Hello. We are considering starting a study using the Vasonova Tip Positioning System on pediatric patients. Of course this is all pending IRB approval etc, but we plan to still a get chest xray with each patient, hopefully demonstrating that our numbers of malpositions (and second procedures required) will decrease. We are a peds only service and for some of our kiddos even pulling a line back seems like a huge procedure, so lines often get left in less than ideal locations. We have a few questions for the IV therapy brain trust:
1) Is anyone currently using Vasonova for pediatric patients? We'd love to hear about your experiences
2) For peds-only services, what are your acceptable tip location parameters? Do you accept upper or mid SVC, or high RA? (as an example, we usually have a discussion with the team weighing risks and benefits, expecially for exchanging a catheter that is a bit short)
3) How much external catheter length can you leave before the line requires exchanging?
4) For those using the Vasonova on adults or peds, are you able to tell during the procedure if a line is short? Do you routinely exchange for a slghtly longer catheter if you do not get a bullseye
We'd appreciate any other thoughts anyone might have
Thanks,
Matt
The standard for tip location for peds is the same as for adults. Neonates have a higher risk of tampanode if the catheter erodes through the myocardium and allows fluid to infuse into the pericardium. Lower third of SVC close to the CAJ. Longer length of external catheter in this age group presents greater problems so I would make this as short as possible. But using an ECG technology will greatly improve this issue. And there is no recommendations for what external length is acceptable. Enough for adequate stabilization is the goal. 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 the response Lynn. I was hoping to hear from some other people as well, particularly about what folks are doing for short lines. While the data is pretty clear about the lower SVC/CAJ being the preferred site, with our currently technology we don't know tip location until after the procedure is complete and a chest xray has been read by a radiologist. If the line is in the upper SVC, I wonder if it is worth makikng the patient undergo another procedure to exchange it. Particulary in peds, where most of our patients require sedation. In our facility, it looks like about 20% of our PICCs end up in Mid-SVC, and about 10% in the upper SVC. Our current practice is to leave those lines as is. I'd be curious to hear what other facilities are doing in this situation, for adults and peds. Thanks
Thanks for the response Lynn. I was hoping to hear from some other people as well, particularly about what folks are doing for short lines. While the data is pretty clear about the lower SVC/CAJ being the preferred site, with our currently technology we don't know tip location until after the procedure is complete and a chest xray has been read by a radiologist. If the line is in the upper SVC, I wonder if it is worth makikng the patient undergo another procedure to exchange it. Particulary in peds, where most of our patients require sedation. In our facility, it looks like about 20% of our PICCs end up in Mid-SVC, and about 10% in the upper SVC. Our current practice is to leave those lines as is. I'd be curious to hear what other facilities are doing in this situation, for adults and peds. Thanks
I would also like to hear from others, but I think your issue will virtually go away with use of ECG. The P wave changes begin as soon as the catheter tip enters the pericardium which begins at the 2nd intercostal space. The P wave reaches its peak when the catheter tip is at the SA node and may become biphasic or turn downward when the tip passes the SA node. The main avenue for this short line to occur would be if external mesaurement was way off. With ECG, you know where the tip is located before you finish the procedure. If you don't use ECG and continue to use chest xray, then I strongly believe that an exchange is the best option, even in peds. There are far too many problems with tips located in the mid to upper SVC including tip migration, vessel erosion, thrombosis, etc. Inappropriate tip location has been an issue in several legal cases I have worked on. 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 again Lynn, that is definitely some useful insight. We may have to re-evaluate our practice in the interim, and I think this point will help us make a good argument for use of tip positioning technology in the IRB and going forward in standard practice.
I agree with Lynn. The ecg technology makes CAJ placement perfect every time the pwave is present. I have even used it with a patient with a pacemaker but of course verified with xray.) The only problem I have run into is if my external measurements are short with the PICC already cut and introducer removed because the reverse taper on the PICC does not allow to enter the right atrium and confirm negative deflection while the introducer is in place. I plan to remedy this issue with the securacath. It will allow the PICC to be cut longer and still be secured properly since it does not rely on the catheter wings.
Our hospital began a trial with Vasonova about 1 year ago. We did chest x-rays on all patients who obtained a bulls eye for approx 2 months and found correlation to be nearly flawless and no false positives. Since February we have eliminated x rays in all bulleye patients. In the same time frame our hospital launched a new pediatric intensive care unit. Consequently we have used the Vasonova on a small number of children, the youngest being 7 or 8 years of age. In all cases we did obtain a bulls eye. Our next venture will be for our team to become Pedi PICC certified using an on-line program from PICCEXCELLENCE.COM. Our intesivists are anxious for us to assume the insertion of PICCs in these children while they will sedate and montior during the procedure. Our plan is to use the VasoNova as well as correlate with chest x-ray. The data will be interesting and may help pave the way for approval in the use for kids. Of all groups of patients, I would think that we would want to eliminate radiation exposure in this population. We have been extremely pleased with the VasoNova technology. While agreeing that are significant differences with adults vs children, in this case an SA node is an SA node and direction of blood flow is the same for both age groups. The question being, "why shouldn't this work in both groups?"