Anyone knows if there is a new position paper coming from AVA or INS or so regarding PICC tip position. The latest was from 1998 (AVA), as far as I know.
The 2006 INS standards of practice address this. I don't think AVA is working on revising their paper but don't know for sure. Do you have specific concerns?
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway, M.Ed., NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
My understanding is that because the AVA position on tip location hasn't changed, there is no need for a new position statement. Position statements are unlike literature used for evidence based practice - if the date seems distant, it means the evidence still supports that position, and there is no need to change it.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
no concern really, but I was thinking that maybe the cavoatrial junction would be considered OK as well as lower third of the cava. What is your view on that? What is anyone elses view? Is the junction as OK as lower third of the cava?
Here is the statement from the INS standards, 2006
"Central vascular access devices shall have the distal tip dwelling in the lower one third of the superior vena cava to the junction of the right atrium. Those central vascular access devices using the femoral approach shall have the distal tip dwelling in the thoracic inferior vena cava above the level of the diaphragm."
So the CA junction is a good place, just not inside the RA.
for pointing out the INS standards. I do have them.
I also now checked the Royal Collage of Nursing Standards of Infusion Therapy (2005) and they say that "Central catheters should have the distal tip dwelling in the lower third of the superior vena cava or right atrium." Also, rechecking NAVAN-98, it actually recommends "the lower one-third of the superior vena cava (SVC), close to the junction of the SVC and the right atrium". There is really a only very small difference between "close to the junction" and "the junction". Probably difficult to clearly differentiate on the x-ray. Do you agree?
So, I think that we could safely start accepting tip locations at the junction and stop pulling those lines 1-2 cm:s, as we have done up to now.
I do agree. Close to or at the CA junction is very difficult to determine on xray. The point is you do not want the tip to be inside the RA or past the SA node which can trigger arrhythmias.
I have previously written in these discussions about the benefits of ECG guided tip localization and this is an excellent example. The chest x-ray is not a good way to determine where the SVC ends and atria begins; the ECG is better. The P wave begins to elongate about 4-5 cm above the level of the SA node. It reaches its maximal negative deflection (usually at least 4x and more commonly 6-8x the baseline voltage) in the upper atrium, opposite the SA node. In addition, when opposite the SA node, it can develop a small upward spike before the much larger downward spike (see http://www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm). (Also see Yunseok Jeon, MD ET.AL., Canadian Journal of Anesthesia 53:978-983 (2006) for a study of Echocardiographic tip location vs. ECG guided tip location.) If the catheter is advanced until the P wave reaches its maximum voltage and then pulled back about 3 cm, you will be in the distal SVC. Alternatively, one can advance the catheter until the P wave enlarges 3-4 fold (i.e., without needing to enter the upper atrium to document the maximum negative deflection). This, too, will put you above the right atrium. Advancing until the maximum deflection is reached will put you in the upper right atrium
An additional advantage over CXR is the results are seen in real time, during placement.
ECG guidance does not work, however, in patients in atrial fibrillation or pacemaker dependent (but this is probably a small percentage of your patients).