It was a 5 Fr 45 cm Groshong that was only inserted 36 cm, so it was long enough. And placement was SVC, although right now, I couldn't tell you where. I'd like to reiterate that our "PICC Team" is one person a day, and that we really are just starting out. Yes, we've been doing them for a few years now, but sometimes it seems like I could have been doing this for 30 years and still have something come up that I'd never seen before. Your technique for repositioning is a little more than flushing it into position, and I appreciate the extra tips. I will attempt them in the future. I did not think to attempt flushing because, as I said previously, it hasn't worked for me and I didn't want to put this poor man through another round of crap when I'd have to replace or reinsert the PICC anyway. I'll also say that we try to limit our insertions to M-F 7a to 5p, because outside of those hours, we have to chase down radiologists and usually don't have the staffing, either. This occurred around 6 pm on Friday. I said I pulled it back to the subclavian but that's probably not entirely true. I pulled it back to 20-25 cms, so it's actually at midline length. I realize all the implications of leaving it in the subclavian.
Again, Chris - thanks for the hints, I had not heard some of those before. Kelly --- Chris Cavanaugh <[EMAIL PROTECTED]> wrote: > 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 > Sent: Saturday, October 14, 2006 10:20 AM > To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; > [EMAIL PROTECTED] > Cc: [EMAIL PROTECTED] > Subject: Re: Malposition > > > > 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., > > 2675 Appian Way > > Pinole, CA 94564 > > 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 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 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] > > > > _____ > > > > 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 > > CONFIDENTIALITY NOTICE: > This e-mail message, including all attachments, > is for the sole use of the intended recipient(s) and > > may contain confidential and privileged information. > If you are not the intended recipient, you may NOT > use, disclose, copy or disseminate this information. > > Please contact the sender by reply e-mail > immediately and destroy all copies of the > original message including all attachments. > Your cooperation is greatly appreciated. > > _____ > > > <http://pr.atwola.com/promoclk/1615326657x4311227241x4298082137/aol?redir=ht > tp%3A%2F%2Fwww%2Eaol%2Ecom%2Fnewaol> Check out the > new AOL. Most > comprehensive set of free safety and security tools, > free access to millions > of high-quality videos from across the web, free AOL > Mail and more. > > > > > > __________________________________________________ Do You Yahoo!? Tired of spam? Yahoo! Mail has the best spam protection around http://mail.yahoo.com
