I work as a PICC nurse along with one other nurse in a 700 bed hospital. We use the Bard Solo Picc and all Bard products including the Sherlock device. Cathy and I have been very successful in getting our Piccs cavo-atrial or at least in the lower 1/3 SVC, however in spite of the placement we frequently have problems with Piccs that are getting about a 4-5cm coiling in the IJ with the remainder of the PICC remaining SVC. These are pt's who have no other lines when the PICC's are placed or afterwards so a CVC removal or insertion issue isn't the problem. What would make the PICC's coil upon themselves for what seems to be no apparent reason? Also, what's the best way to correct this problem other than replacing the PICC by an over wire exchange? I've tried flushing briskly which makes the PICC end up contralateral or has no effect at all. We were told that we can't pull the PICC back to attempt to straighten it and then re-advance it due to possible contamination issues so we're left with just replacing it. Does anyone else have this problem? Any advice would be greatly appreciated.
Annette Asbury
I am not quite sure what you are actually seeing. 4-5 cm of PICC length in the IJ could not possibly result in the catheter tip being in the correct SVC position. To travel up the IJ and coil, the tip would to be in the IJ as well. Are you saying that it turns upward toward the head in the IJ, coils and then extends downward. If that is the case, I still do not see how it could be long enough to have the tip pass through the brachiocephalic and then reach the lower SVC. I have seen PICCs go up the IJ, loop and then turn downward toward the SVC but never reach the SVC. When you used "coil" I think of multiple loops on itself. The only thing that has ever been suggested to reduce passage into the IJ is to have the patient turn the head to the side you are working on and place his chin on his chest. The arm should be at a 90 degree angle from the body. The goal here is to reduce the curve in the subclavian vein, and close the junction of the subclavian and IJ. Sometimes it works, sometimes it does not. This was the recommended patient position since we first began placing PICCs. Is this the patient position you are using. Are you placing these at bedside or using fluoroscopy? Are you getting the chest xray with the guidewire still in place or has it been removed? A PICC without the wire will usually move spontaneously due to the normal blood flow and this would straighten out the coils or a single loop. I have seen some very strange pathways for PICCs to travel without any plausible explanation. One patient had a PICC travel up the basilic, across to the contralateral subclavian, up the contralateral IJ, extend off the xray and then back downward and angle inward. The radiologist told me I had catheterized the parathyroid vein - go figure! I met no resistance or interference of any kind as this PICC was advanced. 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
Hello Lynn,
Thanks so much for your comments! The most recent PICC that this has happened was on one that was placed on 2/13/11. At that time the xray showed that the PICC was perfectly placed just at the cavo-atrial junction as was the xray results since then until today. For some odd reason the PICC has formed a loop that is extending up into the RIJ with the remainder of the PICC extending down into the SVC about midway. The PICC's are just spontaneously looping! I really don't know how or why as no other line was in place when the PICC was placed and no line added since. It's so frustrating to Cathy and I because it's happening so frequently and we don't have a cause???!!! It almost looks like a cursive "L" or like the PICC was placed, looped and passed down into the SVC when which was not the case originally as seen on xray. We're finding this occurrence about 3-4 days or more after the PICC has been placed. I think I'm going to call someone from bard to find out if anyone else has complained about this problem.
Thanks again,
Annette
Who is flushing these catheters? And how are they being flushed? There have been presentations, posters, and animal labs that have clearly shown that rapid, forceful flushing can lead to infusion-induced catheter movement. Greg Schears, MD and I gave a breakfast symposium on Perils of Power Injection at the 2010 AVA meeting. He has very good pictures of this actually happening. Are these silicone or polyurethane PICCs? Silicone, especially very small size PICCs are much more likely to do this. I have seen a 3 F silicone PICC flip into a wide range of positions just from a rapid forceful flush with a small 3 mL syringe. This was in a swine under fluoroscopy. So that would be my next avenue to investigate. What size syringes are being used? But more importantly what technique is being used. All catheters should be flushed with a slow, gentle steady force applied to the syringe plunger. If any resistance is met, additional force should never be applied to overcome that resistance. I would bet this may have a lot to do with what you are seeing. Let us know what you find out. 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
You might have something there Lynn. The PICC's we use are the Bard Power Picc Solo 5fr and 6fr and it happens with either, however the patients go to CT and get the power injected dye scans so perhaps the pressure injectors are the culprit. I'll have to investigate that further. The nurses only use 10cc syringes to flush the lines and it does seem to happen more often in the ICU than any other unit. In fact, I think that it happens only in the ICU's. You've at least given me a starting point. I think we may be able to figure this out after all. Thanks so much!
Annette
You may want to try advancing the picc more slowly, 1cm every 2-3 seconds. We found when the nurses were rushing to get the picc in, it did something goofy. Just advance slowly, you may be able to feel if the catheter is trying to loop.
elizabeth ferguson
Are you saying that during your insertion procedure, it you find it is malpositioned, you cannot pull it back any and re-advance? Are you implying you used to be able to do that, but cannot now?
