We have seen a dramatic increase in severe reactions during or immediately following PICC insertion (approximately 12 cases over the past two years). The primary s/s are exteme flushing, severe airway obstruction, anxiety. In the vast majority of patients, s/s resolve within seconds or minutes without intervention and/or catheter removal. There seems to be no specific diagnoses, age group, sex or patient condition that predisposes patients to these reactions. Several similar reports have been posted on this forum.
We'd appreciate hearing from others who are experiencing similar events and, most importantly any information regarding possible causative factors/agents (i.e., flushing solution, PICC product, etc).
Thank you,
Jamie Bowen Santolucito, RN,CRNI
Staff PICC Nurse
Oregon Health & Science University Hospitall
I have never seen this in the 4 years I have been placing PICCS.
dsnyrn
We have had a few cases of this. It seems to occur most often after the picc is in position and we are taping it down. A couple of patients have seemed to react to the smell of the skin protectant we use, stating "What is that smell?" and then doing the facial flushing and in a couple of cases, passing out. We have learned to be prepared to intervene in this situation by putting the patient rapidly in trendelenberg. That seems to prevent the passing out. A couple of other instances we attributed it to a vagal response, possibly to the catheter moving inside the vessel. Would love to hear more about your deductions. [email protected]
Kelly Smith
PICC Nurse
Boone Hospital Center
Columbia, Missouri
I am a little surprised at what I am hearing. #1 that reactions are occurring and #2 that the catheters are continuing to be used. If we knew a particular catheter caused infections we would immediately stop using it, the same for great increase in thrombosis or occlusion, is it just about convenience or is patient safety really important? The issues here are that serious reactions are occurring, so serious that airway obstruction is involved in some cases, that multiple catheters are involved and so it is not isolated to just one of the Bard PICCs, it is happening all over the country and are they all being reported through the MedWatch FDA program so we can track occurrences effectively? I have personally gotten two reports in the last month. We've had no occurrences at my facility, but who wants to wait and see. What are we waiting for, deaths?? and how do we know they have not already occurred?
When these problems occurred in the Menlo Landmark it took 5 years for people to be aware of the problem and an initiative to start looking into the problem. Despite great effort by Lynn Hadaway and a group of experts no solution or even specific cause could be found. Now the same thing is happening again. What is being done?? One response I heard from the company was the occurrence was so small in percentages that it was not significant. The company did encourage reporting through Medwatch https://www.accessdata.fda.gov/scripts/medwatch/ by telephone at 1-800-FDA-1088. This type of reporting helps us all to make informed decisions based on fact rather than anecdotal information.
Nancy Moureau
PICC Excellence.com
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
These events are not limited to one type of catheter or to one or even a few brands of catheters. They have occurred with midlines and PICCs and with multiple brands. I also strongly disagree that it required 5 years to get any attention to the problem with the Landmark Midline Catheter. This is simply not true and it was never regarded as "not significant". But removing that catheter from the market did not stop these events.
These events present with the same signs and symptoms as an allergic reaction or an anaphylactic reaction. This means that histamine is being released. When you look at the physiology of mast cells, you will find there are 4 mechanisms to stimulate the mast cell. IgE antibodies cause the allergic reactions. Previous exposure to the substance is require for the development of the antibody. So allergy does not happen on first exposure. The other 3 mechanisms produce the exact same signs and symptoms but are not mediated by IgE antibodies. Chemical stimulation of mast cells comes from drugs such as vancomycin, morphine, ACE inhibitors. Activation of complement proteins and physical trauma also stimulate mast cells. It has always been hypothesized that physical stimulation of the mast cell during catheter insertion was the precipitating factor in these events. Mast cells are located close to veins and nerves. Exercise is also documented to cause similar events.
Mast cell activation syndrome is found in the literature and is a diagnosis of exclusion. All other causes have been eliminated and the allergist will use this term when there is no explanation of these events. These events are not limited to catheter insertion. Skin scratch testing is usually performed by allergist to rule out true IgE mediated events and identify the substance to which the patient is allergic. This is critical for the patient's future healthcare.
