Forum topic

7 posts / 0 new
Last post
PICC tip in RIJ when contrast injected!!!

50's y/o male came back to the hospital c/o abdominal pain. Lab tests showed elevated amylase and lipase. He had a PICC which was previously placed for about a weeks for home health ABX for colitis. He was admitted to floor. GI physician ordered abd CT with contrast, pancreatitis protocol. When contrast was injected, patient screamed in pain and holding onto the right side of the neck. His neck was swollen. A stat Xray of the area showed the PICC tip in the RIJ!!! US doppler showed ruptured RIJ!!! He was transferred back to the floor and had a surgery that night to repair the vessel.

OP or ER pts come in with a PICC, they need to have a CXR to confirm the tip.

I found out CT pancreatitis protocol contrast injection rate is 4 ml/sec = 14,400 ml/hr !!!!!

What a terrible situation! I

What a terrible situation!

I have made it our practice to x-ray every patient that is admitted with a PICC line. That is my greatest fear that a patient has a malpositioned PICC line and either chemotherapy,TPN or CT dye is infused causing great harm.

Recently a patient was admitted from Home Care TPN with Right ear pain and neck swelling. Turns out PICC was in the Right Internal Jugular vein. This event really made the staff stop moaning and groaning about my insistance on x-rays with patients admitted with PICC lines.

Wendy Erickson RN
Your situation was added

Your situation was added ammunition for an ongoing discussion we have been having here regarding the practice of getting an xray to verify tip location when a patient is admitted.  Some of our physicians have objected and cancelled the order, which leaves the nurse caring for the patient in a difficult situation of needing to use the line and knowing that she does not know for sure that it is placed correctly.  I think our mistake was having the standard order read "If patient is admitted with a PICC line, contact the physician for an order for a chest film to verify tip location".  After looking at the INS standards and Lynn's comments and at the direction of our medical director, we are changing the order to read " If patient is admitted with a PICC line, obtain CXR to verify tip location". 

My question is related to the frequency of getting an xray.  Some oncologists say "So it's OK for us to be giving chemo through the line daily, but when the patient is admitted, suddenly they need an xray".  I don't know that it IS OK to never get a repeat film!  But a daily chest xray is unreasonable.  I have encouraged staff to assess the patient for signs of malposition (Lynn's post listed them very well).  Are oncology nurses doing this prior to every use?  Is a blood return good enough?  In your case, Donna, it obviously was not enough! 


Wendy Erickson RN
Eau Claire WI

I am reasonably sure that the

I am reasonably sure that the new ONS Chemo Guidelines state to get diagnostic studies on any line that is not producing a blood return or when there is any question about the functionality of the line. They are specific about blood return, I know and have instructions of what to tell the patient when the nurse must hold the chemo until the fluid pathway is known. But a chest xray alone will not tell you this. So no blood return actually means a contrast injection under fluoro. 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

Donna Fritz
I am uncertain how the above

I am uncertain how the above scenario became attributable to me.  I remember reading it on this listserve as a post from someone else.  Maybe in all the tinkering with the site, something happened. 

Lynn, to address ONS' stand on this issue, the 2009 Chemo/Bio guidelines state on pg 100: 

"After CVC insertion and before administering agent, perform the following:

1.  Verify that the catheter's placement is correct prior to initial use per institution guidelines.

2.  Inspect exit site for evidence of erythema, swelling, drainage, and leakage.

3.  Inspect ipsilateral chest for venous thrombosis (INS, 2006)

4.  Aspirate the line to verify blood return.  If blood return is not evident,

a.  Flush with saline, gently using push-pull method . . .

b.  Reposition . . .

c.  Ask pt to cough.

d.  Explain why delaying therapy is necessary  . .

e.  Obtain physician's order for declotting procedure; follow insititutional protocol.

f.  Use x-rays or dye studies to confirm proper CVC placement per institutional policy and rule out catheter malfunction or migration in the absence of a blood return."

picc line flipping into ij after power injection

  A patient of ours had his power PICC flip up into his IJ after being power injected for cat scan.  Has anyone had this happen?  I think I have heard this called "whippet syndrome"  but I cannot recall where or when and cannot find any info.

Migration of the catheter tip

Migration of the catheter tip from changes in pressure are quite common. 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

Log in or register to post comments