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rsmullen
F/U Chest Xrays after picc reposition

We have been a picc team almost 2 years. We use the Sherlock to help position into the SVC. My question is: If the CXR shows the picc tip overlies the R atrium and using the CXR to measure how far back to pull the picc to the atrial/caval junction. After pulling back the picc do you f/u with another CXR? It seems to me that if you measure correctly then it reasons to stand that the picc tip will be at the point that you measured and a f/u CXR is redundant.

What are your thoughts?

Penny
I would think that you need
I would think that you need a follow-up chest x-ray, one that documents the correct position.
PMRMD
This is an ideal situation

This is an ideal situation for ECG guidance. As I've written in other posts, you can derive an ECG from the saline in the catheter. If you are already in the right atrium, the P wave (assuming the patient is in sinus rhythm) is entirely positive (upright) at the bottom of the atrium, biphasic (half up, half down) in the mid atrium, and mostly negative (downgoing) at the top, near the SVC-Atrial junction. While watching the ECG on the monitor, pull the catheter back until the p "spike" becomes a "u". (see http://www.pacerview.com/HOW_PACERVIEW_FACILITATES_PLACEMENT_OF_A_TEMPORARY_TRANSVENOUS_PACEMAKER_WITHOUT_FLUOROSCOPY.HTML)

A paper recording documenting the transition is your proof, no CXR is needed, and the whole thing takes under 5 minutes.

 Peter

Cindy Schrum
Cindy Schrum RN CRNI It's
Cindy Schrum RN CRNI

It's ideal only if your patient needs a pacer.  

If the radiologist would give us a measurement, we would document 'Picc pulled back 3cm for SVC placement.'  This way anyone who saw the report and knew enough (or cared enough) that the tip was in the atrium, could see documentation that it had been addressed.  If it needed to be pulled back more than 5 cm we got a repeat CXR.

Cindy Schrum RN CRNI

PMRMD
I'm not sure where you're

I'm not sure where you're getting the idea about "needing a pacer". The PacerView  allows any intravascular ECG signal to be displayed on a bedside monitor. The ECG 's you see on the pacerview website are tracings from electrodes passing from the SVC to the atrium and to the RV. Whether that signal is derived from a pacing electrode, guide wire, saline in a catheter, etc. is immaterial - they are identical and the same principles that guide pacing wire placement can guide CVC placement (really a subset of the pacing procedure since you have to pass through the SVC and atrium to get to the RV to pace). ECG localization is more accurate than chest x-rays (again, as long as the patient is in sinus rhythm). It is also cheaper, avoids radiation exposure and saves a lot of time. (How long does it take your hospital to take a chest x-ray, interpret it, then for you to return to the bedside and adjust the catheter - ECG guidance takes only as long as it takes to snap the patient's ECG lead onto the pacerview and to connect the pacerview to the guide wire/ saline column and then pull back the catheter a few centimeters.- ? 5 minutes ?)

sesymons
The pacerview sounds pretty

The pacerview sounds pretty cool but I think is beyond the scope of many PICC RNs.  Plus, you pretty much have to be in a cardiac monitoring unit and of course have this particular piece of equipment. Other posts have mentioned monitoring the CVP during repositioning.

Measuring the CXR is not a truly accurate way of determing how far to pull back a PICC although it works pretty well most of the time. 

Its best to get a repeat CXR for documentation purposes even though we are pretty sure we will end up "in a good place".  That way you have a leg to stand on should there be any legal entaglements for some future problems. Its a sad state of affairs when we have legalities ruling our practise. But its a fact, mam.

PMRMD
Although you do need a
Although you do need a cardiac monitor, you do not need to be in a "unit". We have put them in on the medical floor using any available portable monitor. (If your portable monitor does not have a "chest" lead, you can snap the "left leg" electrode onto the Pacerview and display a "Lead II" . ) Once you have actually seen the tracings "in real life", you will realize it is not beyond your scope. The changes going from the "u" shape in the SVC to the spike in the atrium are dramatic with the voltages increasing up to 8 fold! (The P wave is commonly of voltage equal to the QRS in the upper atrium so you see a double spike)
lynncrni
I do not think it would ever

I do not think it would ever be beyond the scope of practice for nurses to use ECG for determining catheter tip location. It would require that we learn this new skill of interpretation of ECG tracings. Several years ago, I was consulting with a company working on such as device that would use ECG but it would display as a series of lights thus eliminating the need for interpreting the exact tracings. I have looked at your website for Pacerview. The setup looks complicated and this means an increased risk for contaminating the field but this may be just my interpretation from the limited amount of information on this website. 

