-------------- Original message ---------------------- From: "Nadine Nakazawa" <[EMAIL PROTECTED]> > > Let me clarify my comments. I would NEVER leave the PICC in the > midsubclavian vein, but might leave it there overnight, until it could be > exchanged the next day or referred to IR for an exchange under fluoro. You > could leave it as a midline in the upper arm, but you have a lot less > catheter to work with if you plan to exchange it the next day. I don't do > an over the wire exchange; I'm talking about a thru the peel away sheath > exchange. For that you need to clean the skin around the exit site several > times with antiseptic (preferably Chloraprep) and pull out the PICC in 5 cm > increments until you have only sterile catheter now sitting on the skin to > be cut and the exchange to occur. This happens rarely, but it I did have > to do this the other day. Lots of notes, kept it wrapped sterilely. > Unfortunately, IR couldn't do the patient the next day and one of our other > PICC nurses removed it. > > Nadine Nakazawa, RN > > > > > >From: "Lynn Hadaway" <[EMAIL PROTECTED]> > >To: "Hallene E Utter" <[EMAIL PROTECTED]>, "Kelly Murphy" > ><[EMAIL PROTECTED]>, [EMAIL PROTECTED], [EMAIL PROTECTED], > >[EMAIL PROTECTED] > >CC: [EMAIL PROTECTED] > >Subject: Re: Malposition > >Date: Wed, 18 Oct 2006 15:53:36 -0400 > > > >Midclavicular tip location should never be the initial goal when the PICC > >is first placed. When you can not reach the SVC, then you make an indepth > >assessment based on many factors outlined in the AVA position paper on tip > >location - call the AVA office to obtain this paper. > > > >Ordinarily, pulling back to midclavicular is not a good idea but this case > >had extenuating circumstances. Malposition was detected on a weekend when > >there was not enough support to manipulate it. > >He was hypercoagulable due to cancer diagnosis, but was on a heparin drip. > >The NP was educated about the risk of this location and plans were in place > >to do something about it on Monday morning. > >The best case scenario might be to give it some time to see if the original > >PICC would spontaneously reposition itself without any intervention. But > >since the length of time the PICC had been in the IJ was unknown this might > >not have occurred. > >Next step would be to have the capability to perform an exchange when the > >malposition was found and get it properly positioned immediately. > > > >If neither of these were possible, pulling it back was the third best thing > >but this is my opinion. Decisions like these require a knowledgeable nurse > >to do a risk vs benefit assessment for the patient at that time and the > >best thing may be different for each patient. > > > >Lynn > > > > > >At 10:02 AM -0600 10/14/06, Hallene E Utter wrote: > >>I am confused. When is it appropriate to "pull back to subclavian > >>placement"? My understanding is that midclavicular is never appropriate > >>placement. > >> > >>Halle Utter, RN, BSN > >> > >>----- Original Message ----- > >>From: <mailto:[EMAIL PROTECTED]>Kelly Murphy > >>To: <mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED] ; > >><mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED] ; > >><mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED] > >>Cc: <mailto:[EMAIL PROTECTED]>[EMAIL PROTECTED] > >>Sent: Saturday, October 14, 2006 8:19 AM > >>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 > >> > >>.AOLPlainTextBody { margin:0px; font-family:Tahoma, Verdana, Arial, > >>Sans-Serif; font-size:12px; color:#000; background-color:#fff; } > >>.AOLPlainTextBody pre { font-size:9pt; } .AOLInlineAttachment { > >>margin:10px; } .AOLAttachmentHeader { font:11px arial; border:1px solid > >>#7DA8D4; background:#F9F9F9; } .AOLAttachmentHeader .Title { font:11px > >>arial; background:#B5DDFA; padding:3px 3px 3px 3px; } .AOLAttachmentHeader > >>.FieldLabel { font:11px arial; color:#000000; padding:1px 10px 1px 9px; > >>background:#F9F9F9; } .AOLAttachmentHeader .FieldValue { font:11px arial; > >>color:#000000; background:#F9F9F9; } .AOLAttachmentHeader a, .AOLImage a { > >>color:#2864B4; text-decoration:none; } .AOLAttachmentHeader a:hover, > >>.AOLImage a:hover { color:#2864B4; text-decoration:underline; } body { > >>background-color:white; font-family:"Verdana"; font-size:10pt; border:0px; > >>} p { margin:0px; padding:0px; } img.managedImg { width:0px; height:0px; } > >>img.placeholder { width:275px; height:206px; background:#F4F4F4 center > >>center no-repeat; border:1px solid #DADAD6 !important; } > >>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=http > %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. > > > > > >-- > >Lynn Hadaway, M.Ed., RNC, CRNI > >Lynn Hadaway Associates, Inc. > >126 Main Street, PO Box 10 > >Milner, GA 30257 > >http://www.hadawayassociates.com > >office 770-358-7861 > > >
I understand why one might leave it (albeit briefly.... 24 -48 hours or so) (depending on what's going through it....) until they could decide an appropriate action to take. There was just such an emphasis on no midclavicular placements, and I didn't initially understand it was temporary. But I have another point/question. I still see people talking about OTW exchanges from time to time. I attended the NAVAN conference in Vancouver and the presentation about the biofilm, and since then we won't do otw exchanges unless we have no other options. We used to do them if a line had been pulled out some and was no longer in the SVC, and there was no indication of infection. But ever since that presentation, let's just say I was convinced!! I didn't want to scrape through the biofilm and initiate a bacteremia! Halle Utter, RN, BSN
