Some of our radiologists have started using the phrase "recommend advancing the PICC (x number) cms" when referencing distance from the tip to the junction rather than using "mid SVC" or "low SVC". The physician who originally ordered the PICC then writes an order to exchange the line. There does not seem to be consistent criteria for deciding when an exchange is necessary or not due to variability in radiologists' readings and interpretation of the tip position, that the tip position fluctuates within the SVC--one day being high while the next day it appears to have dropped down in the SVC again, that there is some disagreement as to whether tip position at the junction is an absolute and where in the SVC the line has potential for it to flip and lastly but not least evaluating whether the patient's expected course of treatment requires exchanges with any tip movement above the junction. It seems the lines do move and fluctuate in position and also some frequently flip despite being very low in the SVC. What specific/best practice guidelines are there in regards to following PICC line tip positions with routine CXRs and doing appropriate exchanges?
See the 2011 INS Standards of Practice, #55CVAD Exchange, Practice Criteria E, page S76. "The nurse should be aware that routine exchanges are not necessary for CVADs that are functioning and without evidence of local or systemic complications. 3 references with a ranking of I, the highest.
I am assuming that your question is about the xray immediately after insertion. You must make every attempt to get it to the proper position during insertion and be able to manipulate the line if the chest xray indicates there is a need to advance it further to the best location. After you have removed the wire, secured and dressed the catheter, this is not possible. That is where new technologies such as ECG guidance can be so valuable.
Any catheter that is not low in the SVC has a greater chance to have a secondary malposition (AKA tip migration) after insertion. Rapid, forceful flushing can produce this migration including power injection for CT. Tip location is not an absolute because it can also change with patient movement and arm position. But you do need to be able to get it in the best location, low SVC near the CA junction, upon insertion.
I would say exchange in these situations is not indicated unless there is a problem with catheter function. You need to have a collaborative practice discussion with your radiologist sharing the literature and making a collective decision for your situation. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks for your response Lynn. Our group does make every effort to ensure tip placement at/near the junction at initial insertion. A problem occurs with subsequent CXRs ordered for other diagnostic reasons that reveal tip migration. The tip may still be in acceptable position but when the rad uses the phrase "recommend advancing..." it seems to generate a response from the primary to order an exchange. Our group does not have a strong consensus on when an exchange is necessary. And further...when a line is frequently migrating as shown by daily CXRs, how often should we be exchanging it when the tip is no longer in its original optimal position?
Thanks for the additional information. Based on this you should read the 2011 INS Standard 53 CVAD Malposition. I wrote this one and it is divided into primary malpostion as soon on insertion and secondary malposition. You are talking about secondary malposition. There are 13 statements about secondary malposition and a total of 36 references for this standard. If you find a tip grossly malpositioned, such as contralateral subclavian or IJ, you should not use the catheter until it is properly positioned. But I would not immediately do an exchange as the tip can spontaneously move back to the proper position. You might need to infuse through a short peripheral catheter if possible until it is back in the right place. I don't think you will find an evidence based answer to your quesstion about when to actually perform an exchange. I think you will have to make a patient–specific decision in each case based on where the tip is, what is infusing, etc. I would also assess what is going on with these patients such as ventilator use, flushing techniques, use of power injection through the catheter, other causes of increased intrathoracic pressure, etc as these are the causes of tip migration. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861