why the catheter goes to contralateral side instead SVC

[fangguixiao]

I am a new PICC line nurse with three months experience.I had one patient yesterday.Catheter all the way in ,no problem, blood return good.X-ray ordered.It shows catheter went to another side instead SVC. Me and my coworker tried 4 times. change patient position and exchange catheter,twist catheter.not work.Final X-ray still shows catheter went to another side .it did not go down. anyone can help me out and explain why? how to deal with this situation?I appreciate your help.

Another question is I had a patient with bilateral upper arm severe edema.I tried put PICC on right upper arm.from Ultrasound, I can see the vein well even though a lot of fluid under skin. I got blood return good but I can not see my needle.I pull back my needle a little,still can not see it from screen. What should I do in order to easily see my needle in the screen?I was taught the needle tip is supposed to in the middle of the intended vein.Is that ok I still can put wire in when blood return is good even though I cannot see the needle?

I know the needle should be at correct angle to enter vein using USG based on depth of vein.My question is how to select appropriate needle guide ? any input is greatly appreciated. happy new year everyone!

[Asystole RN]

When placing a catheter keep in mind that the patient's internal anatomy is 3-dimensional. Depending upon how long the SVC is, what angle the right brachiocephalic is to the SVC, how large the brachiocephalic/SVC junction is, what angle the left descending brachiocephalic is, all these things can alter the course of the catheter.

What can help in these cases is site the patient up and sometimes forward while power-flushing. If you are advancing from the right sometimes having the patient lay on their right hand side helps (keeping the arm out of course). Anything odd in the radiograph? How did the anotomy look? Any odd scars or masses? Are you sure the brachiocephalic from the right actually directly connected in a straight path to the SVC? I generally do not like to use a guidewire, especially in these cases. The more rigid a catheter is the less likely it is going to be able to navigate around odd anatomy to find the flow of blood.

As far as visualizing the needle during insertion I use that as a secondary form of confirmation, not the primary. I look for blood return, the feel of the needle, and the ease or resistence I feel from the guidewire to determine placement, not visuals. Like when you start a PIV, do not allow your eyes to be the only form of assessment. I have seen where the tunica intima has seperated from the tunica media and the needle looks like it is in the vessel but in reality is between vessel layers.

[fangguixiao]

Hi Asystole RN,

Thank you so much for your information.From radiograph ,nothing looks odd.We did try again from left arm . We got down right way but too deep. We pulled back 2 cm.X-ray showed catheter went to contralateral again. we repositioned. It finally went to SVC. Me and my coworker so surprised how that happened ? why catheter went to contralateral again we just pulled back 2 cm?any explaination ? I appreciate your time and help! Thanks a lot!