There has been limited work on measurement of histamine release when blood samples were challenged with extracts of silicone and polyurethane. These challenges were all negative, leading one to believe that these polymers do not produce these events. There could be other substances in the procedure that cause or contribute to this problem. We do need more attention to this problem and to conduct studies to confirm or refute the hypothesis. This is the missing piece. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
This reaction is not new, but I don't think there has ever been any evidence supporting what it actually was or the cause. Several years ago, I created a presentation comparing the signs and symptoms of a hypersensitivity/allergic reaction, vasovagal reaction, and an anxiety/panic attack. All are very similar and hard to distinguish at the bedside. The literature labels strange reactions like this as idiopathic anaphylaxis or anaphylactoid reactions, but this is only because there has not been a causative agent identified through allergy testing. I think it is similar to red man syndrome from vancomycin. See A&P chapter in INS textbook for explanation of the 4 mechanisms that stimulate the release of histamine from mast cells. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
Thank you for your response. I agree that we've seen these reactions previously...but they were isolated. I personally saw only three episodes in twenty years. But recently we've seen a dramatic increase in the number of cases and we're desperately trying to identify why. The reactions we're seeing appear to be anaphylactoid-type (i.e., extreme flushing, severe airway obstruction, tachycardia, anxiety). In contrast, vasovagal reactions produce pallor, bradycardia and hypotension.
Jamie Santolucito
I have never seen, nor heard of this....I've been inserting PICC lines at bedside for 6 1/2 years and probably have over 5000 insertions and I have not seen this. We had a large team at Penn and you would think this would have popped up at some time?
Could it be something in your procedure? Maybe something your using..???
We have experienced this reaction once and we have been inserting PICCs since 1990 - The reactions sound similar to the symptoms of Mastocytosis
Two times in the past year I had to call a Rapid Response after inserting a PICC
Both patients were compromised and at the time I attributed their reactions to their medical condition
Should I go back and research the circumstances of the incidences and report them to the FDA???
I sent this exchange of ideas to the Maryland INS group as this topic was a part of our last meeting
Several in the group including myself and Dr. LeDonne wondered if this could be a reaction to other agents in use during the insertion
Chlorhexadine--Latex--Lidocaine--In addition to the Catheter material
Robbin Goerge RN Vascular Access Resource Dept Alexandria Hospital Virginia
Robbin George RN VA-BC
Hello Jamie,
How is it coming along with the reactions?
I have had five of the described reactions in the past few months. They are sudden and severe and occur immediately after flushing the lumen that contained the navigation wire with NS. The patient reactions are similar each time; sudden choking/dyspnea, eyes roll back, SOB, "I can't breath", panic, red face, BP shoots up, O2 sat goes below 90%, all subsides within five minutes.
I have placed over 3045 PICCs since 2000 and this only started happening in the last year.
Thank you.
Thank you for your post.
The clinical s/s you're describing are identical to what we have seen. Can you identify anything that you are doing differently over the past year?
How much chlorhexidine are you using to prep the site prior to insertion?
We were using two to three 10 ml chlorehexidine prep swabs prior to insertion and at least one 3ml prep swab after insertion. Several months ago we reduced our prep to one 10 ml chlorhexidine prep swab and one 3 ml prep swab prior to insertion and we replaced chlorhexidine with normal saline to clean the insertion site after catheter insertion. Since then we have seen no further reactions...but we're not convinced that the reactions are related to the amount of chlorhexidine.
It is critical that you report these incidents to the medical manufacturer and your risk management department, who should report the events to the FDA.
Thank you,
Jamie Bowen Santolucito, RN,CRNI,VA-BC
Just one other observation - these events began long before CHG was used for skin antisepsis. I think CHG can create contact dermatitis and if it is not dry, it could be tracked into the bloodstream during catheter insertion. But I have my doubts about it causing these systemic reactions immediately after catheter advancement. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hello Lynn and all,
I wanted to post an update about the severe reactions I was encountering. Since I rearranged how I set up my tray, I have only had one reaction and it happened while I was using the CHG to clean the site at the end of the procedure. Now, I don't use the CHG afterward at the punction site. I have had no further problems. It seems that the CHG was the culprit all along. Before, I cracked my 10 ml CHG and set it on my tray so that the sponge had time to get saturated while I was setting up the rest of my tray. I think that the CHG was co-mingling with either the syringes or catheter. This would explain why I never had a reaction (2000 PICC insertions) before the CHG was standard practice.
