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smarison
Picc tip placement
We are having some issues with our readings and appropriate placements.  Can anyone offer any articles that discuss optimal placement for Piccs.  I have INS and documentation from an xray class, as well as FDA recomendations.  Also, when they read sometimes I feel that it is at the junction (SVC/RA) but they say pull back 2cm.  Or we have a radiologist who documents it is the RA, another who places in the RA but calls it the junction.  So many discreppencies.  I am in the middle of pulling dovumentation for the director of radiology, and any info would be help full.  Do you think it would be OK to state OK to use if tip is within a 2cm range of the SVC/RA junction?  Feel free to email me directly at [email protected] Thanks Susan
lynncrni
Try these 2: 1.    Vesely

Try these 2:

1.    Vesely T. Central venous catheter tip position: A continuing controversy. Journal of Vascular and Interventional Radiology. 2003;14:527-534.
2.    Vesely T. Optimal positioning of central venous catheters. Journal of Vascular Access Devices. 2002;7(3):9-12.  

 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

smarison
Thanks
Thanks
momdogz
Mari Cordes, BS RN  Nurse
Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care
 
Wise, Marchia, RN; Richardson, Deborah, RN, BS, BSN, MS, CNS; Lum, Philip, RN, BS, CRNI "Catheter Tip Position: A Sign of Things to Come",JVAD Summer 2001.
 
Smith, J.P., JIN 21 #2 "Thrombotic complications in Intravenous Access"
 
Masoorli, S.; Nursing Malpractice 3rd edition, 2006
 
Royer T. BS RN, CRNI;  Earhart, Ann, MSN, CRNI, APRN "Taking the Leap from PICC placement to Tip Placement"
 
DeChicco, MS, RD, CNSD, Seidner, Douglas L. MD FACG, CNSP, et.al; study about tip placement
 
Professional SOP and Guidelines:
INS 2006
FDA CVC working group 1989, 1994
AVA (NAVAN)
ONS (Oncology Nursing Society 2004)
NKF 2001
SIR 2003
 
It's good you can help educate the radiologists (and be prepared for them not to be happy about it, though some will be collegial).  There are still many radiologists who are not as accurate about vascular anatomy interpretation in the thorax as they are about diagnostic interpretation (this is supported by comments from radiologists and IR ists).  For eg believing that CAJ is at the convexity of the right superior cardiac border.  The right superior cardiac border is 100% formed by the right atrial appendage, and the jct. of the SVC and RN is approximately 1.8 cm below that.
 
I was taught the "landing zone" - 2 cm below the right atrial appendage and 2 cm above - distal SVC, and range of optimal tip placement.
 
Hope the articles help.  What xray course did you take? 
 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Gwen Irwin
We have had an interesting

We have had an interesting development with our largest radiology group.  They have had internal conflicts about SVC placement.  I was amazed with this sequence of events!  They have reviewed anatomical locatioins and are getting more in alignment with those junction calls vs. tip in the atrium, based on the anatomy.

Hope this can happen for you.

Gwen Irwin

Austin, Texas

Kevin Travis Flint
Does anyone have

Does anyone have radiologists that give the "ok to use" on piccs terminating in the subclavian vein?  I have seen piccs insereted that go up the jugular vein and when pulled back end in the subclavian, it cannot be advanced so it is left in that location.  Any thoughts on leaving the picc in the subclavian?

Kevin

momdogz
Kevin:  On this forum, go

Kevin:  On this forum, go to "Pull Back to Subclavian", IR docs say.  There are a few other posts re: this issue that also might be useful.

We've been "working on" this issue with our IR MDs.  Also, read the articles posted in some of the replies on this thread, especially Tom Vesely (IR MD).

 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Kevin Travis Flint
Thanks
Thanks
lynncrni
Not a good not, not

Not a good not, not considered to be safe practice to leave the tip in this location. Risk of vein thrombosis is high. Knowing the anatomy I have never seen a PICC with the tip in the IJ end up to be in the subclavian vein. Are they retracting the PICC to get it out of the IJ and then not re-advancing for infection control reasons? If so, change this practice. Just leave the PICC alone, remove the stylet wire if the xray was taken with the wire inside and allow time and normal blood flow to move the PICC to the SVC. This has always worked for me in these situations. ARe you using ultrasound? If so, you can rule out IJ placement before you break your original sterile field, so this problem goes away.  

