I would appreciate information on nerve damage occurring with PICC insertion. How do you recognize nerves using ultrasound? Does anyone have experience with this complication?
I have seen numerous legal cases where an IV catheter or infiltration/extravasation resulted in nerve injury. It can occur from direct transection or damage to the nerve during venipuncture. It can occur from compression which is causes by a tight dressing or infiltration of fluid. I don't think that most of the US manufacturers make the claim that nerves can be identified with their machines.
The outcome of many cases of nerve damage is chronic regional pain syndrome, Type 1, which leaves the patient with a permanent, life-long pain syndrome. Lynn
Most of the ultrasound systems out there are able to visualize nerves - you may want to contact your ultrasound rep. Also, many anesthesia departments are using ultrasound to do regional nerve blocks in surgery. If you know any CRNA's at your hospital, they could probably help, as well.
I would not count on "seeing" the nerves when using US, but going more by the patient's response to the insertion procedure. You need to be more cautious when attempting to access the brachial veins, as it is the median nerve that lies with that bundle (the brachial artery & 2 brachial veins) that is usually the one that can be affected. IF you see the bright white dot next to the artery & veins, then of course you want to avoid it. But you oftentimes do not see it. If the patient jerks their arm, and/or complains of a pain that resembles an electric shock going down their arm, and/or has numbness and/or tingling in their fingers/hand, then by all means pull out the needle. You have to discern if this is procedural pain or pain because you hit or touched the median nerve. There are other nerves that can be affected, but this is probably the most common one. I've hit the median nerve in a comatose patient, but the way they jerked their arm, I knew I hit the nerve and pulled out right away. If the patient complains of pain, but it seems to go away after a few seconds, then I would NOT pull the needle out, but proceed cautiously. I continually assess if the patient reports numbness/tingling or more shooting pain down the arm.
You can't always see the nerves very distinctly but you need to be cognizant that they are there somewhere. As Nadine pointed out,they are usually closely associated with the brachial artery/vein complex. With a good US,the nerve will show up as a darkish,round area with "echogenic" spots inside. It won't compress when you push down with the probe. I have found they are harder to see distinctly when there is more US "static" (i.e. edema or fat) in the area and all you might see is a round area that stays round and doesn't displace as much when you push down with the probe. I saw a rad hit a nerve during a PICC placement once---I swear the lady jumped a foot off the table when he hit it.
I just testified yesterday on a case dealing with a PICC and median nerve, where the PICC was place through the nerve and left there. I have to say that not only should we be aware of nerve responses such as electric shock, numbness and tingling, but we should also "LOOK" with the ultrasound as part of the assessment. We can learn to identify the median nerve as it is usually pinkie to thumb sized in the brachial bundle. Identification of artery and identification of the median nerve location needs to become part of our normal process of assessment. The nerve looks like a combination of dark small circles with white edges making rings. The nerve is in a circular bundle that sometimes looks like a vein, but it is non-compressible. Look closely at the brachial bundle and identify two veins, one artery and one nerve. The newer ultrasound units such as the Site Rite 5, Sonosite I-Look and 180Plus, the Punctsure and the Medcomp Second Site all have adequate resolution for nerve differentiation.
Boston Scientific has a new program available through the clinical educators on Advanced Ultrasound Assessment, that Kathy King UNC and I authored, that may help.
I have seen numerous legal cases where an IV catheter or infiltration/extravasation resulted in nerve injury. It can occur from direct transection or damage to the nerve during venipuncture. It can occur from compression which is causes by a tight dressing or infiltration of fluid. I don't think that most of the US manufacturers make the claim that nerves can be identified with their machines.
The outcome of many cases of nerve damage is chronic regional pain syndrome, Type 1, which leaves the patient with a permanent, life-long pain syndrome. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Most of the ultrasound systems out there are able to visualize nerves - you may want to contact your ultrasound rep. Also, many anesthesia departments are using ultrasound to do regional nerve blocks in surgery. If you know any CRNA's at your hospital, they could probably help, as well.
Nadine Nakazawa, RN, BS, VA-BC
I just testified yesterday on a case dealing with a PICC and median nerve, where the PICC was place through the nerve and left there. I have to say that not only should we be aware of nerve responses such as electric shock, numbness and tingling, but we should also "LOOK" with the ultrasound as part of the assessment. We can learn to identify the median nerve as it is usually pinkie to thumb sized in the brachial bundle. Identification of artery and identification of the median nerve location needs to become part of our normal process of assessment. The nerve looks like a combination of dark small circles with white edges making rings. The nerve is in a circular bundle that sometimes looks like a vein, but it is non-compressible. Look closely at the brachial bundle and identify two veins, one artery and one nerve. The newer ultrasound units such as the Site Rite 5, Sonosite I-Look and 180Plus, the Punctsure and the Medcomp Second Site all have adequate resolution for nerve differentiation.
Boston Scientific has a new program available through the clinical educators on Advanced Ultrasound Assessment, that Kathy King UNC and I authored, that may help.
Nancy Moureau, BSN, CRNI
PICC Excellence, Inc.
[email protected]
1-888-714-1952
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com