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barbara bonito
PICC tip locator

Our PICC team  will soon be looking into the possibility of getting a tip locator, probably a Navigator.  Since a good portion of our malpositioned PICCs are in the R atrium, I'm wondering how successful those of you using the Navigator, or the Sherlock, are at identifiying R atrial tip placement.    Thanks, Barbara


I used the Navigator for 7
I used the Navigator for 7 years and found the it indeed could assist with right atrial tips.  Not sure how familiar you are yet with it, as you said you are probably going to get one, but when you get nearer that point, give me a holler and I'll tell you how I did it.  I also have a special measuring technique that gets me at the SVC/RA junction about 90 % of the time.  You can email me at [email protected]

Cheryl Kelley RN BSN, VA-BC

Hi Barb,  How is Colorado?

Hi Barb,

 How is Colorado? Miss you back here in the east.

Jose Delp RN BSN

Clinical coordinator IV Team

Upper Chesapeake Health

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

Gwen Irwin
After using the Sherlock

After using the Sherlock system for some time (about 8 months), the PICC nurses are becoming more comfortable with recognizing PICCs that are too long with the Sherlock tip locator system.  They will withdraw the PICC before the CXR based on what they see on the Sherlock screen.  They have become very proficient in this and have fewer PICCs that require withdrawals and another CXRs.

Gwen Irwin

Austin, Texas

barbara bonito
Hi Jose, Loving

Hi Jose,

Loving Colorado..and you were absolutely right...doing PICC's by U/S is easy, once you get the hang of it...currently doing 40-50/month (working part-time)

I just started placing PICC
I just started placing PICC lines 5 months ago. The team was already using the Sherlock system when I started. I work on week-ends, and I'm by myself now. I feel the Sherlock system has been great for my confidence in placement. We do still get portable CXR after each insertation.
ECG guidance is an ideal way

ECG guidance is an ideal way to document tip location in the right atrium. There is really nothing else that can occur in the course of a PICC line placement that can produce the "spike" configuration of the P wave (see seen when the catheter tip enters the RA. Obtain the ECG signal off the guide wire or saline column in the PICC catheter. The pull back into the SVC is documented in real time by documenting the transition from the P "spike" in the RA to the "u" shape in the SVC. Stop pulling back as soon as the "u" appears. The technique is more accurate than CXR or any currently marketed tip location system.

The chest xray is for the
The chest xray is for the purpose of ruling out the many veins where a catheter can go, not just the right atrium. An ECG-based device is only for the purpose of determining tip location in the heart, but we are still concerned with contralateral subclavian, jugular, azygous, and several other aberrant locations. So nothing yet can be totally substituted for a chest xray, although these technologies improve our techniques. Lynn

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

If we are talking about PICC

If we are talking about PICC tip location during placement and not migration after placement, and if we are talking about location and not iatrogeny, ECG guidance is sufficient by itself without CXR. When the P wave spike is seen (which documents RA location) and, on pull back, the spike shortens and just becomes "u" shaped, the tip of the catheter will be in the distal SVC, about 10 - 20 mm  from the SA node (taken to represent the SVC-atrial junction). A CXR may be desired for other reasons but, purely for tip location, the transition from a P spike to "u" documents distal SVC positioning. Migration into the RA can be documented by the reappearance of the P spike (i.e., without CXR). Once the "u" is seen, it does not distinguish between proximal and distal SVC (and a CXR might be necessary here). At minimum, with ECG documentation at the time of placement, one can leave the bedside knowing the catheter is in proper position. Whether a CXR is felt necessary to document other concerns is a separate issue.

Heather Nichols
Dr. Peter and Barbara,   

Dr. Peter and Barbara,

   What Lynn means is that the Navigational devices, like Navigator, will show you where you are no matter where the picc is.  I am sure the device you use is fine to determine if the picc is in the heart or close to it, but we need to know where the tip is so that we can reposition the patient to try to reposition the line to SVC.  If it goes jugular or contralateral, ( or anywhere else those crazy things can go) there are certian manuvers that the patient can help with to get the line to go where it should be.  Your device does not do that, does it?   The Navigator will usually give you an arrow that flips back and forth (side to side) if the line is in the atrium.  It's very predictable when used with a good measurment system.  It also helps to be able to view a CXR before line placement to determine just how deep the heart is.  Then you can determine if you need to go a little further the the 3rd or 4th intercostal spaces.  The Navigator and Sherlock are not guidance systems, they are Navigational systems.  They assist you to place the line where YOU want it to be, so if your measurements are off, you will have deep or shallow tip placements depending on which way you went off.   Both of these devices however, will show you where you are even if you are not in the heart.  That is important for bedside placements.  I use Navigator, and like it better, because I and my team feel it is easier and we are all about easier, but I am very familiar with Sherlock also, and I just encourage everyone that Kathy was right when she said that it is the way of the future and very beneficial to the patient to use a navigational system, so try both and use the one that suites ya.  You will not regret it.  Let me know if you have anymore questions about Navigator Barb, and I would be glad to come and teach it to you or have you down to my neck of the woods for a demo.  Good Luck!


Hi Heather - You're correct

Hi Heather -

You're correct in saying the PacerView/ ECG guidance only can document passage from the SVC into the RA (or RV). It cannot document  passage into other vessels. It is  a quick, easy way to exclude migration into the RA post-placement - inexpensive and immediate (you have your answer literally in under 60 seconds) rather than doing a CXR. I was not aware that the Navigator could specifically document atrial entry. I thought it only could document the position of a sensor relative to an external landmark. Since the position of internal anatomic structures relative to these external landmarks is very variable, dependence on these external landmarks can be misleading. ECG guidance uses the patient as his own control, so to speak, and, for a specific patient, it is accurate to within millimeters (rather than centimeters with the navigational systems). I think the two systems complement each other.

Our department trialed the

Our department trialed the Sherlock and the Navigator...we ended up with the Navigator. It has really helped my adjustment rate. There is a learning curve, of course, but once you get the hang of it, again it really can help. There have been many times where my PICC was contrallateral and I couldn't tell because it went in so smooth, there was a brisk blood return and it flushed with ease...I would have left the bedside with a smile on my face thinking everything was okay only to find out after the CXR was done that I needed to do an adjustment! The Navion has saved me in those times and in multiple others. I am starting to get the hang of seeing that my PICC may be a cm too long (in the RA) and therefore pulling back 1 cm to get an end result of CAJ. It really is a cool gadget.

Liz Holowasko BSN, RN, CRNI

Liz Holowasko BSN, RN, CRNI

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