Forum topic

quick question, if you can't get a picc line to thread, do you pull that line back to midline and secure it?  I am just curious about this procedure - I am hesitant to leave a picc placed as a midline because exteriorly it is marked as picc and then this becomes "off labeled".  We all know that despite the signs, education, and charting we as picc team members provide - someone will still take for granted that this is a picc line and infuse some type of vesicant through it without verifying true tip placement and therefore increase the probability of an adverse outcome for the patient (thrombus or other vessel problem).

I did this early on in my picc insertions because our IR informed us to.  After researching and finding out more education about why this shouldn't be done, I presented this info to IR and they no longer advise us to do that.  I realize you don't have IR to help with your lines, but if you provide this education to your MD's who may not be aware of the potential risks involved, I think you will find many of them will eventually come to support you and respect you for watching out for your patients.  If we can't advance a picc line into the SVC where it is truly a PICC, we discuss options with the physician such as a Hickman, PAC or a central line depending on how long the therapy is needed.  It's a difficult and tedious process to work through sometimes, but in the end you know that what you are doing is the right thing to protect you and your patients.

Hi Karen,

We (here at our facility) fully & completely agree w/ you.  We will occasionally receive an order from outside, for an OP to have a "midline" placed.  We then promptly call the ordering MD to advise... "we do not place midlines at this hospital" & ask if they'd like a picc while their Pt is already here.  The answer is always "YES".

Over the last 2 years, we've had 2 Pt's that couldn't be threaded to SVC D/T assumed thrombosis or sclerosis.... both were end stage renal Pt's, in ICU w/ significant need for immediate access & after exhausting the possibilities for a picc... left them as midlines.  This was considered to be the best course of action while the intensivist consulted a vascular surgeon.... it was felt that the midline was superior to the 24ga PIV's.  We will attempt both EJ's & UE's as appropriate to the Pt before surrendering to a possible midline. 

I do remember that one of these Pt's was attempted by the surgeon.... both IJ's failed to thread central & the best they achieved was a femoral line.... I don't recall the others outcome.

Because the midline is EXTREMELY rare here, we have our sign to help remind the RN's & the MD's that it's not a picc.... We make sure it's repeated everywhere.... Kardex, computer, above the bed, etc.... And, most important.... we're VERY anxious to see it replaced ASAP if LT access is still required. 

To sum up all this rambling..... we never start out w/ the intent of placing a midline.  If faced w/ a line that won't thread SVC, no other options (switching arms or moving to EJ) exists, we will then pull the tip back till our Navigator indicates that the tip is ~ mid-clavical & where a brisk blood return exists.  Next, evaluate this Pt for what would be the best possible access for the need & discuss w/ the attending MD.

Jim