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PICC and Midline in same vein at same time?

At our facility, a radiology technician placed a PICC line in the basilic vein, which at that time also contained a midline catheter.  The PICC was placed proximal to the midline.  The chest xray clearly shows the tip of the midline in the axillary region along side the PICC.  Both were 5Fr catheters. 

As we prepare a written discussion of our concerns to give to the administrators, we have been unable to find anything written (standards, studies, etc) that states this is not best practice.  You all agree this is not ok, right?  Does anyone have any thoughts or advice?  Presently, we only place midlines and radiology places all PICCs.

watch the pt for CRBSI.

1. The Tech put the pt at risk for infection. I just dont know how they prepped the arm with an old line in it, for a new PICC.

2. I will not be surprise if pt gets DVT in that arm. 

Gwen Irwin
PICC and Midline in the same vein

Was the midline removed immediately after the PICC insertion?  I hope so.

To me, this is an example of a comparison of assessment for the need of the patient for the best outcome.  A nurse would assess the situation and make the best decision for the best outcome.  The radiology tech didn't assess for the need or for the risk, but placed a line.  Their training might not include assessment for the best outcome related to PICC insertion.  Does it?  

Who is evaluating the vein size for the risk of DVT of a dual, much less 2 duals?

A nurse might have planned an exchange to meet the patient's need.  A nurse might have decided to go to the other arm for the PICC.

Why is it that only radiology is placing PICCs?  I would strengthen your case for the additional assessment skills that you, as a nurse, have and try to be the ones doing the PICCs.  How many times does this happen?  How much waste in supplies is your hospital experiencing with a midline first then a PICC?  How does this impact patient satisfaction?  How does this impact delays in patient care?  How cost effective is it for the radiology department to do all of the PICCs vs. an RN PICC at the bedside, based on reimbursement?  I am sure that there are more questions that I am not taking time to put down that would strengthen the case.

Is my thinking off base?

Gwen Irwin

Austin, Texas


There are other factors you

There are other factors you need to know to make your case against this dangerous practice. As stated, nursing assessment and judgment would have led to very different decisions. The rad tech may also have been simply "following orders" without using any critical thinking skills at all, which is something that a nurse would definitely do. We function under our own license and most rad techs are not required to have a license, but this is varies by states.

What was the length of dwell time for the midline? What had been infused through it? Chances are that a fibrin sheath and possibly vein thrombosis was formed around and/or at the catheter tip. Insertion of the PICC through this thrombus probably produced small emboli.

The other issue is the amount of vein diameter being consumed by catheters and obstructing blood flow through this vein. Studies on catheter-related vein thrombosis have clearly demonstrated that larger catheters produce greater risk of CRT. Two catheters in the same vein would definitely put the patient at risk for CRT because of increased contact between the catheters and vein wall disrupting the endothelial lining. This leads to immediate thrombus formation. Also obstructing the blood flow leads to thrombus formation distal to the puncture site.There have also been presentations suggesting that only 30%, and no more than 50% of the veins internal diameter should be consumed by catheter. The pathologist that has given these presentations is working on getting this work published, but I don't think it is out yet. However a literature search on catheter related vein thrombosis will produce lots of information to help you.

What was the patient's diagnosis? Any other factors that create hypercoaguablablity - cancer, diabetes, fluid volume deficit, pregnancy plus others. These factors compounds the risk of CRT.

Your situation with nurses placing midlines and radiology placing PICCs is clinically and financially unsupported from the recent trends in the literature. This case is a great example of why this should be changed. I wish you success, 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

Gwen Irwin
PICC and Midline in the same vein

One of the nurses (Teresa) that works with me read this and pointed out another concern. Actually, her 1st concern.  The PICC was placed proximal to the midline.  What are the chances of the needle entering the vein hitting the midline and severing it, causing an embolus??? 

Why wasn't an exchange considered?  Another option that might have provided the access needed without additional risks for DVT, embolus, etc.

Gwen Irwin

Austin, Texas

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