Best way to measure for PICC placement

[bethchpn]

I have been placing PICC's by ultrasound and with Sherlock for 10 months. I only place 1-4 a month as I work in a small hospital. I have had good success but my measurements are deep a lot and I have to pull back 2-4 cm often. I measure from insertion site to mid clavicle down to third intercostal space. Do any of you that use Sherlock feel like the sound change helps to see where it is at? I do realize that everyones anatomy is different. Is this to be expected or will I get better? What is the expected ratio of perfect to off by 2-4? If we pull back 2-4 we don't usually re-xray as they will still be distal SVC. The radiologist reads them in right atrium or CAJ a lot.

[iluvivt, BSN, RN]

Bard will tell you to go by your measurment b/c of parallax...and Yes everyones anatomy is a bit different..make sure you are running your tape measure just under the clavicle..sometimes when I am in a hurry I notice I run it above it and then I am in the RA...I can give you a few tips that may help

1. I actually use a skin marker and put a little mark at the third IC space..that way I can hold the tape measure taut...I also put a mark next to my selected insertion point...my co-workers use an end cap and put a little indent into the skin

2. If you a CXR for that patient...view it...you will get an idea of just how long their SVC and you know you may want to measure a little long...you may also see a suprize or two...like a port..or a pacer

3. The left side is longer b/c the BrachioCephalic is longer on that side.so I usually add 2 cm to my measurment

4. We all watch our stylet pull and just look at when it takes the turn out of the SVC to make sure it is long enough

5 Be aware that sometimes if you are in the RA you will be unable to get a blood return from the lumens...You can also watch the monitors for any ectopy....if you get some ectopy during the last few cms of threading....good chance you are in the RA

6 Remember still better to be in the RA and pull back than in the upper or mid SVC.......the farther away you get from the lower third of the SVC...the more complications increase including thrombosis..and YES this includes ALL complications..Also remember that the Azygos vein enters from the upper to mid SVC so you can have a PICC migrate into that vein from there..even after insertion

7 Also remember that rads do differ in how they read a film we see this all the time..so if you see something different please call them and have a discussion.....The cavoatrial junction is just a designation and there is still some disagreement out there about where the SVC ends and the RA begins. We often will check subsequent films esp in our ICU pts since they get a CXR everyday

[bethchpn]

Thanks for the reply. Very helpful. I do agree that Rad all disagree. Do you have or know of a good picture with landmarks on it. I received a book when I was trained but the chest x-rays and photo of the heart/landmarks was photocopied and hard to see. I have been looking a previous CXR's and that does help a lot.

[iluvivt, BSN, RN]

You need to read Dr Vesleys article on this....I need to check on that name as I am not sure of the spelling....he really explains the anatomy well...let me look for it and I will get back to you. The best way to get a good CXR is to ask for a copy after PICC placement on a young adult without ant chest pathophysiology...say for example, the PICC is being placed for ABX for a knee infection basically some young otherwise healthy individual. I just ask the techs for the film and cut off the pts name and any identifying information...we have it all on computer as well and we can copy for training purposes within our facility....we do a lot of PICC insertion training....Once you have a really good film of "normal it is really easy to see the abnormal...but you are just looking for the anatomy that will help you state wher the PICC tip is..such as the carina and right atrial appendage