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Neonatal picc placement question....

I accidentally nuked my last post of this… starting over.... thanks for your patience!!

Ok, I'm looking for those of you with pretty good x-ray & anatomy skills. 

I'm attaching 3 x-rays, 1 is the original for plcmt on 12/23 & the other 2 were taken on Christmas day.  I'd love to hear opinions on these regarding tip placement.

Hx - Placed this line 12/23... it's a 2FR silicone catheter, insert site is Rt Saph. vein.  I'll leave out the preliminary reading that I put in the "memo" & the Radiogist's initial reading for now.... I did pull the catheter back 1cm.

12/25 - Neonatologist tells the NI RN to pull this line immediately!!!  He documented in progress notes, after shooting the 2 films from 12/25, that "the picc tip is in a spinal vein". 

I'm sure this is going to be a hornet’s nest..... I haven't found one person to agree with his Dx, he's not going to be back here for a few weeks & nursery upper management is off till after the 1st. 

If he was incorrect, I want this to never happen again.... I had to put this baby thru a re-insertion in the opposite side (and, the films are identical after the iliac)..... if he's correct, please help me understand!!!!Thanks for your time & professional opinions, Jim.

Hi Jim, I wonder if the MD

Hi Jim,

I wonder if the MD is concerned that the catheter is in the ascending lumbar vein, which arises off the iliac vein.  It is more likely to happen from the left side due to the angle of entry.  I wrote an article about this in the Newborn and Infant Nursing Reviews, 2006, 6, 212-224.  The lateral xray will show the catheter to reside within the bony structures of the spine rather than on top as your xray shows.  While this malposition can be detected often on AP view, the lateral clearly demonstrates it.  I think the 12/23 film shows the catheter to be too deep and when you take into consideration the leg position (extended) it will probably be deeper when the baby is lying in the typically flexed position.

Janet Pettit NP/CNS 

Hi Janet, Thanks for your

Hi Janet,

Thanks for your reply.... I'm going to have to look for your article, I'd love to read it.  I heard exactly what you said at the AVA mtg in Phoenix this year.  That's why I was feeling confident that the plcmt was NOT "spinal vein".... just really needed to hear it from others.

Since I posted this.... our house supervisor armed herself with a Radiologist & another Neonatologist then proceeded to have a conversation about the way this went.... sounds like it shouldn't happen again without at least a Radiologist's input.

As far as depth.... I also felt 12/23 was a bit deep.  I pulled back 1cm on the 23rd (did NOT re x-ray), on the 25th it stll looks a bit deep.  Where exactly, in your opinion, is perfect tip plcmt on these little people?  My typical insertion site is Saph.  I'll attach x-rays of the re-inserted picc on the 26th.  The first one was shot AP, I knew it was deep, pulled back 2cm..... shot a LAT view just to cover myself & it almost looks like 2cm was too much.... I'd love your opinion.

Thank you,


Jim,   At least the



At least the original neo was thinking about the possibility of malposition and I would give him credit for that as too many don't.  The ideal tip location for leg insertions is unclear due to a lack of data.  I like to keep them in the upper or thoracic IVC below RA.  Probably closer to T9(though I always look at the anatomic  location and don't rely on the position adjacent to the rib. There are some good reports about UVC tip location that support this.  I also try to flex the knee for the film and put the infant in the position where I think they will spend the most time.  And, remind others to always try to perform same positioning for all xrays on that baby.  I agree that I would like to see the catheter a bit higher, but I can't tell leg position.  Some authors have recommended the tip be above L1 to keep it above the renal veins, which should improve hemodilution.  As you mentioned, sometimes a little pull back places the catheter in a suboptimal place and why I believe another followup xray is good practice; it could show that you might not have pulled it back far enough.  A legal case was recently won ($3 million judgement) where the tip was too deep and the catheter retracted, but not rexrayed and the baby had a pericardial tamponade and died.




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