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etroesch
R Atrial Tip Placement

Has anyone seen PICC tips intentionally placed at the top of the R Atrium, just beyond the CAJ?  Our IR dept is suggesting this, citing a decrease in fibrin sheath formation. 

Has anyone seen this...What are your thoughts?

lynncrni
When I have requested that

When I have requested that these radiologist provide studies to support this idea of less fibrin when the tip is in the RA, I have never been given any published articles, non-published opinions, or white papers - nothing! I have done lit searches and not found this published either. So I question where their evidence actually is to support this practice. I know that there is no study comparing the outcomes of SVC/RA junction location vs RA location. 

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

Dan Juckette
Daniel Juckette  RN,

Daniel Juckette  RN, CCRN

Some Interventional Radologists I have spoken with say their rationale is that they place dialysis catheters down in the RA because fibrin clogs them if placed in the SVC. I have noticed an interesting phenomenon with the SherLock Tip Locator. As you are advancing the tip near the CAJ, when you pass the transition, the respiratory artifact of the tip changes. In the SVC there is side-to-side artifact that becomes in-and out ( or up and down) artifact when you pass the junction.

Daniel Juckette RN, CCRN, VA-BC

rivkalivni
I found out that there is a

I found out that there is a wide range of opinion amongst chest radiologists where exactly is the CAJ?

Some radiologists use the margins of the Right bronchial main stem as the position of CAJ which to other chest radiologists will appear as Mid SVC.

Some radiologists say the CAJ is 5cm below the Carina which to other radiologists will appear as 2cm in the RA. 

We have placed PICC tips in proximal RA in Endocarditis patients with severe Tricuspid valve regurgitation who have a history of "coughing" their PICC into the IJ for a late malposition and if we were unable to "flip" it back into the SVC we will exchange them with a longer PICC.

Rivka Livni PICC RN

Gwen Irwin
We are experiencing quite

We are experiencing quite the opposite.  Our IR and other physicians are in support of shor t of the cavoatrial junction.  We keep getting calls about ectopy, v-tach, et. al.

We also have many differing readings about CAJ with radiologists and intensivists.

Gwen Irwin

Austin, Texas

JackDCD
[quote=etroesch] Has anyone
[quote=etroesch]

Has anyone seen PICC tips intentionally placed at the top of the R Atrium, just beyond the CAJ?  Our IR dept is suggesting this, citing a decrease in fibrin sheath formation. 

Has anyone seen this...What are your thoughts?

There is still much confusion about the proper placement of a PICC tip. The general opinion now is the tip should reside at the cavoatrial junction. The problem is many Radiologists are unfamiliar with the location of the CAJ. On a standard CXR the location of the CAJ has been identified at the portion of the right heart boarder that begins to laterally move away from the mediastinum. However, recent studies revealed the what we are seeing on Xray is in fact the Caval-Atrrial Appendage. The CAJ is actually located 2 cm below that point So, the latest and greatest is the perfect position for the tip is 2cm below or above the Atrial Appendage. that is the new "landing zone"

PMRMD
Unless you are using

Unless you are using fluoroscopy or echocardiography, the caval-atrial junction is best defined electrocardiographically. As pointed out, chest x-ray may be misleading 20% of the time. There is great patient-to-patient variability and surface landmarks (the underpinings of navigational systems), relationships to the carina or other structures on x-ray, etc. are not reliable. Studies correlating echocardiography with ECG guidance (see http://www.pacerview.com/index_files/ECG_GUIDANCE_FOR_CVC_PLACEMENT_IN_THE_LITERATURE.htm) show that the point of maximal P voltage correlates best with the caval- atrial junction. Also, as you enter the atrium, a small spike oppositely deflected from the rest of the P wave appears. It gets larger as you advance further so that the P wave will be biphasic (half up, half down) in the mid-atrium and totally positive (as viewed in a lead II) at the bottom of the atrium.

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