Did everyone who attended AVA read the poster presentations, there were some really good ones. Holly Hess from Jacksonville did a very interesting preliminary report on a new technique for repositioning PICCs in the jugular. Holly can likely explain it better, but I will give it a try. After confirming catheter location up the neck, hold the arm straight bracing the elbow while the arm is down at the patient's side, raise the arm in the straight position first forward out in front perpendicular to the body/chest, then straight above the head. As you begin to move the arm back down, bend the elbow and move the elbow out, away from the body laterally. Check position of the PICC with ultrasound or a stethoscope with flushing, it could be in the SVC now. Holly is having good success with this technique, but more testing is needed to verify success levels and perfect the technique.
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 Lynn Hadaway Sent: Wednesday, September 20, 2006 5:35 PM To: [EMAIL PROTECTED] Subject: [vascular] Re: pulled out lines Are you currently using ultrasound? If so, you can rule out jugular placement by imaging the jugular vein on the side of insertion. Flushing through it helps to identify the catheter if it is there. If you still find a malposition when you get the original chest xray results, there are several things you can do. If in the jugular or contralateral subclavain, pull the wire and allow a couple of hours if possible and repeat the xray. Spontaneous repositioning is documented in the literature. If this does not work, you can try power flushing - patient in a semi-fowlers position, the flushing vigorously with a 20 ml syringe of saline. This will force the tip to the SVC. If intracardiac, just pull it back. If you need to pull out and reinsert, I would do that only if you have encased the external portion within sterile 4X4's and not allowed the catheter to contact the skin. Hope this helps, Lynn At 7:32 PM +0000 9/20/06, kam_eap wrote: >Thank you Lynn, THAT is what I was looking for. However, the >discussion seems to have taken a fork somewhere. The initial question >was a line that was pulled out and a few people were referring to >repositioning a line that was malpositioned. Of course, if a line is >pulled out by accident, it would never be reinserted. I wasn't saying >we reinsert in that situation and I apologize for my misunderstanding >the initial post due to some of the other posts that followed. >What I was asking was repositioning a line that is malpositioned >(i.e., jugular, etc.) We do not presently have a navigator system >as our PICC team is relatively new and that is among the many things >we are researching and begging for. We utilize several tricks we >have learned from those more experienced to avoid malposition, but >since the human body is NOT an exact science, there will always be >exceptions. In this case, what is the protocol? > >K. Pater, RN > >--- In [EMAIL PROTECTED], Lynn Hadaway <[EMAIL PROTECTED]> wrote: >> >> I was agreeing with you up until your statement about sterile >site, >> sterile catheter, sterile dressing, etc. The skin can never be >made >> sterile. This is proven fact. The best agents and techniques will >> only remove about 80% of organisms leaving the remaining 20% which >> will be located deep in the epidermis near glands and hair >follicles. >> As the epidermis cells shed, new cells and these organisms rise to >> the surface. The catheter is lying on top of the skin. The >external >> portion can never be made sterile again while a portion is still >in >> the patient. No amount of scrubbing or agent application will >render >> the catheter sterile again. The catheter is only sterile when it >is >> removed from the packaging. >> >> I would agree that we do not know the risk of infection associated >> with exchange procedures. This needs to be reported by someone >> tracking this data. >> >> But reinsertion of a dislodged catheter has never been accepted >> practice in my 30+ years. No one has ever studied it to my >> knowledge, probably because we know the how organisms on and in >the >> skin behave. So there are no published statements about this but I >> submit it is because this is such a basic concept that would have >> ethical issues if anyone tried to study the reinsertion of a >> dislodged catheter. Can you imagine any patient agreeing to have >the >> catheter cleaned