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Greg Scott
Not in the lower 1/3rd of SVC

I am a vascular access RN at a large hospital.  There are only two of us and we stay very busy.  I need to know what others do when the picc is in the upper to middle SVC.  I'm sorry to say our hospital has not provided us with necessary and time saving equipment like the locator devices that many write about.  When I do a picc I don't want to have to worry constantly about it being too short.  I am also aware that lower 1/3 svc or cavoatrial junction is the preferred place.  Can every picc be perfect?  Do you replace piccs in the upper to mid svc.  Please respond

Greg Scott

Leigh Ann Bowegeddes
Hi, Greg. We always shoot

Hi, Greg.

We always shoot for lower SVC, preferrably C-A junction, but it doesn't always happen. The length of the SVC varies so much (4.5 to 10 cm), and the only way to assure always getting to the exact chosen spot is to place the catheters under fluroscopy. If the catheter makes it to the SVC, we leave it in place. I think it is too traumatic to replace a catheter just because it isn't as far into the SVC as we prefer. If we have problems with migrations due to high placement, that may indicate a good reason for exchange.

Leigh Ann Bowe-Geddes, RN, CRNI

University of Louisville Hospital

[email protected]..
T. Nauman RN, CRNI  IV

T. Nauman RN, CRNI  IV Educator SHMC Eugene, OR

We still do as Lynn mentioned...we're fortunate to have the time and freedom to do it!  We place the PICC, place sterile 4/4's under and over the catheter to maintain sterility, cover all with a Tegaderm and wrap it all in sterile towels.  We then get a portable chest x-ray(the turnaround time is fairly fast...10-15minutes), we then "fine-tune" the line placement by advancing or withdrawing the catheter.  We do try to measure accurately beforehand to minimize later manipulation, but we like to be sure the line is deep...we have had too many placed mid or proximally in the past that ended up in the jugular vein later.

T. Nauman RN, CRNI

lynncrni
As Leigh Ann indicated, your

As Leigh Ann indicated, your actions must be reasonable for the patient situation. If you find a high number of your PICCs are falling short of the lower third of the SVC, I would look at your external measuring techniques. The new catheter tip location technologies are good, but we placed PICCs long before those were even thought about, much less made available. Our process was to leave the stylet wire inside the catheter, enclose the external catheter segment in sterile 4X4 gauze, wrap the arm with a roller bandage, then take the patient to xray or get a portable xray. If the catheter was not correctly placed, we could then manipulate it into the right location because the external catheter had not been in contact with the skin and the original wire was still in place. This method requires the nurse to have the time to return to finish all PICC insertion procedures after the xray results are known. It also requires a fast turnaround by your radiology dept.or the nurse must be capable of assessing tip location on the film to avoid having to wait for the radiologist final report. The situation to allow this to happen is not possible in every hospital. When your catheters fall too short, I would assess what fluids and medications were to be infused before I automatically left it too high. For TPN, I would probably exchange the short PICC for a longer one using an overwire exchange. If the short PICC was allowed to remain in place, I would also closely monitor that patient for tip migration. This would be evident by your patient complaining of hearing a running stream or gurgling sound on the side of insertion, lack of blood return, and difficulty flushing. This indicates the need to stop infusions through this PICC, get an xray to locate the tip and replace it. So you would need to assess your situation for the time required, staff available, etc, to determine the best approach for your hospital. 

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

www.hadawayassociates.com

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

Greg Scott
Thanks for your help Ms

Thanks for your help Ms Bowe-Geddes and Ms Hadaway

rivka livni
We trim all our catheters.
We trim all our catheters. If the catheter is too short (proximal SVC) we exchange if we know the pt will need it for more then 5 days. Mid SVC we leave in and do not exchange. It's worth perfecting your external measurement, don't forget with obese pt to add at least 2-3 cm to measurment to make up for the depth of the vein. 
pjean
We have recently altered our
We have recently altered our pre-insertion process with two things that have been extremely helpful in improving our success in terms of C-A junction placement. we too trim all our catheters.  Part of our pre-assessmnet of the patient includes looking at the most recent CXR.  This is particularly helpful in estimating the length for example when you can see that the pt. obviously has what we love to call the "butternut squash shaped heart" or other changes that would alter our measurements.  We also changed from adding the standard "2 on the right and 4 on the left" that we were taught, to 4 on the right and 6 on the left when we do our external estimations.  Depending on other factors such as depth to vein, barrel chest, pt over 6 foot, older pts with left side approach, we may either add or subtract from that, but the standard 4 and 6 has helped us alot.  Occasionally we do have to retract 1-2 cm, but thank God our days of being to short have pretty much come and gone.
Pauline Hodge RN
As a NEW comer, what does

As a NEW comer, what does that mean, add 4 on right and 6 on right from the right clavicular head?

vasallese
This refers to adding 4 cm
This refers to adding 4 cm down from the right clavicle for the right sided PICC, and 6 cm for a left PICC. We measure, measure and measure. We have gotten much better by measuring using several different methods, including the PICC Excellence method, looking at chest x-rays and taking to heart the research that INS has presented. Call Bard, they have some great classes that will  help you. Good luck and just keep at it.

Victoria Sallese, RN, VAT, PICC service

Rhonda Wojtas
What is this chart you are

What is this chart you are referring to? I am new at this. Only been dong PICC since December. In the begining were doing excellant. All were placed in the lower SVC. Some exactly at the CA junction. This past two weeks we have had a bad spell of measuring. We have had to pull back 2 of the last 4 PICCs about 6 cm. I guess it is better to be too long rather than too short. 

We found when we use a skin marker, the cholaprepp washes all of the marker off. We thought maybe that was throwing us off our original measurements as we couldn't really see the mark to go by. Today we used a regular black permanet marker. 99% of it washes off but we can see our begining mark that we measured from. Today 2 of the 3 lines we placed were in the SVC. One had to be pulled back 6cm.

We use the Sherloc but more to make sure the catheter doesn't go up. It doesn't helps us with the length going in.

I am hoping as time goes on we will get better with measuring.

 Rhonda Wojtas, RN

Rhonda Wojtas, RN VA-BC

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