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Gwen Irwin
Malpositioned PICCs

If you have a malpositioned PICC, what are the steps that you follow at that point?  Do you power-flush?  What are the steps that you follow?  Meaning how much saline?  How is the patient positioned?

If you have spontaneously malpositioned PICC after confirmed tip location in the SVC, what are the steps that you follow at that point?  Do you power-flush?  What are the steps that you follow?  How much saline?  How is the patient positioned?

What is your success with repositioning the PICC in the SVC with the steps that you take for either of the above?

Do you know of published outcomes that support either?

Gwen Irwin

Austin, Texas

lynncrni
You will find some

You will find some information in:

1.    James L, Bledsoe L, Hadaway LC. A retrospective look at tip location and complications of peripherally inserted central catheter lines. Journal of Intravenous Nursing. 1993;16(2):104-109.

This study was done when we were using the original PICC, Intrasil from Baxter. It was a 16 g silicone PICC. We reported that primary malposition on insertion is most often spontaneously moved to the SVC with time. So waiting a couple of hours and repeating the xray was all that was needed. When we power pushed, the patient was placed in an upright, sitting position and a at least a 20 mL syringe was attached and flushed.

For a secondary malposition or tip migration during the dwell, I would recommend immediately stopping all infusions. Then try the power pushing to see if it works. I would assess for factors that encouraged this malposition such as excessive coughing, ventilators, congestive heart failure, etc. If these factors are still present, it may not remain in the correct SVC location.

Also placing the tip high in the SVC is associated with more frequent malpositioning. And I have been in an animal lab and seen where forceful flushing can cause some PICCs to severely malposition. I watched a 3 F silicone PICC move to the subclavian vein and coil excessively with forceful flushing and other polyurethane larger PICCs whip around in the SVC. This whipping motion caused lacerations in the vein wall. I think we need to learn a lot more about this problem. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

patgt8
Pulling malpositioned picc line to midline until can rewire

I am looking for any information, policy, procedures, recommendations, established practice or articles discussing pulling back malpositiioned piccs to midline until they can be rewired.  Is there a guideline to pull them back if it is in the IJ, upper third of SVC....etc.  Any information would be most appreciated.  Thank You.

lynncrni
 I would consider this to be

 I would consider this to be dangerous practice. First, if the indication for a PICC is determined by the type of therapy being given (pH, osmolarity, vesicant, etc) then it can NOT be infused through a midline. Also I don't know what you mean by "until we can rewire it". Why would you do this step, leave the patient and return at a later time? How much later? What could happen to that catheter during this interval with the extreme length on the outside. I think you should finish with this patient, before you move on to another one. When a PICC has gone up the IJ, you can do what once was called a "power push". Sit the patient up in bed, attach a 20 or even 50 mL syringe with saline and push to move the catheter to the SVC. Or simply wait and allow the blood flow to move it to the SVC and repeat a chest xray in a few hours. This is documented to work from as far back as the early 1990's. If you have not broken your sterile field OR you have protected the external catheter in a sterile field, you can withdraw and readvance to see if it will go to the SVC. If the catheter has been in contact with the skin, this is not possible as it is no longer sterile and you can not handle the catheter and readvance it. IJ is a common site for the tip. You can use your US to detect tip location here before you break the sterile fleld. ECG guidance will also show you that it is not in the proper SVC location. So withdrawing to midline would be the last choice and then I would only allow it to stay in that position long enough to obtain the extra wire, another kit, etc, which should only be a few minutes. I would never allow this to remain in place for more than a very short period of time. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

VAT RN
I am so curious how on earth

I am so curious how on earth you would check the IJ for the PICC using ultrasound, while staying sterile, and using a full-body drape. Can't get my head around that one.

My best advice is to beg borrow and hustle to get some sort of tip positioning system. There are several available. I have only worked with one brand but I would never ever ever ever go back to the "old way" of asking the patient if they hear the flush and a milliion (only a slight exaggeration) x-ray's.

After placement we will attempt the power flush technique. In addition to what Lynne described, I will have the patient raise their arm up to at least 90 degrees or higher and extend it back if possible. Before this process I will evaluate the chest x-ray so see just how far the picc is repositioned. In my practice it seems like anything more than 5cm is not likely to power-flush back into position.

VAT RN
I am so curious how on earth

I am so curious how on earth you would check the IJ for the PICC using ultrasound, while staying sterile, and using a full-body drape. Can't get my head around that one.

My best advice is to beg borrow and hustle to get some sort of tip positioning system. There are several available. I have only worked with one brand but I would never ever ever ever go back to the "old way" of asking the patient if they hear the flush and a milliion (only a slight exaggeration) x-ray's.

