Implications of Precise PICC Tip Location: The New Gold Standard in Clinical Practice?

Transcription

1 Implications of Precise PICC Tip Location: The New Gold Standard in Clinical Practice? Nancy Moureau, BSN, CRNI, CPUI, PICC Excellence, Inc. About the Speaker Nancy Moureau is an educator, legal consultant and clinician with 30 years of vascular access experience PICC Trainer and expert witness in legal cases for more than 21 years IV/PICC Team prn staff nurse with Greenville Memorial CEO and Owner of PICC Excellence an educational company Speaker Bureau for: 3m Access Scientific AngioDynamics Teleflex, Inc. Cook Excelsior Objective Evaluate clinical practices and legal implications of tip positioning for most accurate and precise placement of peripherally inserted central catheters Accuracy versus Precision Accuracy the degree of closeness/proximity to the true value High accuracy low precision Close to value, but no bulls-eye Precision reflects the degree of reproducibility/ repeatability in accomplishing the target value Wikipedia accessed 4/6/12 Hostetter, et al. Precision in CVC Tip Placement JAVA 2010;15(3): High precision low accuracy All in one area, but no bulls-eye Accuracy versus Precision Accuracy AND Precision Matter Why do we need both accuracy and precision? Ideally CVC placement is both accurate and precise with terminal tip both close to and positioned at the target area Because, medically speaking, close is just not good enough anymore Target Migration Looping Azygos Vein Tip on the wall Tricuspid Valve AV Node Superior Vena Cava/Cavoatrial Junction TM Suboptimal tip placement increases risk of many complications Thrombosis up to 16x higher Higher rates of occlusion and loss of function Increased risk of infection with relationship to thrombosis Malposition flipping into internal jugular more common 2cm 1

2 Goals of Terminal Tip Confirmation Designed to: Verify placement in vein versus artery Reduce complications associated with malpositioning Reduce liability from terminal tip complications Establish catheter tip into optimal high flow area Promote patient safety Why Distal SVC near Cavo Atrial Junction? Established as standard by FDA CVC Working Group in 1994 Included in instructions for use by manufacturers Reduces potential for malpractice Why is Tip Location Important? 45.2% 87% 19% 31% 4.2% 18% 1.5% 0-2% 5.6% 5.6% Caers J, et al. Catheter Tip Position as a risk factor for thrombosis associated with the use of subcutaneous ports. Support Care Cancer : Petersen et al, Silicone Venous Access Devices Positioned with Their Tips High in the Superior Vena Cava Are More Likely to Malfunction, Am J Surg 1999, 178:38-41 (Special thanks to Lorelle Wuerz) Case Study Clinical Applications Potential for Malpractice Situation - Emergency transport Background 10 year old boy receiving long-term medications at home. MD ordered recheck of PICC placement after 4 months when pt having mild SOB. Prior to X-ray pt developed acute SOB, anxiety, then cardiac arrest. Cause Catheter was positioned in right atrium Eroded through the heart wall Resulted in cardiac tamponade Action 911 Patient died en-route to hospital Malpractice potential, huge, which was why I was contacted. Original confirmation was deep. Solution Accuracy and Precision the first time Pinpointing for Safety and Reduced Liability Precision Matters What Position for X-Ray? Upper RA placement increases risk Factors Moving Tip Upward or Downwards External Landmark Without Guidance Magnetic Tip Navigation ECG Guidance ECG with Doppler 1. Trerotola et al. J Vasc Interv Radiol 2007; 18: Naylor JAVA 2007:12:1: Starr et al, Ann Surg, 1986: Salmela et al. Acta Anaesthesiol Scand 1993: 37: Hostetter, et al. Precision in CVC Tip Placement JAVA 2010;15(3): cm 2-4 cm 1-2cm Catheter induced Afib or V-Tach Other RA wall related complications Irritation from TPN and other high osmotic solutions creating thrombosis risk Increased infection risk - thrombosis and infection related SVC 2cm Cavo Atrial Junction R Atrium 2

