A common problem continues to be raised – the absence of information about the original tip location for a PICC when the patient is transferred to another venue of care, especially if multiple transfers are involved. For instance, the PICC is placed while the patient is in the hospital. He is then transferred to a rehabilitation or skilled nursing facility for a period of time and is then transferred home and admitted to a home care agency. No information is provided to the home care agency about the original tip location, or any change in the external measurements.
How should the PICC be used until the original documentation can be obtained? Will it be possible to obtain the original information? Should administration of vesicants and non-vesicants be managed the same way? Without the original documentation, should the PICC be removed with the patient in the home or should the patient be sent to the hospital or practitioner’s office for removal?
While a PICC may be the most common CVAD used in these situations, the standard of practice for tip location applies to all CVADs. As we all know, information about the original tip location should go with the patient with each transfer but we know that does not always happen. Additionally, a tunneled cuffed catheter or implanted port may have been inserted months or even years before admission to the current home care company. So there are many situations where the original tip location will not be known. But remember this documentation was only for the location of the CVAD tip at insertion.
Many factors can lead to CVAD tip migration during the dwell time, including physical activity, heaving lifting, ventilation, congestive heart failure, or anything that changes intrathoracic venous pressure. Although specific data on the frequency of malposition is not available, patients that have been receiving physical therapy in a rehabilitation program could easily have changes in the tip location. This may happen more frequently if the original tip location was sub-optimal in the mid to upper superior vena cava.
Tip migration means that only the CVAD tip is moving and the external segment of the catheter remains unchanged. The tip could migrate to the jugular vein, the opposite subclavian vein, or any number of small tributary veins. Tip migration is sporadic and unpredictable. Dislodgment is a change in the length of the external catheter, which also means that the tip location is retracted by that same distance. These are just 2 examples of malposition but this could also include the catheter tip eroding through the vein wall or cardiac wall, formation of a fistula between an artery and vein or other structures such as the trachea.
Before infusing through any CVAD, a complete assessment is necessary. This goes way beyond reliance on information about the original tip location. In addition to assessing for a blood return from each lumen, you should also include flushing to detect difficulty or resistance; changes in blood pressure, heart rate, and/or respiratory rate; any type of pain, discomfort, and/ or presence of edema in the back, neck, shoulder, or chest; complaints of hearing a running stream on the side of the CVAD insertion; and neurological problems like paresthesia. Any problem found during this assessment means the CVAD should not be used until a diagnostic test can be done to determine the cause of the problem. The presence of a blood return that is the color and consistency of whole blood and the absence of all other signs or symptoms of a complication indicates the CVAD can be used. I would apply the same assessment to vesicants and non-vesicants. Although a vesicant has the potential to cause tissue damage for a variety of reasons, a non-vesicant can also cause tissue damage due to compression from the volume infused. Also remember that a vesicant causes the damage OUTSIDE the vein but vein thrombosis is quite common with intravascular malposition.
Removal of a PICC or other percutaneous CVAD in the home is routinely done and the nurse may not know the exact location of the tip. If there is a change in how the catheter is functioning or some other complication, it might be wise to have the patient return to a clinic or practitioner office for removal. Each situation requires a thorough assessment and application of critical thinking skills.
While the original tip location information is important to have, it really provides no information about where the tip is located weeks or months into the dwell time and use of the catheter. You must rely on your assessment of the patient and the CVAD. When signs and symptoms of malposition are present, a diagnostic test such as a chest radiograph or ultrasound is needed.
Author: Lynn Hadaway
Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.