Thank you everyone for your thoughts and experiences.
I am up to 3420 PICCs now:-) and no more reactions, YEAH.
Thank you for your quick response Jamie and Lynn.
It is interesting that you are no longer experiencing the reaction. I do not think that the CHG is the cause. The reaction occurs instantly after the NS flush through the lumen that contained the navigation wire. I have reported this to the manufacturer as well as the FDA.
I do not think it is related to any product being used. I think some people have a greater tendency to have subcutaneous mast cells activated by physical stimulation of passing a catheter into the vein. We definitely need more research on this issue but it has been with us for about 20 years now. It happens with many brands, catheter materials, and types of catheters. Early studies have ruled out the catheter material as the cause. The question is how do we identify patients at risk for this problem and how do we manage it when present. I would never immediately remove the catheter as you may actually need it for IV meds and this may be the only route you have to give treatment if this is severe. If it is the physical stimulation, removing and reinserting a new one will only produce the same response. This is usually a very transient condition that quickly resolves. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I have been on an IV Team for 14 years and had the department's first experience with this last month. It occured when I was advancing the PICC catheter up the vein and by TLS, I could see the catheter coil near the jugular and over to brachiocephalic vein. I wasn't flushing the catheter @ the time and usually don't flush the lumen with the wire until later in the procedure. I retracted the catheter and the patient suddenly said she couldn't catch her breath and began breathe rapidly, look wide eyed, flushed and soon said said she saw black spots. She then fainted and her breathing returned to normal and awoke slightly disoriented but oriented immediately. Once fully alert, she began to feel short of breath, anxious and be flushed once again. Once the catheter was in place and dressed, the patient vomited. The symptoms did resolve after that. The MD's thought it was a vasovagal response.
This was very a frightening experience for me and the patient and not one I want to repeat anytime soon.
I appreciate this discussion and take some solice in knowing others have experienced this. The fact that there are no answers for what I saw happen still frightens me. Kathleen
Many years ago, I wrote a presentation comparing vasovagal, panic reactions and mast cell activation. The signs and symptoms are very close but there are differences. Perhaps I need to revise and update that course. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you Lynn,
For one of these patients, the first PICC she had inserted did not cause a problem. The second PICC however, caused the extreme reaction. She was hospitalized and even had a cardiac cath due to ECG changes after the reaction. One would summise that the first PICC sensitized her and the second caused the reaction, if indeed it was a mast cell/allergic-IG mediated response. Interestingly, she c/o a *metallic* taste with the flush (not a salty taste as they do with the NS) and a burning sensation in her chest.
My quandary has to do with the fact that I have placed over 2000 PICCs since the year 2000 without this reaction but in the last few months I have had 5 reactions. To me, it *does* seem like it is something with the product. The reactions I have observed occur *immediately* (within 1 minute) after flushing the catheter. For now, I am taking extra time to flush and prep the catheter prior to insertion including flushing it with extra NS with and without the wire in place. After insertion, I draw a full syringe of blood back as waste prior to the final NS flush. There are still many questions left unanswered and not much in terms of published evidence. I appreciate this forum to discuss this important matter.
Your assumption of the first PICC sensitizing the patient and the second PICC producing the reaction is correct IF this is an IgE-mediated allergic reaction. Mast cell activation syndrome is not an IgE-mediated reaction. There are 4 ways that mast cells can be stimulated - IgE, chemical (think of red man syndrome from Vancomycin and many other drugs), activation of complement protein, and physical. All published evidence of this problem thus far have pointed to the physical stimulation of the mast cell. This could be a combination of physical stimulation in patients that are also taking medications that produce chemical stimulation. Just a guess on this but we definitely need more information for sure!! Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn, is there any possibility that the reaction could be caused by the lidocaine given prior to insertion?
How long does it take to get a mast cell mediation and reaction? Is there a delay between exposure and systemic reaction? I'm not real familiar with this.
