Your thoughts on repositioning piccs after cxr when malpositioned? I've understood this not to be a good practice because sterile technique is compromised. Thanks.
Repositioning after CXR is still done, but not much, thankfully. A lot of people do it in different ways, but it is a risk no matter how you do it. If you place a dressing on it, and remove it to reposition after CXR, the exposed catheter has laid on the skin. Skin can never be truely sterilized, no matter how much we scrub, so the exposed portion of the catheter has been laying on staph and who knows what else on the skin. Maybe nothing, maybe several bacteria, who knows? If you wrap it in a sterile gauze to keep it sterile, are you absolutely sure that know one (x-ray tech lifting pt, patient himself, nurse while your gone, doctor, patient family) has touched, moved, or manipulated the catheter in any way what so ever? I would find that hard to believe, and a very big risk to say the least.
It is much easier to have your facility purchase a navigational system, like the Navigator, or Sherlock (Sherlock is for Bard picc's only) to make sure you are in the right place while you have your sterile field set up, and then you have the confident feeling that you can leave the room and nothing is gonna happen to your picc while you are gone. If you are one who has to stay with your picc, you can leave and go do other much needed things, I am sure. Contact Viasys healthcare Medsystems for a free trial with the Navigator. It will save your facility a lot of money in CXR alone and much more. It is so easy, and you will love it. We have used it for the last 6 years. Email me privately if you would like some more info on either product.
There are numerous ways that a PICC can be manipulated after a chest xray has shown it to be in the wrong position. If it is in the RA, simply pulling back is acceptable, then get a repeat xray. If it is in the IJ, a power flush should move it down to the SVC. Heather is correct about the infection risk if you want to advance more catheter or pull out and then re-advance. I am from the old school where we did encase the external catheter in sterile 4X4's then wrap with a sterile Kling or Kerlix, then we took that patient to radiology and looked at our films. So we were with the patient and knew that no one was messing with the dressing or catheter. I know that this is not possible with today's workloads and the navigation technology is one way to get an idea of where the catheter is before you break your sterile field. This technology has not yet replaced the chest xray and after each catheter repositioning, you will need to repeat the xray. Lynn
Lynn, You say that a power flush should drop a PICC from the IJ to the SVC. Is that with the wire still in or out? What is the risk of injury with a power flush? How much do you recommend to use? Thanks, Larry
After the wire is removed, attach a 20 ml saline filled syringe. Sit the patient up in bed and flush. This has been know to drop the tip from the IJ to the SVC and has been included in the PICC literature such the beginning. I have also seen numerous times when wire removal and waiting a couple of hours will do the same thing as the blood flow moves it to the SVC. Since you are using a large syringe, I have never seen any catheter damage from the flushing procedure. But have never had to use it much because spontaneous repositioning has worked for me most of the time. Lynn
Thank you for your responses. I am familiar with the power flushing techniques with IJ/EG placment for repositioning. Is there some sort of standard out there that states not to pull back and and reposition these piccs? I've recently starting working at a new facility and I'm not comfortable with the taking out and putting back in after CXR. I would just prefer to do an exchange over the wire instead or the flushing technique depending on how bad the malposition is. I have never seen the navigator, but have heard a little about it. What is the cost?
There is really no standard or guideline statements that say specifically do not pull out and push it back in. But this is based on basic infection control principles. Get the support of your infection control nurse if needed. Lynn
After I finish advancing the PICC, while still w/ strerie field, I always scan the IJ with my Ultra sound probe while the stylet is still in the catheter, if I see the catheter in the IJ that's when I repostion until I can no longer see it.
p.s just remember that after the probe touched the pt's neck, it is no longer sterile.
I work in peds, and have never had "power flush" be successful for IJ malposition, although many who work with adults find this useful. We also scan the neck with the US and reposition if necessary prior to completion of the procedure. Of course, that does not mean it is in correct position, just likely not in the IJ. As an alternative to manipulating the catheter, we have used an alternate method which has been very successful. It involves moving the arm in which the PICC has been inserted in a certain series of motions which we know moves the tip. The dressing is not removed and the external catheter portion is not touched. I have done this with fluoro post-procedure(we don't usually have fluoro available during the procedure), and also "blindly", using the US as a test to see if it has moved out of the IJ. This technique with the arm movements has also been effective to correct contralateral subclavian tip malposition. I presented a poster on this at the 2006 AVA conference, and it was posted on this site under downloads at one time, I'm not sure if it still is.
