Rational for PICC guidwire removal prior to CXR

Remove the guidewire before taking the CXR.

Reason: guidewire removal can cause position to change. I've seen them move from SVC to contralateral subclavian; and from SVC to ipsilateral jugular.

Granted, change in position doesn't happen often, and some of that movement can be mitigated by removing the guidewire slowly. However, you can only truely confirm placement if you check the Xray after the guidewire has been removed.

We remove the guidewire prior to the cxr at our hospital.

It depends on the situation. If the patient is obese or if there is a pacemaker or other hardware present, leaving the stylet in the PICC can make for easier viewing on the xray. Also, if there is a chance that the radiologist or MD will be looking at xray from home computer, leaving the stylet in can help them see the position of the tip more clearly. Personally, I prefer removing the stylet prior to the xray. Hope this helps.

Yes that is correct you should not leave the guidewire in place b/c upon removal you can malposition the PICC. Are you having trouble seeing the PICC or the PICC tip. If this is the case, there are several other viable options to get a good film. We just write in the order after the CXR what our special requests are. Do you want me to be more specific about what some of these techniques are? It is better to identify the patient that may need special CXR techniques than messing around all day with repeat chest X-rays. Some examples are the morbidly obese.pts with multiple chest lines, pts with liver disease,and pts with chest tumors. Let me know if you need any of these directions.

Another way to identify PICC tip location is with ECG guidance. An ECG signal can be derived from the guide wire or from a saline flushed PICC (e.g., after guide wire removal). The technique is based on the dramatic changes in the P wave as you get within about 4 cm of the caval-atrial junction (see http://www.pacerview.com/index_files..._PACERVIEW.htm). These changes can be seen in real time, at the time of placement. You can also derive a signal from the saline after placement to see if the tip has migrated into the atrium. It's less expensive and faster than x-ray and well established in the literature (see the references page at the PacerView website).