Thank you,
Kathleen
Anything is possible but with the ones I have dealt with, the lidocaine was not the issue. Signs and symptoms of mast cell activation sydrome occursj when the catheter has been advanced into the vein, sometimes immediately upon the initial flush after it has been fully advanced. The delay you are asking about suggests that there must be a sensitisation process. Exposure to the antigen creates the antibody and the reaction happens with the next or subsequent exposure. This is the case when there is a true allergic reaction which is caused by the development of IgE. However there are 3 other causes of mast cells to release their histamine - physical, chemical, and complement protein activation. These last 3 are a non-immunologic reaction and happen immediately. There are even cases where exercise has been attributed to mast cell activation syndrome. The diagnosis is made by ruling out all other causes that could create and IgE mediated allergic reaction, leaving only nonimmunologic mechanism to stimulate the mast cell. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think this would be a great topic for the next AVA conference.
I would like to share my experience today: I inserted a BARD groshong (Sherlock) picc. While I was applying the dressing, the pt. suddenly became flushed and dyspneic. He had difficulty speaking but shook his head yes when asked if he was having difficulty breathing. He quickly became pale and diaphoretic. Within a minute he became apneic and pulseless. We initiated CPR and ambuing. After approximately 15 mins. (I don't know all of the details of the sequence of events, because there were too many people in the room and I had to step aside) he was awake and conversing. I was told he got some steriods, not sure what else, but sure was scary!
Our vascular access team changes all the picc dressings throughout the hospital and with the excep
Do you think this looked like an anaphylactic reaction to something? If so, I would say it could be mast cell activation syndrome. The signs and symptoms of the IgE-mediated anaphylactic reaction is exactly the same as the syndrome known as idiopathic anaphylaxis, anaphylactoid reaction or mast cell activation syndrome. The diagnosis is one made by an allergist where all allergens are ruled out leaving no true cause obvious. Was this patient also receiving either morphine, vancomycin, or any one of the ACE inhibitors? All of these drugs can produce chemical stimulation of the mast cell. Add the physical stimulation by advancing the catheter and it might be possible to see this reaction in some patients. I also think the patient does need to be referred to an allergist for a diagnostic workup just to make sure that there is no true allergies in this patient. I would not label the patient as "allergic" to anything without this workup. So mast cell activation syndrome has the same signs and symptoms and the same treatment as an IgE mediated anaphylaxis or allergy. Histamine is being released from the mast cells located everywhere - SC tissue very close to veins (about 10,000 cells per cubic mm of tissue), lungs, GI tract - but the actual cause of what stimulated this histamine release is different. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I recall seening a handful of these reactions with the old Landmark catheters and they were frightening. So far I have not seen any with the PICCs we place. If a patient does have an anaphylactoid reaction during or immediately post PICC placement, should he then no longer be considered a PICC candidate or should pre-medication be considered? I know we premedicated at least one patient in the past which seemed to be effective but obviously that number is too small to draw conclusions.
Many people attributed this reaction solely to the material used in the Landmark midline catheter, but now we can see that this reaction happens with all materials and catheters.
Premedication remains the unanswered question. A PubMed search of mast cell activation syndrome pulled up 174 references. Idiopathic analyphylaxis pulled up 143 references. Anaphylactoid reactions brought up 918 references. When those terms were combined with "catheter" nothing comes up. So we know very little about this problem. Here is a link to the abstract of a recent article about the controversies surrounding this term.
http://www.jacionline.org/article/S0091-6749%2810%2901333-3/abstract
We typically think of an antihistamine as the treatmet (e.g. Benadryl) but this will not effect the immediate s&s after histamine release. The histamine is released from the mast cells and binds to the receptors, thus blocking the attachment of the antihistamine. So it would make sense to have some drug in the system to prevent the initial attachment of the histamine, but there are no recommendations for any drug so far. The only thing we can do is be prepared to manage the patient when it happens. The first reaction is often to immediately remove the catheter just inserted. This could be the wrong action since this may be the only route to give the required drugs for treatment. I would also be vigilant in patients that have many documented true allergies and those taking morphine, vancomycin, and ACE inhibitors as those are known to cause chemical stimulation of the mast cell.
There is no question that much more research and information is needed on this whole issue.
Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I will go back and research what medications this patient was on. Very interesting discussion. I met with my manager and expressed my concerns.....even printed up this dialogue for her to review. I am told that our risk management is reviewing the case and has 10 days to respond....i.e. notifying manufacturer and/or fda. In hindsight, I remember a pt. about 10 months ago who had a similar reaction (although not as severe). At the time, I assumed I had advanced the catheter too far into the atrium and had stimulated a SVT. I withdrew the catheter and within several minutes, her syptoms abated. Now I'm not so sure. I will stay vigilant in observing if this should happen again. I administer my lidocaine so that I make a wheal directly at the insertion site. I had one nurse raise the possibility, since these two instances occurred with me, that perhaps it was the way I was administering my lidocaine. My co-workers tend to go a little deeper into the SQ tissue. Any thoughts? Thank you for everyones input.
Jennifer Estela-Stollwerck, RN, BSN, CRNI
Our vascular access team changes all the picc dressings throughout the hospital and with the excep
Systemic reactions from intradermal lidocaine have been reported many years ago but I have not seen anything recently. If you are injecting directly over the vein, you could be taking some of it into the bloodstream, but this drug is given IV all the time. I can not see how this small amount taken into the vein would cause this reaction unless the patient had a history of other reactions to lidocaine. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Jennifer,
You are correct in administering lidocaine intradermally. The sensory intracutaneous nerves are located within the dermis, not subcutaneously.
It is doubful that these reactions are associated with lidocaine as we use lidocaine with the vast majority of our PIVs without reactions.
Thank you for your post.
Jamie Santolucito, RN,CRNI,VA-BC
I appreciate the continued dialogue on this problem. An interesting thought for everyone to consider is how often you have seen this happen with short peripheral intravenous catheters (PIVs). I have inserted over 10,000 PIVs in my 26 1/2 years of nursing and have never, not once, experienced the severe reaction with flushing the PIV after placing it. I have used multiple brands of PIVs over the years.
It is imperative that nurses are reporting these occurances to the manufacturers as well as the FDA. Treating the reaction is one thing but we must find an answer to preventing it from occuring in the first place. Premedications are not the answer as PICCs are not like blood products or biological agents where possible reactions are anticipated. PICC lines should be constructed with extremely safe and biocompatible materials. Anaphylactoid reactions should not be an anticipated event. Answers need to be forthcoming.
Has anyone experienced patients having the reaction after subclavian or jugular catheter insertion? The reaction= sudden choking/SOB, "can't breathe", red face, eyes rolling back, BP up, O2 sat down, panic, back to normal within 5 minutes with no treatment.
This sounds like your are assuming that this problem is caused by the product. I do not believe that it is. It has happened with midlines and PICCs. I has occured with different materials. There have been blinded scratch test in patients with this reaction to test for an allergic reaction to the catheter material both silicone and polyurethane - all negative. I believe that there are some patients that are at a greater risk for this to happen due to a) their individual mast cell physiology or b) the presence of drugs that also cause these reactions, or c) a combination of both.. I believe that the length of vein exposed to the catheter advancement is what adds to the risks already present. I could easily be wrong about this and I do believe that these events should be reported to the manufacturer and to the MedWatch system. But I do not believe that it is related to the design or manufacturing process of any one specific product. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I have seen a similar reaction on a few occasions. It has always occurred during the procedure or during the setup. In speaking with the patient, I almost always found they had a history they describe as "panic attacks". I have usually been able to "talk them off of the ledge" and complete the procedure, but a couple of times I had to terminate the procedure. In those cases, I was able to come back the next day and after the patient was de-escalated and more psychologically prepared, place a line without an "adrenaline storm" taking place. The "flight or fight" response can be like claustrophobia. You may never experience it until a situation where you do. If the first time you experience it is when you are sick, flat on your back and covered over with sterile drapes, you may not recognize it as the same response you would have if a mountain lion jumped in your car window.
Daniel Juckette RN, CCRN, VA-BC
A patient recently arrested a few hours after being sent to the floor post-PICC insertion (thankfully revived). Sorry I have very few details but chief complaint apparently was itching and burning to the arm I believe during and post-insertion. It apparently was attritubed to CHG reaction. With these mast-cell reactions described on this thread, I'm curious whether anyone has had complaints about burning/itching to the arm as well?
