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PICC TIP LOCATIONS
Bedside
placement of a PICC is very difficult since tip location is a mystery until
confirmed by chest Xray. The catheter is placed in the arm and it is
threaded up via the basilic or cephalic vein and it curves near the shoulder
into the subclavian vein and curves again into the innominate vein, which
leads the catheter down into the superior vena cava (SVC). This path is full
of valves in the arm and subclavian area and strictures in the subclavian,
which can cause the catheter to take another path. Jugular placement,
opposite subclavian placement, right ventricle and right atrium placement
are a few tip placements which are considered malposition of a PICC.
HOW ARE MALPOSITIONS FIXED?
·
Right atrium and ventricle -
the Vascular Access Nurse or physician can pull the catheter back (as
recommended by the radiologist) to leave the tip in the SVC.
·
Tip placement in the jugular
is often left to fix itself. Another chest Xray is taken the next morning to
verify that movement has occurred. If it is still in the jugular, the
patient is sent to radiology for manipulation of the line.
·
Others malposition are
referred to Interventional Radiology for correction.
WHEN CAN A LINE BE USED IF
A PATIENT HAS TO GO TO IR?
Placement is done under fluoroscopy
(real-time visualization), so the tip is seen during the entire procedure.
The physician and/or nurse will be notified by the IR staff if immediate
use of the line is not recommended.
WHERE IS THE TIP LOCATION
DOCUMENTED?
The nurse who
receives the Xray result from the Vascular Access Nurse is responsible to
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document the results on
the Vascular Access Consultation sheet in the Interdisciplinary Note section
of the chart. At the bottom of the Vascular Access Consultation Sheet there
is a section where you will check off the vein where the tip terminates.
Next to “comments”, note the radiologist who read the Xray. If there is a
problem with the tip placement, which requires adjustment by the PICC nurse,
this will be documented by the Vascular Access Nurse. IR is beginning to use
this form as well. However, they may document tip placement in the
interdisciplinary notes.
REMEMBER: Good placement is either SVC or Junction of SVC and Right
Atrium.
HOW DO I OBTAIN TIP
PLACEMENT WHEN A PATIENT IS ADMITTED WITH A PICC?
You can not
know where the tip is unless measurements of the external catheter related
to the tip placement are available from the person who placed it. The only
way to be sure of tip placement is by taking a chest Xray.
ARE THERE OTHER TIMES I
NEED TO OBTAIN AN XRAY TO VERIFY TIP PLACEMENT?
Yes!
When you see more
catheter externally than noted on the wall sign. Increase in external
catheter means that the tip is pulled back out of the SVC and placement
needs to be verified. This is especially important when infusing vesicant
and/or irritant solutions.
REMEMBER: Even when a
tip is not verified, you CAN draw blood and you MUST flush the catheter
routinely or it will become occluded.
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