Chris Nahrwold is undergoing treatment for cancer of the esophagus. Oncology nurses first tried to put chemo intravenously into the 40-year-old Fort Wayne man's vein in his left arm, but the vein “blew,” or became unusable, due to the difficulties of inserting the needle.
“They didn't get any chemo in this arm,” Nahrwold said, showing the scarring in his left arm. Last week, in the outpatient treatment center at Parkview Hospital on Randallia Drive, nurses Kathy Matson and Julie Mijatovich, part of the intravenous team at the hospital, used the Sherlock system to place a semi-permanent catheter, or PICC line, into the main vein at the top of Nahrwold's heart for his chemotherapy drugs.
PICC is the acronym for peripherally inserted central catheter. A PICC line is also used to administer liquid food or antibiotics over a long period of time. Some antibiotics are so powerful they can only be given intravenously through a large vein.
The challenge of placing a central catheter is knowing for certain if the tip is where it should be, said Jackie Myers, nursing director over the IV team. Until now, the only sure way was to take an X-ray after placement, which sometimes resulted in painful manipulation of the catheter if it wasn't in the right location. Patients had multiple X-rays, giving them greater exposure to radiation.
The Sherlock system, made by Bard Access Systems of Salt Lake City, uses real-time ultrasound scanning so the specially trained nurse can visualize the major veins and project the images on the ultrasound screen.
Matson numbed the crook of Nahrwold's right arm with a local anesthetic, then found one of the three major veins in his arm and inserted a needle through which the catheter would be threaded using the Sherlock Tip Location System, which includes a magnetic-tipped guide. She could stay away from the artery because its pulsating action showed on the ultrasound.
No magnetic energy is generated by the screen or sensor module, which is the ultrasound probe rubbed on the arm. The magnets are enclosed within the tip of the Sherlock stylet. As the stylet is advanced under the sensor module, the sensor “reads” the magnetic field generated by the stylet. The sensor calculates the exact location of the tip in reference to the person's anatomy and the location shows on the screen.
As Matson guided the catheter toward Nahrwold's neck the first few times, the sensor showed it was heading toward his right jugular vein, so she pulled back a little on it and repositioned his head. In a short time, the sensor showed the catheter had curved downward and was right where it should be in the main vein, the superior vena cava.
Chemotherapy drugs are so powerful that infusing them into the superior vena cava, where ample blood flows, dilutes the drugs and gets them dispersed throughout the body, said Mijatovich.
“I didn't feel much of anything,” Nahrwold said, as he was wheeled to X-ray for final confirmation of placement of the PICC line. No one looks forward to chemo treatments, but he said the ease in which the PICC line was put in was reassuring.
Ports implanted under the skin of the chest are also a means by which some people get chemotherapy or antibiotics, but Myers, the nursing director, said a PICC line is less costly and, unlike a port, does not require surgical placement and removal by a doctor.
Both Parkview Health and Lutheran Health Network have been using the Sherlock system for about six months.
A similar but more portable PICC system called Sherlock II is used by the 17-member Parkview IV team in outlying communities. The team does about 250 PICC line insertions a month for Parkview Health.
Positive resultsParkview Health is involved in a study using a new method called the Sherlock Tip Location System for inserting central catheters for intravenous chemotherapy, liquid food or antibiotics. Parkview receives no financial incentives from Bard Access Systems, which makes the
system. Outcomes so far are favorable, showing:
♦A 50 percent reduction in need for multiple X-rays after insertion.
♦A 41 percent reduction in the need for catheter manipulations after insertion.
♦The number of patients who had to be sent to radiology for repositioning of the catheter under fluoroscopy, requiring higher cost and a physician's attendance, dropped from an average of eight patients a month before the Sherlock system was implemented to one patient since.