The thing that I am most concerned about is your idea that ECG can replace or eliminate the use of chest xrays. While this may be possible, there are numerous documents from professional organizations and regulatory bodies that establish the national standard to be obtaining a chest xray from final tip location. Changing this standard would require clinical studies to document the effectiveness of this process. As nurses, we adhere closely to those national standards and would not easily change our practice without those clinical studies to establish that the safety and efficacy of using ECG. I think this may be the future, however I think the products used for connecting the ECG to the catheter or wire must be more user friendly and nurses who insert PICCs will have to add this skill to our current practice through more education. Lynn

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

PMRMD
Actually, the literature is

Actually, the literature is replete with studies documenting the accuracy of ECG guidance. The BBraun "Certofix" catheter, a CVC widely available in Europe, is based upon this technique with an ECG signal obtained from a guide wire and routed through their "Certodyn adapter" to a monitor. The BBraun Alphacard (also only available in Europe) is also based on this technique (and, in fact, was based on an American product that was not very successful, the Arrow-Johans adapter). ECG guidance cannot tell you if you are going transthoracic or up an I.J. It can absolutely tell you that you have obtained an atrial signal and the demonstration on pull-back of an SVC signal is documentation of tip location. For lines initially placed in the atrium (as documented by CXR), ECG is a highly accurate way to reposition without the necessity of a follow up film. Do your own brief study of 5 or 10 patients. While the concept may be intimidating at first, when you actually see it (again, the tracings are exactly the same as on the Pacerview website), the learning curve is very short.

The connecting wire is non-sterile and would be clipped onto the proximal-most part of the guide wire during insertion. It is long enough so the wire and Pacerview are well off field.

Heather Nichols
  Dr. Peter,       I

  Dr. Peter,

      I have to agree with Lynn whole heartedly.  I have already stated in previous email that it sounded intimidating, but after looking at the website, I can say it LOOKS intimidating.  I must also ask about the possibility of contamination.  Things do not seem to be very sterile to me.  I would also question pricing on this whole venture.  I asked around the hospital, and in order to use a monitor and/or, the ekg machine, you would have a patient charge of at least 125.00 or more.  That does not include interpretation of the ecg readings.  A nurse can interpret the reading for him or herself, but in a court of law, I am sure you would have to have a MD to back you up, and they aren't gonna read it for free.   If I got the wrong impression about how this works, your website is to balme.  I read the site through, and as a very experienced ER trauma nurse/PICC nurse, it was confusing to me.  Maybe if I was actually using it, it would be different.  I don't know. 

   To answer the question about the CXR repeat for pull back, I would say that legalities rule these days, as the other nurse pointed out.  Sad but true.  Better safe than sorry.  PICC's do the crazyiest things!  You just never know where they will end up.  I once had one to deep in the atrium, so I pulled it back 4cm, and it floated into the azygous vein before the next CXR could be obtained.  How often does that happen?  I would never had known if I had not repeated the CXR.  We made it a policy that if you have ANY manipulation of the PICC, you re-xray.  It does not happen much since we use Navigator, but we still occasionally have a second CXR.  The Navigator keeps us pretty precise.  Good luck.

Heather

    

PMRMD
Heather - You raise good

Heather -

You raise good points and I appreciate them:

1) I'll try to re-do the web site to make it more clear. The Pacerview works the same way any unipolar lead does.  For those who want to understand that aspect, the information is on the site. If you don't, apply the patient's limb leads (right arm, left arm and left leg) the same you would do for any monitor and snap the "chest " lead onto the Pacerview. From there, any ECG signal plugged into the Pacerview will display on the monitor. To get the signal into the Pacerview there is a connecting wire (not shown on the website) that will clip onto the guide wire.

