I had an experience today and am hoping that some of you may shed some light on the occurrence. I was placing a PICC line on a gentlemen who had previous PICC's in each arm approx. 1 year ago. He ended up with thrombus in both arms after PICC's placed in these arms. I ready carefully through the venous duplex follow up reports. The last ultrasound of the right arm indicated that no clots or thrombus were present in the right arm. I accessed the basilic vein,which was 3.4cm deep and fully compressed under ultrasound. I accessed the vein and the pt. c/o discomfort, no tingling. The wire threaded beautifully through the needle. I removed the needle and the discomfort went away. I then inserted the introducer. He complained of some discomfort, no tingling. I then threaded the catheter through the dilator approx.15cm. He immediately complained of his arm being "on fire", pain to the arm and itching to the arm. I removed the PICC and dilator immediately. Pt. states that the pain resolved almost immediately but he was experiencing itching to close to the site of insertion. He denied any tingling or numbness. He continues to complain of some itching near that site and some in his hand approx.2 hours after this occurrence.
Could this be the mast cell activation syndrome or related to the previous thrombus from the other PICC's?(again, the right side was clear on the latest report)
It was the itching at the site that makes me think that it is. I've had this happento me once and the physician believed that it was mast cell activation.
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
From what you have included, I would guess that this was not mast cell activation syndrome. This usually includes hives, itching, respiratory difficulties such as tongue or throat swelling, nausea. It does not go away when the catheter is removed, but will continue to progress because this is a systemic reaction due to the release of histamine from the superficial mast cells. From what you have said, I would expect this to be nerve pain due to the intensity and timing. There could also have been some histamine release that lead to the itching. Nerves and veins are surrounded by a large number of mast cells. Think of mast cell activation syndrome as idiopathic anaphylaxis or an anaphylactoid reaction. True anaphylaxis is caused by the introduction of an antigen to which the patient has previously been exposed and subsequently developed the antibody. MCAS, idiopathic anaphylaxis or anaphylactoid reactions have the same clinical presentation but are caused by stimulation of the mast cell from physical or chemical mechanisms or activation of complement proteins. In a true case of MCAS, I would never remove the catheter because this may be the only means of providing rapid drug delivery if the case is severe.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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