I work in a large hospital where >95% of PICC lines are placed at the bedside and not in the IR dept.
Occassionally we cannot advance the catheter to the SVC region and the PICC is left in a suboptimal location with the tip in the innominate or subclavian veins. (Midline use at my hospital is very rare).
If we are unable to send the patient to the IR dept for catheter repositioning, we then obtain an order from the MD that Oks the use of the PICC line for peripherally concentrated IV medications and lab draws only.
Recently we had a patient that was to receive an Amiodarone drip through a left-sided PICC where the tip was at the junction of the left subclavian and innominate veins.
To complicate matters the patient had a documented history of a left subclavian occlusion, and old pacemaker wires not retrieved from a failed left-sided pacer placement.
I felt since the PICC tip was not in the SVC, the Amiodarone should be administered through the peripheral IV site that was present to the RAC vein. That way the site could be closely monitored for complications such as phlebitis and infiltration.
Two more experiened IV nurses I work with disagreed, and felt the left innominate vein was an appropriate location for a peripheral dose of IV Amiodarone, even though us super IV/PICC nurses lack the needed X-ray vision to monitor the infusion site for complications.
Fortunately this patient was on IV Amiodarone for less than 24 hours. But I still feel a bit bullied, and think my rationale is not wrong.
Any thoughts?
You are NOT wrong. If you cannnot advance the PICC into proper positioning (Distal SVC) then it should be pulled back to a midline, HOWEVER, that is only if you have a benign drug which can infuse via midline. I too would ifuse this drug only via a PICC or a short term peripheral. Amiodarone has a pH of 4. It should be infused into a PICC, or a short term periph where you can see the sight and assess the vein for s/s of extravasation. Midline catheters terminate before the axillary vein and since the go deep into the upper arm, if there were problems, the problems would be monumental by discovery time. Stopping in the subclavian or brachiocephalic is a huge No-NO. Thrombus rates increase considerably here.
Neither approach is a good one. Many years ago, AVA (NAVAN at that time) produced a position paper on tip locations of PICCs to address the issue of midclavicular vs SVC locations. Based on several studies showing much higher complication rates with a midclavicular tip location, this paper stated that a midclavicular tip location was only appropriate when anatomical or pathophysiological reasons prohibitied advancement into the SVC. This would require much more than what we can do at the bedside to assess why the catheter will not advance to the SVC. So I am concerned that your practice may not have the appropirate information upon which to base your decision to allow the catheters to remain in this risky location. Are you working with a radiologist to attempt advancement under fluoroscopy? If not, you probably do not have any idea about why the catheter will not advance. Is it simple vasospasm or an anatomical variation of the venous pathway or surgical/trauma created changes or a large chest tumor encroaching on the SVC? The inserter needs to know before you can make a proper decision. Once you have this information, that AVA paper stated that you must assess all characteristics of the prescribed fluids and meds to assess the risk vs benefits of the more dangerous midclavicular tip location to determine what is the lesser risk to the patient. This includes drug pH, osmolality, and vesicant nature of each drug. If this tip location is judged to be the best alternative for that patient, then any new presciptions must also have this same assessment for safe infusion. I am not in my office to check the pH of Amiodorone. Also, I do not know how your pharmacy compounds this infusion so don't know the final osmolality. But these are facts that must be assessed before using any tip location outside of the CAJ. I would agree with you that a peripheral infusion would be much easier to assess for any complication. This catheter must be the smallest gauge, shortest length, placed in the largest vein outside of an area affected by joint movement, properly stabilized with a stabilization device, and meds compounded to have the lowest osmolality. You mentioned a catheter in the RAC, gauge size not stated. I assume you mean right antecubital fossa. This would not be an acceptable location for this drug as it is directly in a joint and extravasation risk are high. The antecubital fossa is not an appropriate location for any short peripheral catheter for infusion. It may be required for CT contrast injection but then should be removed. Also, punctures distal or below a previous IV catheter are dangerous as the fluid/meds can easily leak from this old puncture site. So in this specific situation, a 24 g short peripheral catheter in the forearm of the left arm with the midclavicular catheter would be your best immediate option. Optimally, you could work with a radiologist to get a PICC correctly located at the CAJ. What I have described is what an expert witness would be assessing if there had been a bad outcome that caused a lawsuit. All I have mentioned is considered to be the standard of care driven by published documents like INS Standards of Practice. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks for the feedback. Yes, Yes, Yes I agree!
Many tangent issues exist here unfortunately, which I won't get into at length. I cannot fix all of these things in my workplace, but I can educate myself and try to do what is best for my patients.