We reposition after chest xray but our repositions are infrequent. With most of our repositionings, we just need to pull back out of the atrium. Occassionally our catheter may go contralateral or IJ. As has been mentioned, the external length of catheter is considered compromised and remains external, meaning we never put more of the catheter in than what was originally inserted. Using sterile technique, prepping, changing sterile gloves and taking precautions not to compromise the internal length of the catheter, we measure how far we need to pull back prior to re-inserting. Again, taking note not to put more catheter in than what was originally inserted. What was external, remains external.
Question --- is anyone familair with any evidence-based articles on repositioning and/or flushing to reposition ??
Pallik, are you using a wire when you need to pull out and put back in?
Holly, I placed piccs in pediatric patients and measured back about half way out of IJ vein and powered flushed at this point...ending in svc or brachiocephalic vein. The trick is to pull back minimally to retain some length. At times the catheter was infused in over night with normal saline and cxr repeated in am...many times this flipped the tip down. I've seen this happen with the babies more so. With adults, I have found asking patients for any sounds or feelings in the ear or neck area helpful. I have heard about using the probe to check for tip in IJ, but have never done that; it sounds good to me.
My insertion technique to avoid IJ placment is to drop my wire back a great deal to give a big floppy tip and slow down my insertion the last 15 - 20 cm to allow blood return from IJ to help quide it downward. I check blood return with NO positive pressure valves because I want a true feeling of where I'm at. I then power flush to seal the deal and get rid of those loopty loops I don't know about. I put 11 piccs in yesterday with no malpositions or pull backs out of atrium. It means a lot at the end of the day when your ready to head home. Having a good reading radiologist also helps:)
Your thoughts on repositioning piccs after cxr when malpositioned? I've understood this not to be a good practice because sterile technique is compromised. Thanks.
[/quote] Are we recommending a standard of care? We have pulled the line back out under "sterile" after the xray has shown the tip malpositioned. The tip is coiled in the axillary. Thank you so much.
Lindap. My issue is with pulling out and putting back in after cxr using a wire. This is very hard to keep sterile. I would much rather do an exchange or go to the other arm depending on what the malpositioned picc looks like.
Pallik, I have no evidence or literature on the power flushing, just from my experience and trial and error. The loose loops tend to flush out much easier.
I've got to ask Holly if putting 11 PICCs in in one day is typical??? That's al lot of PICC line placements for 1 nurse in 1 day!!!! I thought I was pretty fast, but that's supersonic! Can I come watch and see how you do it? Do you go room to room, floor to floor? Are you in IR and the patients come to you? Just curious!! You may reply privately to me at [email protected] if you like. Thanks. Halle
I recently started placing PICCS using ultrasound guidance and always check the IJ using the ultrasound probe. I found that saved alot of time and repeat CXR's. Well, we just started a trial using the Sherlock and I dont ever want to place another PICC without it! At first I still checked the IJ with the probe(didnt really trust it ) but now I feel confident that the Sherlock is accurate. You still have to trust your measurements for best placement, but the most important thing is you know is the PICC is pointing downward. We plan on collecting some data on how using this tip locater device will decrease our numbers of malpositioned PICCS.
Lily,
Repositioning after CXR is still done, but not much, thankfully. A lot of people do it in different ways, but it is a risk no matter how you do it. If you place a dressing on it, and remove it to reposition after CXR, the exposed catheter has laid on the skin. Skin can never be truely sterilized, no matter how much we scrub, so the exposed portion of the catheter has been laying on staph and who knows what else on the skin. Maybe nothing, maybe several bacteria, who knows? If you wrap it in a sterile gauze to keep it sterile, are you absolutely sure that know one (x-ray tech lifting pt, patient himself, nurse while your gone, doctor, patient family) has touched, moved, or manipulated the catheter in any way what so ever? I would find that hard to believe, and a very big risk to say the least.
