Should a Peripherally Inserted Central Catheter (PICC) line be imaged prior to use if it was inserted at the same facility 2 days ago?

PICC Line Imaging Prior to Use After Recent Insertion

Radiographic verification of PICC tip position is inappropriate when the PICC was placed at the same facility 2 days ago, provided the line was placed with electrocardiographic guidance and proper documentation of placement exists.

Evidence-Based Rationale

According to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), routine radiographic verification of PICC tip position is considered inappropriate when:

1. PICCs were placed with electrocardiographic guidance
2. Proficiency with this technology has been demonstrated
3. Adequate tracings (such as P-wave deflections) were observed 1

However, radiographic verification is appropriate in specific scenarios:

• After blind bedside PICC placement
• Upon admission to a hospital with an existing PICC from another facility
• When there is uncertainty about the PICC tip position

Clinical Decision Algorithm

When to Image a Recently Placed PICC:

1. DO NOT image if ALL criteria are met:

   • PICC was placed at your facility within the past 2 days
   • Placement was done with electrocardiographic guidance
   • Documentation confirms proper placement
   • No clinical signs of malposition exist

2. DO image if ANY of these are present:

   • Blind bedside placement was performed
   • Documentation of proper placement is absent or incomplete
   • Clinical signs of malposition (difficulty flushing, pain during infusion)
   • Patient reports symptoms suggesting malposition
   • The PICC was placed at another facility

Important Considerations

Potential Complications of Malpositioned PICCs

• Thrombosis (especially with malpositioned tips)
• Catheter occlusion
• Infiltration of medications
• Vessel erosion
• Cardiac arrhythmias

Tip Position Recommendations

The FDA and specialty societies recommend that central venous catheters terminate in the lower one-third of the superior vena cava or cavoatrial junction 1. However, the MAGIC panel noted that termination in the right atrium may also be appropriate and does not necessarily warrant adjustment in adults 1.

Special Patient Populations

For patients with chronic kidney disease stage 3b or greater (eGFR <45 mL/min), special consideration should be given to vein preservation for potential future hemodialysis access 1, 2. In these patients:

• Consult nephrology before any central access placement
• Consider tunneled small-bore central catheters instead of PICCs
• Avoid PICCs whenever possible to preserve veins

Maintenance Practices After Confirmation

Once proper positioning is confirmed:

• Use normal saline rather than heparin to maintain catheter patency 1
• Evaluate the insertion site daily for signs of phlebitis
• Use clear, transparent dressings that permit site examination
• Change dressings weekly or when wet, loose, or soiled 1

Common Pitfalls to Avoid

1. Unnecessary imaging: Performing routine imaging on properly placed and documented PICCs wastes resources and exposes patients to unnecessary radiation
2. Missing documentation: Failing to document placement method and confirmation can lead to duplicate imaging
3. Ignoring clinical signs: Disregarding symptoms that might indicate malposition or complications
4. Advancing migrated PICCs: Never advance a migrated PICC regardless of how far it has migrated 1

By following these evidence-based guidelines, you can ensure appropriate use of imaging resources while maintaining patient safety when using recently placed PICC lines.