3 SVC Pulse Doppler Case Study Situation Friday 4pm PICC placement requiring confirmation prior to use Background 72 yo female requires PICC for fluids, K+ and medications. Radiologist leaves at 16:30, PICC nurse not authorized to read films. X-ray report dictated PICC in the IJ Action choices Remove (patient required access) Wait for catheter to drop (no PICC nurse available S/S) Pull back to alternative position (K+ is an irritant) Replace with new insertion or exchange Nurse pulled catheter back no X-ray recheck Response LOC change within 24 hours, pt confused, died within 48 hours Cause Arterial placement Potential for Malpractice Radiologist misread film (too difficult to differentiate vein from artery up the neck final report PICC in vertebral artery), Nurse did not correct or confirm the placement, cleared the line for use. Nurse suspended from work. Patient s family sued, hospital settled for undisclosed amount. Solution Better forms of confirmation that allow location pinpoint during insertion, and vein and artery differentiation. Target Area Superior Vena Cava/CAJ Complications Cause Result Cardiac Arrythmias Arterial Access Erosion through vein wall Thrombosis Erosion through heart wall Pulmonary Emboli Cardiac Tamponade Positioning too deep, malposition or in artery High position of terminal tip Left sided position without making downward turn into SVC Irritation to vein wall. Suboptimal position high in SVC, subclavian or collateral veins Positioning in the right atrium or ventricle Coagulation and thrombotic development resulting in emboli blocking pulmonary artery into lungs Erosion of catheter through heart wall allowing infusion of solutions into the pericardium Atrial fibrillation, flutter, premature ventricular contractions, emboli, stroke Infusion into pleural space. Failure to achieve blood return Pneumonia, infiltrates, abscess Poor function, lack of blood return, pulmonary emboli, post thrombotic sequellae Compromise of heart function, cardiac tamponade with 70% mortality Difficulty breathing, chest pain, palpitations and sudden death Pericardial effusion results in pressure on the heart resulting in decreased cardiac function and death Measuring Liability Levels of success with Landmark: 46-75% 2,3,4,5 Success with Magnetic navigation: 80% 3 Success with ECG: 55-88% 6,7 Since SA node is located near the CAJ in the posterior wall of the right atrium, the P-wave acts like a beacon used to guide a catheter tip, towards the CAJ ECG and Doppler potential success 95% or greater 8 References: 2. Trerotola et al. J Vasc Interv Radiol 2007; 18: Naylor JAVA 2007; 12:1: VSN Market Research 5. Hostetter, R. et al JAVA 15:3, Starr et al, Ann Surg, 1986; Salmela et al. Acta Anaesthesiol Scand 1993; 37: Clinical data on file at VasoNova, Inc. 15 Liability Issues Performing tip confirmation: Where is the risk? Where is the safety? X-ray The Current Standard Simple chest X-ray confirmation Frequently difficult to read General area validation. Placement frequently too deep or too shallow (10-15%) Malpositions: 5-8% in IJ, 3-5% contra-lateral or looped back 1D flat film reading missing Azygos and other malpositions More than 50% need some kind of adjustment after first placement Failure to differentiate arterial placement ECG Confirmation Greater accuracy and precision Requires discernible P-wave and interpretation Measures changes in P-wave once reaching superior vena cava Requires understanding of P-wave polarization and depolarization Unable to detect arterial placement Improved accuracy and precision ECG with Doppler Confirmation Same advantages as with ECG Indicates position or malposition with flow indicator Detects arterial flow Combined use designed to measure target location and provide all clear Blue Bullseye indication Broad application for accuracy and precision with cardiac patients No interpretation required Reducing Potential for Malpractice How can you effectively reduce the potential for malpractice? By developing processes that promote consistent outcomes greater than 95% of the time Provide confirmation in timely manner with insertion while ruling out arterial placement Put the tools in the hands of the inserter X-Ray General location for terminal tip Accurate most of the time Is that good enough? ECG/EKG Greater accuracy and precision, applicable to most patients with P-wave ECG/EKG + Doppler Achieves maximum accuracy, precision and safety, greatest application Doppler Principles for Tip Position Flow in veins is pulsatile driven by heart cycle hemodynamics Systolic inflow S D A Atrial Contraction Diastolic inflow 3