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Raised red whelps and itching has been seen with this adverse event in the past, especially with midlines. This is part of the histamine release from the mast cell. There are also components of the mast cell wall that create leukotrienes and cytokines that can perpetuate an idiopathic anaphylactic reaction after the initial episode. So the symptoms can continue. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
About 6 months ago, immediately following the picc insertion when the dressing was being applied, the patient broke out in red whelts over her body. We had to call a rapid response, as she had difficulty with breathing also. At the time, it was attributed to a "lidocaine" allergy. I think this diagnosis was made because there was no other apparent contributing factor. Now looking back, it could have been a mast cell reaction. My understanding is that an allergist would need to make the determination. By the way, we have had 3 such episodes in 11 months.
Jennifer Estela-Stollwerck, RN, BSN, CRNI
Our vascular access team changes all the picc dressings throughout the hospital and with the excep
What type/brand of PICC are you using
Lynn,
Having been the one with each patient and observing the timing and characteristics of the reaction, I lean toward believing that the reaction is due to the product. I wonder if the hydrophilic coating on the wire is the culprit? Of course this is intuitive-based, not evidence-based thinking.
That may indeed be what it appears based on clinical signs and symptoms. Research has not proven that fact. Of course there has not been any research into this issue for at least 15 years. I still believe it is not the product based on the anatomy and phsyiology of human mast cells and those old studies. We definitely need new studies on this issue. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hi,
I have been either assisting or inserting PICCs and seen the exact patient responses listed. It is very scary. I have spoken with Lynn after INS meetings and expressed my concern for these patients, trying to find the root cause and how to prevent it from recurring. We have discovered that the difficulty breathing, face flushing, etc (usually lasting 30 seconds to a minute or so) at the tail end of the insertion or instillation of the final normal saline flush, is resolved after pulling the PICC back approximately 2 cm. The chest x-ray usually reads the tip in the mid-distal SVC. So 2 cms deeper would have been CA junction or possibly proximal RA. We keep a list of the patient's who have had this reponse and if they are ever re-admitted and ordered a PICC, we recommend that the line be place in IR. IR places the exact same PICC and usually has a CA tip termination. The only difference, is that the patient is sedated for the procedure.
I have a question for those of you that have had patients with this reaction. Was the PICC insertion on the right arm or left arm? Just curious.
Gwen Irwin
Austin, Texas
It will be a great research to find out what brand/type catheters are used with these reactions. This problem seem to be increasing in the last 3-4 years. Interestingly, the s/s usually resolves after the catheter is removed. Historically, we attributed these reactions to several factors i.e lidocaine and the patient's apprehension etc... Would like to hear your input.
Thank You
Mercedes Mccoy RN, BSN, CRNI
There is no evidence that this reaction is caused by a specific type or brand of catheter. And I would definitely not remove the catheter immediately as this may be your only route to give needed drugs. These events most often resolve without catheter removal. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I have been inserting PICCs for 15 years and read with interest about this unusual occurence which I have only recently seen. This inpatient was a pleasant, very strong looking, large young man (early 20s) with a pineal gland tumor who was eagerly anticipating his bedside PICC insertion for IV antibiotics; PICC was his key for discharge. He was actually standing outside his door watching for me to arrive.
4 fr Groshong PICC insert was to his left basilic vein via ultrasound--prep with chlorhixidene with alcohol. Totally uneventful insertion until the end of the procedure while I was applying stat lok and 3M tegaderm dressing he became restless and asking when we'd be finished. He appeared to be scratching his trunk under the drape and said he had to pee.
As soon as the procedure was complete he got up to the bathroom. When he returned to the bed, the PICC site was saturated with blood, both arms and trunk were rapidly being covered with raised red whelts and he was complaining of itching all over.
He receivied antihistamine immediately. When discussing this occurence with the attending physician I was advised that pt had prior exposure to central lines, chlorhexidene lidocaine, saline and had no known allergies. The PICC was left in place with CXR showing position within the SVC.
