Optimizing the patient positioning for PICC line tip determination

Central venous catheters (CVCs) are used for both emergent and long-term vascular access for the infusion of numerous therapeutic agents such as chemotherapy, parenteral nutrition, antibiotics, and analgesics, as well as for temporary hemodialysis or hemoperfusion. Current standard of care dictates that CVC insertion should be followed by an immediate chest radiograph to confirm appropriate position. Radiographic confirmation of central venous line placement is important because it is not possible to determine CVC tip position clinically. Although many catheter tips can be localized on the standard frontal radiograph, there are occasions when a second radiograph is necessary to localize the position of the CVC tip accurately. We hypothesized that a right posterior obligue chest radiograph would more consistently enable the catheter tip to be seen as it reduces the superimposition of mediastinal structures. One hundred chest radiographs taken in an anteroposterior (AP) projection and 100 chest radiographs taken in a right posterior oblique (RPO) projection after a peripherally inserted central catheter (PICC) line placement at UCI Medical Center from June 2000 to November 2002 were read by two radiologists. Forty-one percent of AP readings were discrepant and 4% had the annotation "difficult to identify the position of the tip" although the identification of tip position was similar. Fifty-five percent of AP readings were in agreement with no note of any difficulty. Eighteen percent of RPO readings were discrepant and 2% had the annotation "difficult to identify the position of the tip" although the identification of tip position was similar. Eighty percent of RPO readings were in agreement with no note of any difficulty.