PICC in subclavian - ok to use??

[CharmedJ7]

Had an issue come at work over the last two days that I'd like to get some more opinions on since I couldn't find much on my initial search. I had a pt with a PICC line that had initially been in the SVC then slid out 11cm and on xray was found to be in the subclavian. The PICC nurse wanted the PICC taken out and replaced, but the doc gave the order to continue to use the PICC (pt receiving IV abx and TPN). That was done the first day, but day two the site of the PICC started to bleed so IV therapy was called back into eval and she got really upset over the whole situation and ended up convincing the float doc to have the PICC pulled. When the primary team came in in the morning they were really upset the PICC had been pulled since they "[knew] the PICC was in the subclavian." I don't know what to think. I know the PICC should be in the SVC but also that the subclavian is still considered a central line, and it's hard to find data on what the risks and likelihood really are. I tend to be on the side of IV therapy since I don't like that the line was moving that much and I'm not sure how much protection I'd have legally using a line that was knowingly in the non-traditional position.

Thoughts?

[IVRUS, BSN, RN]

AN IV catheter which stops in the subclavian is NOT a central line. A Central LINE is defined as a catheters which terminates, or stops in the SVC only.

Years ago, we used to put in what was called Midclavicular lines... Meaning they stopped in the middle of the clavicle or the subclavian, even the brachiocephalic and we would leave them there, namely because we were doing it in homecare and CXR was a pain to get, and if it wasn't in the SVC, we didn't need a CXR, it wasn't mandatory for the infusion company I worked for.. Unfortunately, what we didn't have then, in 1990, was outcomes. With ongoing data collection, it was found that catheters that stop short of the SVC have a much greater percentage of thrombus formation. Therefore, Infusion Nurses Society (INS) no longer recognizes this tip as appropriate. IT has to be in the SVC to be considered appropriate. TPN in the subclavian... DON'T DO IT!

[iluvivt, BSN, RN]

No...once you know it it has become malpostioned even if it DID not start out that way you must take appropriate action. In this case a reasonable, prudent and knowledgeable nurse should know that leaving the tip of the PICC or any Central line for that matter puts the patient at an increased risk for all complications but especially thrombosis. Unfortunately, you can NOT always expect the MDs to be up on the current standard of care so you must be. Some are and some are not. TPN is particularly of concern here because of its high osmolarity and yes can be quite damaging even to a large vein such as the Subclavian. I have seen a few supraclavicular abscesses when TPN was inadvertently administered through a malpositioned line not to mention thrombosis and other complications. Nursing would be at fault here if anything happened for not properly maintaining the line and preventing outward migration and also by NOT having the line removed and or replaced if further IV therapies indicate the need for for it. I can not stress the importance of proper securement and timely dressing changes with an appropriate securement device. In dealing with the MDs you stress that your policy does NOT allow for the line to remain malpositioned if indeed an optimal tip location in the SVC ( preferably in the low SVC and the cavo-atrial junction) can be achieved. A Proceduralist needs to exhaust viable options before considering using a sub-optimal tip placement. Have I used a sub-optimal tip placement...YES I have......BUT you need to look at the benefit risk profile and confer with others on the case..then you must document the whole sordid issue. We have sent cases down to IR where even the radiologist could not advance a catheter into the SVC and we used the catheter weighing the benefits and risks while all the while monitoring the patient closely. Both the INS and NAVAN have position statements about CVC/PICC tip placement and yes they will use these in court against a nurse when they must...I can think of one recent 7.5 million dollar lawsuit that a patient won due to a Subclavian line tip placement . So yes replace it in a timely manner. I may or may not stop the TPN until it could be replaced..it just depends upon the situation and how fast I could get a new line and what else I needed it for and the pts overall quality of veins.

[CharmedJ7]

Thanks for the feedback. The whole situation was making me pretty uncomfortable and I'm glad in the end that the line got pulled on an off shift - don't think the primary doc really understood that him giving us an order to keep using it would be sufficient protection if it came down to an adverse event and legal issues. Anyhow that powers that be have since gotten involved and it's been mostly resolved at this point. A good case for future reference though.

[Ellie G]

Big time no no. I agree that it should have been replaced.