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Rob Burr
repositioning PICC after CXR
The policy at my facility states that after initially placing the PICC the external portion should be placed on 4X4s and wrapped in Kerlix prior to CXR. This is to facilitate repositioning should the CXR show the tip to be malpositioned. I have never been comfortable with this procedure and prefer to completely dress the line prior to CXR. I check for Jugular malposition with an agitated Saline injection, and cut the Line at the long end of the measurement to avoid being caught short. Between these two precautions I have rarely been in need of repositioning other than possibly pulling the line back a few cm's, which I do under the dressing change protocol rather than the full barrier precautions of insertion. My question to others is how you deal with malpositions revealed on CXR.
Rob, you are asking the

Rob, you are asking the million dollar question!  LOL  As I travel thru out the United States, I see a little of everything being done.  I encourage the nurses that I work with not to "re-thread" the catheter if it is malpositioned.  If we look at truelyl what is best for the patient, then we have the answer-- no rethreading.  But we all know that things happen.

Once several years ago in my practice, I did re-thread, of course sterilly, max barriers, within the hour, etc.  The outcomes were quite negative for the patient--to the ICU, sepsis, etc.  What did I learn?  I learned that I was not  truely doing what was in the best interest of the patinet that was entrusted to my care.  I hope that for me or mine, a nurse will never re-thread a catheter.

If you have the funding for navigational devices, that is great.  If not, it sounds like you don't have much of an issue with malpositions, but there are some littel things that we can do to help us get the PICC to the SVC.  

Hope this helps.

Cheryl Kelley RN BSN, VA-BC

This is where ECG guidance

This is where ECG guidance is so helpful It provides real time guidance for tip location so no line manipulation is necessary. In a study by Chu et. al (Anesth. Analgesia, 2004, see accurate tip positioning was ensured by transesophageal echocardiography.Simultaneous ECG guidance was 100% accurate, CXR 80% accurate, and surface landmarks (cf. the underpinning of navigational systems) 53% . It may be performed during placement by deriving the signal from the guide wire. After placement, the saline in the catheter may be used.

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