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Repositioning of malpositioned lines

 I'm curious to know how everyone manages malpositioned lines at the bedside that have already been dressed. Do you set up another sterile field and attempt repositioning at the bedside, or do you send them to radiology for repositioning?

Glenda Dennis
I never reposition unless it

I never reposition unless it is only a pull back.  I would only do an exchange.  There isn't a way to reposition safely.

mary ann ferrannini
If you are not using a Tip

If you are not using a Tip locating system...this is a great reason to advocate for one!!!!!.Measure twice if you have to....remember that the left side is longer and make appopriate adjustments in your measurements. You really need to get it in the Low SVC/CAJ as this is critical in keeping the risk for thrombosis low as well as other complications. can pull back but you are not supposed to advance or attempt to reposition as you can drag that bacteria on the skin into the vascualture

My question....Are you

My question....Are you looking at the IJ with your ultrasound if you don't have a navigation system?  You have technology in your hands...use it!

 I agree use the ultrasound

 I agree use the ultrasound to identify if the tip is in the IJ, but take a look on BOTH IJ's.  i have seen an xray with the tip in the left IJ when the PICCt was inserted on the right, it dawned on me when looking at that the xray that I probably would not have looked on the opposite side with the ultrasound and would have missed this easy diagnosis of tip location.  We have sherlock as well, we love it.

sandi Kishi RN, BSN, CRNI

We have had a few azygos

We have had a few azygos malpositions slip through our TLS.  

First, I ignore the radiologist's reading of it "looped in the SVC" and I ignore his/her instructions to pull back 2 cm and reinsert 4cm. 

Second, I place the pt. in high fowlers position or leaning forward if they are able. You are trying to get the catheter tip which is pointing toward the patient's spine to move toward the sternum and drop. 

Third, attach saline syringes to the picc

Fourth, ask the patient to take a deep breath and quickly inject the saline.  I usually do this 3 times.

Works best with silicone catheters but can be successful with polyurethane. 

On the followup film, if successful the tip is much lower than you would expect. 



Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA


The only reposition that we

The only reposition that we do is a pull back. We use the Sherlock with great results. If it is malpositioned - they are taken to fluoro for an exchange if the site is already dressed.

We place the majority of PICCs under fluoro to eliminate this problem

Karen Day
Karen Day's picture
Darilyn, we use the exact

Darilyn, we use the exact same technique that you mentioned.  It works nearly 100% of the time.  I have also found that this flushing technique works on piccs that are malpositioned in the IJ, contralateral IJ and even some that are looped in the subclavian.  It is a very easy technique that can be done at bedside without ever having to remove your dressing or do any other manipulation of the catheter.  It will require a repeat CXR, but much more cost effective than sending the patient to fluoroscopy.  On malpositions that are in the IJ, if you will palpate or auscultate as you flush, you can feel/hear the flushing.  Once you no longer hear this, you can be pretty much assured that the catheter has been repositioned and then order your chest XRay


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