 

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

smarison
Lynn, your last comment is
Lynn, your last comment is interesting to me.  How long do you leave your Picc in the IJ ussually(hours), then I assume you re xray?  Most times we can identify with US if in the IJ but not always.  We normally do an exchange with an IJ placement, but if it works would love to see if it floats on its own.  Thanks Susan
lynncrni
2 to 4 hours is usually what

2 to 4 hours is usually what I have seen as the most common practice. Without a stylet wire inside the catheter, the PICC will spontaneously move to the SVC. I and several colleagues documented and published this in 1993 but it had been reported by others. I would not do an exchange for an IJ placement without waiting for a couple of hours to see it it will move.  

 

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

Gwen Irwin
We have had success with

We have had success with power flushing (turbulent flushing) to get it to reposition into the SVC in a very short period of time.  Not waiting 2-4 hours.  Also, tip locator system is amazing to prevent IJ tip location.

Gwen Irwin

Austin, Texas

Laura M.
Gwen, are you referring to
Gwen, are you referring to the Sherlock when you say tip locator system?  If so, can you tell me if it can tell whether the tip is in the brachiocephalic vs. svc or distal svc vs. proximal?  Or is it just good at telling you where it's not...like the IJ?  Thanks!

Laura McRae, RN, BSN, CRNI

PMRMD
Appropriate tip location has

Appropriate tip location has also been defined electrocardiographically - the SA node sits at the SVC - right atrial junction and as you get within 10 - 15 mm of it or so from the distal SVC, the normal appearing "P" wave increases its voltage several fold (http://www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm) - advance your catheter until the P wave starts to increase its voltage, then pull back until the normal configuration is just regained. This will put you into the distal SVC essentially all the time assuming the patient is not in atrial fibrillation or pacemaker dependent. This technique has been commercialized in Europe by BBraun (see their Certofix and Alphacard products at CVC-partner.com) but these products are not available in the U.S.

 ECG guided tip location is less expensive and more accurate than chest x-ray or navigational systems (since the relationship of surface markings to anatomic landmarks is highly variable patient to patient). As the results are available immediately, there's no waiting for an x-ray for placement purposes (although the technique does not rule out iatrogeny) and you leave the bedside onto the next PICC knowing you are in good position.

Gwen Irwin
We are using the Sherlock

We are using the Sherlock system.  We can tell with our repeated experience using this system if it is in the SVC.  We don't use this to determine only if is in the IJ.  Based on the info at the time of the PICC insertion and using the tip locator system, we have withdrawn the PICC to the position in the SVC vs. in the right atrium.  Chest xrays have confirmed this as being the correct action.

With experience, we have also been able to recognize the PICC that is too long or too short  and adjucted before the xray.

 Gwen

Dana Downes
PICC tip verification

I am searching for States with PiICC tip verification by the PICC nurse.  There are many states that are Decision Tree states. 

I would like to collect some data on how these nurses are covered for reading the tip placement, via the chest x-ray, and how this is documented in the chart.

I live in AR and am working on this project for our facility.

Thank you for any info.

Dana Downes, RN

lynncrni
Nurses do NOT read the xray!

The first thing you must do from a legal standpoint is to change your language. Nurses do not read a chest xray. This is the term for what is considered medical practice. Physicians are looking for anatomy changes that indicate disease or changes in function. So if you continue to use the term "reading" the xray, you may not get very far as you would be considered to be encroaching on medical practice. Nurses assess the chest xray for tip location. We are not assessing the entire film for pneumonia, tumors, etc. We are only looking at the film to determine if the catheter tip is properly placed. I have done this since 1981 in GA. We are a decision tree state. The infusion nurse placing the PICC looked at the chest xray, documented the tip location in our insertion note, and began the infusion therapy based on that assessment. If we had a question, we could consult with the radiologist or the ER doctor after hours. This was long before the digital films of today. This hospital never saw a problem with this process, no lawsuits, nothing. In fact, we were usually more accurate than the radiologist. The radiologist report showed up on the chart about 24 - 48 hours later.

