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kobi888
Picc looped in axillary vein

Chest x-ray showed Picc was looped like a perfect circle in the axillary vein.  Tip was mid clavicle in report.  Suggestions on how to fix this besides sending them to IR ?  Would power flushing ever work on this problem?  I have not been trained on an over the wire exchange, how many of you experienced PICC nurses can do this?  Is this another option?

lynncrni
When looking at the film,

When looking at the film, could you tell if the catheter was only a circle or did it appear to be a loop? By loop I mean one that would cinch itself into a knot if you retracted it. You could try retracting and readvancing then repeating the chest xray. This would be possible if you still had the original stylet wire in place or if you have access to the correctly sized guidewire that will go into the catheter lumen. Power flushing works to flip the tip from the IJ down to the SVC but I have never tried it with a catheter in a circle such as this.

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kobi888
I could not tell by the film
I could not tell by the film if it were in a loop or a circle.  It apperared to be like the letter O.
Angela Lee
We do not have an IR and I
We do not have an IR and I cannot rewire the small catheters that I use.  Nor do I relish the prospect of replacing a neonatal or pediatric PICC if I can avoid it.  I have had the occasional PICC to loop in the axillary vein, the subclavian vein and even in the SVC as well as the tip being in the jugular.  In most of these cases I have found they will correct themselves in time.  For some reason power flushing does not seem helpful for me in repositioning tips--I don't know if that's because of the size of catheters and the inability to get very forceful flushes or for another reason.   In any case, I have waited as long as overnight and in two cases-two days ( the patients had other access) for the lines to unloop or tips to reposition.  Usually that occurs in a few hours, however. I have found that the more distal the loop the less likely it is to spontaneoulsy straighten.  It's also a judgement call for me--I can usually tell those that are not likely to correct vs when it's worth it to wait it out. 
Karen Day
Karen Day's picture
I have actually had this

I have actually had this happen a couple of times.  I have tried several different techniques - most of which worked and one or two I had to send to IR.

 the first thing we have done is power flush, this has been successful.  We have also connected normal saline at a rate of 50 - 100cc per hour and repeated CXR in 2 hours and have found the loop to work its way out.  We have left them overnight as well and they have worked out also.

I can understand the difficulty in doing the power flush in small, peds catheters - but maybe the last two options would work.

 

rivka livni
Speaking only about the

Speaking only about the adult population.

The Axila vein is too far out for power flushing to un-loop in most cases.

As a PICC nurse, you should learn and know how to exchange over a wire, if you have not done it yet.

When evaluating a "loop" or "circles" you should pay attention to two points:

a. Is the catheter tip pointing against the blood stream (those are more successful in power flushing), or with the blood stream (hader to un-loop)

b. Is the loop in danger to create a knot, if attempted to un-loop. Those who can create a knot, should be exchanged.

When un-looping using power flush,for any loop, it is very helpful to have the patient do a deep long Val-Salva and when they exhale immediatly power flush.

I have fliped loops from Subclavia, Brachiocephalic, IJ, and Azygus, but never saw a loop in Axila, my understanding of Anatomy says it is too far out in the peripheral. I would also not leave an Axila loop overnight for fear that it may creat a throbus, due to the small vein diameter being crowded with that loop.

Mike Brazunas
It would be great if you

It would be great if you could learn how to do a catheter exchange. It helps a great deal in situations like this.  It also helps with many other PICC issues; pulled out of the SVC, single to dual, non-blood occlusions on dual lumens (you use the good lumen) or malposition. 

Of course you have to be VERY careful (I could tell you some stories I've heard!) but it is a great tool to have once you've been taught.

Thanks,

Mike Brazunas RN

AngioDynamics

barbara bonito
At the 1st COVAN meeting in

At the 1st COVAN meeting in Dec. we were given a handout showing different positions to use when flushing to correct malpositioned PICCs.  I wish I knew who to thank for this....our entire PICC team uses it now and find it to be successful 80 to 90% of the time.  We remove the caps from the PICC and have 3-4 10cc  flushes lined up and ready to go.  If a double lumen we flush both ports simultaneously.  Unless the patient is able to cooperate fully, a 2nd person is helpful. 

JUGULAR AND CONTRALATERAL VEIN

     Sitting position, raise affected arm overhead and have patient take a deep breath and hold and then flush vigorously.   Repeat 3-4 times.

AZYGOUS VEIN

     Sitting position, lean forward, deep breath and hold, flush 3-4 times

MAMMARY VEIN

     Sitting position, lean backward, deep breath and hold, flush 3-4 times

LOOPED BACK IN AXILLA

     Lying down on opposite side, raise affected arm, deep breath and hold, flush 3-4 times

Just got one into SVC last week that was looped in the Axillary.  Always surprises us when it works and yet it does!  The only malposition we haven't tried is the mammary.

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