I have recently had 2 patients with pulmonary hypertension/cor pulmonale and both had PICC lines that spontaneously flipped up into the jugular (both were on vents and having daily CXR's.) Has anyone else seen this happen and does anyone have any literature/data on use of PICCs in patients with pulmonary hypertension. I wondered if they will always flip up or if this was just a coincidence. One of the patients had the line corrected and it was up the jugular again the next day. The radiologist suggested I discontinue the PICC and said it would just continue to flip up the jugular. Thanks for any input.
Catheter tip migration is a complication that is well defined and addressed in the published literature. We have always associated this with increases in intrathoracic pressure and a ventilator would do it. Tip positioning high in the SVC is associated with more frequent tip migration, so the tip must be at cavoatrial junction to reduce the risk but it still is not totally eliminated. The patient complaining of hearing a running stream or gurgling sound is a sure sign that the catheter tip is not aimed cephalad in the IJ usually, however it can go to the the contralateral subclavian. This increases the risk for thrombosis so it must be corrected before infusion therapy continues. Infusion into a tip angled cephalad in the IJ can produce neurological problems due to retrograde perfusion of the intracrainial venous sinuses. RE PICC removal, you would first need to consider the other option for vascular access. What therapy is needed? For how long? If less than a week and the pH and osmolarity permit, you could finish with a PIV. If a CVC is needed, you should have a surgical consult for a tunneled, cuffed catheter. These are a much larger catheter and do not tend to migrate as freely as the smaller lumen PICCs. Tip position must be at the cavoatrial junction though.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
I recently had this happen to a ptient twice awithin 2 weeks. The line was initially in the lower SVC. He was a ptient who had gone home on home IV's and they were having difficulty in getting a blood return. This patient was obese at over 400 pounds. The patient complained of discomfort with flushing. I did a chest xray and it had migrated up and coiled in the subclavin vein. IR redirected the PICC line under fluro with a wire. The second time he came in I was at a loss as to what to do. I again rexrayed and this time it was coilied in the IJ. The patient still needs a few more weeks of home IV meds. The only thing I could think to do was to go on the left side and hope the less direct route might help. So far so good. He hasn't come back with any more problems.
Rhonda Wojtas, RN PICC Team
Lowell MA
Rhonda Wojtas, RN,BSN, VA-BC