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Leann Kennedy
Any thoughts?

I placed a 4 fr single lumen SOLO in the R brachial vein on Friday--pt had no other veins.  She is awaiting liver transplant and 3rd spacing everywhere, she's on coumadin (INR 2.7) for a-fib, the coumadin caused a small subdural hematoma, the altered LOC from the SDH caused her to aspirate and she now has pneumonia....shall I go on?

Anyhoo...Her arm grew over the weekend due the the third spacing (don't get me started with the measurement thing), and I was worried about a possible DVT (despite the coumadin).  U/S showed no DVT, but the edema was severe enough to compress the vein and allow zero blood flow around the PICC line. 

I d/c'd the PICC, and luckily was able to start another one in the other side, much higher in the extremity. 

What do you all think?  Any similar experiences/advice?  Also, in regards to measuring arm circ (if it was done correctly), what instructions do you give the bedside RN?  How much increase in arm circ do you ask the RNs to call...what do you do with the info?   We don't have covg on Sat or Sun, what should you ask the MD to do with the info?

Any help would be appreciated. Thanks


Technically you are not
Technically you are not supposed to place a PICC in an arm with edema, because it becomes very hard to differentiate  between PICC induced problems, as opposed to other causes such as the 3rd spacing.  (not that most of us haven't done it in a critical situation).  The best you can do is do what you did--get an order for an ultrasound. Measurements are always going to be arbitrary, and everything has to be assessed not just the measurement.  I encourage the bedside RN's to call with any questions, better a little overkill then to overlook something.
Kevin Travis Flint
Doesn't sound like this

Doesn't sound like this patient had much left to access and you did the best you could do with what you had.  If in the same situation I would've probably done the same as you.


Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Tunneled small bore central catheter via the jugular should be done.  There is one published article on their use in JVIR which is SIR's journal.  Slyvia PYC on clinical hotline can give you reference.  800-443-5505

Manufacturers who have such a device are Angio, Bard and Medcomp.  I don't think I missed anyone.  These are 6 french single or dual lumen devices.




Kathy Kokotis

Bard Access Systems

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