I work in a large hospital where >95% of PICC lines are placed at the bedside and not in the IR dept.
Occassionally we cannot advance the catheter to the SVC region and the PICC is left in a suboptimal location with the tip in the innominate or subclavian veins. (Midline use at my hospital is very rare).
If we are unable to send the patient to the IR dept for catheter repositioning, we then obtain an order from the MD that Oks the use of the PICC line for peripherally concentrated IV medications and lab draws only.
Recently we had a patient that was to receive an Amiodarone drip through a left-sided PICC where the tip was at the junction of the left subclavian and innominate veins.
To complicate matters the patient had a documented history of a left subclavian occlusion, and old pacemaker wires not retrieved from a failed left-sided pacer placement.
I felt since the PICC tip was not in the SVC, the Amiodarone should be administered through the peripheral IV site that was present to the RAC vein. That way the site could be closely monitored for complications such as phlebitis and infiltration.
Two more experiened IV nurses I work with disagreed, and felt the left innominate vein was an appropriate location for a peripheral dose of IV Amiodarone, even though us super IV/PICC nurses lack the needed X-ray vision to monitor the infusion site for complications.
Fortunately this patient was on IV Amiodarone for less than 24 hours. But I still feel a bit bullied, and think my rationale is not wrong.