Re: Malposition

[Kelly Murphy]

Okay, we JUST had something like this happen yesterday.  It wasn't due to power injection, but nonetheless, it made us rethink some things.

A gentleman came in with a PICC I had inserted in the beginning of August.  Apparently he had gotten a one or two doses of chemo before he was admitted.  He had heparin running since admission.  The PICC was out 1 cm from my insertion record, so I ordered a CXR to confirm placement.  Low and behold, the tip was up the IJ!!  Well, as you can imagine, my mind started going in circles.  I contacted his heme/onc CRNP and we decided, at this point, to pull it back to subclavian placement so he could continue to get his meds for the weekend, and come Monday, we'd figure out what we wanted to do.  She asked why he couldn't get chemo with subclavian placement, and I explained what it could do to the vein, comparing it to as bad or worse than what Vanco will do to a subclavian with prolonged treatment.  She understood and I need to have a plan of action for Monday morning of what I want to do with this guy.

Background:  he has lymphoma in his abdomen (this is what I was told).  I don't believe the first insertion was traumatic (I remember his name, but nothing specific, telling me it went smooth), meaning he had veins. 

What is everyone's suggestion?  Do an exchange or insert a whole new PICC in the other arm?  Like I said, I need your help so that I can go back in on Monday with something to tell the heme/onc people with a rationale.  They are usually very receptive to what we want, so it won't be a hard sell, I just want to be prepared.

Also, this made me think that there should be some protocol to reconfirming PICC placement, but how often is often enough?  This patient was just admitted, but we can probably assume that his last chemo treatment went up his IJ. 

Thanks in advance,

Kelly

----- Original Message ----
From: "[EMAIL PROTECTED]" <[EMAIL PROTECTED]>
To: [EMAIL PROTECTED]; [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Sent: Friday, October 13, 2006 10:42:55 PM
Subject: Re: Malposition after power injection

I had also heard that the distal end of the Power PICC was the same as the Poly Per-Q-Cath, and I wondered how we can be confident that it will not migrate out of the SVC. I have seen it happen with the Poly PQC with movement.

Paul makes a good point about making sure the tip is in the lower SVC. This is not something we can count on radiology techs to consider. If a power injectable PICC is in mid or upper SVC, it probably should not be left in place, as it will be assumed that it can be used for pressure injection. 

Leigh Ann

 
-----Original Message-----
From: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Sent: Fri, 13 Oct 2006 3:11 PM
Subject: RE: Malposition after power injection

I wouldn’t think so. You have gravity working in your favor when you are attempting to flush the tip out of the IJ. Also from what I understand, the composition and dimensions of the Power PICC catheter body is the same as the Poly Per-Q-Cath (it was beefed up in the hardware of the hub, Y-section and extensions to cope with the pressure of the speed injectors) so should respond to that procedure in the same way as a Poly Per-Q-Cath.

Regards,

 

Dianne Sim RN
CEO & President

 

 

IV Assist, Inc.,

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Phone: (510) 222-8403

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From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Roger Soriano
Sent: Thursday, October 12, 2006 7:21 PM
To: Blackburn, Paul
Cc: [EMAIL PROTECTED]; Nadine Nakazawa; [EMAIL PROTECTED]; [EMAIL PROTECTED]; Kokotis, Kathy
Subject: Re: Malposition after power injection

 

So does this mean that the POWER PICC is not easily flipped when it is inadvertently placed in the IJ??

On 10/12/06, Blackburn, Paul < [EMAIL PROTECTED]> wrote:

Susan, Nadine, Dennis, et al

 

The Bard PowerPICC was designed and tested to ensure that the catheter tip does not whip about during power injection of contrast media.  The catheter in fact may back up slightly (about 1cm), but does not whip about in the SVC during injection.  The testing was done in a model that simulates normal human body temperature, blood flow and pressures.  The contrast media that was used for the testing was the most viscous product available on the market.  The testing was conducted on many catheters over the course of several days.  In other words, the catheter was in place in this simulated human environment for nearly two weeks, with power injection of contrast media taking place daily.  So in reality the testing simulated conditions that would be found in the patient care environment, outside of the fact that very few patients would recieve power injection of contrast media on a daily basis.  With that being said, we did not see the catheter soften or flex enough to flip into another vessel--unless the catheter was not properly situated in the first place.  In other words, if the catheter tip is located any where from the lower 1/3 of the SVC to the Caval/Atrial junction, it does not leave the SVC even with repeated power injections over the course of serveral days.  To that end, I don't believe the Bard PowerPICC will malposition merely because of the injection of contrast media. 

 

Hope this helps to explain things a little.  Please let me know if you have additional questions or need more detail.  Paul

 

Paul L. Blackburn, RN, MNA

Manager, Clinical Education

Office:  800-443-5505, ext. 4981

Mobile:  801-598-1657

Email:  [EMAIL PROTECTED] 

 

 

 

 

 

Confidentiality Notice:  This e-mail and any attachments are intended only for the use of those to whom it is addressed and may contain information that is confidential and prohibited from further disclosure under law. If you have received this e-mail in error, its review, use, retention and/or distribution is strictly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message and any attachments.[ v1.0]

 

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From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] On Behalf Of [EMAIL PROTECTED]
Sent: Thursday, October 12, 2006 11:20 AM
To: Nadine Nakazawa; [EMAIL PROTECTED]; [EMAIL PROTECTED]
Subject: RE: Malposition after power injection

Makes me wonder if this is something that was considered and or studied by any of the manufacturers.

Paul????Are you reading?

 

 

--
Susan Schuetrumpf, CRNI
VASPRO
Atlanta, GA
cell-404-606-1194

 

-------------- Original message --------------
From: "Nadine Nakazawa" <[EMAIL PROTECTED]>

>
> I was wondering that once power PICCs have been out for awhile if we would
> see this phenomenon occur ---secondary malposition because of all the
> whipping around. How deep to you place your original PICCs?
>
> Nadine Nakazawa
>
>
>
>
> >From: "DAVID LONGSETH"
> >To: [EMAIL PROTECTED]
> >Subject: Malposition after power injection
> >Date: Wed, 11 Oct 2006 20:05:42 -0500
> >
> >Saw a set of CXR's last week that were of interest. Pt had a 5Fr Power PICC
> >placed in the AM,then a CT in the afternoon (chest for PE,I think). Later
> >in the evening pt. began having discomfort and swelling in the neck. CXR
> >af ter PICC placed showed a good lower SVC placement but the evening's film
> >showed the line up the IJ,perhaps with the tip in smaller collateral vein.
> >Apparently the CT contrast injection was strong enough to flip the PICC up
> >there.
> >Was wondering if anyone else has seen this occur,but then also wonder if
> >this doesn't happen more frequently and we just never know....
> >David
> >
> >
> >
>
>
>

--
Roger Soriano, RN
Vascular Access Specialists
818-687-8348

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