a couple picc questions

[lovingRN2009]

when measuring the picc line while doing the dressing change how many centimeters difference does there have to be, before you are concerned of migration?

is a new onset of pink without drainage at a picc line insertion site alarming to you?

[iluvivt, BSN, RN]

You need to know a few facts about that particular PICC.....I have that information before I go in and perform the dressing change......Where was the original tip placement and how many cms were originally visible or if they made any adjustment,either advanced or withdrawn immediately after insertion....so say for example, a PICC was placed 2 weeks ago and the tip was at the cavoatrial junction and there was 4 cm externally visible.....you are going in to perform the dressing change and you need to measure that amt visible and never pull any out unless you have a good reason to do so...hopefully, you still have 4 cm externally visible..lets say now you have 11 cm externally visible...now you have to do something...WHY.?....the length of the SVC varies a little but it averages at about 7 cm so you can see if you had a perfect tip placement with 4 cm visible at 11 cm visible you are most likely in the brachicephalic vein or at best in the Upper SCV. One of the mistakes I see all the time is that nurses inadvertently pull the PICC out 1-2 cm with each dressing change...well.... you can see after a few dressing changes you can be out of the SVC...Why is that so important?...the Standard of care is to have the tip of the PICC or any CVC for that matter. in the SVC and preferably in the distal SVC...every complication is decreased with the tip in optimal location..especially a decreased risk of thrombosis...so you need to get a CXR and if malpositioned,usually a new PICC will need to be placed. Now for the redness at the site..usually it is a mechanical issue....is the PICC insertion site at an area of flexion.?..Did the site get wet from bathing or perspiration?..try to determine the cause and prevent it!! Does the patient have any s/sx of infection..either local or systemic?...if Not I would try to determine the cause and try to minimize the cause or prevent it..it is usually mechanical if it is only at the insertion site if it is NOT a skin infection..the PICC must be dressed properly..with a stabilization device and sterile strips so that it does not piston in and out of the insertion site not only increasing the pts risk for infection but causing skin issues

[rbyrdrn]

You need to know a few facts about that particular PICC.....I have that information before I go in and perform the dressing change......Where was the original tip placement and how many cms were originally visible or if they made any adjustment,either advanced or withdrawn immediately after insertion....so say for example, a PICC was placed 2 weeks ago and the tip was at the cavoatrial junction and there was 4 cm externally visible.....you are going in to perform the dressing change and you need to measure that amt visible and never pull any out unless you have a good reason to do so...hopefully, you still have 4 cm externally visible..lets say now you have 11 cm externally visible...now you have to do something...WHY.?....the length of the SVC varies a little but it averages at about 7 cm so you can see if you had a perfect tip placement with 4 cm visible at 11 cm visible you are most likely in the brachicephalic vein or at best in the Upper SCV. One of the mistakes I see all the time is that nurses inadvertently pull the PICC out 1-2 cm with each dressing change...well.... you can see after a few dressing changes you can be out of the SVC...Why is that so important?...the Standard of care is to have the tip of the PICC or any CVC for that matter. in the SVC and preferably in the distal SVC...every complication is decreased with the tip in optimal location..especially a decreased risk of thrombosis...so you need to get a CXR and if malpositioned,usually a new PICC will need to be placed. Now for the redness at the site..usually it is a mechanical issue....is the PICC insertion site at an area of flexion.?..Did the site get wet from bathing or perspiration?..try to determine the cause and prevent it!! Does the patient have any s/sx of infection..either local or systemic?...if Not I would try to determine the cause and try to minimize the cause or prevent it..it is usually mechanical if it is only at the insertion site if it is NOT a skin infection..the PICC must be dressed properly..with a stabilization device and sterile strips so that it does not piston in and out of the insertion site not only increasing the pts risk for infection but causing skin issues

This is why I love Infusion Nurses!

[iluvivt, BSN, RN]

I love all nurses...I think they are very special people on this earth....one more thing...if you have a minor discrepency by say 1 or 2 cm and you know you are in the low SVC..it is not a big deal b/c it is not enough to take it out of the SVC...I always check the most recent CXR as well and make a note of that in my charting....if a radiologist does not comment on the PICC tip location you can call them and ask them to comment on the PICC tip location ..there is no current recommendation on frequency of CXRs to re-verify tip placement...get one if you have s/sx of malposition...its been mos and mos since the last one.....there is a 3-4 cm difference in the amt externally visible......in the upper to mid SVC (depends upon what anatomy book you use)..there is a vein called the Azygos that enters into the SVC from the back part of the body..and a PICC tip can malposition into that vein during and after insertion...so there you can see another reason to keep it in the Low SVC or at the SVC/RA junction

[picclineman]

it depends on where the tip of this PICC was originally. If the tip was SVC/RA junction and it migrated 3 cms, you still will be in the SVC area. If you were left sided PICC and the tip was proximal SVC 3 cms will place your tip in the innominate vein. So check the xray first and see where the tip was originally. The PACs usually has a measuring device which will aid you in determining where the tip could be. It would be nice if the catheter does not migrate at all.

[iluvivt, BSN, RN]

yes that is correct and in first post that is what I said...check the original tip placement after any adjustments made by the proceduralist or PICC nurse..and of course you can always call the picc nurse :yeah:if you have one..they can figure it all out and advice you on the best course of action.....also do not wait to change any compromised dressing..b/c you do not want any pulled it