Forum topic

11 posts / 0 new
Last post
Difficulty seeing PICC tip on x-ray

We are having difficulty with the radiologist's report with several of our recently placed PICC's. We order a portable chest x-ray after we are completely finished with the procedure. On what seems like many occasions  the radilologist will read the x-ray with the tip in the subclavian vein when we know it has to be lower than that. They do not recommend another film just advance the PICC 5-10 cms (based on where they think it is).We have explained that our PICC's are trimmed and can not be advanced.At least 4 times we have monitored a pt. that the initial report was tip in the proximal svc or higher and the next day when the pt goes to the department for the film they read it in the distal svc. If we suggest or order the pt to go to the department for an x-ray the radiologist seems to become quite offended. One radiologeist has suggesed that we iinject dye and repeat the x-ray. Do you have any suggestions that can help us in having better films or talking with our radiologists? None of them place PICCs-only RN's at the bedside.

Portable chest xrays are

Portable chest xrays are more challenging to determine tip location because the spine is in the forefront of the film. For this reason, a portable chest xray should be reserved only for patients that can not be transported to radiology. If the patient can go to xray, a portable xray is not the recommended method. Obviously the radiologist does not appreciate the recommendations for correct tip location and the risk associated with suboptimal tip locations. You will need to locate articles from radiologists to educate your physician. Look for articles by T. Vesely.  Also, without a chest xray, you have no way to "know" that the tip is passed the subclavian. There is nothing about your advancement technique that can tell you where the catheter is actually going. You should investigate the use of the current catheter locating systems (Navigator and Sherlock). There are also ECG-based methods to determine tip location which depends upon your ability to recognize a change in the P wave when the catheter passes the SA node. These devices have been discussed many times in this forum and should be easy to locate by searching. Infrared light devices are also in development that will provide tip location information but they are not available yet. 


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

There seems to be a

There seems to be a misunderstanding as to how ECG guidance works. (And, incidentally, ECG guidance would eliminate the problem you are having with chest x-rays since no x-rays are necessary for tip location purposes. (They would be necessary if there were a concern for pneumothorax or some thoracic consequence of the procedure.) Also be aware that, even under the best of circumstances,  x-ray may be misleading 20% of the time (when compared to echocardiographic tip location.))

The P wave does not suddenly change when you reach the caval-atrial junction; there is a gradual increase in size starting at about 4-5 cm proximal to it, i.e, in the proximal to mid SVC. (see representative tracings at As you become adept at the technique, you may place the tip of your catheter at approximately the mid, distal, very distal-caval-atrial junction by seeing this gradual increase in P voltage.

I have had a different experience regarding ectopy: Ectopy may be atrial or ventricular, may be seen in patients with no central lines at all and, in the literature and in my experience, I have not seen anything to suggest any certain pattern (singlets, couplets, frequency, etc.) is reliable enough to connote caval-atrial placement. (If there are papers supporting the use of ectopy as a location tool, I would be very interested in reading them...)

From my experience, when we

From my experience, when we have difficulty locating the PICC tip position in the pediatric hospital, we would either do a lateral oblique CXR (patient somewhat flat with a wedge on the side) or if still not visible we used Optiray (a contrast/ dye) and inject it at the same time as the tech takes the xray. I'm not quite sure if your PICC is radiopaque (which I'm sure it is). Another good point as what Lynn had pointed out  was attaching a monitor to during PICC placement (with the QRS tone high), the moment you here an ectopic beat this somewhat tells you that the tip has reached the RA junction (SA node).  How exact are you with your measurements, by the way.  Having the perfect measurement is optimal but sometimes if thinking that you'll be short of the line, adding a couple of cm's. wouldn't hurt. You'll just have 1- 3 cm external catheter at the worst case scenario.  Are your lines trimmable on the proximal end? Thanks

Sheila McChesney RN

Sheila McChesney RN CRNI 

We are getting much better with our measurements.We found that so many people really have no idea how tall they are! We do trim our PICCs on the distal end. Have you actually seen the monitor used? At INS last summer I sat in on the class about this, but haven't heard much more. Also, is the Optiray something our x-ray department would have? Thanks for your help.l 