Kathleen Wilson, CRNI
Hello Kathleen,
No. The PICC's are placed and correct placement confirmed by xray and then for some reason several days or a week later the same PICC's are showing this malposition for no reason. After the PICC has been in for this length of time we have to replace the PICC using a wire exchange rather than manipulating it to attempt to repostion it. In the past if something like this happened we would just try to reposition that existing PICC rather than totally replace it. The original PICC is placed using a Sherlock and is seen on xray in the lower 1/3 SVC or even cavo-atrial. So the question was how does this perfectly placed PICC become spontaneously malpositioned several days later?
Thank you for your comment!
Is is possible the patients are being placed in Trendellenburg and having vigorous flushing from a transducer pressure bag when they are zeroing a CVP?
Daniel Juckette RN, CCRN, VA-BC
You did not mention if you are using SherLock during insertion, but if this is happening 3 and 4 days post-insertion, patient positioning during flushing wouid have a high suspicion index. Is the CT power intector regularly calibrated? Do they note any change in contrast pathway during power intection? Are they actually using the power injector, or is it out of service and someone is trying to duplicate the effect manually? If the tip is migrating during power injection there should be some evidence in the CT images..
Daniel Juckette RN, CCRN, VA-BC
Daniel, why would there be such evidence with tip migration. The contrast is still being injected into the venous system, however if the pressure from the injector has changed the tip location it would be entering the vein at the relocated site. In other words it would be entering the bloodstream in the subclavian vein vs the SVC. With the rapid bloodflow in these large veins, I would not think that this would make much difference in the quality of the pictures for the organ being tested. 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
How does the dressing look? Has it been pulled partially out a few days later, then an attempt made to readvance?
Hi. Excellent question and observations. The secondary malpositions of the PICC tip are seen here in our ICUs also. I call it Flipping a PICC Loop (FAPLs). We find that several conditions or practices are "guessed" or "assumed" to cause this. Strong correlation probably, as one or several have all been present on the 14 patients in my short list.
The list: The "Heave-Ho": Very BIG patient moved mauka in bed with 4-6 nurses while the very BIG patient is in Trendelenberg position; CPR: found post Chest compressions; Ventilators: Higher PEEP settings, or any settings; Strap-ons: continuous anterior chest percussion/thumbing therapy with the automatiic 1hour strap-on chest vibrators; Flushing and CT injectors: Rapid pulsatile stop-start flushing and CT injectors ; Cough and Vomit: prolonged or forceful.
Often the loop is either tip pointing up or tip pointing down...but still with a single loop.
"Power flushing" with 20-30 ml of NS works less than 50% of the time and nearly never when the tip is pointed caudally. I believe and hope that performing jumping jacks in place would work, but never tried it and have no studies to support it.
I do not think it is a manufacturer's issue but a care and patient specific issue. Sure smaller light weight catheters may be more easily pushed around by the blood flow. High intrathoracic pressures and BIG SVCs with high volume also contribute. What is the CVP in which direction....when it occurrs? Not sure! I like to think of the SVC as a big wide river (supine) or a waterfall (upright) flowing into a turbulent pond. The regurge happens occassionally in an upstream direction pushing the PICC in retrograde. Why it doesn't always return downstream is also a mystery. Perhaps the sticky biofilm over time is too adherent and the tip is caught against the shoreline.
I would like to do a poster presentation someday on this with more patients in a study. We replace the PICCs that do not respond to the power flush or jumping jacks. : )
Scott Gilbert
Scott Gilbert RN, VA-BC, MPH
Honolulu,
Love it Scott! Actually the one or more of the circumstances you mentioned are also present in our patients in which this phenomenon occurs and always the ICU patients. Thank you for your response and insight!
My thinking was that, at least on a thorasic study, a change is the origin of the contrast would show on our 64 slice scanner. However, our CT techs have told me that they might see unusual variations in the injection pressure profile during tip migration but that would not trigger further investigation. The images are cued by the appearance of the contrast medium in the pulmonary artery, so the source of the contrast would not show a variance after passing the RA. They would not do a post injection scout image, even if the injection pressure had an unusual profile, unless the images were unsuitable for the ordered study. So that would not be a way to identify if the power injection was the cause of tip migration. Too bad post-injection scout images are not obtained. They might teach us something about the effect on lines.
Daniel Juckette RN, CCRN, VA-BC
I would suggest that this happens a lot more than we are aware. You may think that it only happens in critical care patients, but that's probably because CCU patients are the ones who tend to get daily chest films where the malposition is found. Once a patient is out of the unit, chest films are fewer and far between.
Wendy Erickson RN
Eau Claire WI
I agree with Wendy. We really do not have a good understanding of the frequency and all the causes of secondary malposition also known as catheter tip migration. The work now being done on infusion induced catheter movemet highlights the issues with flushing techniques but there are other causes. 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
Yes Wendy, you're probably right about that.
Thank you all for your help and responses!
Annette