Forum topic

Try these 2:

1.    Vesely T. Central venous catheter tip position: A continuing controversy. Journal of Vascular and Interventional Radiology. 2003;14:527-534.
2.    Vesely T. Optimal positioning of central venous catheters. Journal of Vascular Access Devices. 2002;7(3):9-12.  

 Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

We have had an interesting development with our largest radiology group.  They have had internal conflicts about SVC placement.  I was amazed with this sequence of events!  They have reviewed anatomical locatioins and are getting more in alignment with those junction calls vs. tip in the atrium, based on the anatomy.

Hope this can happen for you.

Gwen Irwin

Austin, Texas

Does anyone have radiologists that give the "ok to use" on piccs terminating in the subclavian vein?  I have seen piccs insereted that go up the jugular vein and when pulled back end in the subclavian, it cannot be advanced so it is left in that location.  Any thoughts on leaving the picc in the subclavian?

Kevin

We have had success with power flushing (turbulent flushing) to get it to reposition into the SVC in a very short period of time.  Not waiting 2-4 hours.  Also, tip locator system is amazing to prevent IJ tip location.

Gwen Irwin

Austin, Texas

Appropriate tip location has also been defined electrocardiographically - the SA node sits at the SVC - right atrial junction and as you get within 10 - 15 mm of it or so from the distal SVC, the normal appearing "P" wave increases its voltage several fold (http://www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm) - advance your catheter until the P wave starts to increase its voltage, then pull back until the normal configuration is just regained. This will put you into the distal SVC essentially all the time assuming the patient is not in atrial fibrillation or pacemaker dependent. This technique has been commercialized in Europe by BBraun (see their Certofix and Alphacard products at CVC-partner.com) but these products are not available in the U.S.

 ECG guided tip location is less expensive and more accurate than chest x-ray or navigational systems (since the relationship of surface markings to anatomic landmarks is highly variable patient to patient). As the results are available immediately, there's no waiting for an x-ray for placement purposes (although the technique does not rule out iatrogeny) and you leave the bedside onto the next PICC knowing you are in good position.

We are using the Sherlock system.  We can tell with our repeated experience using this system if it is in the SVC.  We don't use this to determine only if is in the IJ.  Based on the info at the time of the PICC insertion and using the tip locator system, we have withdrawn the PICC to the position in the SVC vs. in the right atrium.  Chest xrays have confirmed this as being the correct action.

With experience, we have also been able to recognize the PICC that is too long or too short  and adjucted before the xray.

 Gwen

I am searching for States with PiICC tip verification by the PICC nurse.  There are many states that are Decision Tree states. 

I would like to collect some data on how these nurses are covered for reading the tip placement, via the chest x-ray, and how this is documented in the chart.

I live in AR and am working on this project for our facility.

Thank you for any info.

Dana,

Look at Tim Royer's article "Taking the Leap from PICC Placement to Tip Placement" from JAVA 2007.  It lists the states that allow Nurse interpretation of CXR for PICC tip placement, both decision tree and advisory opinion (page149). The article is excellent for those who are planning to ask for expanded scope of nursing practice, via their State Board of Nursing, and delineates the necessary steps.  I am in the process of doing this in Illinois, with support through our IVAN chapter (Illinois Vascular Access Network), a network of AVA. There is also excellent advice in the JAVA 2009 article "Accuracy & Timeliness of RN vs. MD Radiological Interpretation of PICC tips". Another source is the class taught by Jamie Bowen-Santolucito, RN & Dr. Dave Vegas from Oregon Health & Science University, "Radiographic Verification of PICC Placement".

April Swenson

Alexian Brothers Medical Center, Elk Grove Village, IL

Susan,

   You might also want to look at using the Navigator navigational device.  We have been using it for years here at U of L very successfully.  With practice, you can tell exactly where your tip is, and I do not mean a guess.  We get a surprise every great once in a while, but 9.9 times out of 10 we are right where we measured.  Now if you measure inappropriately, you will not have a tip in the correct place.  That is where a few other tips can be helpful.  If you possibly can view a chest x-ray before placement, you can better determine your measurement needs.  Of course you probably already realize that everyone has a different structure, and the more people you PICC, the more experience you get at judging externally how deep a persons SVC is gonna be, but it is nice to look at an x-ray to be sure.  The Navigator allows you a little bit more freedom to evaluate external land marks as you place the PICC as long as you have your full barrier drapes in place.  The Nav will also tell you where it is no matter where it is.  If it comes back down the arm, contralateral, up either IJ, into a chest vein, into a left sided SVC, or even in the atrium, you can find the tip and figure out where it is so that you can better position your patient to fix it. 

   I do not know where you are located, but if you are anywhere near Louisville Kentucky I would be glad to let you shadow our team to see how well it works.  It is definately not fun to deal with radiology.  Good luck with that. 

What communication from the physician who placed the CVAD to the nurse who will use it, is acceptable when documenting confirmation of tip placement of CVAD?
I was always taught that "OK to use" is not acceptable order by the physician because it can be misinterpreted.
Is there literature to support this?
the new INS standards does not speak directly to the role of the floor nurse and how to confirm placement. Standard 23 I. Does say " document the CVAD tip location ... but does not say what the nurse caring for the patient should do.