Recently one of our nurses placed a PICC in a woman weighing 611 lbs. Portable chest x-ray could not penetrate through the layers of adipose tissue to see any of the PICC. The picture looked like a "white-out". After a repeat x-ray the view was unchanged. The nurse consulted with the primary stating that she could clearly see the PICC going down using Sherlock tip locating system and she had an excellent blood return. Patient displayed no cardiac arrhythmias. The primary physician consulted IR who state they didn't have any other options to visualize the PICC due to the woman's weight. The primary physician gave an order to use the PICC.
I had suggested that the stylet could have been left in place during x-ray and was told that given the poor quality of the film that even that wouldn't have been seen.
My question is, what are others doing when placing PICCs in patients that are too large for any diagnostic table (CT/fluoro)?
This was our first experience with a patient this size but I'm sure not the last.
If the patient is not allergic you can use contrast dye such as Isovue to "light" it up. Inject 1ml prior to CXR then withraw the contrast and flush as usual. Also - tell your rad tech to use a grid - they'll know what this means.
Hope this helps,
Nancy Costa CRNI
My first question is do you see these xrays as digital images? If they are digital, there might have some options to enhance the CVC to see the tip location. If not, there isn't much you can do to determine where the line is. I think that before we had digital images, that I could "hallucinate" the tip. HAHA
I am sorry to report that we have had many patients larger than this. I understand from the radiology techs that technique of the portable xray is critical. However, when we have patients larger than this (as much as 926 pounds), we have them use the Bucky grid. We have rarely had to use dye since we have had digital images.
Gwen Irwin
Austin, Texas
Yes we do have digital imaging. The radiologist still could not see anything. This woman had a huge chest/neck.
I'm not familiar with a Bucky grid so I'll have to ask about that. I thought dye could be injected at the bedside just prior to the film. The nurse that placed the PICC stated she was told it couldn't be done, that the fluoro machine would have to be used and this was not an option for a patient her size.
I would just like to clarify a process because I'm sure we will come across this situation again.
Sorry for the quick second response. I just spoke with the manager of medical imaging. He said that we haven't seen someone that big so having a plan would be a good idea for the future.
We use a CR system which he isn't sure if when you are saying you use digital imaging it is the same thing? A bucky grid was used on this woman. For those of you (including myself) a Bucky grid prevents scattering of rays when penetrating fat for a clearer picture.
Use of contrast dye can be an option for us and he is going to do some more investigating on this use. If anyone has anymore help info. on the subject, I would appreciate it.