2) As far as contamination, once the guide wire is already in place, the connector is attached to the farthest end of the guide wire (sticking out of the patient). The wire is 2 ft long, carrying it well off the sterile field. In the procedures I have seen, this tip of the guide wire is generally treated as a "no-man's land" anyway.

3) Cost: I have not seen charges applied for simply using a monitor. No technician is needed. I guess the question here is what is your time worth? If you can leave the bedside knowing it is good position and place another, isn't that worth something also? What are the hazards of leaving the line while manipulating the patient to position for a CXR, waiting for the interpretation, etc. Before I started using ECG guidance for CVC's, it would take me close to half an hour or more to stabilize the line, get the x-ray, look at it, and return to the bedside, reposition, re-suture, re-dress the site, etc. That's a lot of time for me to waste.

4) As far as your experience in your pullback, I think the key is it was an empiric pull back. If you are getting an atrial spike, you are in the atrium. You can actually watch the P wave get smaller as you pull back and you are literally monitoring your position millimeter by millimeter. With ECG guidance, you don't pull back an extra cm "to be sure". You precisely place your tip (and the ECG is accurate to within about 10 mm or so.)

I would encourage you to Google "ECG guidance PICC" or "ECG guidance tip" or look at this: http://www.evanetwork.info/uploads/pittiruti_2007_-_tip_location.pdf.

Once you see it work, you'll question your hesitance.

Please keep your suggestions and concerns coming.

Peter 

lynncrni
I don't think we are

I don't think we are hesitant to use new technology that will benefit our patients and save us time. But at the present, I can totally understand Heather's reservations about the time and costs to use such an ECG-based system. I do not believe that a vascular access team would easily be given access to freely use any ECG machine, leads, etc without the usual charges to the patient. Historically we have not used such equipment and therefore it is not readily available to us. 

With the current recommendations of maximum sterile barriers for all CVC insertions, your concept of the external tip of the guidewire being treated as "no-man's land" is completely outside of our thoughts and practices. All catheter components, stylet wires, guidewires, etc must be maintained on the sterile field and kept sterile. From my understanding of your system, you must clip something to the wire that extends from the catheter hub. For PICCs, there may not be a wire extending from the catheter hub. There may be a hub on the stylet wire that is seated inside the catheter lumen. So there would be no wire to clip to the ECG leads. For the most part PICCs are inserted using the modified seldinger technique instead of a true seldinger technique.

I think that ECG and infrared light technology will help us to better identify tip locations in the future. But I do not think this ECG system is very user-friendly at the present time. And it remains to be seen whether ECG or infrared light will be the "winner" in this race to gain clinical acceptance.  Lynn 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Heather Nichols
         Thanks for

   

     Thanks for the response Dr Peter, but I think I will stick with my Navigator for now unless you want to come and work with me for a while.  It really does sound neat, but a whole lot more comlicated then the navigational device we now use with a simple CXR.  I cannot wait to see the devices of the future.  I think we are VERY close to replacing the CXR, but we are not there yet. 

   Heather

Beth George
*****

*****

Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL

Gwen Irwin
Interesting discussion. We

Interesting discussion.

We (and the radiologist) believe if the tip is different from the original position due to withdrawing however many cm., then another CXR is needed.  For legal purposes, we do another CXR to determine the final tip location.

Gwen Irwin

Austin, Texas

lejohnson
We have also had this

We have also had this happen, with different radiologists or the same.  We do look at the CXR film ourself. But we still take that last image.

On several patients, especially those with large vessels, we were being questioned as to whether we had moved it all.  We had in fact withdrawn 3 or 4 cm as recommended by the radiologist.  There was no doubt on our behalf and we had the external graduations visable to prove it.  But when you view the images beside each other, you can see that the tip has not moved.  You can see the curvature of the line has moved; we had apparently just taken up the slack.  We point this out to the radiologist, make the necessary adjustment, and monitor more frequently.   We typically know if this is a  possibiliy any time we place lines in extremely large vessels.

If we don't have an image showing the final position with an accompanying report by the radiologist, we get orders the next day anyway stating it is too deep, we have to take one anyway before we pull back more.  At least taking the final shot, provides record of what was done and eliminates the situation described above.

Larry

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