After placement we will attempt the power flush technique. In addition to what Lynne described, I will have the patient raise their arm up to at least 90 degrees or higher and extend it back if possible. Before this process I will evaluate the chest x-ray so see just how far the picc is repositioned. In my practice it seems like anything more than 5cm is not likely to power-flush back into position.

lynncrni
 You are right about this

 You are right about this being a logistical problem. But this would be done after the use of the US probe for venipuncture at the very end of the procedure. If you contaminate the sterile probe cover by applying it to the IJ region, and find the tip in the IJ, you could change the cover if you needed it again at the puncture site, but changes are that you will not need to repeat the venipuncture. Eager to know what others are doing. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

RWalsh
When I get an picc that is

When I get an picc that is malpositioned in the IJ or crossed over to the other side subclavian vein after the first xray I then will change the line over a wire and attempt to place a new line in the SVC.  This does not happen very often because as Lynn suggested I do check my jugular before I finish.  I do this at the very end of the procedure.  The probe is contaminated but I will not be making another needle stick.  Once I check the neck I simply place the covered probe at the end of my bed on my blue drape.  The only thing that has touched the patient is the tip of that probe.  I can then grab the US again if needed to check the neck again after a reposition (all before the line is competed and dressed). 

MarkCVL
I also check the neck at the

I also check the neck at the very end of my procedure....not a problem if you are mindful of sterile tech!!!!!

RoseFeltner
I remember seeing a poster

I remember seeing a poster about repositioning techniques at AVA several years ago. It was very good and spook to the specific type of malposition and what to do to correct it.

I do ultrasound the IJ at the end of PICC placement. This is when the catheter is advanced all the way (ususally dilator still in vein). I am still sterile and the only thing contaminated is the tip of my ultrasound probe. If catheter is seen then I can flush or retract and readvance catheter maintaining sterility and then see catheter no longer in IJ. Most of my PICCs are placed with an other PICC nurse who can US the IJ for me and many times we can watch the catheter being flushed out of the IJ.

When talking about other malpositions and latter malpositions everything is dependent on patient specific information and the severity of malposition. This would be difficult to have a specific protocol adreessing. Many times this is more of an specialized assessment made by PICC trained teams using thier advanced assessement of the situation to make decisions based on what is best for the patient.

Rose Feltner RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]

kathykokotis
under drape check of IJ

The glove holding your ultasound probe is no longer sterile the minute you go under a drape.  Think about that action hard.

sterile field is broken if you go under the drape with a hand and ultrasound probe.  You have broken the sterile barrier

I never see an MD go under the drape in a sterile procedure in the operating room.  Nor would you want an MD to go under a drape on your family member.

that would break sterility - no if, and or but....... about it

I would like to see you explain to the operating room director this technique of clean and dirty hand in yiour sterile procedure

Aorn guidelines would not tell you to go under the drape in a procedure and check a dirty neck in an area that has one of the highest rates of colonization.  The neck is loaded with bacteria last I heard.

Safe practice should prevail at all times

kathy kokotis RN BS MBA (former infection prevention nurse director in Chicago)

Bard Access Systems

patgt8
Pulling malpositioned picc back to midline

Please let me clarify my question.  A tip is found to be malpositioned post picc insertion , perhaps many days after insertion, perhaps weeks, or months. The pt is  on the floor and the cxr finds the tip malpositioned and the picc room is closed until the next day or until Monday, if it happened Satruday afternoon.  My question then would be, would it be best practice to pull the picc back to midline until the picc room was able to get the patient in for a rewire?    Or is it accepted practice to power fllush to reposition and do a cxr, and how many times would one try this?

  Thank you

lynncrni
 If a PICC was placed, the

 If a PICC was placed, the therapy indicated the need for CAJ tip location and a midline tip location will not work. I have an issue with this type of retraction as it is not meeting the patient needs. Also most everyone inserts PICCs at the bedside and a special procedure room is not required. So I would do the flush and repeat xray in a few hours. If that does not work, I would put in a new PICC. I would not do an exchange overwire. I am now researching this issue and have found at least 1 study in the neonatal popluation that overwire exchange has a greater infection risk than a newly inserted PICC. I do have an ethical problem with any system that cannot meet patient needs regardless of the hour or day of the week. A special room that is only available during certain hours or days represents a 2-tiered standard with the less than desired situation during hours when this room is not open.  Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

MarkCVL
Agree with Lynn.....my issue

Agree with Lynn.....my issue deals with initial insertion.  Was it short in the beginning...and if you reposition it with flush...is there anything to keep it from happening YET again? 

New PICC...New Hole...CORRECT LENGTH!

MarkCVL
I do agree with your

I do agree with your statement Kathy...but there was never a mention to going "Under the Drape".  The highest level of sterile technique must be employed with any placement.

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