If this was a mast cell reaction--related to length of catheter exposed to mast cell--if the PICC was removed and reinserted at another site would he have had the same reaction?
Patrice Wilken RN
Vascular Access Team
Winnipeg
Patrice,
We have a patient who has had 4 PICC's in the last year for IV antibiotics. She is a 22 year old female, very nervous. First 2 times she had this reaction. 3rd time we gave her Benadryl and she had the reaction again. Last time she got Ativan and she was fine. So yes, he would have had the same reaction.
Karen Y. VA-BC
Denver CO
Hi,
In response to Gwen's question, I have seen this response with both right and left arm insertions.
Tessy
I just experienced 2 picc reactions. One was with a 29 year old. The patient was anxious, so was medicated with Ativan 1 mg po. The reaction occurred when I had the picc inserted to the shoulder area and flushed it with saline to aid in floating it down towards the SVC. The patient said he tasted something, became short of breath, flushed to bright red, and became diaphoretic. Another nurse was present in the room. We sat him upright in bed, encouraged slow deep breathing and attempted to reassure him he would OK. After about a minute or two his color returned to normal and I was able to complete the PICC insertion. The second patient had had a similar reaction 6 weeks earlier. We decided to use bacteriostatic saline instead of lidocaine, administer ativan 1 mg, put the patient on a monitor and have oxygen available. The PICC went in texbook, then when I flushed the picc with saline, the patient became short of breath and began to flush. Oxygen was applied. Reaction was lessened. Vital signs increased some but returned to normal in a few minutes.
Karen Bement
Lynn, I agree in keeping the line in the patient, but to be honest, in the 3 or 4 times this has happened over the last several years, there doesn't seem to be much time to educate the doctor during the accute phase when they are telling you to take the line out as they feel it is a reaction to the catheter, nor do they want to hear what you are telling them it could be, as we do not have MD behind our name. Your right, more research needs to be done and education of this side effect to practitioners needs to be done. Just as education on DVT's and pulling PICC's!
Kimberly Masser CRNI
Vascular Access Services
Frederick Memorial Hospital
Frederick, MD 21702
At out instituion we have had several patient who have had reactions when placing PICC's. Unfortunately all of them have been with outpatients, which does not make a difference. It seemed that the reaction would occur when the nurse was finishing up and doing the last flush with normal saline. In fact lately I have been having more and more complaints from patients regarding smell and taste after flushing with normal saline. I have don an extensive liiterature search for any similar reactions but all I usually come up with are allergic or anaphylactic reactions. Maybe we all need to get together and do some type of research on this, because it seems to me it is occuring more and more.
Bonnie Clemence, MSN, RN, CRNI
Staf Nurse
IV Therapy Department
Pinnacle Health System
Harrisburg, PA
If you are placing Bard PICC's they want to know about the adverse reactions. Contact [email protected] We have had many of these reactions but I have found since we decreased the amount of Chlorhexidine from a 26 ml applicator to 10 ml applicator the occurence rate has decreased a lot. In my previous place of employment we used 2-3 ml Chloraprep applicators and we never saw this occur in our patients. We find the majority of patients who experience this is young people who are very nervous about having a PICC placed. I have never had to remove the PICC and docs are good about going with it until it passes. Usually only lasts a few minutes. The faster it comes on the faster it leaves. The slower it comes on the longer it lasts. Usually occurs when we are placing the dressing on post PICC insertion. There is some info out there about it being a "mast cell" reaction. We do take precautions with very nervous people. Explain, take our time, insert the PICC slowly, use a slow minimal saline flush.
Karen Yankus, RN, VA-BC
Vascular Access Nurse
St. Joseph's Hospital
Denver CO
Karen Y. VA-BC
Denver CO
I have had 3 of these reactions in the last 2 months. Two of these were severe. The 2 pt's were talking, as I was putting on the PICC dressing, and then they went unresponsive, shallow breathing, color change, gurgling in throat. Very scary. Lasted approx 30-45 seconds then woke up alert and talking. Both PICC's were appropriatly positioned and I did not remove lines. I did use Chloraprep to clean, so maybe I should take out this step?? I am so interested in what is causing this, as there seem to be more reactions and more thoughts as to the reason why.
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