Dear colleagues,
Congratulations on the new AVA certification holders. My PICC trainer received hers in January as well.
It has recently come to my attention that PICCs placed in the brachial vein 2-3 inches proximal to the antecubital fossa can cause a pneumothorax. I was surprised to hear that. I certainly don't want to cause a pneumothorax.
Can anyone share your experiences with this with me, or provide references to sources I can study to ensure my PICCs don't cause pneumothorax.
Thank you,
Art
Art,
Can you share how this came to your attention? I ask, because I don't understand how this location is related to a pneumo.
Our first choice is, of course, the basilic, but I am sure that over the years of using ultrasound that we have placed PICCs in this exact location in the brachial. We have never had a pneumo.
Gwen Irwin
Austin, Texas
I would also love to know the source of this information. In my review of the literature, I have never found a report of pneumothorax associated with a PICC insertion. 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
Sounds like BS
I would like to respond to some of the comments, but I need to protect confidentiality.
I can be contacted at [email protected].
Art Hansen BSN, RN
[email protected]
If an incident of pneumothorax associated with PICC insertion has been published, it is already in the public domain. So there is no issue of confidentiality with sharing the reference information. If you are aware of an incident that has not been published or is in litigation, that is a different story. 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
Here is why I presented the question the way I did.
I was mortified to see the 30% right lung pneumothorax on the XRay that showed my latest PICC insertion with its tip at the RA/SVC junction. The radiologist and my PICC instructor assured me pneumothoraces cannot be caused by a PICC. A surgeon and an anesthesiologist, however, asserted that my PICC insertion did cause a pneumothorax. One commented, "it's a central line, just like any other". They are the only two who assert this. Every other source I consulted assures me this is impossible with a RUE PICC insertion just proximal to the antecubital fossa. The only event the other sources can imagine causing a pneumothorax is a jugular approach, with the cannulating needle coming in contact with lung tissue under the clavicle. I don't use the jugular approach.
I didn't want to present these details to the forum and then ask, who is right. I wanted to pose the question impartially and see what the response was without me cuing the desired response, that is, "that I did not cause the pneumothorax".
So now I pose the question again, having providing the background. "Can arm placed PICCs cause a pneumothorax?".
Art
Art Hansen BSN, RN
[email protected]
Are you certain that the surgeon and anesthesiologist realize that the actual puncture site is so far away from the apex of the lungs? I suspect that they do not know this for them to make such a statement. Puncture sites into the lower IJ IS near the apex of the lungs and can cause pneumothorax. The only way that I can see a PICC causing a pneumothorax is for the inserter to forcefully advance a large diameter catheter, possibly with the stylet wire (not a guidewire) extending beyond the catheter tip, puncturing through the vein wall through the pleura and into the thorax. That would have to be a rough aggressive catheter advancement!! Is there any possibility that your patient's pneumothorax was already present before your PICC insertion and found on the post procedure xray? 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
Hi Lynn.
I suspected from the start that the providers are not accustomed to the intracacies of the ultrasound guided bedside approach. The fact they said what they said revealed it to me.
The only thing I can conceive is that:
the catheter pierced and left one the innominate v, took a tour around the chest, pierced the lung, re-entered the innominate or SVC ending up with the tip dangling at the RA/SVC junction. That would be peculiar because I didn't measure for the extra distance.
Any possibility that the pneumothorax was present before the PICC attempt? Yes, my trainer and I noted respiratory distress the patient was being treated for before we started. Her xray the day before showed no pneumothorax, but the picc tip confirmation image did. In the minds of many correlation means causation. I am quite aware that often correlation means nothing more than correlation. And finally I am also aware of my human trait of denial, and not wanting to admit causation when it is in play. I don't want to start any bad habits now, so I am just checking to make sure there was not something in my technique the caused the pneumothorax. Oh, how reassuring [or not] it would have been had the pre procedure xray been snapped just before the PICC, not the day before.
Back to work.
Thank you,
Art
Art Hansen BSN, RN
[email protected]
Art:
Go back to the chart and see if there were any un-successful attempts to place a CVC prior to your placing the PICC line during the course of the patient's hospitalization. I have seen this before. I actually saw a resident drop a lung and it was not found until 24 hours later. To date in a literature search the only pneumothorax I have found with a PICC was a neonate.
Kathy Kokotis RN BS MBA
Bard Access Systems
I agree 100% with Kathy Kokotis. The standard of care should be that a CXR be taken after FAILED CVC insertion, but it rarely is done. This is the only time I've seen a pnemo that was first detected on the post PICC placement CXR. Pt had had multiple attempts by the housestaff on both subclavian veins using a landmark (blind technique). This was in the mid-90's and we (hopefully) won't see this now. Nowadays there is a much more stringent training for housestaff (on manikans 1st and vein models) using US guidance) with proper supervision and check-off. No more blind sticks.
Nadine Nakazawa, RN, BS, VA-BC
Most doctors don't know the procedure on how piccs are placed. That is why they think you caused the pneumo. They think the wire we use is as big as the seldinger they use. They also think we push this wire we use to where the tip enters the chest. You can cause pneumo if you stabbed the patient's chest with the echo needle prior to accessing the vein in the arm(just kidding). I had a good conversation with a surgeon one time and told him the only way I could cause pneumo is if I stab the chest with echo needle.
Patricio Collera BSN CRNI VA-BC