Malpositioned PICC line question

PICC ACE · Dec 25, 2009

Any central line,including PICC's,can indeed cause arrythmias if placed too deep. The tip of the line may "tickle" the heart tissue enough to trigger something. If the radiology read was to pull back 6cm,the line may have been much too deep,but the issue of optimal placement unfortunately vfaries from rad to rad.

ST changes are associated with repolarization or perfusion issues with the ventricles--iscemia,injury,strain,etc. These changes would be unlikely to be related to a central line/PICC tip in the atrium.

Kudos to your staff for getting the line properly adjusted!

Z.

iluvivt, BSN, RN · Dec 25, 2009

Yes !!!!!! any line in the heart can cause problems...we usually see PVCs ...and often when pt is on there left side. We also tend to see it in the pediatric population,very thin individuals and individuals with liver disease or any condition where the abd can apply pressure to the chest. Just because the radiologist says "OK" to use does not laways mean safe to use....ALWAYS ask for or look for the exact anatomical PICC tip or CVC tip placement. Both INS and NAVAN have clear postion statements stating that optimal tip placement is in the low SVC or at the cavo-atrial junction.....and YES some radiologist are misinformed about this and think it is OK to leave a tip in the right atrium we too have had to educate our radiologist. Your hospital SHOULD have a PICC/CVC policy indicating where the tip of any CVC should be. The only exception you may see is a HD catheter as there is still some contraversy about this.

allnurses Guide · Dec 25, 2009

Absolutely.

PICC ACE · Dec 26, 2009

This situation exemplifies two additional aspects of central line placement. First of all,the statement "line OK to use" or "line in good position" is useless. How does a rad know that a line is OK to use? OK to use means not just with tip in proper position but also with good blood return,not plugged/ruptured/defective,not stuck through an artery into the vein,etc,etc. Also "in good position" means different things to different people. Define "good". "Good" for a knowledgeable interpretter of line CXR's means "lower 1/3 of SVC at or near the CA juncture" (SIR,AVA,INS). "Good" for anyone else might be anywhere from rt ventricle to contralateral IJ to aortic arch (seen 'em all). What I want to know when I read a CXR report for line placement is where the tip lies anatomically,e.g. "lower SVC 1.5 cm above CA juncture". That,plus MY assessment of the line's patency and function is what makes a catheter "OK to use".

The second issue is the importance of getting a repeat film after a significant line adjustment.A few years ago,there was a tragic case in Pennsylvania. A neonate had a line placed and the initial reading was that it was too low and needed to be pulled back a few cm. Either no one actually adjusted the line or there was no repeat film,and the line eroded through the atrium. Results-ruptured heart--tamponnade--dead infant--big lawsuit. Moral of the story? Reshoot after an adjustment.

MNRN2009 · Dec 26, 2009

To clarify, it wasn't the radiologist that gave the "ok to use" order. He read the x-ray for placement and the ICU doctor gave the "ok to use" based on the radiologists read. The PICC team had also determined it was patent and had blood return. Thanks everyone for your replies!!!

Emergency RN · Dec 28, 2009

My question is, can a PICC line catheter tip being in the right atrium cause ECG changes?

Maybe, but generally, it would be limited to rhythm abnormalities secondary to tissue irritation rather than ischemia (ST segment) infarction (troponin) events. If having a line in the RA or RV were that clinically dangerous, then it would negate the use of Pulmonary Artery (Swan-Ganz) catheters. PICC lines can also be used as a poor man's CVP line. That said, there is nominally a danger of perforation (tamponade) events but those are generally historically statistically small in view of the numerous central venous lines that have been inserted. Further, pacing wire tips routinely are placed directly into either the RA or RV, and if untoward events related to line presence were a big risk, that process would not be even possible.

My two cents? It was good that the nurses were astute enough to have caught the missed pull back, but in the final analysis, it was probably clinically insignificant.

iluvivt, BSN, RN · Dec 30, 2009

Yet the risk is still there and it does not suprize me that was a pediatric case in which the RA was perforated. When any CVC is placed form the left side it can be a rather sharp turn from the brachiocepahlic into the upper SVC region and you will often see the tip of the catheter butted up against the wall of the vessel. or the RA The bottom line is that every hospital and healthcare institution should have a policy stating where the tip of any CVC should lie..and of course this should be supported by evidenced based standards of care. It used to be OK to leave CVCs in the RA..as a matter of of fact they were called right atrial catheters ...not any more...there is no benefit and potential harm. If anything happened to the patient "it does not happen often" would not hold up in court...Get it out of the RA..it is not supposed to be there