Hi, our Vascular Access Service Team receives conflicting information regarding obtaining a CXR for a PICC placed in the RA and pulled back 1-3cms. Is is necessary to obtain a repeat CXR for a simple pullback? INS standards 14 under Practice Criteria #7 states:
"Confirmation of the anatomic location of the catheter tip for all CVADs prior to initial use and as needed for evaluation of catheter dysfunction".
Some radiologists state to us not to repeat the CXR. Also, are ther legal ramifications to doing this pullback adjustment and not repeating the CXR?
Thank you.
The primary concern is having a tip migration into other veins without a chest xray to know exactly where it is. Based on textbook anatomy, the azygous veins joins the posterior side of the SVC at about the 2nd intercostal space. So malposition into this vein is the biggest risk. If there were to be a clinical problem that lead to a lawsuit, this would be a major issue because the catheter tip was changed without some type of confirmation. This is one of the primary reasons that ECG-based technology for tip location is superior to xray for the vast majority of patients. 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
Okay,
Let's say that you didn't get another CXR and that patient is harmed because maybe it was "accidentally" pulled back too much and the tip is now in the brachiocephalic, or maybe it wasn't pulled back enough.. so now it is still in the right atrium. If is goes to court because the patient was harmed, (suffered arrhythmias, cardiac tamponade, or thrombosis etc) all you have is an cxr showing incorrect placement!
I'd re-xray!