Painful vein entry

[Gwen Irwin]

Cathy, This is the type of reaction that we see in some patients when using ultrasound to place PICCs.  This is the reaction "before" we enter the vein.  Like you said, the skin entry was benign.  We have seen it happen with brachial veins and with basilic veins for PICCs.  I had a question to the group in August wondering anyone else seeing this happen.   We use lidocaine 1%.  By the time we are ready to actually insert, sufficient time has passed to assure anesthesia of the skin AND for most patients the subq area and vein area.  We inject with 27 or smaller needle for lidocaine and try to infiltrate as deep as we can (usually the depth is not greater than 1-2 cm for infiltration of lidocaine).  We also do use as much as 0.6-1.0 ml.  However, we still see a small percentage of patients react to vein entry BEFORE we enter the vein, in spite of local anesthesia.  These same patients also react more to the insertion of the dilator/sheath for the PICC.   The exceptions are interesting to note, but we have no advance warning about which patients might react like this and are the ones that possibly need more anesthesia at the vein depth.  I just find it interesting to see the difference in patients' responses and became aware of the differences in their reactions to vein entry by observing the proximity to the vein using ultrasound.    My hypothesis would be that there are differences in innervations of the vein for this population of patients.  I also think these might be the patients that vasoconstrict with periperal IVs, since they have a pain response before entry to the vein.    How could that be proven?  I am not sure that there is a scientific way to prove this.  However, I am sure that I have been right in predicting success with a PICC based on these patients reacting when I can see that I am on top of the vein (using ultrasound).  If I continue in spite of their reaction, the PICC insertion is successful.   Comments are welcome.   Gwen Irwin Austin, Texas ----- Original Message ----- From: Cathy J To: [EMAIL PROTECTED] Sent: Monday, August 14, 2006 8:51 PM Subject: RE: Catheter length exposed--evidence or opinions? I recently was called to place a PIV in a pt had a case of shingles on his face.  I had to use US d/t no palpable or visible veins.  The intial skin poke was benign.  It wasn't until I got close to the vein that the pt began to c/o intense pain.  (I was going for a vein in the forearm.)  I left my catheter in place and called for some buffered lido.  I injected the lido at the depth of the vein, about .75 cm.  I was then able to advance my needle into the vein without any complaints of pain from the pt.  This has happened before with PICC insertions but usually when cannulating the brachial veins and only a few other times with PIVs.  I consider that maybe the increase in sensitivity was d/t his already hyperactive nervous system from his condition.  Cat Johnson RN From:  "Nadine Nakazawa" <[EMAIL PROTECTED]> To:  [EMAIL PROTECTED], [EMAIL PROTECTED] Subject:  RE: Catheter length exposed--evidence or opinions? Date:  Sat, 12 Aug 2006 10:28:27 -0700 > >We always adjust the PICC tip so that it is at the caval-atrial >junction or deep distal SVC.  We place the wing 1.5 cms away from >the exit site and suture to one side, placing a steristrip over the >wings.  Then we use Statlock on the hub portion.  We're doing that >with the PowerPICC as well for consistency sake.  It's easier for >the nurses to change the PICC dressing with similar landmarks.  We >also allow for enough PICC externally to advance if our external >measurements are off.  We will it's more important to have the tip >correctly placed, and allow for the adjustment to be outside the >skin. > >Nadine Nakazawa > > > > >>From: "DAVID LONGSETH" <[EMAIL PROTECTED]> >>To: [EMAIL PROTECTED] >>Subject: Catheter length exposed--evidence or opinions? >>Date: Sat, 12 Aug 2006 10:11:34 -0500 >> >>The majority of the PICCs I place are Bard's Groshongs,so I have >>only two lengths to choose from. I always try to measure accurately >>enough to leave out more than 1.5cm (to accomodate the Biopatch >>under the dressing) and less than 5cm (to take advantage of the >>tapered end to plug the vein and the tract). Due to differences in >>patients' anatomies,it doesn't always work out that way but I try. >>Does anyone have any thoughts on the matter? >>Thanks >>David >> >> >> > > >