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Mats Stromberg
Infection risk and PICC tip in cavoatrial junction/RA


placed a PICC this morning (4 Fr Groshong). Tip got placed in deep vena cava sup near entry to right atrium. Radiology dept suggested to pull the catheter 1-2 cm, but I told the physician on the ward that it was really fine where it was.

She the told me that they had had a patient with a Hickman residing with the tip some centimeters down into the atrium and he had developed a "thick layer of bacterial growth" on the catheter surface. This growth, the physician told me, was due to the low tip location where the turbulant blood flow would give a higher risk of infection and thrombosis. Thus she wished to pull the PICC 1-2 cm, and I said OK, then you should probably do that.

- Is it correct that a tip location in the atrium means a higher risk of infection and of thrombosis?

- Is tip placement 1-2 cm above cavoatrial junction better than at the junction?




In the US, recommended tip
In the US, recommended tip location for all CVCs, including PICCs is at the cavo-atrial junction. There is no evidence that I am aware of to support your physician's idea about this being a higher risk for infection. Tip location has not been associated with bloodstream infection, other than the risk of first developing thrombus and then it becoming infected. Toward that end of reducing the risk of thrombus, the cavoatrial junction is recommended. Also there are no studies comparing lower SVC, CA junction or RA tip locations, so we do not actually know which produces the best outcomes. But infection is linked to skin and its antisepsis and hub management, not tip location. Lynn

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

Mats Stromberg
Thanks Lynn, What is your

Thanks Lynn,

What is your and everyone elses practice when a PICC gets tip placement

- in the CA junction?

- 1-2 cms into the RA?

What catheters do you pull up and how much?


Heather Nichols
Mats,    How are you? 


   How are you?  Haven't heard from you in awhile.  Hope you are doing well.

  Just thought I would add that there have been studies that show (and I can't quote them to you, but I do know they were disscussed at the last AVA conference by a vascular radiologist) that the best placement for a dialysis catheter is in the right atrium, and those catheters are huge and usually not well cared for on the outside, so if what your doc said were true, I think we would not see physicians placing these lines in the right atrium.  And this does not make sense to me anyway.  I always thought that the more blood flow you have, turbulant or not, the better it was for the catheter to NOT develope thrombus.  I would ask your doc to provide you with some info on this statement.  I do not know about you, but I get tired of looking up stuff to refute these doc's.  Let her bring you the studies to show she is correct.  I bet she can't. 

  Have a nice week!


Mats Stromberg
Thanks Heather, I bet she

Thanks Heather,

I bet she can't. And my reasoning is just like yours: the more flow and the more turbulance, the risk of thrombus and infection should get lower, if anything. Not greater.


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