This was posted on the ARIN (Assoc of Radiologic and Imaging Nurses) Listserv, I thought you would be interested.
---- "Mary K. Berman" <[email protected]> wrote:
Hi all!
We had a case in point just this past week! A patient came to our IR department to have her power injectable PICC rewired as she was having some issues with the line...one of the hubs of the dual lumen was cracked and leaking. She had the PICC placed for access reasons and for a continuous Dilaudid drip for treatment of her metastatic cancer pain. The PICC was initially inserted in early July 2011 at the bedside by one of our best IV team nurses with loads of experience under her belt. The post-insertion CXR was read out by a very experienced radiologist as being in the cavo-atrial junction of the SVC. So, it was ready to use...right?
We got her on the table, prepped and draped the existing PICC area and line according to our protocol, and our IR doc accessed the line by wire. Something centrally looked a little strange to him, so he injected a little puff of contrast...and it went distally to her head, neck, arms, and hands! Yeah, you all know what's coming...it was inserted into her brachial artery, with the tip in her ascending aorta near her valve...and had been there since July!!
Needless to say, the line got pulled and pressure was held for the appropriate amount of time for a 6 Fr. arterial puncture in an anticoagulated patient (she was receiving Lovenox injections for hypercoagulability seen in oncology patients). As soon as the line was out, and not reported earlier, she said she had been having an intermittent dull ache in that hand which now had changed to a "pins and needles" sensation (aka reperfusion pain?). The Dilaudid and anticoagulation in combination, most likely masked her hand ischemia and helped to prevent full occlusion of the artery below the line. Incidentally, she reported "going blind" for 2-3 days during the prior month and had tons of imaging, presumably receiving contrast for some of the studies through that line! Some brain imaging doesn't require contrast and she never had any chest imaging with that episode, which would have shown the line in the wrong vessels. They found no lesions in her head, but still passed off t he transient blindness as progression of her disease. In exploring her symptoms more, she reported her symptoms always seemed to follow "something new going into the line".
This all just makes me shudder! But it clearly illustrates that we never really know where the tip OR the line is without verification of flow. A good blood return and easy flushing do not guarantee proper placement or flow direction, just patency. And the follow-up CXR can be read incorrectly, as happened in this case (I pulled up the archived image and the CXR wasn't the best quality...the patient is quite obese and it wasn't exactly AP...the patient was on a stretcher and slightly askew, making it appear that the line was in the correct position).
So let's take this discussion a step further...should it become best practice to not only take a spot film prior to injecting (to confirm current tip position), but also to do a quick injection to establish direction of flow, especially for those lines that were NOT placed under fluoro to begin with?
These are just my opinions. I don't mean to offend any of our infusion nurses or their techniques. They are very knowledgeable and skilled at what they do...and they perform a great service to many, many patients and also to those of us in IR, who wouldn't be able to handle the additional volume of PICCs that are screened out and done by them. This case, though thankfully very rare, makes a great argument for ALL PICCs to be placed under fluoro; OR at least verified under fluoro, not just by a spot. I know that calls into play the problem of extra radiation as well as potential issues with the contrast, not currently needed for every fluoro-placed PICC...Perhaps a flow-directed wire or balloon could/should be used in each case? I'm just throwing these thoughts from "the world according to Mary" out there for discussion! I would love to hear your thoughts...the ARIN community is the best resource for everything radiology!
Regards,
Mary K. Berman, BSN, RN, CAPA, CRN
Interventional Radiology
Baystate Medical Center
Springfield, MA 01199
[email protected]<mailto:[email protected]>
INdeed this is a dangerous situation, but the original author identified problems with the quality of the xray. So I don't think this is a case that should drive placing all PICCs under fluoro or requring the spot file as suggested. With such a bad quality of film, why was it not repeated to obtain a better position for a PA view? Arterial placement can be detected on xray by assessing the pathway of the catheter arching high over the clavicle. Any question requires one of two interventions - transducing the line for pressure or obtaining a blood sample from the line for blood gases. Either of these will easily determine arterial vs venous placement. This sounds like a situation of "confirmation bias" where one sees what one expects to see, both the nurse placing the line and the radiologist looking at the film. Then why did so many people ignore the patient complaints assuming it was her disease. We should all be highly suspicious of any catheter when signs and symptoms such as these occur. Finally I would hate to think this is going to become a turf war between radiology nurses and infusion nurses. That is not necessary. We need to work together because we need each other. We both have knowledge and skills to share with each other. 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
Reading the post on picc placed in artery for months, was horrifying. I agree with you Lynn regarding transducing the linfe for pressure or obtaining a blood sample from the line for blood gases is a good and appropriate action. A upper extremity venous ultrasound would have revealed the "malpositioned PICC immediately. Additionally I'm certain the medications were not being delivered properly, it's a blessing she is alive. This would be an interesting case study.
