PICC in wrong place

Ellie G · May 25, 2016

Where was the tip? It makes a difference. Some malpositions are worse than others

~PedsRN~, BSN, RN · May 25, 2016

That was a big miss, especially by the first nurse that started using it before the X-ray. :/ But don't they usually X-ray in interventional as it is placed? Or maybe that's a kid thing.

Oh'Ello, BSN, RN · May 25, 2016

It just depends on what med it is and where the displacement is. For example... if you're pushing chemo through a PICC thats recoiled and is in the mid axilla, you could have a nasty extravasation of the vessels in the armpit, If its advanced too far, like on a valve or well into the ventricle, and you're dumping fluid, you can have some arrhythmia issues. Sometimes the line escapes the subclavian and into the lung during insertion actually giving the patient a pneumo....but that'd be pretty apparent right off the bat.

PICCs get displaced a lot. Even without ideal placement, they are often still OK'd to use, but sometimes with a restriction... like "No pressers, no chemo" because its essentially a midline. and you can't manage extravasation of the deep vessel if something occurs. Blood, most antibiotics and fluids are usually ok.

Oh'Ello, BSN, RN · May 25, 2016

That was a big miss, especially by the first nurse that started using it before the X-ray. :/ But don't they usually X-ray in interventional as it is placed? Or maybe that's a kid thing.

Many hospitals place PICCs at the bedside now, with an ultrasound-y contraption. If the patient is low risk and the nurse placing the picc was able to visualize p-waves during the procedure, some hospitals don't require additional imaging. Some higher risk patients (obese, severely dehydrated, cachetic, elderly, etc) they still require an additional x-ray. Even so, PICCs are at high risk for displacement right after they are placed, because patients often require an additional dressing change d/t bleeding and haven't yet built scar tissue around the insertion site, allowing for mobility of the line.

mistymae22 · May 25, 2016

Patient got admitted with the PICC and had antibiotics given during outpatient the day before admission, through the PICC. It was in the physician notes. Last Chest Xray for it was the beginning of this month when it was first placed. I forgot exactly where they said it was but if it was deep in the heart, the heart rhythm would be out of whack. He was on a tele monitor and he was sinus rhythm the whole time. His vitals were stable and there were no signs or symptoms of any respiratory distress or discomfort. I asked him at the end of the shift if he felt any different than before he got any blood, and he said he didn't feel any different. He was getting blood and plasma through the PICC. And then antibiotics outside the hospital. Would the reactions come way after the blood and plasma were given? Anyway, he's HGB ended up moving up 2 points. So the body absorbed it even though PICC was not in the ideal place.

Oh'Ello, BSN, RN · May 25, 2016

Patient got admitted with the PICC and had antibiotics given during outpatient the day before admission, through the PICC. It was in the physician notes. Last Chest Xray for it was the beginning of this month when it was first placed. I forgot exactly where they said it was but if it was deep in the heart, the heart rhythm would be out of whack. He was on a tele monitor and he was sinus rhythm the whole time. His vitals were stable and there were no signs or symptoms of any respiratory distress or discomfort. I asked him at the end of the shift if he felt any different than before he got any blood, and he said he didn't feel any different. He was getting blood and plasma through the PICC. And then antibiotics outside the hospital. Would the reactions come way after the blood and plasma were given? Anyway, he's HGB ended up moving up 2 points. So the body absorbed it even though PICC was not in the ideal place.

We rarely if ever, verify PICC placement on admission. Unless there is something wrong with it, like has crappy blood return, sluggish flush, looks infected, or has an excessive amount of line coiled under the dressing. I can tell you this, if you worked where I work, you would be a-ok. Nobody would think twice about this. I guess just know your hospitals policy on the matter. PICCs migrate. And most of the time, when they do, they are essentially just fancy peripheral lines.

That said, the timing of a blood product reaction would have nothing to do with whether or not the PICC was in the right place.

IVRUS, BSN, RN · May 25, 2016

To give any medication into any central line and NOT know where the tip of the IV catheter is just negligence, and that includes a PICC as it is one type of central line. Yes, any IV catheter can migrate, but that is why it is so important to get a baseline CXR, or have an ECG showing that the tip is in the Distal SVC, or CavoAtrial Junction (CAJ). Once you have a baseline, make sure that someone is following and recording the external amount of IV catheter frequently. If that external amount changes, then repeat the CXR and assess where the tip is. IT is NEVER acceptable to have the tip in the Brachiocephalic, or in the Subclavian. It either is a true PICC with its tip positioned correctly, or if the drug is appropriate, pull the line back to a Midline, where the tip will stop right before the shoulder, or axillary vein.

Ellie G · May 25, 2016

We rarely if ever, verify PICC placement on admission. Unless there is something wrong with it, like has crappy blood return, sluggish flush, looks infected, or has an excessive amount of line coiled under the dressing. I can tell you this, if you worked where I work, you would be a-ok. Nobody would think twice about this. I guess just know your hospitals policy on the matter. PICCs migrate. And most of the time, when they do, they are essentially just fancy peripheral lines.
That said, the timing of a blood product reaction would have nothing to do with whether or not the PICC was in the right place.

We always verify appropriate placement on a pre-existing picc line. Dangerous not to in my opinion. Some malpositions can cause all kinds of problems

~PedsRN~, BSN, RN · May 30, 2016

We suture the line... is that not standard? I only do kids. And all placed in radiology. When they come back from placement, an order is given in the form of a "nursing communication" from the doctors that the PICC has been cleared for use.

CelticGoddess, BSN, RN · May 31, 2016

We also verify by CXR for PICCs. Actually, all preexisting central lines (with the exception of ports). And the IV team rounds on all central lines (except ports, at least on my unit) q shift. It's especially important when the patient is on chemo!

Ellie G · May 31, 2016

We suture the line... is that not standard? I only do kids. And all placed in radiology. When they come back from placement, an order is given in the form of a "nursing communication" from the doctors that the PICC has been cleared for use.

We don't suture. We use a stat lock to secure, but I only do adults at bedside.