Hello
We have a patient who has PICC where the tip lies in the axillary vein. Further distal, there is occlusion of the brachiocephalic vein from the extrinsic compression from the tumor. The physician reported that there seems to be cutaneous collaterals on the chest wall that bypass the SVCO through drainage via IVC. Patient needs urgent chemo - 2 of the chemo are vesicant. The physician stated that it is safe to administer the vesicant chemotherapy via the existing PICC and don't think it is necessary to insert femoral PICC. Is this approach safe? Appreciate your expert advice.
Thank you
Deedee
No it is definitely not the safest tip location and it is not the one supported by evidence and standards and guidelines. The tip in the axillary vein increases the risk of tip impinging on the vein wall, causing vein thronbosis and vessel erosion. I would refuse to use this for any infusion, especially vesicant chemotherapy.
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
Hello Deedee7065
We had several cases where we could not advance the tip into the SVC. Those cases are very predictable, and chart review will easily indicate occlusion or tortuosity issues. We kept the tip more proximal and released the catheter to be used but not for TPN. Each case is dealt with differently, so there is no white and black situation.
Ibraheem Aljediea
Johns Hopkins aramco Healthcare
Saudi Arabia
The question would be why the tip could not be advanced to the correct SVC location. If there are anatomical reasons that prohibit the tip reaching the SVC, the next step would be to assess the characteristics of the prescribed infusates - osmolarity, pH, duration of therapy, hypercoagulablity of the patient, etc. Based on this assessment it might be determined that the risk of leaving the tip in a suboptimal location is a greater risk for vein thrombosis. In that case, would this anatomical obstruction be present with all upper body insertion sites? If yes, then a mid-thigh PICC is indicated so the tip would lie in the IVC. Another scenario would be if the the obstruction is a tumor, a couple of courses of the antineoplastic drugs thru peripheral veins could reduce the size of the tumor and allow for an upper body insertion site to reach the SVC. Thrombosis is the greatest risk of suboptimal tip locations followed by vessel erosion with extravasation injury likely to occur,
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
Thank you both
DeeDee