My institution follows INS and AVA guidelines and does not allow a PICC line to terminate in the right atrium. I am the only trained PICC nurse at this facility. There have been times when the last PICC of the day will be found to be in the right atrium, well after I have gone home. I have been able to talk the staff RN through the retraction process over the phone so the PICC can be used. I decided to create a policy that would out line the steps needed to retract a PICC line. I am asking for any references reagarding this topic. INS does not specifically outline steps to retract a PICC from the right atrium. Your help would be appreciated.
I can not give you any references to support what you want to do. It is my firm belief that the PICC nurse must finish the procedure. This should never be turned over to the staff nurse to do. I would also direct you to the INS Standard 53 CVAD Malposition, Practice Criteria G, page S73. "The inserter/operator should know the results of the chest radiograph, properly reposition the CVAD if required, obtain a confirming repeat chest radiolgraph and document all actions taken." This is supported by 2 references and has a ranking of IV. This means that the inserter is responsible for total completion of the entire insertion procedure through final confirmation that the catheter is in the correct location. If you can not complete the procedure before the end of your shift, then you would either need to defer the insertion to the next day, stay late, or hire additional PICC inserters. But generalist staff nurses should not be doing this procedure. Lynn
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
I agree with Lynn in regards to a PICC nurse knowing their lines. As a PICC nurse , I would never take a Radiologist interpretation as gospel. There have been too many interpretation issues, what one MD calls right atrium another calles Caval-Atrial Junction. So get acquainted with your lines and the wet readings.
Now here's where Lynn and I may part ways. I feel a nurse should be comfortable retracting a PICC 1-2 cm. If you still believe in the 24hr guaze dressing then to a Biopatch dressing the next day nurse will have to retract 1-2cm to put the Biopatch on properly. Contrary to what I read on these forums, patients still bleed and require you to advance the PICC to the hub. So, naturally the next day, the Biopatch needs to be applied. I see too much of the Biopatch just lying on the top of the PICC hub. But if you stay and own your line, you won't have this problem
Jack Diemer, RN BSN
Coordinator Vascular Access
Kennedy University Hospital
Do you mean any and all primary care nurses? Do you mean PICC retraction to obtain correct tip location? If your answer is yes to both of those questions, then we will have to agree to disagree on both issues. The PICC inserter is responsible and accountable for the outcome of the complete insertion procedure, which means achieving correct tip location. This can not be delegated to a primary care staff nurse.
Regarding retraction for other purposes, I see that as a completely different issue. However I do not follow your rationale for the need to retract a PICC. There is no need for a dressing change within 24 hours if the dressing remains clean, dry and intact. Are you saying that you see a large majority of patients bleeding from the puncture site after a PICC insertion? If so, use of a CHG-impregnated dressing would not be indicated. Use of a coagulation dressing would be needed. There is at least one brand that combines both coagulation with the CHG. Seems like that is more appropriate. Also, I am not a belliever in the reverse taper on PICCs. Putting the largest diameter of the catheter into the smallest diameter of vein simply makes no sense to me. Now that there are coagulation dressing, the need for reverse taper to tampondae the site should go away. Also, tamponading the site was not the original purpose for the reverse taper. This became a perceived benefit through marketing, not clinical evidence.
Lynn
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
We do complete all aspects of our PICC insertions before leaving each day including release for use. When the PICC cannot be used immediately the nurse is informed, documentation is done and alternate access is available. Follow-up is done the next morning.
I've found, like Murphy's law, the last PICC of the day is usually the most problematic...so we've learned to proceed with caution on end of the day PICCs and consider placement the next day unless circumstances dictate otherwise. We would not ask a bedside nurse to retract the PICC post insertion.
Nevertheless, I believe internal catheter migration is something the bedside nurse must be able to assess and address. I have seen several situations in which neither the nurse nor the physician wanted to withdraw the catheter to the correct position (for illogical reasons). This increases risk for the patient and certainly increases cost when a patient must return to the facility (if not inpatient) to specifically see a vascular access nurse.
The risk of not retracting a malpositioned catheter and doing nothing is something I seem to not be able to get across.
