I was wondering if anyone has had simular problems with PICC's causing runs of VT when pt's are lying down on either side. The pt's never have VT when the PICC is placed but hours later or in the middle of the night! We have been placing PICC's at the SVC/RA junction as a rule but now we are leaving them in the low to mid area of the SVC.
Does anyone have any articles or info on why a PICC would cause this?
Thanks
Victoria Sallese, RN, VAT, PICC service
Doctors have tried to tell us that our PICC's cause V tach. If the line is not in the ventrical, how can it be the cause of ventriacular tachycardia?
Victoria Sallese, RN, VAT, PICC service
Wendy Erickson RN
Eau Claire WI
I also agree with Wendy. Have personally placed 2 PICC's with tip at CAJ without any prior ectopy that developed short runs of VT. Consulting interventional cardiologist agreed PICC related due to resolution of VT after catheter tip retracted to mid SVC.
Timothy L. Creamer, RN
Clinical Specialist, Bard Access Systems
Florida Division
Timothy L. Creamer RN, CRNI
Clinical Specialist, Bard Access Systems
Florida Division
Staff R.N. with no affiliation to any product or health care company(your basic front line grunt/wage slave)
I concur with Wendy. It should also be noted that EKG changes are evident with tips entering the RA. Remember the SA node lives there ;~)
Inhttp://www.cja-jca.org/cgi/content/full/53/10/978
"In conclusion, during ECG-guided central venous catheterization, the tallest peaked P wave may be used to place the CVC tip at the SVC/RA junction, the normally-shaped P wave identifies the mid to upper SVC, and a biphasic pattern of the P wave can be used to locate the RA. "
"In a study by McGee et al.,10 the point of maximal P wave amplitude was presumed to be the catheter tip position closest to the sinoatrial (SA) node and the catheter was subsequently withdrawn 3 cm to locate the tip just proximal to the SVC/RA junction."
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
Never said V-Tach comes from the SA node. I have been taught that central catheters can elicit SVT(a quick search will return references). A quick search will show central catheter related V-Tach also and not necessarilary ventricular tip placment.
Mayo Clin Proc 2000 May;75(5):542.
"However, the PICC has associated risks. We present 2 cases of body position-dependent ventricular tachycardia related to PICCs. These events occurred in patients with no prior history of cardiac arrhythmia and were corrected by repositioning of the PICC. They serve to identify a potentially serious cardiac complication of the PICC that, to our knowledge, has not been described previously."
http://66.102.1.104/scholar?hl=en&lr=&q=cache:VFGGODKh0FoJ:www.mayoclinicproceedings.com/inside.asp%3FAID%3D1417%26UID%3D
Arrhythmia occurs commonly with placement of central venous catheters; ventricular arrhythmias may occur in as many as 25% of patients during guidewire insertion.11 In a series of 70 patients, Smith et al12 noted 3 with premature ventricular contractions during insertion of a PICC. Artru and Colley13 observed ventricular ectopic beats in 5 patients in whom a PICC was initially inserted with its tip positioned in the right ventricle. Similar ectopic beats were noted in 1 patient in whom the tip was in the right atrium and in 1 in whom the tip was in the SVC. In their experience with 963 successful PICC insertions, Ng and colleagues7 found delayed complications (not at the time of insertion) of palpitations, premature ventricular contraction, or ventricular tachycardia in 4 patients.
[quote=Glenda Dennis] VT does not come from the SA node, it comes from an irritation somewhere in the ventricle. If the PICC tip is in the ventricle, it can cause arrythmias, usually self limiting VT.
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
I have had only one documented episode of a patient experience a sustained VT with post PICC placement. I had finished a PICC in the ICU on a young man "30 something" as was finishing my paper work at the ICU nurses station. I saw them wheeling the crashcart into the room, looked up at the telemetry monitor he was in a sustained VT. The first thing that entered my mine was the PICC. On entering the room they were preparing to cardiovert him. He was not unconscious but not complete oriented either. I removed the dressing and put on sterile gloves while they were preparing for the cardioversion, I pulled the PICC back about 3 cm VT stopped.
Jeffery Fizer RN, BSN
Hi Lynn,
Yes we see that occasionally as well. One of the problems with piccs is that the tip will drop with arm position. I've seen it drop as much as 5 cm comparing an upright portable (arms down) to CT scan (supine, arms up). This is something that does not happen much with neck or chest inserted lines. The radiologists tend not to understand the motion of piccs in the body compared to subclavian and jugular lines. Hence they see no problem with piccs in the atrium. It is the potential for them to drop that is of concern.
The smaller a person is the more dramatic you will see this. Another factor is a patient's abdomen. If there is a lot of distention, it will shift everything up. Many factors to consider actually when positioning picc tips.
Darilyn Cole, CRNI
Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA
Hello,
I have a question for you all. At our hospital we only have picc nurses here from 9a-5p. If a pt has had a picc and then develops some arrythmia after placement and the team is gone who would pull the line back? We are trying to figure this out here. My recommendation would be to have a nurse who is competent to remove a picc be the one to pull the line back and ask for an xray since they are familiar with the measurement markings on the line.
Next question is if you also allow this then do you have a policy or steps in how you would do this to add to a policy?
Thanks,
Renee
I strongly believe that anyone manipulating, readjusting, retracting, etc a PICC should be one of the staff that is inserting this line. I do not think it is appropriate to turn this over to the staff nurse. They already have enough on their plate, along with not having the same body of knowledge and skill as the PICC inserters. Turning tasks like this over to the staff nurse is abdication of the responsibility of the PICC inserter in my opinion. This is the type of attitude that allows for other professionals (respiratory therapist, radiologic technologists) to step in and convince administration that they can meet the needs of patients for all vascular access much better than the infusion/vascular access nursing staff. Removal of a PICC and making adjustments to the tip location are not the same thing. What would be the cost of educating and documenting competency on every staff nurse? I think it would be cost-prohibitive. And having the PICC inserters on call for this type of action would be a more cost-effective approach.
If you do decide to allow primary care staff nurses to do this catheter manipulation, you absolutely must have policies and procedures to a) incorporate this into their scope of practice, and b) guide them in exactly how to do it, and c) you also must have documented competency that each one can do this. If your team is to be a vascular access service, that is a 24/7/365 role. If you are only focused on the task of insertion from 9 to 5 Mon-Fri, you are making a serious mistake in my opinion.
Also, I am curious to understand more about why a PICC properly positioned on insertion, documented to be in the lower SVC or CAJ and appropriately secured would suddenly be the cause of a cardiac arrythmia. Does this happen frequently? Are the inserters assessing the chest xray for correct tip position? Are you using ECG guidance for tip location? 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