4 TEE IMAGING Doppler Flow Signatures Pt No. 2 Sinus rhythm: SVC-RA Junction RA inflow blood flow away from the transducer = Antegrade flow Proximal SVC Mid SVC CAJ Blood flow towards the transducer = Retrograde flow RA +1 cm Catheter Position and Precision Establishing the best position for a catheter tip involves knowing how to place the tip at the upper edge of Blue Bullseye zone for SVC lower 1/3 and CAJ placements 21 Move the tip upwards by 1cm or smaller steps Once reaching transient Blue Bullseye or Green Arrow, reposition tip until stable Blue Bullseye is achieved. Watch Doppler signal for balanced flow signature Improving the Process and Making it Happen Gain support Medical director/unit director/nurse executive proposal Outline savings of time and dollars Faster time to use reduces liability Improved outcomes with more rapid time to treatment Recovery time reduced thus impacting length of stay Improving the Process and Making it Happen Changing policies and processes requires evaluation of the old with new process Establish evaluation comparison in coordination with radiology X-ray readings in correlation with ECG/Doppler documentation Set up a specific number of correlations rather than a timeframe more effective. Use established X-ray guidelines that reduce variables Example: PICC placements with X-ray = ECG/Doppler reading of CAJ readings Submit for approval with your proof of correlated readings and evidence of equal or greater performance Draft the policy changes with radiology Allow a safety check and include order for X-ray any time there is position question or patient that is within limitations of device Maintain documentation of evaluation as evidence Accuracy + Precision + Safety Which do you consider optional? Accuracy Precision Or Safety For greatest reduction in terminal tip malposition all three Accuracy, Precision and Safety are vital To minimize liability - Safeguard your patients with processes that correctly determine terminal tip location ECG + Doppler = Safe Position 4

5 Questions? References Cadman A, Lawrence J., Fitzsimmons L, Spencer-Shaw A, Swindell R. To clot or not to clot? That is the question in central venous catheters. Clinical Radiology 2004;59: Crowley AL, Peterson GE, Benjamin DK Jr, et al. Venous thrombosis in patients with short- and long-term central venous catheter-associated Staphylococcus aureus bacteremia. Crit Care Med 2008;36: Gebhard RE, et al The Accuracy of Electrocardiogram-Controlled Central Line Placement. Anesth and Analg 2007;104(1): Grove, J., Pevec, W. Venous thrombosis related to peripherally inserted central catheters.. J Vasc Interv Radiol, 2000;11(7): Hostetter R, Nakazawa N, Tompkins K, Hill B. Precision in Central Venous Catheter Tip Placement: A Review of the Literature. JAVA 2010;15(3): Infusion Nurses Society (2011) Infusion Nursing Standards of Practice Revised Supp: 34(15):S1-S110. Nancy Moureau Thank You, Teleflex for Sponsorship nancy@piccexcellence.com Kearns PJ, Coleman S, Wehner JH. Complications of long arm catheters: A randomized trial of central vs peripheral tip location. Journal of Parenteral and Enteral Nutrition. 1996;20: McGee W, Ackerman B, Rouben L, Prasad V, Bandi V, Mallory, D. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Critical Care Medicine, 1993;21(8): Meyer BM. Managing Peripherally Inserted Central Catheter Thrombosis Risk: A Guide for Clinical Best Practice. Jour Assoc Vas Access. 2011;16(3): Moureau N, et al. Electrocardiogram (EKG) Guided Peripherally Inserted Central Catheter Placement and Tip Position: Results of a Trial to Replace Radiological Confirmation. 2010;15(1):9-14. Nakazawa N. Changes in the Accurate Identification of the Ideal Catheter Tip Location. Journ Assoc Vas Acc 2010;15(4): Nakazawa N. Infectious and Thrombotic Complications of Central Venous Catheters. Seminars in Oncology Nsg 2010;26(2): Pittiruti, M., Scoppettuolo, G., LaGreca, A., Emoli, A., Brutti, A., Migliorini, I., et al. The EKG method for positioning the tip of PICCs: results from two preliminary studies, JAVA 2008;3(4): Scott WL, Kondratovich M, Blum D. Central venous catheter tip placement and catheter occlusion. Am Jour Surg 2000, 180(1): Starr D, Cornicelli S. EKG guided placement of subclavian CVP catheters using j-wire. Ann. Surg, 1986;204(6): Tierney, S., Katke, J., & Langer, J. Cost Comparison Of Electrocardiography Versus Fluoroscopy For Central Venous Line Positioning In Children, J. Am. Coll. Surg. 2000;91(2): Timsit JF et al. Central Vein Catheter-Related Thrombosis in Intensive Care Patients: Incidence, Risk Factors and Relationship with Catheter-Related Sepsis. Chest 1998;114(1): Trerotola S, Thompson, S, Chittams J, Vierregger K. Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Interv Radiol, 2007;18, Van Rooden CJ, et al. Infectious Complications of CVCs Increase Risk of Catheter Related Thrombosis in Hematology Patients: A Prospective Study ASCO 23(12): Vesely, T. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol, 2003;14(5):