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rillim
"Peripheral Use Only" for PICC line that has migrated

I am hoping someone can answer my questions concerning PICC lines that have migrated back out of the SVC. 

Scenario: A patient was admitted with a PICC line and it has been determined that the tip is not Centrally located.  The doctor has been called and does not want the PICC removed and replaced, and there are no current "Central Line Meds" ordered.

1.) Is it acceptable to leave a migrated PICC as located (Brachial-Cephalic, Subclavian, etc.) and get a "Peripheral Use Only" order from the doctor?

2.)  or would it be preferable to get an order to pull the migrated PICC (no longer in SVC) back out to a Midline position and treat as a peripheral line?

Thanks,

Roger Miller RN VA-BC

Migrated PICC

Roger,

The tip of a central line must be in the SVC, or you should get an order to pull it back to a midline.   The IV catheter should NOT be dwelling in the brachial cephalic nor in the subclavian vein.   If he/she is still requiring IV access, and the medication is such that it is safe to go via midline, pull it back. Your thrombosis rates can sky rocket when the tip is malpositioned in the aforementioned vessels.

jill nolte
agree but

have any attempts been made to reposition, such as sitting the patient upright or powerflushing?  I would try this before retracting the line.

rillim
Catheter Migrated Out

I am referring to a PICC line that has migrated back and out.  Accidently pulled back by the patient or nursing staff with weekly dressing changes.  The external catheter length has increased.  

I believe you are referring to a malpositioned PICC tip.  Thats good advice though - thanks.

 

jill nolte
you're right I didn't realize

you're right I didn't realize it had been pulled.  There are other considerations though.  I'd probably do a good assessment of the site and arm etc. and go from there.

lynncrni
First thing is it is never

First thing is it is never appropriate to leave tip high SCV, brachiocephalic, subclavian, or jugular, ever! Pulling back to be midline tip must be carefully considered and is not an automatic. Excess external length will be very difficult to maintain integrity of dressing, increasing infection risk. Plus to have this occur in the first place means dressing removal technique and stablization is inadequate now. How long is remaining therapy needed? If a few days, maybe. Or change to a different route or use a PIV for a couple of days to finish. If a week or longer, this one should come out an a new one put in, IMHO. 

 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JackDCD
Roger,

Roger,

I understand you have heard that the PICC that is not in the SVC is ALWAYS a bad thing. However, why do you think that?..your a nurse that inserts, I'm assuming, so you know that sometimes a PICC that has been inserted into the contralateral brachiocephalic, for example, frequently falls into the SVC after a day or two. So walk me through what you think CAN happen if you don't intervene immediately?

lynncrni
Lack of immediate attention

Lack of immediate attention to the problem of suboptimal tip location causes one to forget about the problem and move on to other patients. Plus one has not finished the job which is to leave it in the correct tip location. Suboptimal tip location is well documented to cause thrombosis, vessel erosion leading to infiltration/extravasation into the chest, neurological issues with IJ tip location due to retrograde flow of medications, nerve damage in the chest. Just the top 4 I can quickly think of. Lynn

 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JackDCD
Lack of Immediate Attention

Lynn,

Again you continue to point out the "what if". Could all the things you mentioned happen?.yes.Is the probability high..absolutely not. As a matter of fact, very low and I would love to see that evidence you speak of. As you know ,Spontaneous malposition happens often enough and not causing death and destruction all over the world. How many home infusion patients are home with TPN, Vanco,etc. and PICCs are flopping up the back down. Probably more than we know. So although I agree with your "side effects" we can't advance our practice by getting stuck on the "what if". 

Additionally as a responsible Vascular Access Nurse I would hope you don't forget something like that, and continue to follow in the following days. But I really don't think you can have those problems you speak of with a PICC in the contralateral brachiocephalic getting Rocephin or whatever in 2 days!

lynncrni
A responsible clinician will

A responsible clinician will always create the situation that is the LEAST risk for the patient, which is a tip correctly positioned, recognition of a malposition tip with correction ASAP. That is the standard of care. 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JackDCD
Well, as a responsible

Well, as a responsible clinician, I would define that a little differently. A responsible clincian will always do what is BEST for the patient based on the situation they find themselves when performing any procedure. There are many scenarios that may fall outside the establishment's standards. A responsible clinician would be able to assess and respond appropriately in order to do what's best for the patient. Standards are just that, guidelines for care based on best practice. In other words: What to do in the perfect world. However, us clinicians know everything doesn't always follow the perfect world. As a responsible clinician you better know how to adapt and perform with what's best for that patient. That knowledge comes from years and years of experience, not a text book or written standards. So I would challenge any non clinical nurse that tasks themselves to be the guiding light, to stop the systematic dumbing down of nursing. Nurses should always be critical thinkers and not color by the numbers caregivers. We have totally aba

ndoned the act of thinking on your feet , or responding to the best of your ability. We now have to be told, Step one....Step two.....I remember a time when nurses had to think about their next move. Now, just follow the step by step guidelines that the non clinical experts have laid out for you and you will be a good little nurse. SAD

lynncrni
The only thing I can add to

The only thing I can add to this strange thread is that the standard of care and the standard of practice are NOT the same thing. You post seems to confuse these different things. End of discussion for me. 

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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