It is much easier to have your facility purchase a navigational system, like the Navigator, or Sherlock (Sherlock is for Bard picc's only) to make sure you are in the right place while you have your sterile field set up, and then you have the confident feeling that you can leave the room and nothing is gonna happen to your picc while you are gone. If you are one who has to stay with your picc, you can leave and go do other much needed things, I am sure. Contact Viasys healthcare Medsystems for a free trial with the Navigator. It will save your facility a lot of money in CXR alone and much more. It is so easy, and you will love it. We have used it for the last 6 years. Email me privately if you would like some more info on either product.
[email protected]
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you for your responses. I am familiar with the power flushing techniques with IJ/EG placment for repositioning. Is there some sort of standard out there that states not to pull back and and reposition these piccs? I've recently starting working at a new facility and I'm not comfortable with the taking out and putting back in after CXR. I would just prefer to do an exchange over the wire instead or the flushing technique depending on how bad the malposition is. I have never seen the navigator, but have heard a little about it. What is the cost?
Thanks again!
Laura McRae, RN, BSN, CRNI
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
After I finish advancing the PICC, while still w/ strerie field, I always scan the IJ with my Ultra sound probe while the stylet is still in the catheter, if I see the catheter in the IJ that's when I repostion until I can no longer see it.
p.s just remember that after the probe touched the pt's neck, it is no longer sterile.
We reposition after chest xray but our repositions are infrequent. With most of our repositionings, we just need to pull back out of the atrium. Occassionally our catheter may go contralateral or IJ. As has been mentioned, the external length of catheter is considered compromised and remains external, meaning we never put more of the catheter in than what was originally inserted. Using sterile technique, prepping, changing sterile gloves and taking precautions not to compromise the internal length of the catheter, we measure how far we need to pull back prior to re-inserting. Again, taking note not to put more catheter in than what was originally inserted. What was external, remains external.
Question --- is anyone familair with any evidence-based articles on repositioning and/or flushing to reposition ??
Pallik, are you using a wire when you need to pull out and put back in?
Holly, I placed piccs in pediatric patients and measured back about half way out of IJ vein and powered flushed at this point...ending in svc or brachiocephalic vein. The trick is to pull back minimally to retain some length. At times the catheter was infused in over night with normal saline and cxr repeated in am...many times this flipped the tip down. I've seen this happen with the babies more so. With adults, I have found asking patients for any sounds or feelings in the ear or neck area helpful. I have heard about using the probe to check for tip in IJ, but have never done that; it sounds good to me.
My insertion technique to avoid IJ placment is to drop my wire back a great deal to give a big floppy tip and slow down my insertion the last 15 - 20 cm to allow blood return from IJ to help quide it downward. I check blood return with NO positive pressure valves because I want a true feeling of where I'm at. I then power flush to seal the deal and get rid of those loopty loops I don't know about. I put 11 piccs in yesterday with no malpositions or pull backs out of atrium. It means a lot at the end of the day when your ready to head home. Having a good reading radiologist also helps:)
Laura McRae, RN, BSN, CRNI
Lily, no wire. malpositions are infrequent. yes, it is a good feeling, isn't it? :) especially when the patients are just tickled pink.
question - power flushing untangles loops? evidence? literature?
Your thoughts on repositioning piccs after cxr when malpositioned? I've understood this not to be a good practice because sterile technique is compromised. Thanks.
[/quote] Are we recommending a standard of care? We have pulled the line back out under "sterile" after the xray has shown the tip malpositioned. The tip is coiled in the axillary. Thank you so much.Linda Burns RN CPUI
Vascular Access Team
Children's Health Care of Atlanta
Lindap. My issue is with pulling out and putting back in after cxr using a wire. This is very hard to keep sterile. I would much rather do an exchange or go to the other arm depending on what the malpositioned picc looks like.
Pallik, I have no evidence or literature on the power flushing, just from my experience and trial and error. The loose loops tend to flush out much easier.
Laura McRae, RN, BSN, CRNI
Hallene E Utter, RN, BSN Intravenous Care, INC