In my years of inserting PICC's with and without ultrasound guidance. I use ultrasound for all Midline and PICc procedures. I for one believe the more you understand ultrasound principles, vascular anatomy and hemodynamics the fewer incidents like this one occur. As we know the vascular system is constantly adjusting because of disease process, and procedural interventions.
We should never go back to placing the majority of our PICC's under fluroscopy. I have on occasion referred a patient back to fluro because of probable central venous obstruction, but that's rare.
My background is in nursing and vascular ultrasound hence the name of our company Registered Nursing & Vascular Ultrasound Services, (RNVUS,LLC). We provide mobile vascular ultrasound and PICC services. Most ofen the PICC placement is in IVDA patienct environment, nursing homes and vent patients. Everyday inserting PICC's is interesting and challenging, (sometimes more challenging than I want it to be.)
Ultrasound guided vascular access accuracy rates (when utilized properly ) rivals fluro. Ultrasound has the additional benefit of color flow (duplex) which allows the user to distinguish veins from arteries with high sensitivity and specificity I am an strong advocate for more knowledge in ultrasound for PICC nurses. Knowledge plus Experience provides the guidance we need to keep point of care services like bedside ultrasound safe. Alfonza
Alfonza J. Riley, RN,RVS
Managing Partner,RNVUS,LLC
Website: www.rnvus.com
email: [email protected]
Alfonza J. Riley, RN,RVS
I came across this topic and have a question. When the brachial artery is accessed while placing a PICC, whether it is identified after the CXR or when the vessel is cannulated with the dialator/sheath and the dialator is removed, how does the PICC nurse provide care other than holding pressure. I have investigated a process for our nurses to follow. I have talked to our cath lab and the process is extensive before the device is removed and after. Care including pain meds, fluids and frequest site checks are part of it. At the bedside alone placing a PICC, if a nurse realizes they cannulated the brachial artery, they remove the device promply and hoild presure. I think that complications can arise when alone in a room and removing the device. Do any institutions have a process/procedure for such a situation?
The devices used in cath labs are much larger than a PICC therefore the puncture site is smaller. I would agree that a CVAD placed in an artery can be challenging to remove. Pressure on the carotid artery and restrict blood flow to the brain. Subclavian artery is not accessible due to the clavicle. But the brachial artery at a PICC insertion is accessible and adequate pressure until hemostasis is achieved is the standard of care. If there are other factors favoring the tendency to bleed (anticoagulants, etc) you may need to discuss the use of a closure device before removal. Some arterially placed CVADs require surgery to remove but that should not be the case with a PICC insertion site. Frequency of site assessment should be included in your hospital policy and procedure as this does need to be done more frequently. I am not sure what other complications you are thinking about other than bleeding. 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
You really cannot compare the Cath Lab practices to bedside PICC placement, it is apples and oranges. In the Cath lab, you are accessing a FEMORAL artery with a much larger catheter and wire, very difficult to manually hold pressure. It is much more painful access (patients are sedated) and there is usually a closure device that is used and a pressure device as well, due to these devices, you have to check distal pulses frequently, as well as assess for bleeding. It takes hours for the puncture to form a solid, stable clot because of the size of the punture and artery.
The brachial arter is much smaller and more superficial, easier to access and easier to hold direct pressure. It is not as painful as a femoral artery puncture, and forms a stable clot much more quickly. Yes, you should still have a nurse assess for bleeding and distal pulses for the next few hours, but the staff nurse can do this easily enough. Yes, complications can arise, but you are not alone, you have an entire nursing staff outside your door, who can contact the MD for orders for you or assist you while you stay with the patient, simply push the call light or hollar out the door...
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I am a nurse that places PICC's at the bedside. This may be overly simplistic, but when I place a line and I check for the blood return I look to see if the blood is stationary or pulsatile. Am I hopelessly low tech and outdated? I just don’t understand how no one noticed pulsatile blood in the PICC for all of those months.
I am a nurse that places PICC's at the bedside. This may be overly simplistic, but when I place a line and I check for the blood return I look to see if the blood is stationary or pulsatile. Am I hopelessly low tech and outdated? I just don’t understand how no one noticed pulsatile blood in the PICC for all of those months.
In my experience (and I have seen several arterial PICCs placed), I have never seen a pulsatile blood return. The CXR ,as Lynn said, can be telling if the line is above the clavical or left sided which may indicate a left SVC or arterial placement. We use ABGs also as an indcator, however, this can be confusing too if, for example, pt is on 100% O2. I have also detected a sublte resistance when flushing and, of course, an unusual blood return in that it's immediate and steady without aspiration. It can be a confusing picture on occasion to determine....so when in doubt, I pull it out.
Hi Angela. Would venous blood gases give a more accurate picture like when the patient is on 100% O2? When cannulating babies, I know how hard it can be especially with an inexperienced picc nurse. So if you suspect arterial placement and the venous gas came back high that might confirm your suspicions.
Also I want to add that pediatric nurses and picc nurses should give attention to the small baby or young childs' hand extremity and not have it covered with mittens which could hide an early sign of complication.