and reinserted after all the risk have been >> explained? This would be required for such a study due to informed >> consent requirements. Such as study would never make it past an >IRB. >> >> Lynn >> >> At 3:27 PM +0000 9/20/06, kam_eap wrote: >> >You know, we reposition according to our P&P that is handed down >> >from our larger sister hospital, not because we're bad nurses. We >> >are constantly trying to gather information that will help us >> >improve our practice. We are continuously researching and trying >> >new techniques in hopes of reaching 100% success. >It seems that >> repositioning vs. exchange is definitely a > > >controversial topic, and I'm guessing this is because there isn't >a >> >set standard? I would much rather hear the INS/AVA standards and >> >reasoning than the soapbox lectures and insults. >Personally, I >> don't see how an exchange is any more sterile than >repositioning. >> Why? Sure, you have a sterile catheter, but the >insertion site >> obviously won't be sterile if you use the same >reasoning that the >> initial line won't be sterile. If the site is >sterile during the >> initial insertion and it is kept sterile and a >sterile occlusive >> dressing is applied, with any outside catheter >contained under said >> sterile occlusive dressing, then one would >think it would still be >> sterile. >I'm not taking a stance on this one, because I joined this >> group >to >> >learn and realize that, as a nurse, I will NEVER have all of the >> >answers. It is my job to continue to improve my practice for the >> >good of my patients. We take all things into consideration when >> >dealing with placement issues, because there is no perfect answer >> >that will work in every case, with every patient. >We look at the >> big picture and consider what is best for the >patient. >> >Can anyone cite specific standards from INS, AVA, NIH, or CDC >> >regarding this topic? > >> >K. Pater, RN >> > >> > >> >--- In [EMAIL PROTECTED], rkg50@ wrote: >> >> >> >> What the "PICC" nurse should have done is an EXCHANGE--Sterile >> >procedure with a new catheter >> >> >> >> -- >> >> Robbin K. George RN >> >> Vascular Access Resource >> >> Alexandria Hospital Virginia >> >> rkg50@ >> >> >> >> >> >> -------------- Original message -------------- >> >> From: Doug Buehrle <dbuehrle@> >> >> It is totally innappropriate to reinsert a line once it is >pulled >> >out. Cleaning it is not the answer. With Blood stream infections >> >having a 25% mortality rate I think this nurse should go back to >> >school on that one. >> Doug >> >> >> >> Mary <musicfae@> wrote: >> >> I was asked a question recently about lines that have been >pulled >> >out. >> >> This PICC was pulled out 10cm and the PICC nurse cleaned the >area >> >and >> >> reinserted the line. Then checked with CXR for placement. Is >this >> >an >> >> appropriate thing to do with that much line contaminated? Are >> >there >> standards set by INS to address this? Thanks everybody >> for >responding. >> >> >> >> M.Moore,RN >> >> PICC Team >> >> Ft Worth >> >> >> >> Douglas Buehrle RN CEO >> >> Triangle Vascular Access Professionals Inc. >> >> Offices in Nebraska and North Carolina >> >> 16 Briarfield Ct >> >> Durham, NC 27713 >> >> (919) 321 6105 office >> >> (919) 215 6957 cell >> >> >> >> You can trust TVAP with all your vascular access needs. >> >> >> >> [Non-text portions of this message have been removed] >> >> >> >> >> >> >> >> >> >> [Non-text portions of this message have been removed] >> >> >> > >> > >> > >> > >> > >> > >> > >> > >> > >> >MedComp Proud Sponsor of the Vascular List Serve. >> >Yahoo! Groups Links >> > >> > >> > >> > >> > >> > >> > >> >> >> -- >> 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 >> > > > > > > >MedComp Proud Sponsor of the Vascular List Serve. >Yahoo! Groups Links > > > > > > > -- 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 MedComp Proud Sponsor of the Vascular List Serve. Yahoo! Groups Links <*> To visit your group on the web, go to: http://groups.yahoo.com/group/vascular/ <*> Your email settings: Individual Email | Traditional <*> To change settings online go to: http://groups.yahoo.com/group/vascular/join (Yahoo! ID required) <*> To change settings via email: mailto:[EMAIL PROTECTED] mailto:[EMAIL PROTECTED] <*> To unsubscribe from this group, send an email to: [EMAIL PROTECTED] <*> Your use of Yahoo! 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