I agree with Angela. Murphy's law is always in effect on those late starts. We do not start a PICC unless we can finish all aspects of the placement, including the final Xray clearance to use. We are subject to the availability of our radiology departement. So if they are tied up with a trauma it can greatly affect our read times. We order all films "stat" but they still have to triage the orders and a Level 1 trauma will always win. Therefore we have had to adjust the times during the day that we are willing to place PICC's. Our department closes at 11pm so we do not start a PICC after 9pm. For the most part this allows us to finish up & clock out on time. You need to look at your average times required for insertion and any repositioning required. We ALWAYS get another film after any repositioning. The PICC shouldn't be anywhere other than the SVC if it was in the RA and you only pulled back a few centimeters. However, anyone that has done this for any length of time will tell you that CRAZY stuff happens all the time.
If your facility has a policy that the RN can pull back a CVL for adjustment I suppose you could create another similar one for PICC's but I would not advise that. The best plan is for your team to take 100% ownership of placement and not clear a PICC for use until you are certain the tip is exactly where it should be, before you go home.
My 2 cents
Martha
Speaking of retracting PICCs, if you have found a PICC tip in the RA, at what point does everyone retake the CXR? If you retract less than 2cm? 5cm? 10cm? or do you repeat CXRs no matter what length you pull , even 1cm? Does Lynn H. have any references to support this? I mean, the average SVC is approx. 7cm, so if you were 3cm into the RA, pulling back even 5cm will still keep you in the right place.
Opinions? Comments please?
Look at the complete anatomy of the SVC. Yes it is approximately 7 cm in most adults. But there are other veins joining it. Azygous vein joins the SVC at the level of 2nd intercostal space on the posterior side. Retracting a PICC, especially in a patient with fluid volume deficit could cause catheter tip to move to azygous vein. This is just one example. Blindly moving a catheter is never a good idea. If you retract it without ECG guidance, you are liable for wherever that tip actually ends up. I would get a repeat chest xray but ECG is better than a chest xray in most patients. Lynn
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
Our team gets an Xray with any and all repositions because of exactly what Lynn said. Also, because we don't trust our radiology reads. Too many stories to recall here but many inexplicable cases of tips going to crazy places when they should not have. A recent one was in what I can only guess was some sort of chest wall vein. It should not have happened. We have no idea how it happened. But it did. So we always get a film & look at it ourselves before we clear the PICC for use. We don't do acutual reads but are more than willing to call the radiology department and argue for an over-read.
We also get an x-ray after any withdrawal of the PICC from its original position.
With chest x-rays being variable, meaning the angle that they are taken when portable, we have found that we have pulled back too much. The original x-ray shows the PICC deep and withdrawing the distance based on that one ends up wrong because of the angle that was not really anterior-posterior but something else. We have had a few that were then replaced/exchanged to the original length. Better x-ray showed that it was perfect position.
ECG technology will eliminate these errors.
Gwen
Xray angle does affect final appearance of where the picc tip position is.... if the operator shoots from too low, the picc will look high, if from a high angle, the picc will appear low.
Often the collar bones will give a clue... high angles make the collar bones look like bat wings, if too low, they l ook like straight sticks....
Proper angle causes the collar bones to look like the wings of a sea gull gliding in the wind.
While these are not offical terms but rather the interpretation of a "non-xray" person as myself....
We must realize that xrays are light and the board that goes behind the patient is like the film of the camera....
Example: Take a pen "simulating the picc line" and hold it about 4 - 5 inches from a wall... now take a flashlight "simulating the xray beam" holding it a few feet away and point it at the pen with the wall in the background.... move the flashlight up, the shadow of the pen goes down.. move the light up and shoot at a higher angle and the shadow moves down.
You may ask.. what does a shadow and a xray have in common?.. they are both negative pictures of an object that got in the way of the beam... no diifference.
Xray techs need to shoot perpendicular to the board and the patient and be reasonalbly consistent.....
Another reason the xray will become obsolete as more definitive methods such as EKG confrimation becomes the norm and phases them out saving everyone headaches, time and expense!
Its so frustrating to have a doctor read and say it needs to be pulled back 3 cm.. just to have the next shot make the picc appear barely in the SVC as if it has moved 7 or more cm?
Yes, the heart moves "with the picc tip" if you change the angle but not to the same degree....
exaggerate the situation... if you take an extreme high angle it will make the picc look like its in the bottom of the heart...
xrays are 2 demensional so changing the angle or the source of the emitting rays is a game changer when trying to get 3 demensional impressions.
The EKG tip recognition technology does a much better job of depicting whats going on in a 3 dementional heart.
The second mouse gets the cheese!