Sheila McChesney RN CRNI

If you can stay with the
If you can stay with the patient and make sure the arm does not move, keep the guidewire in until the x ray is shot, then remove.    That should greatly improve visualizing the tip.
1. in response to ectopic

1. in response to ectopic beat, when you place an Cardiac apnea monitor on your patient, youll know what kind of rhythm your patient has pre-line placement.  Our surgeons and intensivist rely on the ECG monitor and QRS tone to determine if the guidewire has reached the  RA junction (SA node).  Once an ectopic beat is heard, he/she stops advancing the guidewire and she then place the CVC.  But nevertheless, listening to the ectopic beat is  NOT the only way to ensure proper line tip placement check.

2. Since you trim your line at the distal end, ensuring you have the accurate measurement would lessen the likelihood of your line being short.

3.  You may need to actually check with your Rad Dept to see if they carry the Optiray dye/contrast.

4. We love placing our PICCs under fluro wherein we can see right away where the tip is and able to secure and place a dressing over the PICC site right away.

5. If checking tip by xray, ensure the picc site arm is at the side (hand down by the hip).

Hope this helps you.

One more thing, I'm sure the

One more thing, I'm sure the Radiologist doesnt appreciate it if we suggest a second film. We came to them to get their recommendations on your line placement. Their recommendation was given and they fell that that's enough.  second guessing them can be perceive offensive.  NOW, in the peds world, we want our tip at the lower third (distal ) of the SVC, NOT the right atrium.  In the adult world, some Radiologist prefer it to be at the RA or SVC/RA junction.  You may need to check what your hospital policy is and per INS standards. 

not all PICCs are equal when

not all PICCs are equal when it comes to radioopacity. I stopped using a brand of PICC because of the difficulty in visualizing. Email me to discuss. 

We do also use RAO (right anterior oblique) to get the tip away from the spinal area where it is not seen so well.  Radiologists love this but then I have difficulty in seeing atrial appendage to verify atrial-caval placement.

|Contrast works but it is a hassle and allergy potential. Also, there may be visualized a "tail" of contrast coming out of the tip which will give you false depth.  (so I've been told by RAD. I think if you dont inject simultaneously with x-ray that should not be a factor.)

[email protected]

Chris Cavanaugh
There are many techniques

There are many techniques used take a portable x-ray.  Your PICC manufacturer is probably the best resource for this information, as sometimes, suggestions coming from the manufacturer hold more power than those coming from nursing.  I have worked with radiology departments to change their techniques for PICC visualization very successfully.  First, the issue really lies with the Radiology Techs that take the x-ray,  not the radiologist.  Go to their supervisor and see if you or your PICC manufacturer rep or clinical support can meet with them to improve this. 

Suggest creating an X-Ray for PICC tip visualization protocol, rather than a chest xray.  This protocol may include such things as a modified shoulder view on the side of placement rather than a chest.  Seeing the insertion site makes the PICC easier to follow.  Then have the patient be obliqued 10-15 degrees.  This moves the PICC outside of the spine.  Have the film taken when the patient exhales.  Suggest the x-ray settings be changed to  65-75 KV 100 MAS 0.5-1.0 seconds.

The next step for you would be if you have access to a PACS system.  In the PACS system, there is usually a "line view" setting you can try, or use the invert and zoom settings.  Invert makes black things white and vice versa, making the line black and easier to see sometimes.  If you disagree with the radiologist, you can then chat with him, pull up the film and use these settings to show him were you think you see it.  Believe it or not, some rads are so busy they don't really learn the PACS system and may never use these settings, nor do they want to spend the time to really play with the film to see the PICC better, and are open to this type of discussion.  They really want what is best for the patient and do not want the patient exposed to another xray either,which is why they rarely request a retake. 

Hope this helps you!

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

Ozzie Downes
Chris, How is this type


How is this type (PICC tip visualiztion) of X-Ray ordered and charged? If you could direct me on creating a PICC tip visualization protocol, I'll be very greatful. We get various reading depending on who is reading.

Ozzie, BSN 

We have had an ongoing discussion at our hospital about the length of time a PICC can sit on the skin before it is repositioned. I was wondering if anyone knows of any research articles on the topic. Please share them with us ( as you know the best arg

Log in or register to post comments