Forum topic

 From an evidence-based practice standpoint, I am not aware of any guidelines stating a restriction on the number of times you should repeat the x-ray to identify correct tip location. The policy you have found is also not evidence based to my knowledge. Every patient is different and retraction of 3 cm could put the tip too high in the SVC, making it more prone to malposition. From a legal standpoint, you need to know where the final tip location actually is. Limiting radiation is a necessary goal, but what are the risk of radiation from 3 chest xrays vs the risk of a malpositioned catheter tip? My initial opinion says that a malposition tip would have a greater risk, but would like to know if someone has evidence to the contrary. Lynn

I totally agree with Lynn.   The example I had just two weeks ago, I listed under 'measuring picc length for an Obese Pt.'   I had to pull it back twice and there were three CXR's in total before the CAJ was confirmed.   I simply could not reallly see the tip of the cath on Xray as it was in too far. 

This situation may be another reason to look closely at a guidance system rather than relying on chest x-ray.

I also agree with Lynn.  I work in a pediatric facility and the difference of a fraction of a cm can mean the line is too high.  We always verify tip placement after a pull back procedure. 

Theresa Reed

Texas Children's Hospital

Houston, TX

If you do not do an x-ray post pull back the x-ray you have on the chart shows a malposition.  You have no proof you pulled back and have a proper tip postion.  Charting is not proof.  you have no visual proof.  there is no magic number that excludes you from performing an x-ray post pull back.  There is no evidence to support a magic number in court.  you must perform additional x-rays until proper tip postion is obtained.  That proper tip postion is from you manufacturer instructions for use, standards of care, or the FDA SVS working group.   You wish to be able to demonstrate that the tip was left in the proper position post pull back.  Your policy should have what is deemed proper tip position and that policy shoud have been approved by a hospital medical board.

if your policy has a magic number you have no evidence to support that magic number for no additional x-ray.  You may be practicing according to the policy but who wrote this policy will be held accountable to the magic number and providing evidence of how they obtained that magic number of no x-ray post pull back. There is no evidence on a magic number.

if you pull back your x-ray is the only viable proof of your actions.  Charting does not replace the visual x-ray on pull back and realistically youi should be able to see that point.  It is black and white as a court of law is.

If the last x-ray shows a malposition your line is still malpositoined regardless of pull back documentation.  Your visual proof is a malposition.

Practice according to your standards of care.  Do you see a magic pull back number in the INS standards 2011 for no re-xay of a malpositioned line.  Thje answer is there is no magic pull back number for no re-x-ray in the INS Standards of Care for 2011.   I think if there was evidence INS would have put it in the standards as they are very evidenced based in their thinking and steer toward the cautious side for the patient's protection and the caregivers protection.  I am a big fan of the INS and applaud their efforts for safe practice.   You have all made up anecdotally this magic number and passed it amongst yourself making it sound valid.  It is not valid.  Bottom line.  you taught each other this made up magic number of no x-ray post pull back that varies from 2 cm to 6 cm in my travels.  There is no magic number.  Show me the proof of this magic number.

Kathy Kokotis RN BS MBA

I agree with Lynn that there is variability in radiology tip termination reports and that fact opens the clinician to leagul issues w/o a commitment on the part of the radiologist to confirm placement. I also agree with Kathy that there is no "magic number" that allows no further evaluation. 

The world I live in, at multiple facilities, with multiple radilogy opinions and variations in obtaining the original and subsquent images, only forces me to add my observations to the unique situation in front of me.  I realize that does not make for easy policy, procedure, algorithm or standard... but if that were all to be expected of this clinician (who just took a tube to an area above the heart) why would the patient need a clinician and not a technician?

How can a facility write policy to give an absolute retraction limitation to release the PICC?  They can't.  I do not point a finger at the radiologist recieving an image without any additional information (length, pt height, vein accessed, blood return characteristics, etc) they weren't there.  I recieve many reports that state "overlying the SVC" because the radiologist truly does not know if I strategically placed this piece a plastic on the chest or in the vein.  I do not have the ability to release or clear the PICC for use, I only interpret the report, if necessary, and pass along the information.  If a retraction of 1.7cm is requested, we will retract the appropriate amount (probably 2cm)  and the decision for f/u x-ray falls on the facility.

We deal with many physicians in this area and those on after hours services across the country (USA).  When I place a line I have to not only consider pt height and habitus, but also calculate who might be reading the image and trim accordingly.  Tip termination technology is great, but I have also dealt with the f/u x-ray from the next facility the patient has landed in and the radilogy report demands a retraction, after "technology" has determined the tip was CAJ on placement.  What then?  Who's right?  Maybe both.  It is a comfortable illusion that any x-ray, or tip terminating technology, anchors the tip in that position now and forever.   The clinician, in conjuction with the physician, may need to look at the big picture.  What has changed?  (ascites, arm position, patient position, technique in obtaining the image, ability to transmit the image to a physicians home computer, etc.) Is the patient symptomatic?   I also realize from my neonatal/pediatric background that the "margin for error" is smaller based on patient age.

It is all about the patient.  Risk/benefit of a f/u 2-dementional portable chest x-ray for a 1.7cm retraction, must be weighed according to clinical assessment.  Where does that leave the clinician?  Probably not in a good position to write a policy or algorithm to remove responsibility for their actions...  Sorry.

Mickey

We've noticed that when a left sided picc is too long and we retract per recommendation of radiologist, it seems as if we retracted twice as much, eg. we retract 2cm, and the follow up CXR shows the picc retracted about 4cm.  Have you noticed this?