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It has always
been my practice based on my training, conferences and knowledge learned here,
that a PICC tip does not ALWAYS STAY in the SVC. Although it is placed there,
and on some patients it may stay there, especially if they are hospitalized and
in bed. But homecare patients move around. They move their arms, cough, bend
over, lift things, laugh, cry, walk etc. All of these things change the intrathoracic
pressures, and move the line up and down within the SVC, so sometimes the tip
will travel to the IJ and back, to the atrium and back, etc. It is important
to always thoroughly assess your patient before giving medications. Did you
get a blood return? Can they hear, feel or taste anything when you flush or
infuse? I am sure that there are patients who have lines that have migrated
and have no symptoms. It is a risk anytime a PICC is used on an ambulatory
patient. I am also sure that all RNs do not do these assessments prior to
infusion, therefore it stands to reason that it is likely many patients get doses
of drug into the IJ or atrium, at least occasionally, and live another day.
If it were my patient, I most likely would not have gotten an XRAY for a 1 cm
movement. I would, however, make sure there was a Statlock in place to
prevent further migration. If I did find out it was in the IJ, either through
assessment or XRAY, I would have the patient sit upright, flush with 10 cc NS
stop/start/stop/start, and have the patient move his arm up and down, above his
head and back down. Eventually, the line will drop back to the SVC. I would
not have replaced or pulled it back. The AVA position paper and the information
from articles, conferences, etc tells me that much more long term damage is
caused by leaving a line anywhere short of the SVC. Another thought—was
the PICC long enough to start with? Lower 1/3 of the SVC? Shorter lines (top
of the SVC) tend to have this problem more often. Chris
Cavanaugh, CRNI From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of 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 ---- 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 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 IV Assist, Inc., Phone: (510) 222-8403 Fax: (510) 222-8277 Email:
[EMAIL PROTECTED] Confidentiality
Notice: This e-mail and any attachments are intended only for the use of
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attachments.[v1.0] From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Roger Soriano So does this mean that the POWER PICC is not easily
flipped when it is inadvertently placed in the IJ?? On 10/12/06, 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 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]
From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of [EMAIL PROTECTED] Makes me wonder if this is something that was
considered and or studied by any of the manufacturers. Paul????Are you reading? --
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- Re: Malposition Kelly Murphy
- Re: Malposition Hallene E Utter
- Re: Malposition Nadine Nakazawa
- Re: Malposition Heather Nichols
- Re: Malposition Lynn Hadaway
- Re: Malposition leighannbowe
- Re: Malposition Kelly Murphy
- RE: Malposition Chris Cavanaugh
- RE: Malposition Kelly Murphy
- Re: Malposition Nadine Nakazawa
- RE: Malposition Kokotis, Kathy
