After PICC insertion, the tip is not stationary. Inserters make every attempt to get the catheter tip at the cavoatrial junction, however arm movement can and often does alter this location. For PICCs, this will usually means the tip moves inward, into the right atrium. This can cause the cardiac flutter feeling or your patient may complain of feeling a fast or irregular heartbeat. Retraction of the PICC by a very short distance may be needed to relieve these symptoms.
Who should be doing this catheter repositioning – the nurse inserting the PICC or the primary care nurse? Legally speaking, this procedure may be within the legal scope of practice for both registered nurses, BUT a policy from your organization is necessary to direct who can actually perform this procedure. There are several decisions to be made before any central VAD is repositioned.
Where was the original tip documented – precisely? How was this tip location confirmed – chest xray or ECG? According to the 2016 Infusion Therapy Standards of Practice, the tip of any CVAD can be anywhere from the lower third of the superior vena cava and extend into the right atrium by 2 cm. If the original placement was at the cavoatrial junction, arm movement may have taken the tip more than 2 cm into the right atrium and this indicates the need for retraction if the patient has any cardiac complaints.
A chest xray may be necessary before this retraction to provide more precise information on the safe length that should be retracted. The adult superior vena cava is usually about 7 cm long. CVAD tips located in the mid to upper SVC are more prone to complications such as tip migration into the jugular vein and vein thrombosis. Retraction without a precise measurement could result in a suboptimal tip location which increases patient risk.
The policy and procedure written and approved by each facility must address which nurse will be doing this procedure. It is my professional opinion that this catheter manipulation should only be performed by the nurse with documented competency with PICC insertion. It should not be performed by the primary care nurse, or anyone without the detailed knowledge and skills for PICC insertion. Retraction itself is not a difficult task, but there are many aspects of patient assessment, critical thinking and decision-making required.
The facility policy should also require documented competency to perform this procedure, especially if the responsibility is given to the primary care nurse.
Two standards of practice address this issue. Please read Standard 53 CVAD Malposition and don’t forget the Section Standards on page 103 as they apply to all standards in this section. The second standard is #5 Competency Assessment and Validation. You should also check with your state board of nursing for any specific statements they may have about PICC insertion and management.