We recently had a patient at our facility who was found to have her port catheter coiled back upon itself and heading in the wrong direction in the brachiocephalic vein. There was no blood return. A vascular surgery consult was ordered. Because the port had been in place for three to four years, the surgeon determined no intervention was necessary despite no blood return and heading in the wrong direction! He considered the braciocephalic vein an appropriate placement and was not willing to admit a malposition. The port was placed at another facility. What I am looking for is the DEFINITIVE evidence for CA junction or lower SVC placement. I have the INS standards but for him it is not enough. HELP PLEASE.
Then use the references listed in the INS Standards. There are many medical references included. Look at the standard on malposition. Pull those studies for him. Your response should be also to have him show you the evidence supporting his position. (He will not be able to do it) IN the meantime, I would refuse to use that malpositioned catheter for any infusion because it is dangerous. Lynn
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
Refer the patient to interventional radiology. They understand vascular access much better than vascular surgeons. They can snare the catheter from below and pull it back into position. Sounds like it may have gone into the azygos vein.
My question is - has the patient been informed of the risk? The patient most certainly has a voice in this.
AVA (1998)
Lower 1/3 of SVC, SVC-RA junction
ONS (2004)
Lower 1/3 of SVC-CAJ
INS (2011)
Lower 1/3 of SVC-CAJ
FDA CVC Working Group (1989, 1994)
Lower 1/3 of SVC_CAJ
SIR (2000)
SVC/RA Junction
NKF/KDOQI
SVC/RA junction or RA
looks like you slammed that one! good job girl. :)
There are no definitive evidence. Just recommendations. My opinion!
Nurse specialist ICU/ANE/PICC.
Dep. of Neurosurgery
Umea University Hospital/SWEDEN
I disagree. INS, ONS, SIR, FDA, plus the catheter insstructions for use all establiish the standard of care, meaning what another reasonable and prudent professional would do in the same or similar circumstance. The documents from all the organizations listed in the previous post establishes what other reasonable and prudent professionals would do. Lynn
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
There is plenty of literature to support why the tip of a "central Line" should be deep in the SVC to prevent complications such as thrombus formation, and insure hemodilution. DR. Pittiruti and Cadman are a few that have done plenty of research on this topic and there are many more.
One would have to weigh the benefits and risks when leaving the device other than the SVC. A Neuro patient is at risk for increased intracranial pressure if a thrombus forms in the subclavian vein or IJ –why would you want to leave it there when an exchange of the catheter could fix this problem and improve your out comes?
Agree that the distal part of the cava, CAJ and a couple of cm in the right atrium is the best tip location. This is out routine since day 1 at our facility. I have also some difficulties to convince some doctors about the best tip location. But "definitive evidence" ? When I read INS I see only level 4 and 5 evidence exept "2. Suboptimal CVAD tip location in the mid-to upper portion of the superior vena cava is associated with greater rates of catheter-associated venous thrombosis.2,6 (II) (S71)". To ME that is NOT "definitive evidence" "Definitve" to ME is level 1 and 2. Some lecturers still says that "this is an unresolved issue"
Nurse specialist ICU/ANE/PICC.
Dep. of Neurosurgery
Umea University Hospital/SWEDEN
You are reading the standard on thrombosis, not the standard on placement. Also look at what those rankings mean. The ranking is the type of study that is available. A level 1 in the INS Standards would require a meta-analysis of many RCTs. It is difficult to find many RCTs let alone multiple RCTs on one issue. Lynn
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
@ kolodny - Hope you got some answers. There is a lot of controversy regarding this issue. Good luck
Nurse specialist ICU/ANE/PICC.
Dep. of Neurosurgery
Umea University Hospital/SWEDEN