Forum topic

I would access it and use it. I would treat it the same as any other CVC if declotting was necessary.  Actually, I would prefer to see this tip location (right atrium) rather than short in the brachiocephalic or upper SVC.  More complications happen there, as evident from the research that has been done.

To me, I look at the guidelines from AVA and INS supporting nurses inserting PICCs and supporting their tip locations in the SVC.  As nurses, nothing supports us putting anything in the right atrium.  However, I don't see these guidelines impacting physicians.  Dialysis catheters are another type of CVC that is frequently in the right atrium.  Am I wrong in thinking that INS and AVA won't impact physician practice related to tip location?

We have had a few short ports (tip location in the brachiocephalic) that the oncology nurses refuse to use the port for vesicant, because the tip was not central in the SVC.  Made a few surgeons mad, but eventually change their practice.

Gwen Irwin

Austin, Texas

I had a conversation with an interventional radiologist on this topic.  It is challenging for them to get tip position perfect due to the fact that on the fluoro table the tip will be in the low svc but on an upright film the tip appears in the high svc.   This illustrates the fact that pt. position causes the tip to migrate.  He has changed his practice to place the tip in the high RA so that it will never migrate out of the low SVC.

I wouild not fear using a port with tip in the RA in an adult.   I don't believe there is any evidence of delivering drugs in the RA is of any concern, so using the line is not the issue.   Does RA positioning have the potential to cause arrythmias?  This is definitely an issue with piccs.  A mid to deep RA picc can drop with pt. positioning and arm placement to the low atrium or ventricle.   That is why we get calls from radiologists to pull back a picc that is showing up in the atrium on CT scan that were previously well positioned . On the CT table the patient is flat with their arms up over their head.  We've learned not to act on those but to ask for an upright film. 

I have had properly placed piccs cause pvcs because the pt. was very short and heavy and the tip can drop when they curl up on their left side. Abdominal distention also pushes the thoracic structures up. The organs migrate not the picc. 

My point being that tip position is variable according to pt position, body habitus as well as film technique.   A kyphotic view can skew the tip to look RA.  It's just not a black and white situation.  Most important is that the tip needs to be low and prevented from migrating to a high position where we do know that there is higher rate of complications.    Also don't forget that all rads have different definitions of what is RA.  Many do not recognize the cavoatrial  junction as defined as 1-2 cm below the junction of the right atrial appendage/SVC and will label it RA.  

I don't believe nursing should write policies denying the use of lines labeled to be in the atrium in adults. It's just not that black and white.    (peds is a whole different ballgame). 

Consult your radiology department. Perhaps they can put in their reports that the line is safe to use.  That would make everyone feel better. 

Good luck, we battle this everyday ourselves. 

The recommended tip location is the lower third of the SVC at or near the cavoatrial junction. The post about the challenges with tips remaining in that exact location is absolutely correct. They can and do move based on patient positioning. However, no catheter tip should be placed far into the RA. There is evidence of arrhythmias from wires and catheters in any location inside the heart. There is also evidence of cardiac tamponade from erosion of the catheter through the vessel of heart wall. Please understand that the pericardium extends from the leve of the second intercostal space downward covering the heart. This means that correct tip location can erode through and produce tamponade, not just RA location. Your practice should be evidence-based and not based on what others may be doing. If others were taking out the appendix through the nose, it does not mean that is the best approach. Evidence is the key to good practice. The standards, guidelines, and papers from all organizations, manufacturers instructions for use, and published studies are the evidence you need to collect and use for your practice decision. In all legal cases, that is what is used. We do not look at what other hospitals are doing in that area. We look at the evidence. Your facility to convene a committee or put this in the hands of an established committee. This group should be multidisciplinary and should thoroughly review the evidence. Then consider your patient population and make a policy based on these factors. Given the evidence that has been presented at several conferences about catheter tip whipping from high pressure injection, I would never allow any CVC to be used for this purpose when it is in the RA. I have seen some situations in an animal lab where complete laceration of the SVC was caused by this whipping action. We definitely need more studies on outcomes with high pressure injection to determine the safest possible method. Peripheral injection is far from safe also because it can lead to severe extravasation and the need for immediate surgical treatment of compartment syndrome. What for news very soon on a new online CE about the Perils of Power Injection on our website. This was a synposium presented at the 2010 AVA conference. Lynn

Lynn, you wouldn't recommend powerflushing a picc to correct it's position from the IJ?  Would you recommend replacement of the picc?

 You can try sitting the patient up , leaning forward, and power flushing. It's works more time than not. As far as tip placement, I go by a study done in Oregon that identifed where the CAJ is. And you are correct , it is 1-2cm below the appendage. I don't like Radiologists determining tip placement, and for one reason. Different Radiologist will read different locations. I find they are all over the map. I trust my eyes and where I want to see the line. Nurses will sometimes say "do you read the xray"..NO..I simply clear the line for use. I don't identify pneumonia, enlarged heart, ...etc. So I don't call it "read". But I have to tell you I have seen ports, permcaths  deep into the right atrium and not cause a problem. I know that is contrary to all the literature...

Jack

This is purely anecdotal, but I have to share a personal experience. I've had 2 PICCs, a midline, and 2 ports in my body (no, not at the same time and don't ask why!). One of the PICCs was, it turned out, in my RA. This was all before I was an oncology nurse, by the way. Every time I turned to lie on my left side, my heart would flutter. After the usual ECGs and ACS assessment, they sent me to IR and saw the deep line under fluoro when I turned. Miraculously, once the line was pulled back, I never had the sensation again! Consequently, I have always personally supported INS's position that tips should not reside outside the RA in the lower SVC (except for HD catheters). Even if someone does not have arrhythmias from a deep line, certain position changes can elicit them.