L. McRae, RN
Laura McRae, RN, BSN, CRNI
A high venous pO2 on a venous gas from a patient on 100% O2 is what I would expect to see so I'm not sure it would be definitively indicative of arterial placement. Whether it's a vbg or abg, results are not always clear cut. Some can be difficult to interpret. We do look at a number of factors and any suspect sign is further investigated.
As far as mittens and other "easy-on...easy-off' hand covers, I think they can be important to protect lines in certain areas (scalp) and are preferable to complete arm immobilization such as arm splints, etc. I agree that assessments should be done as necessary with removal of any cover-ups but I don't think that negates the use of them.
Since this PICC line was discharged my biggest concern is did the outside provider not notice an issue. I can see an x-ray being questionable and a RN not noticing arterial if the pressure was low but in two months I would assume some signs should have shown. When meds were given and blood return checked? Pulsating blood in tubing? I am not surprised that the catheter hub cracked. All that blood likely caused the need for hemostats to get the needleless connector from the catheter hub.
I think check and balance is blood return during the dwell time of this line
this is a rare instance but can happen
kathy
Arterial placement does not always mean that you will see a pulsatile blood return or a difference in color of the blood coming from the PICC. Any and all questions require verification with transducing or gases. 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
An easy solution for confirming venous placement may be the Compass Vascular Access.
The Compass is a disposable, connection-free, digital pressure transducer. It has a standard luer slip so it can be connected to any needle, sheath or the catheter itself depending on when your suspicion arises. Once connected, it provides an instant digital pressure measurement in mm Hg which will tell you if your access is venous or arterial.
As a disclosure, I work for Mirador Biomedical, makers of the Compass. I try to refrain from making commercial posts, but this seems like an easier/quicker/more definitive solution than the others being discussed. There is more information and an animated demo video at www.miradorbiomedical.com
Steve Gappa
Mirador Biomedical
[email protected]
I wanted to be clear that my intent in posting this was to bring to our attention that not every nurse or clinican that places or uses PICCs is comfortable with determing arterial placement. This case is clearly one with MULTIPLE missed opportunities to catch the arterial placement before it ended up in the IR for replacement, there were many clinicians that missed the signs of arterial placement in this true case.
I was also one who thought it would be easy to catch, for all the reasons stated below, but clearly it was not caught.
We all have to be diligent with our line placement, to trust our insticts when something does not seem right, and also with our use of catheters. We cannot get comfortable or complacent and assume the "other guy" did everything right. Most of all, we have to listen to our patients.
No, I do not think all lines need to be placed using fluro, but I do think we need to move away from chest x-ray as confirmation of line tip location. This is a great example for this. There is better technology available now that can tell us if we are arterial, and can confirm CAJ placement in 90% of our patients, and I think the 90% deserve this better technology.
This is a great example to use when teaching other clinicians about PICCs, as there are multiple lessons to be learned here.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
pt just had recent new PICC inserted on 12/22/2011, confirmed by CXR. pt complaining she feels the solution going down her forearm like "leaking sensation" everytime it is flushed. Pt denies pain, no swelling noted alsoI never had anyone complain of that and IR MD could not give me an explanation also. Anybody had this complain?
Emma Lei Santos
Unfortunately, the radiology dept may think more radiology services is the answer to this problem, but that is on the wrong track, in my opinion. Radiology services failed to recognize the serious problem in this case and injecting dye to determine tip location will only add additional unncessary risk. An arterially placed PICC can be seen on xray by 2 signs - the catheter pathway arching high over the clavicle and the tip location on the left mediastinum. This message said the original chest xray had issues, but I would have to ask why did they rely on this xray to determine tip location.
We are moving away from radiology with the increasing use of ECG based tip location devices, which are more accurate that a chest xray could ever hope to be. Transducing the line for pressure and obtaining blood gases are 2 much better methods to rule in or out an arterial placement. We definitely need lots of collaboration with the radiology nurses as there is much that we can learn from then and also teach them!
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
any chance you could snag a copy of the cxr image and post here - no chance you know the person that submitted the article? As someone who determines tip location via cxr regularly and over the past few years has caught 2 arterial PICCs that radiology didn't catch, would be instructive for me to see the actual image.
Thanks,
Mari Cordes
Fletcher Allen Health Care, Burlington VT
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Mari, are you thinking about the catheter arching high over the clavicle indicating an arterial placement? I have also caught this on xrays that have been overlooked by radiology. 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
Yes - and coursing to the right of the mediastinum - classic. We ruled out L SVC, did blood gases, and informed radiology (as well as the MD and completing incident/SAFE reports).
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Yes, I caught one that radiology had read as SVC. I saw the catheter arched over the subclavian and in the left mediastinum. This one was easy because there was also a hemodialysis catheter from the right IJ into the SVC. Radiology did not realize the fact that the PICC should be seen very close to that HD catheter! 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
right of mediastinum - in my head looking at film - but meant left of mediastinum.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center