Nurses taking on this role can provide benefits to your patients and facility because the process flows more smoothly. Rather than waiting on radiology to get there verbal information to the nursing unit, getting the correct anatomical tip location description from them ("in good position" is not sufficient), and then beginning therapy, the nurse can get the infusions started much faster based on his/her assessment of the film. Lynn

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

swensonals
States that have formally allowed Nurse interpretation of CXR

Dana,

Look at Tim Royer's article "Taking the Leap from PICC Placement to Tip Placement" from JAVA 2007.  It lists the states that allow Nurse interpretation of CXR for PICC tip placement, both decision tree and advisory opinion (page149). The article is excellent for those who are planning to ask for expanded scope of nursing practice, via their State Board of Nursing, and delineates the necessary steps.  I am in the process of doing this in Illinois, with support through our IVAN chapter (Illinois Vascular Access Network), a network of AVA. There is also excellent advice in the JAVA 2009 article "Accuracy & Timeliness of RN vs. MD Radiological Interpretation of PICC tips". Another source is the class taught by Jamie Bowen-Santolucito, RN & Dr. Dave Vegas from Oregon Health & Science University, "Radiographic Verification of PICC Placement".

April Swenson

Alexian Brothers Medical Center, Elk Grove Village, IL

Cyndi Dautel CRNI
Progress in petitioning of Illinois State Board of Nursing

April, 

I am just wondering how the progress is going in regards to petitioning the Illinois State Board of Nursing for the ability to assess CXR. I attended Jamie Bowen-Santolucito, RN & Dr. Dave Vegas class over a year ago in Indianapolis. I would recommend their class to everyone. It made a big difference in my scope of practice. I had learned so much in their class that I made it a requirement for the rest of my PICC team attend the class in December at St. Alexius  and I even attended the class all over again with the rest of my team. I was glad to hear that you were working on petitioning the Illinois State Board of Nursing with the help of IVAN. I had started collecting data and doing case studies in September at my facility with the intentions of working towards the same goal. We have been struggling with inconsistencies, inaccurate radiology interpretations and delay of treatment for our patients. Please keep me posted as to your progress and if there is anything that I can do to help, please let me know.

 

Cyndi Dautel RN, CRNI

Centegra Woodstock Hospital, Woodstock, IL


 

Cyndi Dautel RN, CRNI
PICC Team Leader
Centegra Woodstock Hospital, Woodstock, IL

Heather Nichols
PICC tip placements

Susan,

   You might also want to look at using the Navigator navigational device.  We have been using it for years here at U of L very successfully.  With practice, you can tell exactly where your tip is, and I do not mean a guess.  We get a surprise every great once in a while, but 9.9 times out of 10 we are right where we measured.  Now if you measure inappropriately, you will not have a tip in the correct place.  That is where a few other tips can be helpful.  If you possibly can view a chest x-ray before placement, you can better determine your measurement needs.  Of course you probably already realize that everyone has a different structure, and the more people you PICC, the more experience you get at judging externally how deep a persons SVC is gonna be, but it is nice to look at an x-ray to be sure.  The Navigator allows you a little bit more freedom to evaluate external land marks as you place the PICC as long as you have your full barrier drapes in place.  The Nav will also tell you where it is no matter where it is.  If it comes back down the arm, contralateral, up either IJ, into a chest vein, into a left sided SVC, or even in the atrium, you can find the tip and figure out where it is so that you can better position your patient to fix it. 

   I do not know where you are located, but if you are anywhere near Louisville Kentucky I would be glad to let you shadow our team to see how well it works.  It is definately not fun to deal with radiology.  Good luck with that. 

morrisod
Confirmation of CVAD tip placement documentation

What communication from the physician who placed the CVAD to the nurse who will use it, is acceptable when documenting confirmation of tip placement of CVAD?
I was always taught that "OK to use" is not acceptable order by the physician because it can be misinterpreted.
Is there literature to support this?
the new INS standards does not speak directly to the role of the floor nurse and how to confirm placement. Standard 23 I. Does say " document the CVAD tip location ... but does not say what the nurse caring for the patient should do.

lynncrni
 The INS Standards of

 The INS Standards of Practice are written for ALL healthcare personnel in ALL settings who are involved in delivery of infusion therapy and the insertion and management of all VADs. See Standard #1 for this information. The committee does not call out different responsibilities for a med-surg staff nurse vs an infusion nurse. So what is wrriten DOES apply to staff nurses caring for the patient. The logostics of how each facility meets these standards are decisions made by the facility itself. You are correct that phrases like "OK to use" or "in good position" are not adequate or appropriate. The professional inserting the CVAD is usually the one to assess tip location and communicate to the appropriate nursing staff with anatomical location of the tip. This could also be reported by the radiologist, but they usually do not see the film immediately and their dictated report may not be available for 24 hours. There are many variables between facilities. A proscess that works for one may not work for another. So your facility must work out a process for communicating this information in a timely manner to the right person. Lynn

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

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