How to deal with catheter issue when insert a PICC line.

Asystole RN · Oct 15, 2014

A lot depends upon your patient's unique anatomy and how the patient was positioned.

Personally what I like to do to prevent this is insert my catheter to around the axilla and mostly remove my guidewire so that the catheter is extremely floppy. Once the catheter starts approaching the brachiocephalic I start flushing the catheter while introducing it. Once in all the way I will power flush to ensure that it is seating in the SVC.

fangguixiao · Oct 16, 2014

Thank you so much Asystole Rn.What difference between flushing and power flush ?I appreciate your time and help!

Asystole RN · Oct 16, 2014

Flushing is just normal low pressure flushing. I want to have a low pressure jet of water that will help the catheter bounce off blood vessel walls or others obstructions but not flip around like crazy. The small amount of pressure will hopefully make it more difficult for the catheter tip to travel against the flow of blood but rather take it to the SVC.

Power flushing is when you flush with some pressure. If you look under fluoro you would see that when you power flush the catheter whips around like crazy. This is to hopefully help seat the catheter in the SVC so that the catheter will uncoil (if coiled) and lay straight or bring it down from the IJ into BC/SVC.

GailAnne · Dec 17, 2014

A couple other things to consider.....

Some types of catheters will want to go north, or contra-laterally at first. Just use a little patience, it seems they are more pliable as they warm up in the body.

I've seen a Rad use the heartbeat to judge when to insert a couple to drop, when they insist on going north instead of south (so to speak) which, of course, we can't do at the bedside. i'm just pointing out the there are sometimes things beyond our control, so again use patience. As well as the suggestions already made, sometimes twisting the catheter a bit helps.

The head positioning can certainly be of help, as you tried. Try again with a bit of a different position. I totally surprised one nurse I was assisting, when she couldn't get one to drop, by having the person look straight ahead and raise their chin up a bit. Line when in right away and likely all it was was getting the person in a better alignment i.e. more relaxed, as I felt they were scrunched up.

Good luck with your continued insertions.

fangguixiao · Dec 17, 2014

Thank you so much for your advise! GailAnne. happy holiday season !

bethchpn · Oct 10, 2015

When this happens I pull back from the jugular and then have the patient cough and it usually drops down.

iluvivt, BSN, RN · Oct 11, 2015

Yes this is a very common problem just look at a venous anatomy chart and you will understand how easy it is for a PICC to head up the IJ.

I have found that I like to position my patents, if able at a 30 degree angle or lower and I pay attention to the pillows. I remove any pillows they have elevating their shoulders or stuffed under their mid back. I have just seen too many primary malpositions when the patient is not as anatomically correct as possible. So just put the pillows under their head.

Always thread slowly at 1 cm per second and as you track your PICC if you see it going up the IJ pull it back to proximal Subclavian or so and make a floppy tip by pulling back the stylet at least 6 cms and then reattempt threading. I may also have my patient put their chin to chest and turn to the side that I am placing the PICC on. The right IJ is bigger than the left. I may try this a few times and if this does not work I add a flush with it as already described. I may also try a power flush but I usually use that for an Azygous primary malposition. We also will have our assistant pull their arm out to the side at a 90 degree angle under the drape,while their head is turned to the side we are on and reattempt threading. With experience you can tell it feels different and it has gone down,

The key is to not give up because you can usually fix it. I have a few more tricks but those are my main ones that usually work!

fangguixiao · Oct 12, 2015

Thank you bethchpn for your advice!

fangguixiao · Oct 12, 2015

Thank you so much for your valuable information !