CVC's and PICC's- to use, or to x-ray, then use?

[RNcDreams]

I was wondering..

What's the policy at your facility regarding the use of preexisting central lines in patients that arrive at your facility?

Are you required to get a portable cxr to verify placement (even if the patient states they use the line daily) or are you able to use it if the patient has used it that day and you are able to get blood return?

Just curious!

[mom4josh]

The only time we xray is when they are first placed. After that, we use them all the time, especially if there is good blood return.

[RunnerRN, BSN, RN]

We do not xray to confirm placement, just confirm through blood return.

[northshore08]

Us, too....initial placement requires verification by xray, but blood return is sufficient otherwise.

[meownsmile, BSN, RN]

Denfinately have to have an xray for placement on a newly placed line. I doubt whoever put it in would allow it to be used if it werent xrayed for placement first initially. However, if it is already established on admission, it is accessed flushed and used.

[iluvivt, BSN, RN]

The bottom line is that if you use the line you are responsible for knowing where the tip is.You can locate the original report or view a recent chest Xray. A blood return only confirms that the tip is in a vessel somewhere. For all you know it could be in the internal jugular vein or if a PICC could be in the arm. I have had this happen. Once I saw a pt that was not on our PICC list. I asked where the pt came from. The pt had come from a long term care facility and they were getting ready to start TPN through the PICC, I insisted on a CXR and we found the PICC malpositioned in the pts arm. This also happenned with a PICC that had been in place for 6 monthes and they were getting ready to give chemo through it! Any line originally placed in the Superior Vena Cava or elsewhere can malposition post insertion. I see it with pts that heavy coughing or vomitting and intubated pts (often whips up into the Internal Jugular). PICCS placed in the upper SVC can also malposition into the Azygous vein. Some pts may also have S/sx of malposition,but not always. I tend to trust tunneled lines and ports a bit more than PICCs and shorter term lines. So we do not allow any one to use a line in our hospital unless we confirm its tip placement.

[Larry77, RN]

Any line originally placed in the Superior Vena Cava or elsewhere can malposition post insertion. I see it with pts that heavy coughing or vomitting and intubated pts (often whips up into the Internal Jugular). PICCS placed in the upper SVC can also malposition into the Azygous vein. Some pts may also have S/sx of malposition,but not always. I tend to trust tunneled lines and ports a bit more than PICCs and shorter term lines. So we do not allow any one to use a line in our hospital unless we confirm its tip placement.

So how many times do you confirm placement...every time the pt coughs??? Or every time the patient starts a new IV med regimen? Or just when you don't "trust" the line?

In the ED we do not confirm placement, this is done post placement. If it works easily we use it, if there is any difficulty we start a peripheral. In my experience the times you have trouble and start "forcing" things is when you get in trouble.

[cardiacRN2006, ADN, RN]

But blood return doesn't tell you anything about placement other than it's inside a vessel. Is it in the IJ? Coiled in the subclavian?

If it's not in its proper place then it's not ok to use, blood return or not.

You dont' have to get an XR every time that the pt moves, but upon transfer from another facility is a must.

Or, you can take them at their word, continue to use the line without knowing placement. Then if the pt goes bad, and gets pressors infused into his IJ then you've got lots of explaining to do.

Advocate for your pt, and get the 5 min simple CXR.