerve, but I do have a technique that Dr. LaDonn taught some of us at AVA and should work nicely in this type of situation. Frequently wires will curve back on themselves when inserted into the vein. Wires used to be J tipped to reduce vein wall punctures and facilitate sliding through the vein with a stiffer wire. Now we use floppy tips that easily turn into a U when it first goes into the vein, making us think it won't thread. Try this...when you know you are in the vein, ie dripping blood and all looks good, then you can't thread the wire, Pull the needle and leave the wire in place. Take a long angio (many kits have an extra in the kit), remove the needle and slide the sheath over the wire and into the vein. After the cannula is in place gently pull the wire back and slowly reinsert. The cannula allows retraction of the wire without risk of shearing with the needle and it also straightens the wire for advancement at a better angle into the vein. Let me know how it works for you!
Nancy Moureau, BSN, CRNI PICC Excellence, Inc. 888-714-1951 www.piccexcellence.com [EMAIL PROTECTED] -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Shirley Ellis Sent: Wednesday, September 20, 2006 7:21 PM To: [EMAIL PROTECTED] Subject: just another picc line insertion, not One of the great things about this venue is learning from each other and sharing experiences, so here goes. Situation: 1. Patient with dx of cellulitis left thumb.. mri negative for osteo... treatment for 3 weeks of IV vanco. (p.s. patient is ARNP, midwife OB/GYN with years of OR expericene). 2. PICC nurse 14 years experience (last 4 with MST and US) using same style of equipment for 2 years and does not perform the through the back wall technique of needle insertion . Procedure: Bedside PICC placement. 1. Patient, along with the nurse, observing real-time ultrasound guidance with 21 ga needle into vessel with free flowing blood return (right basilic vein size of a dime). Needle easily visualized on the screen and into vessel. Upon advancement of nitinol wire, stated "now I feel that". Wire was GENTLY retracted without difficulty, established 3 ml of blood return via a syringe(good drip throughout procedure) and wire was gently advanced but at 7 cm again stated "feel that again". Denied sharp, tingling, etc. but just "funny". Immediately removed the needle from the site, engaging the safety feature, then started retracting on the wire which became stuck. (past cases) a. On 3 separate occasions with PICC placements over the last 2 years, while utilizing fluro, I have visualized the wire kink, coil, etc. Advancement of the dilator sheath over the wire allowed the wire to be removed successfully without trauma (except to the nurse, me!). 2. Unable to pass the sheath (gently) on 2 attempts and I stopped and called Radiology. (Did I mention that this was for discharge and that it was 4 PM?) Arm was wrapped and the patient was transported in her bed to specials. Action: (short version) 1. Diagnostic Radiologist started the fluro to determine what was going on. NO coil, kink was present but there was a small backwards C to the path of the wire. Measured 4 cm of wire that was inside the skin. (Now the vein visualized on the ultrasound screen between 1/2 and 1 cm depth). He pulled on the wire and the patient came off the table. 2. IR was called in and the reaction was duplicated x 2 when he stopped. 3. Wire was coiled outside the skin, tape applied and tegaderm to maintain sterile area. 4. Transported back to room and attending MD called, with orders to obtain "urgent" vascular consult. 5. Vascular surgeon arrived, held discharge, put her on the OR schedule for the next day. His intent was to "yank it out" (I was present when he told her his plan of action ...done it many times, doesn't hurt a thing). Result: 1. Surgeon reported to me: a. He was glad that when the dressing was removed and site prepared, that he broke the nitinol wire. He had about 10-12 cm to work with. Because by the wire breaking he had to change his plan. Fluro was used, the skin opened, and the vein exposed. "Never saw anything like it!" b. The soft end of the nitinol wire had punctured thru the vein and wrapped around the nerve. He was able to release the wire. Said no thrombus formation started, vein looked good, etc. c. She did not demonstrate any nerve damage or numbness to her fingers with good ROM. Good luck guys! Shirley
