PICC EXPERTS

[Goofaroo]

I work in a nursing home as an MDS nurse. Friday I arrive and immediately the floor nurse needs me to draw labs from a picc. Only RN can draw labs from a picc at our facility. So as the only RN in the building besides DON I go draw the labs. It all goes well. Now today I happen to be reading through the orders and notes and to my surprise the picc I had drawn from was newly placed and the xray confirmed it was in the right atrium with no complications. But they had called the picc company to come out and fix placement. So turns out at the time I was drawing labs and yes flushed it with normal saline they were awaiting for the placement to be fixed !! Now I feel like I did something I shouldn't have. How big of a deal is this ? I guess I literally have to double check everyone's work before I go do one simple skill.

[CritterLover, BSN, RN]

Not a big deal at all.

RA placement isn't widely accepted yet, but is becoming so (as long as the patient is over 1 year old). Many radiologists I've worked with deliberately place their lines in the RA.

Without looking it up I think INS still says tip should be lower 1/3 of SVC to cavoatrial junction (so above the RA) while AVA and SIR consider RA placement to be acceptable.

[JKL33]

The particular complications of interest when tip position is being debated are not likely to be further induced by a single incident of drawing blood and flushing the catheter. In your scenario there is also a plan in place for adjusting the catheter tip position as desired by the team in charge of it.

On the other hand:

1 hour ago, Goofaroo said:

I guess I literally have to double check everyone's work before I go do one simple skill.

Well, yes, but it isn't so much about checking everyone else's work but rather just doing what is prudent--which in this case is to take minimal action to verify that it has been cleared for use.

[Mavnurse17, BSN, RN]

I learned in nursing school that you always need to check the X-ray report to make sure a new line is placed properly. Let me tell you about being a new grad and the one night that I didn't:

I received report on a patient receiving Primacor through his PICC. He was a new admit to our step-down from the CVICU, where the PICC was placed. Doc didn't order the xray, ICU nurse started the drip, and the day nurse I got report from only had him for enough time to get him settled into his room. I drew a venous blood gas from the PICC with AM labs and noticed the blood looked a little... bright? Was it the lighting in the room? Was I seeing things? I didn't investigate further like I should have.

When I had my next shift 3 days later, my coworker told me he had that patient and had been preparing his d/c paperwork when he collapsed and had a suspected TIA. His scan showed that the tip of the PICC was in the R carotid! This patient had been getting a primacor gtt directly infused to his brain tissue for DAYS and none of us caught it.

Thus, I always always check the xray report before I do anything with a PICC now.

[DextersDisciple, BSN, RN]

2 hours ago, Mavnurse17 said:

I learned in nursing school that you always need to check the X-ray report to make sure a new line is placed properly. Let me tell you about being a new grad and the one night that I didn't:

I received report on a patient receiving Primacor through his PICC. He was a new admit to our step-down from the CVICU, where the PICC was placed. Doc didn't order the xray, ICU nurse started the drip, and the day nurse I got report from only had him for enough time to get him settled into his room. I drew a venous blood gas from the PICC with AM labs and noticed the blood looked a little... bright? Was it the lighting in the room? Was I seeing things? I didn't investigate further like I should have.

When I had my next shift 3 days later, my coworker told me he had that patient and had been preparing his d/c paperwork when he collapsed and had a suspected TIA. His scan showed that the tip of the PICC was in the R carotid! This patient had been getting a primacor gtt directly infused to his brain tissue for DAYS and none of us caught it.

Thus, I always always check the xray report before I do anything with a PICC now.

Had a pt transferred to my unit from an OSH after having TPN infusing through a CVC also in the carotid artery. Irreversible brain damage.

[DextersDisciple, BSN, RN]

A picc tip terminating in the right ventricle would cause ectopy but I’m going to have to ask our picc team what happens when it’s just a little too long (in RA). Ours are all places under fluoro so we don’t have this issue

[CritterLover, BSN, RN]

RA placement can potentially cause atrial ectopy in sensitive patients but it isn't very common. In infants (<1year) it can erode the lining of the RA.

Many radiologists prefer RA placement as they tend to clot less.

Not all facilities Xray PICCs for placement anymore. There are a few different types of non-Xray technology that can confirm placement at bedside, so don't always expect to see an Xray report.