Forum topic

 I'm not getting enough image, is the PICC the looped line on the right side or the line coming in on the patients left side?  The image seems to cut off at the upper svc  

 Definitely not the expert here!!! These are fun though. I agree it looks like mid-low SVC, but the loop in the IJ (?) could be problematic. Seems like every flush will cause the catheter to press against the walls of the vessels that are containing it creating a phlebitis risk. I think you were right to replace it. If the loop has spontaneously resolved, the tip would have displaced far too deep in the RA.

What do the experts say? 

 Was xray taken with or without the stylet wire inside the catheter? If the wire was still in place, removing it may cause the catheter to straight out. You would just need another xray to confirm tip location. If without the wire, you must find some way to remove this coil, usually by inserting a new sterile wire into the catheter to get the tip to the appropriate location. Malpositions like this can never be left without some intervention to remove the coil and get the catheter tip into the lower SVC. This is a primary malposition that must get some attention. Lynn

Sometimes if you leave it alone...it will fix itself. That particular malposition could drop on it's own. So I would want to know...is the patient staying in the hospital so you can monitor it?....if not then yes you'll have to intervene and power flushing probably will not fix that position. But alot of times they can spntanously correct. Besides, you'll learn the more insertions you have that PICC lines can malposition on their own. A spontaneous malposition happens, I bet , more that we know. I often wonder of all the homecare infusions at any given time, how many have done that. We know it happens, but without an xray everyday, we are probably missing quite a few malpo's.

Jack Diemer

I think it definitely has to be fixed. I've had this happen. I just took out the wire and flushed and it straightened out. I agree the problem will be when you do this the catheter will be RA and then need to be pulled back. I think it is a fluoro guided fix.

I've had great results with power flushing - though we don't call it "power flush". I would attempt positioning and power flushing once (flushing all lumens 3 times simultaneously) and if it didn't work go ahead and exchange. If you can prevent the increased risk of an exchange the patient would benefit. However too many quick flushes would cause the PICC to bump into the vessel wall and cause irritation and possibly lead to phlebitis. So after one honest to goodness great attempt to power flush I'd go ahead and exchange it. I have seem some return to the malpositioned placement after power flushing too. In this case you may want to consider a whole new site. There may be something going on with the patient's anatomy that is either causing or allowing the malposition. If this is true chances are any PICC going into the same site will suffer the same fate.