Repeat cxr after picc line adjustment?

[sorlando]

What does your hospital require after a Picc line adjustment? Do you always have to get a repeat cxr? We just started a new picc program at our hospital. When we recieved training we were taught that you can pull back up to 3 cm without getting a repeat cxr. Today we put in a picc and it was too deep so we pulled back 2 cm. The radiologist read the x-ray about an hour later and had a fit that we let the patient go without a repeat cxr. I'm wondering if there is some lititure or guidlelines that would apply to this situation.

[iluvivt, BSN, RN]

There is not one blanket answer to that but there are some general guidelines and NOT all radiologist are in the know. It has taken us years to get them all on relatively the same page in understanding where we want the tip and that we want them to state the exact anatomical location. It is really important that you view all the chest radiographs as well because the nurse insertor knows the whole story..say for example your PICC tip is read as upper to mid SVC BUT you know that by your measuremnt you should be at the junction...so you decide to power flush and order another CXR...and then its perfect at the cavo-atrial junction....yep it was in the Azygous..this has happened to us many times even if our tip locating system did not lead us to believe that. If you are in the RA and the tip is clear and the rad tells you to pull it back 2-3 cm..there is really no place for it to go but to the low SVC or junction...so if initial film was clear and nothing was obstructing the view of the PICC there really is no need. BUT if tip was not clear and rad made an educated quess they may want to get another film...this is why you need to look at it yourself...maybe you can see it really well and you need to call them...maybe you do need to order another but this time you may want to get an RPO or call the nurse and make sure all the tele wires are out of the way. You can also measure to make sure tip is 5 cm below the carina.

If you have to power flush a line out of the azygous or if the line had a secondary malposition up the ipsilateral IJ (say for example after a power injection)..yes you absolutely need to get a CXR to see if your corrective action was successful. On occasion it is necessary to use a suboptimal tip location..we had a mammary vein tip location recently and we were desperate for an access and only had one arm to work with...so in this case we had to pull it out of the mammary and into the mid subclavain..and yes yoiu need to get another CXR for that as well.

I really think the rad overeacted in this case unless I am missing some data you did not mention. So if you are in the RA a few cms and pull it back..where can it go really? yes you need to get it out of the RA but its generally not the crisis some nurses make it out to be...the Kidney foundation guidelines for HD catheters is to have the tip in the RA to maintain the necessary flow rates needed for dialysis and those catheters are quite large.

be a bit skeptical of upper SVC placements (as azygous enters in at upper SVC) and measure your left sided placements really well as they are always a bit more difficult to get those perfect.

So ALWAYS look at the film yourself...talk with the rad if you disagree with them..where can the PICC go if I pull it back? I always measure it for myself as well...if you pull it back from the RA and now it ends up in the mid SVC..that is not a good resolution either..so make sure it makes sense to you..the further away you get form the low SVC the greater risk the pt has of every complication esp thrombosis.