We recently had an incident of an arterially placed PICC discovered after several weeks of treatment.
The nurse who dc'd the PICC noticed pulsing of blood from the insertion site after removal of the
catheter.  A few days later, another nurse noticed on the x-ray film that the path of the PICC was
unusual...both of these films showed the catheter rising above the level of the clavicle and crossing
the midline, rather than dropping down into the SVC. Both these PICC's were placed in the right
arm.
 We(PICC nurses) view our PICC x-rays and release them for use...the really interesting thing was that in both cases,
(a different radiologist each time)the radiologist stated the PICC tip was in the mid SVC. I took copies of these
films to the radiology dept. for them to use as a "teaching tool" and we have had an inservice on this
situation.  Any one else have something like this happen?
Tanya,
we have not experienced this and hopefully we will not need to.
For the teaching purposes of me and maybe others, could you perhaps...
- elaborate on why the arterial stick and placement was not recognized at insertion
- tell us what was administered in this PICC and how the patient reacted to these infusions/injections
- consider publishing (of course without patient data) the x-ray pictures in the IV-therapy.net gallery.
Thanks
Mats
We had a PICC insertion that was in the artery. It looked "different" on the X-ray, and the radiologist wanted a re-xray, which was inconclusive. We took the pt. in for a flow study and that is where we discovered it was in the artery. The only reason we feel that this was not picked up at insertion, was that the patient was severly dehydrated, thus, no pulsating or blood flow back.
Jan
Cheryl Kelley RN BSN, VA-BC
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Tanya: Can you write up an article for JAVA on this case? I've hit the artery, but I knew it (the PICC pulsated as it stuck out of the upper arm), and have never left one in. In a patient with relatively low BP (eg, end-stage heart failure) it may not do so. Cynthia Chernecky, the new editor of JAVA, will help you if you don't feel comfortable writing. Just do the best you can. We'd all love to see the CXRs.
Nadine Nakazawa
Nadine Nakazawa, RN, BS, VA-BC
T. Nauman RN, CRNI IV Educator SHMC Eugene, OR
I just located my xrays that show this. I would like to write this up eventually...I am having surgery on Wednesday. Mayber I can get started on an article while I'm an home for a few weeks.
T. Nauman RN, CRNI
We recently had an incident of an arterially placed PICC discovered after several weeks of treatment.
Tanya - I'd be happy to help you write it, and/or provide some information about our case for your article; I was thinking about writing our case up also. In our case, the PICC RN who inserted the PICC could note NO signs that she was in an artery. The patient was an ICU patient, I believe he was hypotensive, but don't remember the rest of the details. We had a case study in our dept. after this - it was unusual in that it was a senior PICC nurse, and she was shocked to discover that it was arterial - AFTER she placed it.
[/quote] Mari Cordes, BS RNMari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Unfortunate. This may be an increasing problem, in particularly in patients with the use of tourniquet in patients with lower blood pressures, and those with implanted LVADs. The use of EKG technology will not protect us from this either. If these catheters are in for extended periods of time I cannot stress the importance of using care and not removing these lines without a thorough ultrasound exam to r/o an arterial thrombus and devastating cardiovascular or cerebrovascular events. This should only be done by vascular surgeons or interventional radiologist.
Jeffery Fizer RN, BSN
I am not sure I understand why you think arterial placement might be an increasing problem. If US is used by an knowledgeable inserter , arteries and veins can be distinquished from each other. I agree that ECG will not provide information about arterial vs venous placement. 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
I think we need to keep in mind that inadvertent arterial puncture and cannulation DOES occur and has NOT been eliminated with ultrasound use therefore assessment during insertion, dilation, post insertion pain and if needed a secondary method of confirmation. If the x-ray doesn’t look right or you question blood flow an ABG or distal lumen transduction is a quick second confirmation.
The primary variance in inadvertently accessing the artery is patient condition during insertion, anatomical variance and ultrasound skill set.
More importantly each of you highlight cases in which a chest x-ray was relied upon for catheter clearance. I must stress we are trending away from x-ray as the gold standard and several teams no longer do x-rays if using tip technology.
ECG/Doppler tip positioning technology is the only technology currently available to detect antegrade and retrograde blood flow via (Doppler), telling me if I am inadvertently in an artery. Personally with the way we are advancing we will rely less on radiology and more on this type of bedside technology.
Lastly arterial cannulation usually comes with pain and or numbness. The patient may complain of a heavy arm or numbness or tingling of the pinky and ring finger in the effected hand. These potential side effects should be well known by all staff working with PICC patients.
Amy Bardin
RRT, MS, VA-BC
Recently I had a panic call to remove and replace a picc the radiologist identified as arterial placement with a right side approach. I'll spare the process of discovery, but the picc was a nicely placed left venous catheter. The patient had a lot going on in the chest and it was difficult to identify much of anything really. Basically the event was an error in the xray tech mislabeling right and left side on the film.
I know arterial placement happens as I have some legal cases involving this situation. I am just curious about the statement that arterial placement was expected to increase from a previous message. Just wondering why the anticipated increase. 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
First, I do not work for any company. That said, I have been placing PICC lines at the bedside for 10 years using ultrasound. We have been using the VasoNova VPS by Teleflex for the past year and a half and the doppler combined with ECG technology is designed to prevent the nurse from completing a PICC insertion in the artery. As the catheter is threading we can also see the doppler waveform. So if we are tring to thread into an artery the device will immediately show us the "red stop sign" and we can also see that the flow is retrograde. I do not know why more Arterial placements would be anticipated. I would think that with advances in ultrasound technology it would be easier to identify the artery.
Linda C. Smith, RN
I do not work for Teleflex, but use their technology. I opted for this technology because it uses ECG, Doppler and an algorithm. After years of using the very subjective single technology of the CXR I didn’t want to depend on another single vector technology like ECG alone.
Arterial placement should not be on the rise. Good assessment with the ultrasound and knowing vascular anatomy should keep inadvertent arterial puncture to a minimum.
In the rare cases were the catheter is placed in the artery, or the azygous vein or IJ even contralateral IJ the VPS Doppler sensor detects that the catheter is being advanced AGAINST blood flow and NOT towards the lower 1/3 of the SVC. I have not had an inadvertent placement in any vein other than the lower 1/3 since I began using this triple vector technology let alone an artery. My malposition rate has gone from 3.5% to ZERO! It is empowering to walk away from a patient knowing that the device is placed precisely where you want it and you can release it for immediate use.