Forum topic

PICC's will flip up into the jugular system after placement.  For me this happens with patients who have strong, continued coughing.  I have a handful of end stage CHF patients that do not get PICC lines placed due to their PICC lines flipping IJ, numeours times.   Another aspect on this subject is coughing can drop a line.  If you are placing a PICC and the tip repeatedly goes IJ, have the patient give you a few deep coughs.  I have had PICC's thread SVC with the help of coughing. Coughing changes the intrathoracic pressure.   

 CVADs, especially PICCs will have a secondary malposition due to changes in intrathoracic venous pressure. Coughing, vomiting, sneezing, ventilators, and congestive heart failure will produce this, in addition to heavy lifting in a home care patient. If the patient complains of hearing a running stream or gurgling sound when the catheter is flushed or infused, this is a signs of an IJ malposition. You should allow time for the blood flow to move the tip back to the SVC before use. If that is not possible, you may need other methods such as sitting the patient up and flushing with 20 mLs saline. Infusion through a catheter tip angled toward the head can cause neurological problems because of meds flowing into the intracranial venous sinuses. In some cases, there may be a need to use a wire to reposition it but this is not usually the case. Lynn

 I had the same problem the other day. There was a gurgling sound when the nurse flushed the PICC. I  forcefully flushed the Power PICC when the patient was sittning up talking deep breaths. Voila..... The sound disappeared. 

This is an interesting topic and I'm suprised it wasn't brought up sooner. I have noticed this phenomena in the last few years but has probably been happening forever. The PICC is inserted, and somehow the patient gets an xray later in the course of therapy and the radiologist calls saying the PICC is malpositioned. I call this a spontaneous malposition because you really don't know how this happens?. Lynn mentioned a few reasons and logically I guess she's right, but I have no explanation. But, what I find even more interesting is...how many patients are on homecare receiving IV antibiotics and this happens...and no one knows?

Makes you wonder.

Jack Diemer

 This problem is not new and has been documented almost as soon as PICC were first used in the mid-1970s. As an educator I am taking this opportunity to remind everyone that this issue should be included in the education course that begins your introduction to PICC insertion. Also CVAD malpisition is addressed in the INS Standards of Practice. Lynn

This can happen with CT contrast injection as well.  It is important to teach patients post insertion to report any sounds they may hear when the catheter is flushed as it may mean that the tip has moved. (Also important to teach staff nurses the same thing so they don't dismiss the patient as being crazy.)  

Prior to any navigation systems, that was our first clue that the tip went up instead of down during picc placment. We learned to ask the patient if they heard any gurgling or wooshing sounds when placing the picc and reposition based on the patient's feedback.   

Ambulation can be an effective strategy for getting the tip to drop.  I remember many years ago placing a picc on the right, film came back IJ, inserted new line on the left, patient got up to the bathroom before second film was taken, both catheters were then in the low svc. 

Technology has taken some of the adventure out of picc placements :)

Darilyn